Rectal Cancer: Watch and Wait
The management of rectal cancer has become increasingly complex. In the 15–20 % of patients who achieve a pathologic complete response to neoadjuvant chemoradiation therapy, long-term local and distant tumor control is excellent. Based on these excellent
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Key Concepts • Pathologic complete treatment response following neoadjuvant chemoradiation therapy and surgery for rectal cancer is associated with favorable prognosis. • Pathologic complete treatment response is observed in approximately 15–20% of rectal cancer patients following chemoradiation therapy. • Clinical and radiographic assessment of neoadjuvant therapy treatment response is suboptimal, and remains a primary challenge for safe implementation of watch and wait strategies. • Approximately one in three patients exhibiting clinical complete response will develop tumor regrowth. • At present, watch and wait should be offered to patients only in the context of a clinical trial. • Local excision following neoadjuvant chemoradiation therapy is associated with significant risk for pain and poor wound healing.
Introduction Over the past few decades, the management of rectal cancer has become increasingly complex. What was once a disease with high mortality and limited treatment options that typically necessitated a permanent colostomy has become a model for multidisciplinary evaluation and treatment and surgical advancement. For over a century, surgical resection has remained the cornerstone of curative treatment of rectal cancer. The principles of treatment include complete en bloc resection of the tumor-bearing rectum and mesorectum with clear margins along with clearance of pelvic lymphadenopathy and, when possible, restoration of intestinal continuity [1]. However, because of the historically high risk of local failure after surgery alone, clinicians have
utilized neoadjuvant radiotherapy or chemoradiation therapy (nCRT) which has improved the rate of local tumor control [2]. Now the oncologic outcomes following treatment of rectal cancer in the modern era can equal outcomes following treatment of colon cancer [3]. Despite these advances, the multimodal treatment for rectal cancer is associated with a significant impact on long-term functional and quality of life outcomes including risks for bowel, bladder, and sexual dysfunction, pain, and potential need for permanent colostomy. Therefore there is great interest in strategies to decrease the toxicity of treatment, including strategies that employ the selective use of radiation, chemotherapy, or even surgery. The modern concept of selective use of surgery following chemoradiation therapy for patients with rectal cancer are based on the fact that pathologic complete response (pCR) is observed in approximately 10–20% of patients following long course chemoradiation therapy. In 2004, Habr-Gama and her group first reported outcomes for selective surgery with a nonoperative (a.k.a. “watch and wait” or “wait and see”) strategy in select patients who achieved a clinical complete response (cCR) following chemoradiation therapy [4]. In the decade since that initial report, a number of other investigators have attempted to bring further light to understanding the potential for a selective surgical approach. They have also highlighted a need for considering a number o
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