Non-Operative Management (NOM) in Rectal Cancer: Current Evidence and Future Directions

79 Background: 20% of rectal cancer patients will have a complete clinical response (cCR) following neoadjuvant chemoradiotherapy. Non-operative management (NOM) with close surveillance can spare patients proctectomy and avoid the sequelae of surgery. Patients are interested in and advocate for NOM, whereas oncologists appear to be reluctant to offer this option. We wished to identify the perceptions and barriers that oncologists face when considering NOM. Methods: This qualitative study explored oncologists’ experiences treating rectal cancer and identified their perceptions and values around NOM. Purposive and snowball sampling identified medical, radiation and surgical oncologists’ who treat a high volume of rectal cancer across Canada. Oncologists varied in length/location of practice and gender. Data were collected via semi-structured interviews. Constant comparative analysis identified key concepts. Results: Data saturation was achieved after 40 interviews: 20 surgeons, 12 radiation and 8 medical oncologists. The dominant theme was “NOM is not ready for prime time’. Most oncologists felt that there is insufficient long-term data around NOM and single center studies appear ‘too good to be true’. Physicians voiced concerns about worsening oncologic outcomes in the setting of regrowth, the challenges in determining a cCR and apprehension around patient compliance to surveillance. Some oncologists felt that NOM is limited to a very select population and voiced reluctance in offering it to younger patients or patients with more advanced disease. There was little consideration to improved functional outcomes with NOM. Overall the majority of participants felt that NOM is ‘ trading the benefit of saving the rectum for the uncertainty of an inferior oncologic outcome’. Conclusions: Oncologists felt that NOM should not be offered as a standard of care option following a cCR. Most felt that there is insufficient data supporting NOM and are concerned around worse oncologic outcomes. Patient views of NOM are critically needed to assess if patients value the same outcomes. Additional research is needed to address barriers should patients wish to consider NOM as a treatment option in the setting of a cCR.

509 Background: Nonoperative management (NOM) of rectal cancer following a clinical complete response (cCR) to neoadjuvant therapy is a non-standard approach. We review our experience with NOM to evaluate safety and efficacy. Methods: A retrospective review of prospectively collected data between 2006 and 2014 was conducted. We compared patients completing neoadjuvant therapy for stage I to III rectal cancers who: a) achieved cCR and were treated with NOM, or b) underwent standard total mesorectal excision (TME) and achieved a pathologic complete response (pCR). Kaplan-Meier estimates and the log-rank test were used. Results: Seventy-three patients underwent NOM after cCR. From 369 rectal resections performed, 72 (20%) achieved pCR and form the comparison group. Median follow-up across both groups was 3.3 years. Rectal preservation was achieved in 56 (77%) of the patients treated with NOM. Of the 19 NOM patients with local regrowth, 18 were salvaged successfully with standard TME (n=16) or local excision (n=2), with one patient pending a salvage operation (n=1). No significant differences were noted in the number of distant recurrences between the NOM and pCR groups. Four-year disease-specific survival and overall survival between the two groups were not significantly different. Conclusions: In this highly selected group of patients with cCR to neoadjuvant treatment, NOM with surgical salvage of local tumor regrowth achieved local control in all patients. The oncologic outcome for NOM patients at 4 years was comparable to patients with pCR after rectal resection. These data continue to suggest that NOM does not compromise oncologic outcome, and that preservation of the rectum is achieved in a majority of patients. [Table: see text]

