Avoiding Unnecessary Major Rectal Cancer Surgery by Implementing Structural Restaging and a Watch-and-Wait Strategy Afte
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ORIGINAL ARTICLE – COLORECTAL CANCER
Avoiding Unnecessary Major Rectal Cancer Surgery by Implementing Structural Restaging and a Watch-and-Wait Strategy After Neoadjuvant Radiochemotherapy J. F. Huisman, MD1, I. J. H. Schoenaker, MANP2, R. M. Brohet, PhD3, O. Reerink, MD, PhD4, H. van der Sluis, MD1, F. C. P. Moll, MD5, E. de Boer, MD6, J. C. de Graaf, MD, PhD7, W. H. de Vos tot Nederveen Cappel, MD, PhD1, G. L. Beets, MD, PhD8,9, and H. L. van Westreenen, MD, PhD2 1
Department of Gastroenterology and Hepatology, Isala Hospital, Zwolle, The Netherlands; 2Department of Surgery, Isala Hospital, Zwolle, The Netherlands; 3Department of Epidemiology and Statistics, Isala Hospital, Zwolle, The Netherlands; 4 Department of Radiotherapy, Isala Hospital, Zwolle, The Netherlands; 5Department of Pathology, Isala Hospital, Zwolle, The Netherlands; 6Department of Radiology, Isala Hospital, Zwolle, The Netherlands; 7Department of Medical Oncology, Isala Hospital, Zwolle, The Netherlands; 8Department of Surgery, The Netherlands Cancer Institute, Amsterdam, The Netherlands; 9GROW School for Oncology and Developmental Biology, Maastricht University, Amsterdam, The Netherlands
ABSTRACT Background. Pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT) is found in 15–20% of patients with locally advanced rectal cancer. A watch-and-wait (W&W) strategy has been introduced as an alternative strategy to avoid surgery for selected patients with a clinical complete response at multidisciplinary response evaluation. The primary aim of this study was to evaluate the efficacy of the multidisciplinary response evaluation by comparing the proportion of patients with pCR since the introduction of the structural response evaluation with the period before response evaluation. Methods. This retrospective cohort study enrolled patients with locally advanced rectal cancer who underwent nCRT between January 2009 and May 2018, categorizing them into cohort A (period 2009–2015) and cohort B (period 2015–2018). The patients in cohort B underwent structural multidisciplinary response evaluation with the option of the W&W strategy. Proportion of pCR (ypT0N0), time-toevent (pCR) analysis, and stoma-free survival were evaluated in both cohorts.
Ó The Author(s) 2020 First Received: 26 November 2019 Accepted: 11 August 2020 G. L. Beets, MD, PhD e-mail: [email protected]
Results. Of the 259 patients in the study, 21 (18.4%) in cohort A and in 8 (8.7%) in cohort B had pCR (p = 0.043). Time-to-event analysis demonstrated a significant pCR decline in cohort B (p \ 0.001). The stoma-free patient rate was 24% higher in cohort B (p \ 0.001). Conclusion. Multidisciplinary clinical response evaluation after nCRT for locally advanced rectal cancer led to a significant decrease in unnecessary surgery for the patients with a complete response.
The standard therapy for locally advanced rectal cancer is neoadjuvant chemoradiotherapy (nCRT) to downstage the tumor followed by surgical resection according to the principles of total mesorectal excision
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