Support For Watch-And Wait Strategy After Chemoradiotherapy For Rectal Cancer

Rectal cancer patients with a complete response to preoperative chemotherapy and radiation may be able to defer surgery

medwireNews: UK investigators believe a watch-and-wait strategy to reduce the use of surgery is feasible in patients with rectal adenocarcinoma without distant metastases who achieve a complete clinical response to chemoradiotherapy.

After a median of 33 months, local recurrence had occurred in 34% of 129 patients who were managed by watch and wait after preoperative treatment with 45 Gy of radiation and a concurrent fluoropyrimidine-based regimen. This gave a 3-year actuarial rate of 38%.

Moreover, the researchers note that patients who chose watch and wait had a significantly better 3-year rate of colostomy-free survival than those who underwent immediate surgery, at 74% versus 47%.

This translated to a 26% absolute difference in the number of patients who were able to avoid permanent colostomy, emphasize Andrew Renehan, from the University of Manchester, and co-authors in The Lancet Oncology.

Non-metastatic regrowth was treated with salvage surgery or radiotherapy in 88% of the 41 affected patients, prompting Rodrigo Oliva Perez, from the University of São Paulo School of Medicine in Brazil, to write in an accompanying comment that regrowth, “thought to be a potential disaster” and a “drawback” to the watch-and-wait strategy, is mostly contained within the rectal lumen and salvageable.

Indeed, in a matched analysis, the 3-year non-regrowth disease-free survival rate was a comparable 88% for 109 patients treated by the watch-and-wait strategy and 78% for 109 patients who underwent surgical resection after chemoradiotherapy.

There was also no significant difference in the 3-year overall survival rate between the matched watch-and-wait group and the surgery group, at 96% versus 87%.

Explaining that the propensity-score matched cohort study included patients treated at a tertiary centre and three neighbouring regional institutions, the team concludes: “In this study, oncological safety was achieved in a real-world multicentre setting, thus supporting the establishment of watch and wait with avoidance of major surgery as standard care.

“Future trials comparing multilevel radiotherapy doses or a radio-sensitising approach to enhance clinical complete response rates, while assessing patient preferences and trade-offs, are worth pursuing.”

References

Renehan AG, Malcomson L, Emsley R, et al. Watch-and-wait approach versus surgical resection after chemoradiotherapy for patients with rectal cancer (the OnCoRe project): a propensity-score matched cohort analysis. Lancet Oncol; Advance online publication 16 December 2015. DOI: http://dx.doi.org/10.1016/S1470-2045(15)00467-2

Perez RO. Complete clinical response in rectal cancer: a turning tide. Lancet Oncol; Advance online publication 16 December 2015. DOI: http://dx.doi.org/10.1016/S1470-2045(15)00487-8

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