As cancer therapies improve, more patients with rectal cancer forego surgery

While surgery to remove rectal cancer can be necessary and lifesaving, it can sometimes come with significant drawbacks, like loss of bowel control. According to a study led by Wilmot Cancer Institute researchers, patients with rectal cancer who respond well to radiation and chemotherapy are increasingly foregoing surgery and opting for a watch-and-wait approach.

The study, published in JAMA Oncology, shows that the number of patients opting out of surgery rose nearly 10% between 2006 and 2020. These data reflect a shift toward what is known as an "organ-preserving" approach to care: It requires patients to undergo frequent follow-ups with experienced oncologists over five years, but potentially allows them to avoid surgery that could alter their bowel function and quality of life long term.

"You don't appreciate your bowel function until it's bad," says Fergal Fleming, MD, MPH, a Wilmot investigator and associate professor of Surgery and Oncology at the University of Rochester Medical Center who led the study. "For many of my patients, their bowel habit, unfortunately, dictates their lives. So, if we can avoid surgery, then that's probably much better for patients in terms of quality of life."

Wilmot's Colorectal Cancer Program has practiced this relatively new approach of watch-and-wait organ preservation for nearly 10 years.

"It's somewhat similar to the evolution of breast cancer care," Fleming says. "Patients used to have very extensive mastectomies and resections, whereas now breast conservation is offered wherever feasible."

Not yet part of standard clinical care, this organ-preserving approach is primarily available to patients through clinical trials. Wilmot is involved in several such trials, including the national Organ Preservation in Patients with Rectal Adenocarcinoma trial, which recently reported that half of the patients who opted to watch-and-wait were able to avoid surgery long-term. The other half, who had surgery after their cancer regrew, had the same disease-free survival rates as patients who did not watch-and-wait.

These positive early results and Fleming's study suggest that a sea change in rectal cancer care is imminent. But Fleming cautions that better guidance is needed before watch-and-wait care can be used more broadly.

Current treatment strategies vary widely—and the intensity and length of the follow-up program can be difficult for patients to adhere to. More work is needed to define the optimal surveillance approach—one that is rigorous enough to spot cancer regrowth early, but easy enough for health systems to implement and patients to follow.

"Having patients in an integrated system like we have at Wilmot is so important," Fleming says. "We're all on the same page, giving our patients consistent messages. We try to facilitate as much of their follow up as possible, and coordinate with affiliate units to try and make it easier for patients to make it to appointments."

But not all cancer centers are set up that way, and not all rectal cancer programs have the resources and experience to effectively implement watch-and-wait. To ensure that all eligible patients have the opportunity to benefit, Fleming says this new approach must be designed with patients from all walks of life in mind and it must be deployed equitably across the nation. "We are committed to providing the highest quality of rectal cancer care to all our patients across our Wilmot-affiliated sites," he says.

The JAMA Oncology study, which reflected data from 175,000 rectal cancer cases in the National Cancer Database, was a collaborative effort of Anthony Loria, MD, Larissa Temple, MD, and Alexa Melucci, MD, from URMC; Mohamedtaki Tejani, MD, John Monson, MD, and Christopher Aquina, MD, of AdventHealth; Carla Justiniano, MD, of the University of Cincinnati College of Medicine; and Adan Becerra, Ph.D., of Rush University Medical Center.