What is the watch and wait strategy in the treatment of lower rectal cancer?

Samir Delibegovic

Surgery following neo-adjuvant chemoradiotherapy has been the standard in the treatment of lower rectal cancer for some time, providing good oncological outcomes. However, for patients who achieve a clinical complete response, in addition to surgery, the concept of a watch-and-wait (W&W) strategy, has been developed, that is, simply monitoring these patients with no surgical intervention. The W&W strategy can ensure a significantly higher organ preservation rate but with similar oncological outcomes as in patients after total mesorectal excision. Thus, the W&W strategy is considered an attractive treatment choice to avoid major surgery and permanent stoma, in patients with lower rectal cancers. It is also a valid treatment strategy for patients who are willing to accept potentially worse oncological outcomes to achieve this goal.

Keywords: words: watch and wait, rectal cancer, neoadjuvant chemotherapy, neoadjuvant chemotherapy, TME

Full Article PDF

DOI: https://10.55791/2831-0098.1.2.211

1. Fujita S, Akasu T, Mizusawa J, Saito N, Kinugasa Y, Kanemitsu Y, Ohue M, Fujii S et al. Postoperative morbidity and mortality after mesorectal
excision with and without lateral lymph node dissection for clinical stage II or stage III lower rectal cancer (JCOG0212): results from a multicentre, randomised controlled, non-inferiority trial. Lancet Oncol. 2012;13:616-21. doi: 10.1016/S14702045(12)70158-4
2. Sauer R, Liersch T, Merkel S, Fietkau R, Hiohenberger W, Hess C, et al (2012). Preoperative versus postoperative chemoradiotherapy for locally advanced rectal cancer: results of the German CAO/ARO/AIO-94 randomized phase III trial after a median follow-up of 11 years . J Clin Oncol. 2012;30:1926-1933.
3. Konradi LC, Rodel C, Ghadimi M. Rectal cancer: Open questions in 2022. Current standards of clinical practice and ongoing trials. Digestion. 2022;103:175-182.
4. Schmiegel W, Pox C, Reinacher-Schick A, Adler G, Arnold D, Fleig W, et al; Federal Committee of Physicians and Health Insurers. S3 guidelines for colorectal carcinoma: results of an evidence based consensus conference on February 6/7, 2004 and June 8/9, 2007. Z Gastroenterol. 2010;48:65-136. doi: 10.1055/s-0028-1109936.
5. Kong JC, Guerra GR, Warrier SK, Ramsay RG, Heriot AG. Outcome and Salvage Surgery Following “Watch and Wait” for Rectal Cancer after Neoadjuvant Therapy: A Systematic Review. Dis Colon Rectum. 2017;60:335-345.
6. Wang Q, Zhang R, Xiao W, Zhang S, Wei M, Li Y, et al. The watch-and-wait strategy versus surgical resection for rectal cancer patients with a clinical complete response after neoadjuvant chemoradiotherapy. Radiat Oncol. 2021;17:16-21.
7. Lim L, Chao M, Shapiro J, Millar JL, Rezo D, Fong A et al. Long-term outcomes of patients with localized rectal cancer treated with chemoradiation or radiotherapy alone because of medical inoperability or patient refusal. Dis Colon Rectum. 2007;50:2032-9.
8. Glynne-Jones R, Huges R. Complete Response after Chemoradiotherapy in Rectal Cancer (Watch-and-Wait): Have we Cracked the Code? Clin Oncol. 2016;28:152-160.
9. Mass M, Nelemans PJ, Valentini V, Das P, Rodel C, Kuo LJ, et al. Long-term outcome in patients with a pathological complete response after chemoradiation for rectal cancer: a pooled analysis of individual patient data. Lancet Oncol. 2010;11:835-44. doi: 10.1016/S1470-2045(10)70172-8