<h3>Introduction</h3> 20% of low rectal cancers respond extremely well to standard long course radiotherapy and on clinical examination apparently disappear from the rectal lumen after chemoradiotherapy; an apparent complete response. There are two dilemmas which follow this: Can we be sure about the complete response and that there is no viable residual tumour tissue? If we believe there is no tumour tissue left, how do we then manage these patients? Our Trust started to suggest non-operative management to ‘complete responders’ in January 2007, and the results were remarkable. <h3>Method</h3> Ongoing study looking at 14 complete responders. Surveillance has been MRI/EUS/EUA under GA during years 0–2 every three months. MRI/EUS/EUA under GA during years 3–5 every six months. MRI/EUS/EUA under GA after 5 years every year. A CT scan and colonoscopy were performed at the two and five year marks. These are the Trust’s local guidelines. <h3>Results</h3> 14 patients in total. Seven are still disease-free and still under surveillance. Three had recurrence; two underwent APR and one underwent ultra low anterior resection; all had R0 resections and are still disease-free. Four were suspected to have recurrence but were not fit for major resections therefore had transanal procedures; all had tumour-free specimens and are still disease-free and under surveillance. <h3>Conclusion</h3> There are an important cohort of patients who have low rectal cancer who may not need an operation. We are still unsure exactly how to manage these patients and it is therefore important for each unit to follow them up and share experiences. As a Trust, we will continue to manage these patients with the diagnosis of low rectal cancer, who are ‘disease-free’ following long course chemoradiotherapy, non-operatively. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> Smith JD, <i>et al</i>. Non-operative management of rectal cancer with complete response to neoadjvant therapy. Ann Surg. 2012;256:965–972 Habr-Gama A, <i>et al</i>. Non-operative management of distal rectal cancer after chemoradiation: experience with the “watch and wait” policy. Dis. Colon Rectum. 2010;52:1137–1143 Habr-Gama A, <i>et al</i>. Operative versus non-operative treatment for stage 0 distal rectal cancer following chemoradiation therapy. Ann Surg. 2004;240(4):711–718 Tennyson MD, <i>et al</i>. Transanal excision with radiation therapy for rectal cancer. Clin Med Res. 2012;10(4):224–229 Schmoll HJ, <i>et al</i>. ESMO concensus guideline for management of patients with colon and rectal cancer: a personalised approach to clinical decision making. Ann Oncol. 2012;23:2479–2516 Deferral of Surgery (Watch And Wait) Study. Royal Marsden Hospital, Pelican Cancer Foundation, Phase II Multicentre Single-Arm Study, Cancer Research Trial Number CRUK/10/006

Long-term functional and oncological results after sphincter-saving resection for rectal cancer - Cohort study

Rectal cancer is the second commonest cause of cancer death within the United Kingdom. Utilization of national screening programmes have resulted in a greater proportion of patients presenting with early-stage disease. The technique of transanal endoscopic microsurgery was first described in 1984 following which further options for local excision have emerged with transanal endoscopic operation and, more recently, transanal minimally invasive surgery. Owing to the risks of local recurrence, the current role of minimally invasive techniques for local excision in the management of rectal cancer is limited to the treatment of pre-invasive disease and low risk early-stage rectal cancer (T1N0M0 disease). The roles of chemotherapy and radiotherapy for the management of early rectal cancer are yet to be fully established. However, results of high-quality research such as the GRECCAR II, TESAR and STAR-TREC randomised control trials may highlight a wider role for local excision surgery in the future, when used in combination with oncological therapies. The aim of our review is to provide an overview in the current management of early rectal cancer, the surgical options available for local excision and the future multimodal direction of early rectal cancer treatment.

