Watch-and-wait Management for Rectal Cancer After Clinical Complete Response to Neoadjuvant Therapy
Jonathan B. Yuval, MD, Julio Garcia-Aguilar,
Colorectal cancer is the fourth most common cancer and second most commoncause of cancer death in the United States, and nearly 30% of all newly diag-nosed colorectal cancers are located in the rectum . Oncological outcomesof locally advanced rectal cancer (LARC) have improved over the last 3 de-cades because of multidisciplinary care and standardization of diagnostic imag-ing, surgical technique, surgical pathology, and perioperative multimodaltreatment. Accepted standard treatment of LARC includes preoperative che-moradiotherapy (CRT), total mesorectal excision (TME), and postoperativesystemic chemotherapy . Intensive multimodal treatment is associated withexcellent local control but inadequate systemic control, with about one-thirdof patients succumbing to metastatic disease . In addition, multimodal treat-ment is detrimental to patients’ quality of life (QoL) because of surgicalmorbidity; risk of permanent stoma; and bowel, bladder, and sexual dysfunc-tion. Two key challenges are improving survival by preventing metastases andimproving patients’ QoL by preventing functional impairments.The rate of pathologic complete response (pCR) is approximately 20% in pa-tients who undergo CRT alone, and can reach nearly 40% in patients who un-dergo preoperative CRT in combination with systemic chemotherapy .Patients with pCR have a 5-year survival rate of 95% and a local-recurrencerate of around 1%  (Fig. 1). In view of these outcomes, surgical removalof the rectum in patients with pCR may constitute overtreatment, and therisk of sequelae from surgery may outweigh the risk of tumor progression dur-ing observation. In this context, avoiding surgery may provide important ben-eﬁts such as lower morbidity, lower health care costs, and better QoL.