Organ Preservation With Watch and Wait in Patients With Rectal Cancer

With growing evidence and evolving guidelines, organ preservation with watch and wait for stage II to III rectal cancer after neoadjuvant therapy is increasingly implemented. However, the true frequency of watch-and-wait use is unknown.

To estimate rates of intentional organ preservation with watch and wait by evaluating secular trends across age groups.

This retrospective cohort study used data from the National Cancer Database (NCDB), with analyses conducted in September 2025. Patients with stage II to III rectal cancer diagnosed between 2006 and 2023 who received neoadjuvant chemoradiation in Commission on Cancer-accredited hospitals participating in the NCDB across the US were included.

Age, year of diagnosis, and treatment strategy (proctectomy vs nonsurgical management).

The primary outcome consisted of watch-and-wait rates, defined as excess nonsurgical management greater than baseline. To account for nonsurgical management unrelated to the decision for watch and wait, joinpoint regression estimated baseline rates of nonsurgical management and annual percentage changes. A secondary analysis examined associations of age and year with watch-and-wait rates using multivariable logistic regression.

Among 101 001 patients with rectal cancer (median [IQR] age, 60 [51-69] years; 37 957 female [37.58%]), 84 324 underwent surgery and 16 677 did not. Baseline rates of nonsurgical management remained stable through 2014. Joinpoints occurred in 2014 and 2019, with annual percentage changes of -0.45% (95% CI, -2.26% to 0.78%; P = .42) in 2006 to 2014, 9.83% (95% CI, 4.66% to 13.73%; P = .001) in 2015 to 2018, and 21.71% (95% CI, 17.74% to 29.57%; P < .001) in 2019 to 2023. Baseline nonsurgical management increased with age, from 1331 of 19 785 patients younger than 50 years (6.73%) to 1748 of 6210 patients aged 80 years and older (28.15%). Earlier adoption occurred in older patients; the group aged 80 years and older surpassed 5-percentage point excess watch and wait by 2015 (33.78% annual rate vs 28.15% baseline rate [5.63-percentage point excess]) and 10% by 2017 (39.56% annual rate vs 28.15% baseline rate [11.41-percentage point excess]), compared with 2019 (12.88% annual rate vs 6.73% baseline rate [6.15-percentage point excess]) and 2021 (20.75% annual rate vs 6.73% baseline rate [14.02%] excess) in patients younger than 50 years. Overall, watch and wait increased from 140 of 6101 patients (2.30%) in 2015 to 2068 of 6280 patients (32.94%) in 2023. Increasing year (odds ratio for 2023 vs 2006, 6.23; 95% CI, 5.48 to 7.09) and older age (odds ratio for ages ≥80 vs <50 years, 4.25; 95% CI, 3.98 to 4.54) were independently associated with nonsurgical management (both P < .001).

In this study, watch-and-wait rates increased across all age groups, with a marked acceleration after 2019 suggesting evidence-concordant adoption of the watch-and-wait approach. This underscores the need for careful patient selection, accurate clinical response assessment, and rigorous surveillance monitoring to ensure safe oncologic outcomes.