The omission of surgery via nonoperative management (NOM) for rectal cancer may be increasing, and this strategy could be particularly attractive for younger patients, whose incidence of rectal cancer has been rising. We sought to assess trends in NOM in young (younger than 55 y) versus older adult (55 y and older) rectal cancer cohorts. The National Cancer Database was used to identify patients diagnosed with stage II to III rectal cancer between 2010 and 2015. Multivariable logistic regression defined the association between sociodemographic variables and odds of NOM, including an age (18 to 54 vs. 55+ y)×surgery (surgery vs. NOM) interaction term. Adjusted Cox regression models compared overall survival between NOM versus surgery. Among 22,561 patients with a median follow-up of 37.5 months, the utilization rate of NOM increased from 10.7% (2010) to 15.2% (2015). Older patients were more likely to receive NOM, although rates also increased among young (7.1% to 10.6%). Black patients were also more likely to receive NOM (P<0.001). Among the entire cohort, NOM was associated with worse overall survival (adjusted hazard ratio [AHR]=2.90, 95% confidence interval [CI]: 2.67-3.15) and there was a statistically significant age×NOM interaction (P=0.01) such that the effect of NOM on survival was worse for younger (AHR=3.37, 95% CI: 2.82-4.02) as compared with older patients (AHR=2.49, 95% CI: 2.27-2.74). The increasing trend for NOM in stage II to III rectal cancer may be driven by disparities in treatment. Management with NOM appears to be associated with poorer survival, particularly in younger patients and could worsen outcomes for groups already at risk for suboptimal cancer care.

Objective: The incidence of rectal cancer is increasing in Western countries. What is it for us, do we have more rectal cancer? The change of our way of life, the aging population could be risk factors. Furthermore the management of rectal cancer has considerably progressed. The purpose of this study is to compare the epidemiological profil and the management of rectal cancer between two series collected to 20 years of interval. Methods : It is about two retrospective cases, the first one, collected from 1981 to 1985 (serie A), includes 80 patients. The second one, recent, collected from 2005 to 2011 (serie R), includes 94 patients. We analyzed for the epidemiological profile, the middle number of case per year, age, sex, seat of the tumor, histological type, metastatique stage. We analyzed for the management: operability rate, resection rate, type of intervention. Results : The middle number of cancer of the rectum hospitalized per year in our formation is respectively 16±4.06 and 18±4.14 in serie A and the serie R (p = 0.91). The mean age of patients was 49.5±14.7 for serie A and 48.6 ± 13.3 for serie R (p = 0.674). There is a masculine predominance in the two series (p = 0.7). The three segments of the rectum are reached in the same proportions in the two series (p = 0.8). The low rectum represented half of the cases (54.5% serie A, 56.9% serie R). The metastatique stage is more frequent in serie R (32 (22.7%) vs 18 (34%) (p = 0.14). Resection rate represents respectively in serie A and serie R, 68.9% and 84% (p = 0.428). Abdomino-perineal amputation has been achieved in 45% of the cases in serie A and 30.3% of the cases serie R (p = 0.003). Discussion : The study found that the incidence of rectal cancer has not increased in our training in the space of 20 years, however, in two series, 25% of patients are aged less than 25. The management of this cancer was marked by systematic preoperative radiotherapy in the serie R for low rectal cancers, by reducing the safety margin to 2 cm and by reducing the number of abdominoperineal resection. Conclusion : Pidemiological profile did not change. However, the management of rectal cancer been influenced by the new data of the rectal surgery. This study showed that rectal cancer in Morocco had different characteristics than that in West country. Environmental and genetic studies may explain this difference.

Rectal cancer is a challenging disease process to manage, with a rising incidence in young adults. Several clinical advances have been made in the past decade with regards to optimal treatment strategies in early-stage (T1-2, node negative tumours) and locally advanced cancers (T3-4 and/or nodal positivity) utilizing a multimodal approach of surgery, neoadjuvant chemoradiotherapy, and adjuvant chemotherapy, all aiming to optimize oncological outcomes, while minimizing associated morbidity. This narrative review aimed to summarize trial level evidence apropos the management of early and locally advanced rectal cancer. All relevant prospective clinical trials were identified through a computer-assisted search of PubMed, EMBASE, Medline databases between 1990 and 30 June 2021. With regards to early rectal cancer, there is limited trial-level evidence in the literature. Total mesorectal excision (TME) is the current standard of care, but local excision could be considered in select patients with pT1 tumours, or patients with near or complete clinical response to neoadjuvant CRT. As for locally advanced rectal cancer, the current standard of care consists of long-course chemotheradiotherapy or short-course radiotherapy, followed by TME. However, the role of total neoadjuvant therapy is promising, with respect to both oncological outcomes, as well as in reducing toxicity. Both induction and consolidation chemotherapy treatment approaches have been described in literature, with encouraging early results. The optimal management of rectal cancer is constantly evolving. More research is needed to investigate the long-term oncological and functional outcomes following new multimodal therapies in the management of early-stage and locally advanced rectal cancer.

