News | Radiation Therapy | November 02, 2020

Some Rectal Cancer Patients Can Safely Avoid an Aggressive Operation

Journal of the American College of Surgeons study authors report that watch-and-wait strategy after chemotherapy and radiation is an option for select patients

Watch-and-Wait Compared to Operation for Patients with Complete Response to Neoadjuvant Therapy for Rectal Cancer. Image courtesy of the American College of Surgeons

Watch-and-Wait Compared to Operation for Patients with Complete Response to Neoadjuvant Therapy for Rectal Cancer. Image courtesy of the American College of Surgeons

November 2, 2020 — A nonsurgical treatment option for rectal cancer that preserves quality of life is safe for carefully selected patients, according to a new study comparing it with the standard operation. The study results appear online as an "article in press" on the Journal of the American College of Surgeons website in advance of print publication and was presented at the American Society for Radiation Oncology (ASTRO) Annual Meeting.

In the United States, the standard treatment for most rectal cancers is triple therapy. Typically, patients first receive chemotherapy pills and radiation therapy at the same time before the main treatment--called neoadjuvant chemoradiation--followed by an operation to remove the rectum and surrounding tissues, and then intravenous chemotherapy to kill cancer cells. The new approach, called watch-and-wait (or watchful waiting), initially skips the operation, with regular patient monitoring for cancer recurrence.

"Rectal cancer surgery is very good for a cure, but it does have certain potential side effects: the ability to control bowel movements, bladder accidents, sexual dysfunction, and in up to half of cases, a permanent colostomy," said senior study investigator Vikram Attaluri, M.D., FACS, a colon and rectal surgeon, and assistant professor at Kaiser Permanente (KP) School of Medicine, Pasadena, Calif. "So someone could be living with a bag outside their body for the rest of their life, which has a huge effect on one's quality of life. Some patients have indicated they would rather live with cancer."

Rectal cancer is common--an estimated 43,000 new cases occur each year1--but eligibility criteria for watch-and-wait are strict. It is an option only if patients can return for follow-up visits and have no visible tumor several months after preoperative treatment, a so-called complete clinical response.

Attaluri estimates that less than 20 percent of patients achieve a complete response after chemoradiation. He said this percentage is increasing as more patients receive both chemoradiation and intravenous chemotherapy in the neoadjuvant setting (called total neoadjuvant therapy).

Despite favorable results of watch-and-wait in many studies,2 concerns exist that any remaining microscopic cancer cells could spread and lower survival rates.3 Therefore, the new strategy has not gained widespread acceptance in the United States outside clinical trials or specialized cancer centers, according to Bryce W. Beard, M.D., a fifth-year radiation oncology resident at KP Los Angeles Medical Center and lead study author.

"What is unique about our study is the community-based practice setting in a large integrative managed care organization," Beard said. "Our results, which are similar to those from past studies, suggest that watch-and-wait can be implemented on a broader scale."

Comparing surgical and nonsurgical treatment

The researchers reviewed the medical records of KP patients who underwent rectal cancer treatment between January 2015 and February 2019 at one of three Los Angeles-area radiation oncology centers. Patients had stages I to III rectal cancer (had not spread to distant organs), were medically fit for an operation, and completed neoadjuvant chemoradiation.

Of 465 patients, 406 had an assessment of their treatment response two to three months later. These patients underwent a digital (finger-guided) rectal exam and rectal imaging via endoscopy. Some patients also had rectal magnetic resonance imaging (MRI) to confirm the absence of tumor.

Ninety-five patients (23 percent) had a complete response and were eligible for watch-and-wait, the investigators reported. Fifty-three of these patients refused an operation and chose watch-and-wait, whereas the other 42 patients underwent an operation.

Three years later, all but six patients from the watch-and-wait group (11 percent) had no local regrowth of the cancer at the original site. All six patients had no evidence of a distant recurrence, and the tumor could be removed surgically, Beard said.

"The ability to perform curative-intent salvage, or rescue, surgery at the time of regrowth was quite good, indicating this approach seemed generally safe," he said.

Seven patients in the watch-and-wait group (including two initially) and four patients in the surgical group experienced a distant recurrence, with a lower likelihood of cure, which the researchers called "nonregrowth recurrence." On statistical analysis, the 85 percent rate of freedom from nonregrowth recurrence for watch-and-wait was similar to the 91 percent rate in the surgical group, Beard noted.

