Journal Review in Colorectal Surgery: Watch and Wait Strategy for Distal Rectal Cancer

Behind The Knife: The Surgery Podcast

Science, Health & Fitness, Medicine, Education

4.8 • 1.4K Ratings

🗓️ 13 January 2022

⏱️ 27 minutes

🔗️ Recording | iTunes | RSS

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Summary

You are faced with a young patient with low rectal cancer who is a complete responder to neoadjuvant chemoradiotherapy. He asks if he should undergo surgical resection despite the absence of visible tumour. How do you approach such a question?

Join Dr. Carole Richard, Dr. François Dagbert and Dr. Maher Al Khaldi in their conversation about the Watch and Wait strategy for rectal cancer, also known as the Organ Preservation strategy.

Learning objectives

- To understand the rationale for Watch and Wait Strategy and the proportion of patients who become complete clinical responders.
- To explain how patients under the Watch and Wait Strategy protocol should be followed up and when to consider a patient a clinical nonresponder.
- To understand the inclusion criteria for patients in the Watch and Wait Strategy

References

In order throughout the episode [1–3]:

1. Habr-Gama A, Perez RO, Nadalin W, Sabbaga J, Ribeiro U, Sousa AHS e, et al. Operative Versus Nonoperative Treatment for Stage 0 Distal Rectal Cancer Following Chemoradiation Therapy. Transactions Meet Am Surg Assoc. 2004;122(NA;):309–16.
2. Valk MJM van der, Hilling DE, Bastiaannet E, Kranenbarg EM-K, Beets GL, Figueiredo NL, et al. Long-term outcomes of clinical complete responders after neoadjuvant treatment for rectal cancer in the International Watch & Wait Database (IWWD): an international multicentre registry study. Lancet. 2018;391(10139):2537–45.

3. Fernandez LM, Julião GPS, Figueiredo NL, Beets GL, Valk MJM van der, Bahadoer RR, et al. Conditional recurrence-free survival of clinical complete responders managed by watch and wait after neoadjuvant chemoradiotherapy for rectal cancer in the International Watch & Wait Database: a retrospective, international, multicentre registry study. Lancet Oncol. 2021;22(1):43–50.

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Transcript

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0:00.0	Behind the Night, the surgery podcast, relevant and engaging content designed to help you dominate the day.
0:22.0	Hello again from Montreal, Canada.
0:25.0	We will be discussing today, myself, Carol, my colleague, François and my aunt, the interesting topic of watch and wait strategy.
0:35.0	In the recent 20 years, significant changes have occurred in the treatment of rectal cancer. Initially, primary treatment was surgery with high local recurrent rates.
0:46.0	In part, based on the NSABP R01 trial and the Swedish trial, post-op radiation therapy was then shown to decrease local recurrence.
0:56.0	In the late 90s, early 2000, many randomized control trials that judged the German, the MRC, then showed the benefit of chemo-regulation treatment in the neo-gebol setting.
1:09.0	In this very same period, surgical precision was also developed in part due to the data of bill heels, one of the main contributors of TME, and TME was shown to decrease local recurrence, and also to improve functional outcome.
1:26.0	All these components together increased better outcome in the treatment of rectal cancer, and also in this same era, pre-op clinical staging was improved by most of Gina Brown's work on assessing MRI in clinical staging.
1:46.0	In doing surgery post-chemo-regulation treatment, findings of total response, I know identifiable tumor cells in pathology report, were reported in up to 12 to 30 percent of patient, this led to the question of what is the impact on patient outcome when they have a complete response.
2:06.0	And many institutions from different countries thereafter reported in fact very good survival outcome with very low recurrence rate in the follow-up of such patients.
2:17.0	And this finally led to the question of can we identify prior to surgery the complete responders potentially can we avoid surgery?
2:28.0	Surgery for rectal cancer even in the hands of expert is associated with important morbidities and major functional outcome.
2:37.0	It is a major surgery even with MIS and robotic development with major impact on patient's lives, not my colon surgery.
2:46.0	This is why today our team chose to address this hot topic of watching with strategy for our journal club.
2:54.0	So Francois, which article did we choose and why?
3:00.0	Well, the first article we chose was the initial article that at that time was a very provocative article.
3:08.0	It's entitled operative versus non-operative treatment for stage zero distal rectal cancer following chemo radiation therapy long term results.
3:18.0	And it was the first article to explore the now commonly referred to concept that is called organ preservation in rectal cancer treatment.
3:27.0	The results of the study have challenged the surgical principles by which patients with rectal cancers are treated.
3:34.0	It is actually not a totally novel concept as it is widely used in the treatment of squamous cell carcinoma, the anus, but was totally shocking in the treatment of adenocarcinoma of the rectum.
3:46.0	The South Pole group of Brazil with Angelita Habagama was really pioneering this field.
3:52.0	Maya, can you give us a summary of this article?
	...

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