10. Mass M, Lambregt DMJ, Nelemans PJ, Heijnen LA, Martens MH, Leijjtens JWA, et al. Assessment of Clinical Complete Response After Chemoradiation for Rectal Cancer with Digital Rectal Examination, Endoscopy, and MRI: Selection for Organ-Saving Treatment. Ann Surg Oncol. 2015;22:3873-80. doi:10.1245/s10434-015-4687-9.
11. Habr-Gama A, Perez RO, Nadalin W, Sabbaga J, Ribeiro U Jr, Silva e Sousa AH Jr, et al. Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results. Ann Surg. 2004;240:711-7; discussion 717-8. doi: 10.1097/01.sla.0000141194.27992.32.
12. Gao YH, Zhang X, An X, Cai MY, Zeng ZF, Chen G, Kong LH, et al. Oxaiplatin and capecitabine concomitant with neoadjuvant radiotherapy and extended to the resting period in high risk locally advanced rectal cancer. Strahlenther Onkol. 2014;190:158-64. doi: 10.1007/s00066-013-0500-5.
13. Marechal R, Vos B, Polus M, Delaunoit T, Peeters M, Demetter P, et al. Short course chemotherapy followed by concomitant chemoradiotherapy and surgery in locally advanced rectal cancer: a randomized multicentric phase II study. Ann Oncol. 2012;23:1525-30. doi: 10.1093/annonc/mdr473.
14. Park IJ, You YN, Agarwal A, Skibber JM, Rodriguee-Bigas MA, Eng C, et al. treatment response as an early response indicator for patients with rectal cancer. J Clin Oncol. 2012;30:1770-6. doi: 10.1200/JCO.2011.39.7901.
15. Shin JS, Gut TG, Ho V, Lee CS. Predictive markers of radiotherapy-induced rectal cancer regression. J Clin Pathol. 2014;67:859-64. doi: 10.1136/jclinpath-2014-202494.
16. Zgang X, Ding R, Li JS, Wu T, Shen ZH, Li SS, et al.Efficacy and safety of the “watch-and-wait” approach for rectal cancer with clinical complete response after neoadjuvant chemoradiotherapy: a meta-analysis Surg Endosc. 2022;36:2233-2244. doi: 10.1007/s00464-021-08932-x.
17. Quezada-Diaz FF, Smith JJ. Nonoperative Management for Rectal Cancer. Hematol Oncol Clin N Am. 2022;36:539-51. doi: 10.1016/j.hoc.2022.03.003.
18. Bipat S, Glas AS, Slors FJM, Zwinderman AH, Bossuyt PMM, Stoker J. Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging–a meta-analysis. Radiology. 2004;232:773-83.
19. van der Sande ME, Maas M, Melenhorst J, Breukink SO, van Leerdam ME, Beets GL. Predictive value of endoscopic features for a complete response after chemoradiotherapy for rectal cancer. Ann Surg. 2021;274:e541-e547. doi:10.1097/SLA.0000000000003718.
20. Haak HE, Gao X, Mass M, Waktola S, Benson S, Beets-Tan RGH, et al. The use of deep learning on endoscopic images to assess the response of rectal cancer after chemoradiation. Surg Endosc. 2022;36:3592-3600. doi: 10.1007/s00464-02108685-7.
21. Ferlitsch M, Moss A, Hassam C, Bhandari P, Dumonceau JM, Paspatis G, et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2017;49:270-297. doi: 10.1055/s-0043-102569.
22. Hupkens BJP, Mass M, Martens MH, van der Sande ME, Lambregts DMJ, Breukink SO, et al. Organ Preservation in Rectal Cancer After Chemoradiation: Should We Extend the Observation Period in Patients with a Clinical Near-Complete Response? Ann Surg Oncol. 2018;25:197-203. doi: 10.1245/s10434-017-6213-8.
23. Beets-Tan RGH, Lambregts DMJ, Mass M, Bipat S, Barbaro B, Curvo-Semedo L, et al. Magnetic resonance imaging for clinical management of rectal cancer: Updated recommendations from the 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting. Eur Radiol. 2018;28:1465-1475. doi: 10.1007/s00330-017-5026-2.
