Prognosis comparison between wait and watch and surgical strategy on rectal cancer patients after treatment with neoadjuvant chemoradiotherapy: a meta-analysis

Abstract

Background:After achieving a clinical complete response through neoadjuvant chemoradiotherapy, a nonoperative management approach for rectal cancer patients known as Wait and Watch (W&W) has gained increasing attention. However, the W&W strategy has been related to higher local recurrence and ambiguous long-term survival. This meta-analysis compared key prognosis indicators between W&W and surgical treatment in an effort to clarify some long-standing points of confusion.Methods:Pubmed, Web of Science, EMbase, Cochrane Library were searched for relevant researches comparing W&W with surgery treatment, with a time criteria set from 1 January 2002 to 4 July 2019. Endpoints were 2-year local regrowth/recurrence, 2-year distant metastasis (plus local regrowth/recurrence), 3- and 5-year disease-free survival (DFS), and overall survival (OS).Results:In total, nine studies with 801 patients were enrolled, of which 348 were managed by W&W and 453 by surgery. Surgery patients were further divided into a pathological complete response (pCR) group (all included patients achieved pCR) and a surgery group (consisting of both pCR and non-pCR patients without deliberate screening). Compared with the surgery group, W&W patients have higher 3- and 5-year OS, and are not inferior on 2-year local regrowth (LR), 2-year distant metastasis (DM)/DM+LR, and 3- and 5-year DFS. On the other hand, compared with the pCR group, the W&W group is inferior on 2-year LR, 3- and 5-year DFS, and 5-year OS, and not inferior on 2-year DM/DM+LR and 3-year OS.Conclusions:In contrast with patients undergoing surgical treatment, the W&W group has higher 3- and 5-year OS, and is not inferior on other major prognostic indicators, which, however, is based on the fact that the tumor stage in the W&W group is generally earlier. Versus surgically treated patients who acquired pCR, W&W group is inferior on all major prognostic indicators except 2-year DM/DM+LR and 3-year OS. Additionally, by comparison of cCR definitions across different studies, we conclude that implementation of the strictest cCR criteria is critical for W&W patients to acquire maximum prognostic benefit.

Assessment of clinical and pathological complete response after neoadjuvant chemoradiotherapy in rectal adenocarcinoma and its therapeutic implications

“…The five-year OS and DSS rates were 84.6% and 93.8%, respectively, for the entire group and 75.4% and 84%, respectively, in patients who developed local re-growth [ 114 ]. A meta-analysis of nine studies compared the long-term outcomes achieved by WW (348 patients) and RS (453 patients) [ 115 ] revealing that WW approach achieved two-year LRRs and five-year DFS rates similar to those observed in patients treated by RS, irrespective their pathological staging. Furthermore, five-year OS rate accomplished by WW was significantly higher than those achieved by RS in all the patients ( p =0.046) [ 115 ].…”

“…A meta-analysis of nine studies compared the long-term outcomes achieved by WW (348 patients) and RS (453 patients) [ 115 ] revealing that WW approach achieved two-year LRRs and five-year DFS rates similar to those observed in patients treated by RS, irrespective their pathological staging. Furthermore, five-year OS rate accomplished by WW was significantly higher than those achieved by RS in all the patients ( p =0.046) [ 115 ]. However, compared to patients with pCR proved by pathological examinations of the RS specimen, the two-year LRR was significantly higher in WW group, while five-year DFS and OS rates were significantly lower in WW group [ 115 ].…”

“…Furthermore, five-year OS rate accomplished by WW was significantly higher than those achieved by RS in all the patients ( p =0.046) [ 115 ]. However, compared to patients with pCR proved by pathological examinations of the RS specimen, the two-year LRR was significantly higher in WW group, while five-year DFS and OS rates were significantly lower in WW group [ 115 ]. Based on this evidence, caution is recommended before offering this approach, whose application should be limited in present only to elderly, fragile (high-risk) patients or those refusing RS [ 26 , 34 , 116 ].…”

A Ten-N6-Methyladenosine (m6A)-Modified Gene Signature Based on a Risk Score System Predicts Patient Prognosis in Rectum Adenocarcinoma

“…READ is defined as cancer between the dentate line and the junction of the rectosigmoid colon, easy to be diagnosed by digital rectal examination and sigmoidoscopy. Surgery is the standard treatment strategy for early rectal cancer (T1-2 and N0), and neoadjuvant chemoradiotherapy followed by total mesorectal excision (TME) is the treatment for locally advanced (T3-4 and/or N1-2) rectal cancer ( 3 ). However, recurrence often occurs after surgery because of its deep pelvic location, complex anatomical relationship, and difficulty in completing the surgery.…”

A Panel of Tumor Biomarkers to Predict Complete Pathological Response to Neoadjuvant Treatment in Locally Advanced Rectal Cancer

“…Organ-sparing strategies such as conservative surgery or watch-and-wait approaches could be considered in patients with clinical complete response to improve quality of life 6 . On the other hand, intensified neoadjuvant programs could be evaluated for poor responders.…”