Abstract
BackgroundThe watch-and-wait strategy offers a non-invasive therapeutic alternative for rectal cancer patients who have achieved a clinical complete response (cCR) after chemoradiotherapy. This study aimed to investigate the long-term clinical outcomes of this strategy in comparation to surgical resection.MethodsStage II/III rectal adenocarcinoma patients who received neoadjuvant chemoradiotherapy and achieved a cCR were selected from the databases of three centers. cCR was evaluated by findings from digital rectal examination, colonoscopy, and radiographic images. Patients in whom the watch-and-wait strategy was adopted were matched with patients who underwent radical resection through 1:1 propensity score matching analyses. Survival was calculated and compared in the two groups using the Kaplan–Meier method with the log rank test.ResultsA total of 117 patients in whom the watch-and-wait strategy was adopted were matched with 354 patients who underwent radical resection. After matching, there were 94 patients in each group, and no significant differences in term of age, sex, T stage, N stage or tumor location were observed between the two groups. The median follow-up time was 38.2 months. Patients in whom the watch-and-wait strategy was adopted exhibited a higher rate of local recurrences (14.9% vs. 1.1%), but most (85.7%) were salvageable. Three-year non-regrowth local recurrence-free survival was comparable between the two groups (98% vs. 98%, P = 0.506), but the watch-and-wait group presented an obvious advantage in terms of sphincter preservation, especially in patients with a tumor located within 3 cm of the anal verge (89.7% vs. 41.2%, P < 0.001). Three-year distant metastasis-free survival (88% in the watch-and-wait group vs. 89% in the surgical group, P = 0.874), 3-year disease-specific survival (99% vs. 96%, P = 0.643) and overall survival (99% vs. 96%, P = 0.905) were also comparable between the two groups, although a higher rate (35.7%) of distant metastases was observed in patients who exhibited local regrowth in the watch-and-wait group.ConclusionThe watch-and-wait strategy was safe, with similar survival outcomes but a superior sphincter preservation rate as compared to surgery in rectal cancer patients achieving a cCR after neoadjuvant chemoradiotherapy, and could be offered as a promising conservative alternative to invasive radical surgery.
Highlights
The current standard of care for locally advanced rectal cancer is neoadjuvant chemoradiotherapy followed by total mesorectal excision (TME) [1, 2]
The watch-and-wait strategy was safe, with similar survival outcomes but a superior sphincter preserva‐ tion rate as compared to surgery in rectal cancer patients achieving a clinical complete response (cCR) after neoadjuvant chemoradiotherapy, and could be offered as a promising conservative alternative to invasive radical surgery
In the early 2000s, reports have shown that approximately 15–27% [8,9,10] of patients who underwent neoadjuvant chemoradiotherapy followed by radical surgery could achieve a pathological complete response, which was associated with favorable long-term outcomes [10]
Summary
The current standard of care for locally advanced rectal cancer is neoadjuvant chemoradiotherapy followed by total mesorectal excision (TME) [1, 2]. In the early 2000s, reports have shown that approximately 15–27% [8,9,10] of patients who underwent neoadjuvant chemoradiotherapy followed by radical surgery could achieve a pathological complete response (pCR), which was associated with favorable long-term outcomes [10]. This stimulated interest to explore the possibility of omitting surgery in such patients. In 2004, Habr-Gama and colleagues pioneered the first report comparing an observational strategy against invasive surgery following chemoradiation in a group of rectal cancer patients who achieved a clinical complete response (cCR) [11]. This study aimed to investigate the long-term clinical outcomes of this strategy in comparation to surgical resection
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