24. Chandrmohan A, Sididiqi UM, Mittal R, Eapen A, Jesudason MM, Ram TS, et al. Diffusion weighted imaging improves diagnostic ability of MRI for determining complete response to neoadjuvant therapy in locally advanced rectal cancer. Eur J Radiol Open. 2020;7:100223. doi: 10.1016/j.ejro.2020.100223.
25. Patel UB, Blomqvist LK, Taylor F, George C, Guthrie A, Bees N, Brown G. MRI after treatment of locally advanced rectal cancer: how to report tumor response–the MERCURY experience. AJR
Am J Roentgenol. 2012 Oct;199(4):W486-95. doi: 10.2214/AJR.11.8210. PMID: 22997398 Review.
26. Perez RO, Habr-Gama A, Gama-Rodrigues J, Proscurshim I, Sao Juliao GP, Lynn P, et al. Accuracy of positron emission tomography/computed tomography and clinical assessment in the detection of complete rectal tumor regression after neoadjuvant chemoradiation: long-term results of a prospective trial (National Clinical Trial 00254683). Cancer. 2012;15:118:3501-11. doi: 10.1002/cncr.26644.
27. Nakagawa WT, Rossi BM, O Ferreira F, Ferrigno R, Valdec J, Filho D, et al. Chemoradiation instead of surgery to treat mid and low rectal tumors: is it safe? Ann Surg Oncol. 2002;9:568-73. doi: 10.1007/BF02573893.
28. Appelt AL, Ploen J, Harling H, Jensen FS, Jensen LH, Jorgensen JCR, et al. High-dose chemoradiotherapy and watchful waiting for distal rectal cancer: a prospective observational study. Lancet Oncol. 2015;16:919-27. doi: 10.1016/S1470-2045(15)00120-5.
29. Habr-Gama A, Gama-Rodrigues J, São Julião GP, Proscurshim I, Sabbagh C, Lynn PB, Perez RO. Local recurrence after complete clinical response and watch and wait in rectal cancer after neoadjuvant chemoradiation: impact of salvage therapy on local disease control. Int J Radiat Oncol Biol Phys. 2014;88:822-8. doi: 10.1016/j.ijrobp. 2013.12.012.
30. Van der Valk MJM, Hilling DE, Bastiaannet E, Meershoek-Klein Kranenbarg E, Beets GL, Figueredo Nl et al. Long-term outcomes of clinical complete responders after neoadjuvant treatment for rectal cancer in the International Watch & Wait Database (IWWD): an international multicentre registry study. Lancet. 2018;391:2537-2545. doi: 10.1016/S0140-6736(18)31078-X.
31. Dattani M, Heald RJ, Goussous G, Broadhurst J, Sao Juliao GP, Habr-Gama A et al. Oncological and Survival Outcomes in Watch and Wait Patients With a Clinical Complete Response After Neoadjuvant Chemoradiotherapy for Rectal Cancer: A Systematic Review and Pooled Analysis. Ann Surg. 2018;268:955-67.
32. Taylor FG, Quirke P, Heald RJ, Moran B, Blomqvist L, Swift I, Sebag-Montefiore DJ, Tekkis P, Brown G; MERCURY study group. Preoperative high-resolution magnetic resonance imaging can identify good prognosis stage I, II, and III rectal cancer best managed by surgery alone: a prospective, multi- center, European study. Ann Surg. 2011;253:711-9. doi: 10.1097/SLA.0b013e31820b8d52.
33. Jankowki M, Pietrzak L, Rupinski M, Michalsi W, Holdakowska A, PAciorek K, et al. et al. Watch-and-wait strategy in rectal cancer: Is there a tumour size limit? Results from two pooled pro- spective studies. Radiother Oncol. 2021;160:229-
35. doi: 10.1016/j.radonc.2021.05.014.
34. Gani C, Gani N, Zschaeck S, Eberle F, Schaeffeler N, Hehr T, BergerB, et al. Organ Preservation in Rectal Cancer: The Patients’ Perspective. Front Oncol. 2019;9:318. doi: 10.3389/fonc.2019.00318.
35. Kennedy ED, Borowiec AM, Schmocker S, Cho C, Brierley J, Li S, et al. Patient and Physician Prefer- ences for Nonoperative Management for Low Rectal Cancer: Is It a Reasonable Treatment Option? 2018;61:1281-9. Dis Colon Rectum. 2018;61:1281-1289. doi: 10.1097/DCR.0000000000001166.