Rectal cancer management: do all patients need to undergo surgery?

The non-surgical management or  “watch-and-wait” approach for rectal cancer is an experimental treatment strategy that aims to safely omit invasive surgical procedures to best preserve patients’ quality of life. Findings from a recent study add to the growing body of evidence that supports the “watch-and-wait” approach in rectal cancer management.

Currently, the standard treatment for most rectal cancers in the US and Canada begins with chemoradiation given before the primary treatment (neoadjuvant chemoradiation), followed by surgery to remove the rectum and surrounding tissues, followed by chemotherapy given after the primary treatment to kill any remaining cancer cells (adjuvant chemotherapy).

The “watch-and-wait” or “watchful waiting” approach begins with chemoradiation followed by strict patient surveillance to monitor cancer recurrence for a determined period of time. Surgical removal of the rectum and surrounding tissues is not performed, therefore avoiding potential life-changing side effects including loss of control bowel movements and bladder function, sexual dysfunction, and the strong possibility of requiring a permanent colostomy. Senior study investigator Vikram Attaluri, MD, notes that while rectal cancer surgery is very good for a cure, the side effects can have a massive impact on a patient’s quality of life: “…someone could be living with a bag outside their body for the rest of their life…Some patients have indicated they would rather live with cancer.”

In order for patients to be eligible for “watch-and-wait”, they must achieve a complete clinical response, or have no visible tumour several months after their initial chemoradiation therapy. Dr. Attaluri says that the number of rectal cancer patients that qualify may be less than 20%, though this percentage is on the rise as more patients receive more effective neoadjuvant treatments.

Based on their findings, the investigators suggest that the watch-and-wait approach appears to be the safest among patients with stages I and II rectal cancer. Patients with stage III rectal cancer experienced higher mortality rates after 3 years, with the exception of those that received oxaliplatin-based intravenous chemotherapy. Rectal magnetic resonance imaging (MRI) is recommended to confirm a complete treatment response. Despite being considered an experimental treatment approach, some specialists in colorectal surgery suggest that there is sufficient evidence to support the use of this alternative approach among eligible patients.

Watch-and-wait surveillance includes monitoring every 3 months for the first 2 years after initial chemoradiation therapy, then every 6 months for the next 3 years, and then annually thereafter.

Take home message:

The non-surgical or “watch-and-wait” approach to rectal cancer management may be a viable, quality of life-preserving alternative for patients with no visible remaining tumours following initial treatment with chemoradiation therapy.