Nonoperative management (NOM) of rectal cancer after a complete clinical response (cCR) to neoadjuvant therapy is controversial. In this article, we retrospectively reviewed the outcomes of patients managed with selective NOM after a cCR to neoadjuvant treatment and compared these with patients who underwent standard rectal resection with a pathological complete response (pCR). Patients completing neoadjuvant chemoradiotherapy (CRT) for stage I to III rectal cancer between January 2006 and August 2010 were retrospectively reviewed. Median follow-up was calculated in months after completion of CRT. Thirty-two patients (median follow-up 28 months) were treated by NOM after a cCR. Among 265 treated by CRT and rectal resection, 57 patients (22%) had a pCR and formed the control group (median follow-up 43 months). Factors associated with selective use of NOM included lower pretreatment stage, older age, and distal tumor location (P < 0.05). In the NOM group, 6 recurred locally (median 11 months, range 7-14), 3 of whom also had concurrent distant recurrence. All 6 local failures were controlled by salvage rectal resection with no further local recurrence of disease (median follow-up 17 months). In the rectal resection/pCR group, there were no local failures. The 2-year distant disease-free survival (88% vs 98%, P = 0.27) and overall survival (96% vs 100%, P = 0.56) were similar for NOM and rectal resection/pCR groups. Rectal resection was successfully avoided in 81% of patients selected for NOM. When combined with salvage surgery, NOM appears to achieve similar local and distant disease control compared with patients with a pCR treated by rectal resection. Longer follow-up and prospective trials are warranted to evaluate this promising treatment option.

It is evident that the use of laparoscopy in the management of rectal cancer has gained popularity in the last few years. It is still, however, not widely accepted as the standard of care. Multiple randomized trials have shown that short-term outcomes and perioperative morbidity and mortality of laparoscopic proctectomy are equivalent to open surgery. However, data regarding long-term oncologic outcomes are still scarce, with only a few randomized trials reporting similar outcomes in both laparoscopic and open group. A more recent trial failed to replicate those results in patients with locally advanced rectal cancer. In this article, we will look at the most recent evidence regarding the use of laparoscopy for patients with rectal cancer. We will also briefly discuss the different approaches and new minimally invasive techniques used in this field, and we will talk about the challenges facing the widespread adoption of laparoscopic surgery in the management of rectal cancer.

