A growing trend among physicians and patients to delay surgery in favor of seeing whether chemotherapy and radiation prove effective against rectal cancer — an approach known as watch and wait — has raised concerns among some cancer specialists.
In a commentary in JAMA Oncology, UNC Lineberger Comprehensive Cancer Center’s José Gaston Guillem, MD, MPH, MBA, FACS, FASCRS, and Dimitrios N. Varvoglis, MD, a colorectal surgery research fellow in the UNC Department Surgery, caution against the rush to extend the treatment approach to patients whose cancer has nearly, but not completely, responded to chemotherapy and radiation therapy.
Rectal cancer that has not metastasized — it has not spread to other parts of the body — typically is treated with surgery and, in some cases, chemotherapy, radiation therapy and in highly selected cases, immunotherapy. This multiprong approach can be quite effective: the five-year survival rate is 89% when the cancer is treated before it has spread, according to the National Cancer Institute. However, surgery, in some cases, can cause a range of side effects that reduce a patient’s quality of life, including bowel, sexual and urinary dysfunction.
Previous studies have found that the watch-and-wait strategy is a generally effective approach for a rectal cancer that has completely responded to presurgical chemotherapy and radiation therapy. However, there are concerns that a growing number of patients whose cancer has a near-complete clinical response are opting for watch and wait to avoid surgery.
“While our goal is to provide patients the most effective therapy with the least amount of side effects, we also need to be confident that we are not putting the patient at increased risk for the cancer to return,” said Guillem, chief of Division of Gastrointestinal Surgery and the Roscoe Bennett Gray Cowper, MD, Distinguished Professor at UNC School of Medicine. “Unfortunately, we currently lack the research data necessary to determine which cancers with a near-complete clinical response will go on to experience a complete response over time, and which cancers will not.”
If surgery is required following a period of watch and wait, Guillem said the delay in performing the procedure, especially if it was a significant delay, could reduce its effectiveness to control the cancer. To prevent this, he said it is important to establish a window of time – a cutoff point – to perform a surgery when it still might provide sufficient benefit. This mirrors an approach used successfully to manage a type of anal cancer.
“We are quite fortunate to have an increasing number of options for treating and managing patients afflicted with rectal cancer,” Guillem said. “However, data is needed to better understand the natural history of near-complete and complete rectal cancer responders. These research findings will help the clinical care team and patients to engage in shared decision-making about treatment preferences.”