Although five of the six watch-and-wait patients with local regrowth eventually had a distant recurrence, Dr. Beard said local regrowth may, but does not necessarily, lead to a distant recurrence. It is also possible that distant recurrences would have developed in those patients even if they had undergone an operation, he added.

Disease-specific survival rates, meaning those who have not died of their cancer, also were statistically similar between groups: 95 percent for watch-and-wait versus 100 percent in the surgical group, according to the article.

Recommendation

Based on their other results, the investigators concluded that watch-and-wait appears to be safest in patients with stages I and II rectal cancer. Patients with stage III cancer were less likely to be alive at three years unless they received intravenous chemotherapy containing the drug oxaliplatin, the researchers found. They recommend rectal MRI to confirm a complete treatment response.

Although watch-and-wait is still considered experimental, study co-investigator Elisabeth C. McLemore, M.D., FACS, a colon-rectal surgeon at KP Los Angeles Medical Center, said, "There are sufficient data to offer this alternative treatment to eligible patients."

She recommends that patients who choose watch-and-wait receive monitoring every three months for the first two years, then every six months for years 3 to 5, and annually thereafter.

For more information: www.facs.org

1 American Cancer Society. Key statistics for colorectal cancer: how common is colorectal cancer? Available at: https://www.cancer.org/cancer/colon-rectal-cancer/about/key-statistics.html. Accessed October 15, 2020.

2 Including the first study: Habr-Gama A, Perez RO, Nadalin W, et al. Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results. Ann Surg. 2004;240(4):711-717.

3 Smith JJ, Strombom P, Chow OS, et al. Assessment of a watch-and-wait strategy for rectal cancer in patients with a complete response after neoadjuvant therapy. JAMA Oncol. 2019;5(4):e185896.

Related Content

News | Radiation Therapy | May 06, 2021
May 6, 2021 — Individuals living with severe...
Research finds that a commonly used risk-prediction model for lung cancer does not accurately identify high-risk Black patients who could benefit from early screening

Getty Images

News | Lung Imaging | May 05, 2021
May 5, 2021 — Lung cancer is the third most common cance
The emergence of #therapeutic #radiopharmaceuticals and its adoption in #cancer care provide one more weapon in combating cancer

Getty Images

Feature | Radiation Oncology | May 04, 2021 | By Vinay Shivaprasad
The term nuclear medicine is associated with the diag
Despite receiving high radiation doses to their tumors, lung cancer patients treated with technique that spares a large part of the esophagus did not develop severe inflammation of the esophagus

Getty Images

News | Lung Imaging | April 30, 2021
April 30, 2021 — For many patients with localized lung cance...
#prostatecancer During the first wave of the corona pandemic, 36 percent fewer men were diagnosed with prostate cancer in Sweden than in previous years.

Getty Images

News | Prostate Cancer | April 30, 2021
April 30, 2021 — During the first wave of the corona pandemic, 36 percent fewer men were diagnosed with prostate canc
A 63-year-old multiple #myeloma patient, with skeletal pain. New #FDG avid axillary #lymphadenopathy 62 days (9 weeks) after second #mRNA #vaccination dose. Image used with permission of the Radiological Society of North America (#RSNA)

A 63-year-old multiple myeloma patient, with skeletal pain. New FDG avid axillary lymphadenopathy 62 days (9 weeks) after second mRNA vaccination dose. Image used with permission of the Radiological Society of North America (RSNA)

Feature | Coronavirus (COVID-19) | April 29, 2021 | By Melinda Taschetta-Millane
A phase 1 clinical trial led by investigators at the University of Chicago Medicine testing the effects of stereotactic body radiotherapy for treating multiple metastases has determined that treatments used for single tumors can also be safely used for treating patients with multiple metastases.

Image courtesy of Accuray

News | Stereotactic Body Radiation Therapy (SBRT) | April 23, 2021
April 23, 2021 — A phase 1 clinical trial led by investigators at the...
A Norwegian study for the first time reveals benefit of the #PARP inhibitor #Olaparib in patients with early #breastcancer not harboring germline mutations

Getty Images

News | Radiation Therapy | April 22, 2021
April 22, 2021 — Targeted therapy in early stages of breas...