George J. Chang, MD, Chief of Colon and Rectal Surgery and Director of Clinical Operations, Minimally Invasive and New Technologies in Oncologic Surgery Program at The University of Texas MD Anderson Cancer Center, Houston, shared his insights on the study by Dr. Smith and colleagues with The ASCO Post.
“Currently, 15% to 20% of patients with rectal cancer who are treated with chemoradiation therapy will be observed to have complete pathologic response with no evidence of residual tumor. Thus, it is an often unsettling discussion that surgeons and patients must have—of the good news of a pathologic complete response and the reality that an abdominal perineal resection with a permanent colostomy was needed,” he said.
“We know that among patients undergoing radical surgery, those achieving pathologic complete response have an excellent prognosis. Thus, the bar we must achieve is very high not to compromise a patient’s outcomes when considering a nonoperative strategy,” Dr. Chang noted.
“I think the group at Memorial Sloan Kettering Cancer Center has the right approach, in that all patients were treated on a prospective trial, that [Memorial] is an expert center in the multidisciplinary treatment of rectal cancer, that there was input from all disciplines, that the patients were closely monitored, and that clinicians had the necessary expertise to perform salvage surgery when the tumors grew,” he said.
Dr. Chang noted that the disease persistence rate in the Memorial study was 26% vs a local recurrence risk approaching 0% after radical surgery.1
Not So Fast With ‘Watch and Wait’
“I disagree with Dr. Paty’s comment that we should encourage more doctors to consider ‘watch and wait,’” he said. “We have to acknowledge that these patients were monitored very closely on a protocol, and currently that is the only way this approach should be undertaken, unless there is some other contraindication to surgery.”
Dr. Chang said he would not encourage nonoperative management outside of a protocol in which patients are carefully selected, closely monitored, and have given true informed consent.
“As rectal cancer management becomes increasingly complex, it is becoming clear,” he said, “that some patients do not routinely need chemoradiation therapy. Perhaps, similarly, routine surgery will not be necessary for select patients,” he said.
“For now, however, radical surgery should remain the standard treatment,”2 according to Dr. Chang. “But rigorous protocol-based treatment should be pursued to help us consider options that reduce the impact of our treatments, such as organ preservation with ‘watch and wait,’” he concluded. ■
Disclosure: Dr. Chang reported no potential conflicts of interest.
References
1. Park IJ, You YN, Agarwal A, et al: Neoadjuvant treatment response as an early response indicator for patients with rectal cancer. J Clin Oncol 30:1770-1776, 2012.
2. Chang GJ: ‘Watch-and-wait’ for rectal cancer: What’s the way forward? Oncology (Williston Park) 28:617-618, 2014.
