Nonoperative Management May Be Possible for Select Patients With Rectal Cancer

A “watch and wait” strategy that includes chemotherapy and radiation may be sufficient for carefully selected patients with rectal cancer, helping them to avoid complications and quality of life issues associated with surgery, found a new study published in the journal Surgical Oncology.

“One surprise was that we found that this strategy did seem to work, even in our clinical lymph node–positive patients as well,” said lead study author Steven Nurkin, MD, who is a surgical oncologist and associate professor of oncology at Roswell Park Comprehensive Cancer Center, Buffalo, New York.

Nurkin and colleagues conducted a retrospective review of patients with rectal cancer over a 5-year period (2012 to 2016) and identified patients who had documented complete clinical response (CCR) of their tumors after neoadjuvant treatments and nonoperative management. All patients were closely monitored through physical exams, endoscopy, and imaging. 

A total of 29 patients were identified who elected to undergo nonoperative management. The mean age of patients was 67 years, and there was an equal distribution of males and females. In this cohort, 88% had low primary tumors (< 7 cm from anal verge), 83% had at least a clinically-staged T3 tumor, and 52% had clinically suspicious nodes during pretherapy staging.

Neoadjuvant long-course chemoradiotherapy was given to all patients, 7 were treated with initial induction chemotherapy followed by chemoradiation, and 11 received consolidation chemotherapy.

The researchers found that 79% of patients were still cancer-free at a median follow-up of 27.6 months. There were 6 recurrences (1 local, 1 local and distant, and 4 distant). Among the 6 relapsed patients, 5 were candidates for salvage surgical resection.

“In the era of patient-centered medicine, we feel that the patient should get to choose what the best treatment is for them. For some patients, it is the maintenance of intestinal continuity and stoma-free life; for others, it is the best chance of a cure no matter the risks,” concluded the researchers.

Currently, nonoperative management is not considered the standard of care for rectal cancer, Nurkin told Cancer Network. However, it can be offered to patients seeking rectal preservation,  although more research is warranted to better identify the appropriate patients, according to the investigators. Based on current data, the majority of patients who experience a rectal cancer recurrence after a CCR were salvageable with surgical intervention, without compromising oncologic outcomes, they wrote.

“The main takehome is that there are a clear subset of patients that can be cured of recital cancer without surgery. We just need to better define who those patients are, so that we can comfortably offer this strategy to more patients without putting any of them at risk,” Nurkin told Cancer Network.

The current study is one of the largest single-institution series in the United States evaluating patients with rectal cancer undergoing total neoadjuvant therapy and nonoperative management. However, it is still limited due to the small number of patients, the various treatment strategies the patients received, and the relatively short-term follow-up, said Nurkin.

Jeffrey A. Meyerhardt, MD, the clinical director of the Gastrointestinal Cancer Center at Dana-Farber Cancer Institute, Boston, Massachusetts, said nonoperative management of rectal cancer was initially considered by a surgeon in Brazil to avoid permanent colostomies for select patients.

“Over the past 15 years, the idea has spread, and more groups are considering this approach for certain patients. This paper by Dr. Nurkin adds to the literature, both the safety and effectiveness of the approach, as well as provides data on how to follow these patients who do not undergo surgery,” Meyerhardt told Cancer Network. “For those with certain tumors that respond very well to chemotherapy and radiation upfront, this is an option that should be offered.”