&lt;p dir="ltr"&gt;Treatment of rectal cancer has significantly changed in the past decades. The implementation of TME, MRI-based staging and preoperative radiotherapy have significantly improved local control. Moreover, the addition of chemotherapy to radiotherapy, known as total neoadjuvant treatment (TNT) has led to an increase in complete response rates. Patients with a clinical complete (cCR) or near clinical complete response (ncCR) at re-assessment can decide to follow a Watch &amp; Wait (W&amp;W) surveillance program and potentially avoid surgical morbidity and colostomy. For these reasons, response assessment after neoadjuvant treatment is getting a prominent role in the management of rectal cancer. Information on clinical and pathological findings, including long-term outcomes, after neoadjuvant treatment are needed for further improvement of rectal cancer care. In this thesis, different aspects of organ preservation are explored, aiming to provide knowledge to guide assessment of response to neoadjuvant treatment and support subsequent multidisciplinary decision- making.&lt;/p&gt;&lt;p dir="ltr"&gt;Paper I. A total of 1010 patients from the International Watch &amp; Wait Database (IWWD) were divided into two groups: 608 achieved a cCR at their first reassessment, and 402 achieved a cCR at a later reassessment based on MRI and endoscopy. At a median follow-up of 2.6 and 2.9 years respectively, no significant difference in organ preservation, distant metastasis, or overall survival (OS) were found.&lt;/p&gt;&lt;p dir="ltr"&gt;Paper II. The aim of this study was to investigate changes in neoadjuvant treatment and its impact on pathological, and overall, complete response rates on a population-based level. Between 2009 and 2020, 10,232 Swedish patients with stage I-III rectal cancer treated with neoadjuvant therapy were analysed. Over this period, the pCR rate remained similar around 3.9% while the overall complete response rate (including both pCR and cCR) increased significantly from 3.0% to 9.6% (p &lt; 0.001). Both changes in neoadjuvant therapy and the start of the national Watch &amp; Wait (WoW) study presumably contributed to these changes.&lt;/p&gt;&lt;p dir="ltr"&gt;Paper III. This substudy from the RAPIDO trial compared patients with a pCR in the TNT arm vs. patients with a pCR in the standard-of-care (chemoradiation, CRT) arm. TNT in the form of short-course radiotherapy followed by systemic chemotherapy resulted in doubled pCR rates compared to chemoradiation (CRT) (28% vs. 14%, p&lt;0.001) in patients with high-risk locally advanced rectal cancer (LARC). For patients who achieved a pCR, 5-year oncological outcomes are favourable and similar between the two groups. We found characteristics associated with pCR to be the EXP treatment, normal CEA, and small tumour size. Within the protocolized treatment times, we did not find an association between prolonging the overall treatment time (OTT) and increasing pCR rates.&lt;/p&gt;&lt;p dir="ltr"&gt;Paper IV. Here we describe the development and evaluation of a web-based educational course designed to support clinicians in implementing the W&amp;W strategy. It focuses on standardizing response assessment and multidisciplinary decision-making to address variability in clinical practice. A feasibility study will be conducted to assess the practicality and effectiveness of the course in real- world clinical settings.&lt;/p&gt;&lt;h3&gt;List of scientific papers&lt;/h3&gt;&lt;p dir="ltr"&gt;I. Watch and wait after neoadjuvant treatment in rectal cancer: comparison of outcomes in patients with and without a complete response at first reassessment in the International Watch &amp; Wait Database (IWWD). Temmink SJD, Peeters KCMJ, Bahadoer RR, Kranenbarg EM, Roodvoets AGH, Melenhorst J, Burger JWA, Wolthuis A, Renehan AG, Figueiredo NL, Pares O, Martling A, Perez RO, Beets GL, van de Velde CJH, Nilsson PJ, Consortium IWWDI. Br J Surg. 2023;110(6): 676-684. &lt;a href="https://doi.org/10.1093/bjs/znad051" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1093/bjs/znad051&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;II. Complete response rates in rectal cancer: Temporal changes over a decade in a population-based nationwide cohort. Temmink SJD, Martling A, Angenete E, Nilsson PJ. Eur J Surg Oncol. 2023;49(11): 106991. &lt;a href="https://doi.org/10.1016/j.ejso.2023.106991" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1016/j.ejso.2023.106991&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;III. Oncological outcomes after a pathological complete response following total neoadjuvant therapy or chemoradiotherapy for high-risk locally advanced rectal cancer in the RAPIDO trial. Zwart WH, Temmink SJD, Hospers GAP, Marijnen CAM, Putter H, Nagtegaal ID, Blomqvist L, Kranenbarg EM, Roodvoets AGH, Martling A, van de Velde CJH, Glimelius B, Peeters KCMJ, van Etten B, Nilsson PJ, investigators C. Eur J Cancer. 2024;204: 114044. &lt;a href="https://doi.org/10.1016/j.ejca.2024.114044" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1016/j.ejca.2024.114044&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;IV. Watch and Wait in rectal cancer: development of a virtual webcourse. Temmink SJD, Szczegielniak S, Halldorsson K, Blomqvist L, Martling A, Nilsson PJ. [Manuscript]&lt;/p&gt;

