Watch and wait approach to rectal cancer: A review

Abstract

In 2014, there were an estimated 136800 new cases of colorectal cancer, making it the most common gastrointestinal malignancy. It is the second leading cause of cancer death in both men and women in the United States and over one-third of newly diagnosed patients have stage III (node-positive) disease. For stage II and III colorectal cancer patients, the mainstay of curative therapy is neoadjuvant therapy, followed by radical surgical resection of the rectum. However, the consequences of a proctectomy, either by low anterior resection or abdominoperineal resection, can lead to very extensive comorbidities, such as the need for a permanent colostomy, fecal incontinence, sexual and urinary dysfunction, and even mortality. Recently, trends of complete regression of the rectal cancer after neoadjuvant chemoradiation therapy have been confirmed by clinical and radiographic evaluation-this is known as complete clinical response (cCR). The "watch and wait" approach was first proposed by Dr. Angelita Habr-Gama in Brazil in 2009. Those patients with cCR are followed with close surveillance physical examinations, endoscopy, and imaging. Here, we review management of rectal cancer, the development of the "watch and wait" approach and its outcomes.

Predictive and Prognostic Molecular Biomarkers for Response to Neoadjuvant Chemoradiation in Rectal Cancer

“…These different responses to nCRT are associated with long-term outcomes including disease-free survival (DFS) and 10-year cumulative incidence of distant metastasis [15]. In addition, given the observation of pCR in a significant proportion of patients undergoing nCRT and the adverse effects of surgery (bowel, urinary and sexual dysfunctions), alternative approaches, such as the “wait-and-see” policy or transanal local excision, have been suggested [16,17,18]. On the other hand, patients exhibiting resistance to nCRT need more successful treatment approaches earlier in their management.…”

Quantitative intravoxel incoherent motion parameters derived from whole‐tumor volume for assessing pathological complete response to neoadjuvant chemotherapy in locally advanced rectal cancer

“…After neoadjuvant treatment, approximately 10–30% of LARC patients may achieve a pathological complete response (pCR), which is defined as the absence of viable tumor cells after full pathologic examination of the resected specimen . For these patients, surgical resection may not lead to an increase in overall and disease‐free survival, but may result in extensive comorbidities, such as sexual, urinary, and bowel dysfunction, and even mortality . On the contrary, other patients who have a lesser degree of response to therapy may also benefit from early prediction because they can be prevented from ineffectively toxic therapy and alerted for a timely therapeutic regimen.…”

“…[3][4][5][6] For these patients, surgical resection may not lead to an increase in overall and disease-free survival, but may result in extensive comorbidities, such as sexual, urinary, and bowel dysfunction, and even mortality. [7][8][9][10] On the contrary, other patients who have a lesser degree of response to therapy may also benefit from early prediction because they can be prevented from ineffectively toxic therapy and alerted for a timely therapeutic regimen. Recently, a paradigm of "nonoperative" or "watch-and-wait" strategy has been proposed for patients with LARC who have a good response to adjuvant therapy.…”

Clinical utility of pretreatment prediction of chemoradiotherapy response in rectal cancer: a review

“…However, various perioperative complications are encountered, including infection, pelvic sepsis, vascular or ureteral injury, anastomotic leakage, and wound complications [9]. The mortality rate is at least 2% even in fit patients, and over one third of patients report some degree of fecal incontinence and urological or sexual dysfunction [9,24]. Some 10-30% of patients require permanent colostomies, with associated significant physical and psychological sequelae [25].…”