ASCO GI: Surgery may not be necessary for some patients with rectal cancer

13 Jan 2015
ASCO GI: Surgery may not be necessary for some patients with rectal cancer

A retrospective review of clinical data on 145 patients with stage I-III rectal cancer indicates that patients whose tumours completely disappeared after treatment with chemoradiation and systemic chemotherapy (known as a complete response) had similar four-year survival rates regardless of whether they had immediate surgery or pursued a “watch and wait” surveillance approach.

The findings add to growing evidence suggesting that, with frequent follow-up exams after initial chemotherapy and radiation, select patients with rectal cancer can achieve excellent outcomes while avoiding the risks and complications of rectal surgery.

The study was presented at the 2015 Gastrointestinal Cancers Symposiumin in San Francisco.

“We believe that our results will encourage more doctors to consider this watch and wait approach in patients with clinical complete response as an alternative to immediate rectal surgery, at least for some patients,” said senior study author Philip Paty, MD, a surgical oncologist at the Memorial Sloan-Kettering Cancer Center in New York, USA.

“From my experience, most patients are willing to accept some risk to defer rectal surgery in hope of avoiding major surgery and preserving rectal function.”

Dr Paty stated that in about 40 to 50 percent of patients with stage I rectal cancer and 30 to 40 percent of patients with stage II-III cancer, tumours disappear clinically after initial treatment with chemoradiation and systemic chemotherapy.

He suggests that those patients are potential candidates for the watch and wait approach.

By avoiding rectal surgery, patients are spared of its risks, including impaired bowel and sexual function, which can substantially diminish quality of life.

In the present report, researchers retrospectively analysed data that were collected at Memorial Sloan-Kettering Cancer Center between 2006 and 2014.

Patients with stage I-III rectal cancer who received radiation and chemotherapy (neoadjuvant therapy) and who experienced complete tumour regression were either followed by watchful waiting (non-surgical management) or taken for rectal surgery.

Patients undergoing the watchful waiting approach were initially followed at three- to four-month intervals by digital rectal and endoscopic exams and at six-month intervals by cross-sectional imaging.

Median follow-up in this report is 3.3 years.

Rectal surgery was deferred in 73 patients who achieved a clinical complete response after chemotherapy and radiation (no cancer detected on physical exam, endoscopy, or imaging).

Among those 73 patients, 74 percent experienced durable tumour regression and avoided rectal surgery; 26 percent eventually underwent rectal surgery to treat tumour regrowth.

In a non-randomised comparison, researchers found that the outcomes achieved in this group of patients were similar to the outcomes of 72 patients who underwent standard rectal surgery and experienced a pathologic complete response (no viable cancer cells found on microscopic exam of surgically removed tissue): the four-year overall survival rate was 91 percent in the no-surgery group vs. 95 percent in the standard surgery group.

No significant differences were noted in the number of distant recurrences between the two groups.

According to the authors, this is one of the largest experiences of its kind, building on prior evidence from research conducted in Brazil and the Netherlands.

Non-surgical management of rectal cancer is becoming increasingly accepted as a standard option worldwide.

A prospective phase II study has recently begun enrolling patients at 20 institutions across the United States, and non-surgical management will be offered to patients whose tumours fully disappear after initial chemotherapy and radiation.

Source: ASCO