&lt;p dir="ltr"&gt;Treatment of rectal cancer has significantly changed in the past decades. The implementation of TME, MRI-based staging and preoperative radiotherapy have significantly improved local control. Moreover, the addition of chemotherapy to radiotherapy, known as total neoadjuvant treatment (TNT) has led to an increase in complete response rates. Patients with a clinical complete (cCR) or near clinical complete response (ncCR) at re-assessment can decide to follow a Watch &amp; Wait (W&amp;W) surveillance program and potentially avoid surgical morbidity and colostomy. For these reasons, response assessment after neoadjuvant treatment is getting a prominent role in the management of rectal cancer. Information on clinical and pathological findings, including long-term outcomes, after neoadjuvant treatment are needed for further improvement of rectal cancer care. In this thesis, different aspects of organ preservation are explored, aiming to provide knowledge to guide assessment of response to neoadjuvant treatment and support subsequent multidisciplinary decision- making.&lt;/p&gt;&lt;p dir="ltr"&gt;Paper I. A total of 1010 patients from the International Watch &amp; Wait Database (IWWD) were divided into two groups: 608 achieved a cCR at their first reassessment, and 402 achieved a cCR at a later reassessment based on MRI and endoscopy. At a median follow-up of 2.6 and 2.9 years respectively, no significant difference in organ preservation, distant metastasis, or overall survival (OS) were found.&lt;/p&gt;&lt;p dir="ltr"&gt;Paper II. The aim of this study was to investigate changes in neoadjuvant treatment and its impact on pathological, and overall, complete response rates on a population-based level. Between 2009 and 2020, 10,232 Swedish patients with stage I-III rectal cancer treated with neoadjuvant therapy were analysed. Over this period, the pCR rate remained similar around 3.9% while the overall complete response rate (including both pCR and cCR) increased significantly from 3.0% to 9.6% (p &lt; 0.001). Both changes in neoadjuvant therapy and the start of the national Watch &amp; Wait (WoW) study presumably contributed to these changes.&lt;/p&gt;&lt;p dir="ltr"&gt;Paper III. This substudy from the RAPIDO trial compared patients with a pCR in the TNT arm vs. patients with a pCR in the standard-of-care (chemoradiation, CRT) arm. TNT in the form of short-course radiotherapy followed by systemic chemotherapy resulted in doubled pCR rates compared to chemoradiation (CRT) (28% vs. 14%, p&lt;0.001) in patients with high-risk locally advanced rectal cancer (LARC). For patients who achieved a pCR, 5-year oncological outcomes are favourable and similar between the two groups. We found characteristics associated with pCR to be the EXP treatment, normal CEA, and small tumour size. Within the protocolized treatment times, we did not find an association between prolonging the overall treatment time (OTT) and increasing pCR rates.&lt;/p&gt;&lt;p dir="ltr"&gt;Paper IV. Here we describe the development and evaluation of a web-based educational course designed to support clinicians in implementing the W&amp;W strategy. It focuses on standardizing response assessment and multidisciplinary decision-making to address variability in clinical practice. A feasibility study will be conducted to assess the practicality and effectiveness of the course in real- world clinical settings.&lt;/p&gt;&lt;h3&gt;List of scientific papers&lt;/h3&gt;&lt;p dir="ltr"&gt;I. Watch and wait after neoadjuvant treatment in rectal cancer: comparison of outcomes in patients with and without a complete response at first reassessment in the International Watch &amp; Wait Database (IWWD). Temmink SJD, Peeters KCMJ, Bahadoer RR, Kranenbarg EM, Roodvoets AGH, Melenhorst J, Burger JWA, Wolthuis A, Renehan AG, Figueiredo NL, Pares O, Martling A, Perez RO, Beets GL, van de Velde CJH, Nilsson PJ, Consortium IWWDI. Br J Surg. 2023;110(6): 676-684. &lt;a href="https://doi.org/10.1093/bjs/znad051" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1093/bjs/znad051&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;II. Complete response rates in rectal cancer: Temporal changes over a decade in a population-based nationwide cohort. Temmink SJD, Martling A, Angenete E, Nilsson PJ. Eur J Surg Oncol. 2023;49(11): 106991. &lt;a href="https://doi.org/10.1016/j.ejso.2023.106991" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1016/j.ejso.2023.106991&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;III. Oncological outcomes after a pathological complete response following total neoadjuvant therapy or chemoradiotherapy for high-risk locally advanced rectal cancer in the RAPIDO trial. Zwart WH, Temmink SJD, Hospers GAP, Marijnen CAM, Putter H, Nagtegaal ID, Blomqvist L, Kranenbarg EM, Roodvoets AGH, Martling A, van de Velde CJH, Glimelius B, Peeters KCMJ, van Etten B, Nilsson PJ, investigators C. Eur J Cancer. 2024;204: 114044. &lt;a href="https://doi.org/10.1016/j.ejca.2024.114044" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1016/j.ejca.2024.114044&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;IV. Watch and Wait in rectal cancer: development of a virtual webcourse. Temmink SJD, Szczegielniak S, Halldorsson K, Blomqvist L, Martling A, Nilsson PJ. [Manuscript]&lt;/p&gt;

