News | Radiation Therapy | November 02, 2020

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

June 24, 2022 — Recently, a collaborated research team led by Prof. LI Hai and Hongzhi Wang from Hefei Institutes of ...

Time June 24, 2022
arrow
News | Radiation Therapy

June 23, 2022 — RaySearch Laboratories AB announced the release of the latest version of RayCare*, the next generation ...

Time June 23, 2022
arrow
News | Radiation Therapy

June 17, 2022 — Accuray Incorporated and Limbus AI Inc. announced they are partnering to augment Accuray adaptive ...

Time June 17, 2022
arrow
News | Prostate Cancer

June 10, 2022 — GE Healthcare provides cutting-edge molecular imaging solutions that enable and increase access to ...

Time June 10, 2022
arrow
Feature

Imaging Technology News (ITN) maintains more than 40 comparison charts of product specifications from various vendors ...

Time June 09, 2022
arrow
News | Digital Pathology

June 8, 2022 — Proscia, a leader in digital and computational pathology solutions, announced that its Concentriq Dx ...

Time June 08, 2022
arrow
News | Image Guided Radiation Therapy (IGRT)

June 7, 2022 — Two-year results from the Dysphagia-Aspiration Related Structures (DARS) trial, which is funded by Cancer ...

Time June 07, 2022
arrow
News | Radiation Therapy

June 3, 2022 — Henry Ford Health is the first in the world to complete a full course of patient treatments using the ...

Time June 03, 2022
arrow
News | ASTRO

June 2, 2022 — The American Society for Radiation Oncology (ASTRO) recently hired Chris Neumann as its new Vice ...

Time June 02, 2022
arrow
Feature | Radiology Business | By Melinda Taschetta-Millane

Here is what you and your colleagues found to be most interesting in the field of medical imaging during the month of ...

Time June 01, 2022
arrow
Subscribe Now