Current concepts in the non-operative management of rectal cancer after neoadjuvant chemoradiation

Neoadjuvant chemoradiation (CRT) is used to downstage locally advanced rectal cancer prior to surgery. This is an established paradigm of treatment in the West. Some patients who undergo chemoradiotherapy achieve a complete clinical response, where no evidence of tumour can be found on clinical assessment prior to surgery. Recent studies have suggested a 'watch and wait policy' for patients who achieve a complete clinical response with close clinical follow-up, and to only intervene surgically if local recurrence manifests. This notion differs from established regimes of treatment, but by virtue of its positive implications for patients, deserves further consideration and scrutiny. This article reviews the evidence for the non-operative 'watch and wait' management of rectal cancer in patients with complete clinical response after chemoradiation, and discusses the limitations in applying a policy of this nature.

The evidence in the literature for non-operative treatment of. Only a few studies have examined this issue. Results have been variable, with only one study supporting non-operative management, where low local recurrence rates were shown on intermediate follow-up (<3%), with excellent overall and disease-free survival rates (100% and 86% respectively). Another two studies found high local recurrence rates (approximately 80%) and poor survival on short-term follow-up (around 20%). Differences in selection of patients were found between studies, as well as other aspects that might explain some of the disparity in results found.

There is not enough evidence to justify a non-operative approach to treating rectal cancer after chemoradiation in complete clinical responders at present. Better designed studies are required to clarify some of the issues involved.