Colorectal Cancer

In a letter to the editor Dr. Hottenrott provides valuable comments [1] on our survey describing international preoperative rectal cancer management [2]. In our opinion, three key messages are derived from our survey: First, most surgeons agree to neoadjuvant treatment when there is an increased risk of finding histologically positive circumferential margins. In addition, we found more than 40 other indications for neoadjuvant treatment (see our Table 4). This emphasizes the need for an international agreement, as different indications for neoadjuvant treatment will select noncomparable groups of patients in outcome studies. Second, we have shown (see our Table 6) that multidisciplinary team (MDT) meetings significantly influence several important decisions in preoperative rectal cancer management. Interestingly, centers with regular MDT have a higher rate of using magnetic resonance imaging (MRI) (Odds Ratio [OR] = 3.62) and consider a threatened circumferential resection margin (CRM) as indication for neoadjuvant treatment (OR = 5.67). We believe that MDT improves preoperative management of rectal cancer by increasing adherence to national guidelines. Similar discussions in international rectal cancer societies are needed aiming towards an international consensus statement. Finally, our survey revealed sparse use (35% of all cases) of MRI. The goal for the radiologic examination in rectal cancer is to explore the tumor’s relation to nearby anatomical structures. This evaluation will conclude with TNM staging, important for chemoradiotheraphy, surgical treatment, and prognosis. Magnetic resonance imaging has a central role in this evaluation and should be the first choice radiologic modality [3]. Not only is MRI crucial in detection of TNM stage but also plays a central role in determination of the tumor’s distance to the mesorectal fascia and the CRM. Magnetic resonance imaging has moderate sensitivity on T1 and T2 tumors, and should be supplemented with rectal ultrasound. In our survey, 18F-fluorodeoxyglucose positron emission tomography (PET) was used by 55% in selected cases and by 1% in all cases. In our opinion PET has no central role in primary management of rectal cancer [4]; however, we believe PET will gain increased importance in management of rectal cancer in the future. Biologically targeted agents for adjuvant and neoadjuvant treatment are promising treatment options; however, patient selection and prediction of treatment effects remain problematic [5]. The wide variations in practice for preoperative management of rectal cancer should alert national and international rectal cancer experts as well as health care administrators. This will influence health care costs, side effects, quality of life, local recurrence, and cancer-specific survival.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer.