Some rectal cancer patients may be able to skip surgery

Last Updated: 2015-01-12

By Megan Brooks

NEW YORK (Reuters Health) - Patients with rectal cancer who achieve complete response after chemoradiation and systemic chemotherapy may not need surgery, new research hints.

In a retrospective study, these patients had similar four-year survival rates regardless of whether they had immediate surgery or opted for a "watch and wait" strategy.

"We believe that our results will encourage more doctors to consider this watch and wait approach in patients with clinical complete response as an alternative to immediate rectal surgery, at least for some patients," senior study author Dr. Philip Paty, a surgical oncologist at the Memorial Sloan-Kettering Cancer Center in New York City, said in a statement.

"From my experience, most patients are willing to accept some risk to defer rectal surgery in hope of avoiding major surgery and preserving rectal function," Dr. Paty added.

He presented the study results during a media briefing today and will present the study later this week at the 2015 Gastrointestinal Cancers Symposium in San Francisco.

Locally advanced rectal cancer is the most common presentation of rectal cancer, Dr. Paty explained. The standard treatment is neoadjuvant chemoradiation, rectal resection, and adjuvant chemotherapy. Up to half of patients with stage I rectal cancer and 30% to 40% of patients with stage II-III rectal tumors achieve complete response (CR) after initial chemoradiation and systemic chemotherapy.

For the last eight years, nonoperative management has been used "selectively" at Memorial Sloan-Kettering for rectal cancer patients with a clinical CR, Dr. Paty said. A look back at these patients suggests the strategy is safe and effective, he said.

Among a total of 145 patients with locally advanced rectal cancer and clinical CR after neoadjuvant therapy, 73 deferred surgery in favor of watchful waiting and 72 had immediate surgery. They were followed for a median of 3.5 years.

Of the 73 patients managed nonoperatively, 54 (74%) had durable tumor regression and avoided rectal surgery, while 19 (26%) eventually underwent rectal surgery due to local tumor regrowth. All regrowths were resectable; two regrowths were treated by local excisions, meaning a total of 56 patients (77%) were able to preserve their rectal function, Dr. Paty said. "On the other hand, of course, none of the patients who had full rectal resection upfront had rectal preservation."

Four-year disease-specific and overall survival were not significantly different between the watchful waiting group and the standard surgery group.

"Non-operative management appears to be a safe and effective treatment strategy and achieves a high rate of rectal preservation. Prospective trials to confirm these findings are in progress," Dr. Paty said.

Briefing moderator Dr. Smitha Krishnamurthi, of the American Society of Clinical Oncology (ASCO) symposium news planning team, said, "These are important findings for patients with rectal cancer because removal of the rectum can result in altered bowel habits or the need for permanent colostomy."

"Longer follow-up is needed, however, to be sure that non-operative management does not result in higher cancer recurrences," added Dr. Krishnamurthi, of Case Western Reserve University in Cleveland, Ohio.

The study was supported in part by funding from the Berezuk Colorectal Cancer Fund. Three of the authors have disclosed financial relationships with various pharmaceutical companies including Intuitive Surgical, Myriad Genetics, Pfizer and Abbott Biotherapeutics.