What’s the best surgical option for patients with locally advanced rectal cancer who have had a clinical complete response to neoadjuvant therapy?
Increasingly, it’s no surgery at all, says Samuel Lai, MD, a sixth-year resident in the University of Colorado Department of Surgery.
In February, Lai published research in the journal Diseases of the Colon & Rectum that showed taking a “watch and wait” approach after people successfully complete neoadjuvant therapy for stage II or III rectal cancer — meaning the cancer has not spread to distant lymph nodes or other organs — has similar outcomes as performing surgery on patients in the same situation. The research was based on data on 545 patients from 33 cancer centers in the U.S. Rectal Cancer Research Group, which was started at the University of Colorado, led by Jon Vogel, MD, and others.
“Once the patient finished their neoadjuvant therapy treatment, they get restaged for the rectal cancer to see what the response was,” Lai says. “If the patient has what we call a clinical complete response, meaning there is no evidence of cancer on MRI, endoscopy, or physical exam, these patients are offered nonoperative management where they undergo an intense surveillance schedule starting at every three months. They are able to avoid surgery if they continue to have a sustained response to neoadjuvant therapy, which helps them avoid major surgery and potential postoperative complications and side effects.”
The watch and wait approach is counter to previous standard of care, Lai says, which is to operate even if the patient responds completely to chemotherapy and chemoradiation.
“If you think about colorectal cancer in general, most surgeons would hesitate to take a nonsurgical approach,” he says. “You still want to take out the area where the cancer was or is. This nonoperative management was started in Brazil around 20 years ago, and the rest of the world is catching up. It's becoming more widely used now.”
Though the technique is effective in many patients, Lai’s research shows that rectal cancer can recur in 20%–30% of patients who successfully achieved clinical complete response and went on to nonoperative management. Further research is needed, he says, to find biomarkers or other methods for identifying the patients most likely to benefit from the watch and wait approach.
“In patients who undergo nonoperative management, we see that a subset of them still have the cancer come back, and they would require surgery,” he says. “They have worse outcomes down the road as well. There's still more work to be done with the U.S. Rectal Cancer Research Group in regard to selecting better target patients for this nonoperative management.”