Surveillance after neoadjuvant therapy in advanced rectal cancer with complete clinical response can have comparable outcomes to total mesorectal excision

Smith, Radhika; Fry, Robert D.; Mahmoud, Najjia N.; Paulson, Emily Carter

doi:10.1007/s00384-015-2165-2

Cited by 69 publications

(52 citation statements)

References 17 publications

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“…Observation group patients seemed to be older than those in the radical surgery group [2, 4, 7–9, 13]. Except for one observation group patient with liver metastasis in Smith et al [8], no patients had distant metastasis (DM) according to the study descriptions. Most patients had medial/distal and locally advanced rectal cancer.…”

Section: Resultsmentioning

confidence: 98%

“…Reports from Habr-Gama's group and others are not consistent regarding the time point for assessment of sustained cCR, which ranged from 12 to 14 months after NCRT completion, or regarding the time point for identifying patients failing to maintain cCR [2, 3, 5, 6, 8, 9, 20]. Only seven studies established a rigorous follow-up system (Table 6), and they suggested that cCR should only be considered sustained after at least 12 months.…”

Section: Discussionmentioning

confidence: 99%

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Wait-and-see treatment strategies for rectal cancer patients with clinical complete response after neoadjuvant chemoradiotherapy: a systematic review and meta-analysis

Yang

et al. 2016

Oncotarget

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Wait-and-see treatment strategies may benefit rectal cancer patients who achieve a clinical complete response (cCR) after neoadjuvant chemoradiotherapy (NCRT). In this study, we analyzed data from 9 eligible trials to compare the oncologic outcomes of 251 rectal cancer patients achieving a cCR through nonsurgical management approaches with the outcomes of 344 patients achieving a pathologic complete response (pCR) through radical surgery. The two patient groups did not differ in distant metastasis rates or disease-free and overall survival, but the nonsurgical group had a higher risk of 1, 2, 3, and 5-year local recurrence. Hence, we concluded that for rectal cancer patients achieving a cCR after NCRT, a wait-and-see strategy with strict selection criteria, an appropriate follow-up schedule, and salvage treatments achieved outcomes at least as good as radical surgery. Long-term randomized and controlled trials with more uniform inclusion criteria and standardized follow-up schedules will help clarify the risks and benefits of wait-and-see treatment strategies for these patients.

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Section: Resultsmentioning

confidence: 98%

Section: Discussionmentioning

confidence: 99%

Wait-and-see treatment strategies for rectal cancer patients with clinical complete response after neoadjuvant chemoradiotherapy: a systematic review and meta-analysis

Yang

et al. 2016

Oncotarget

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“…13–27 Eight studies reported data for an adequate control proctectomy group, but there was significant variation. Four used a post-surgical pathological complete response (pCR) group for comparison 14,16,25,26 , 2 used cCR tumors undergoing surgery, 19,20 1 used both, 22 and 1 used a surgical group matched for clinical stage (regardless of tumor response). 23 Outcome data for incomplete response, non-response, and local excision were excluded from comparisons as these were not regarded as adequate control group data.…”

Section: Resultsmentioning

confidence: 99%

Nonoperative Management or ‘Watch and Wait’ for Rectal Cancer with Complete Clinical Response After Neoadjuvant Chemoradiotherapy: A Critical Appraisal

et al. 2017

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Purpose There is increasing interest in non-operative management (NOM) for rectal cancer with complete clinical (cCR) response after neoadjuvant chemoradiation (nCRT). The aim of this review is to summarize the available data on NOM, with the intention of formulating standardised protocols on which to base future investigation. Methods Systematic review following PRISMA guidelines was conducted. A highly sensitive literature search identified all relevant studies published between Jan 2004 and Dec 2016. Data extraction and quality assessment was performed independently by two authors, and resolved by consensus with a third. Results In total, 15 studies met inclusion criteria including 920 patients, 575 (62.5%) who underwent NOM after cCR, and the rest forming a surgical control group. The weighted mean followup was 39.4 (12.7) months in the NOM group and 39.8 (5.1) months in the surgery group. The pooled re-growth rate in the NOM group was 21.3% at a mean of 15.6 (7.0) months. Surgical salvage was possible and undertaken in 93.2% of these patients. Overall survival in the NOM group was 91.7%, and disease free survival was 82.7%. For the comparison proctectomy group, pooled rates of local recurrence, overall survival and disease free survival were 8.4%, 92.4%, and 87.5%, respectively. Conclusion NOM may be a feasible option for surgically eligible rectal cancer patients with cCR after nCRT. Before such a strategy can be widely implemented, further prospective data is required with standardised definitions, diagnostic criteria, and management protocols, with an emphasis on shared patient-provider decision making and patient centered outcomes.

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“…6 Emerging data suggest that certain low-risk tumors may be appropriate candidates for this strategy. 7–11 However, it is well established that cCR does not equate to pCR as residual tumor may be identified in up to 75 % of resected specimens where the gross tumor has clinically disappeared. 12,13 Furthermore, even among patients with complete pathologic resolution of the primary tumor, residual nodal disease is present in up to 15 % of cases 14,15 and is an independent predictor of poor outcomes.…”

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confidence: 99%

Predictors of Pathologic Complete Response Following Neoadjuvant Chemoradiotherapy for Rectal Cancer

et al. 2015

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Background Some patients with rectal cancer who receive neoadjuvant chemoradiotherapy (nCRT) achieve a pathologic complete response (pCR) and may be eligible for less radical surgery or non-operative management. The aim of this study was to identify variables that predict pCR after nCRT for rectal cancer and to examine the impact of pCR on postoperative complications. Methods A retrospective review was performed of the NCDB from 2006 to 2011. Patients with rectal cancer who received nCRT followed by radical resection were included in this study. Multivariable analysis of the association between clinicopathologic characteristics and pCR was performed, and propensity-adjusted analysis was used to identify differences in postoperative morbidity between pCR and non-pCR patients. Results A total of 23,747 patients were included in the study. Factors associated with pCR included lower tumor grade, lower clinical T and N stage, higher radiation dose, and delaying surgery by more than 6–8 weeks after the end of radiation, while lack of health insurance was linked with a lower likelihood of pCR. Complete response was not associated with an increased risk of major postoperative complications. Conclusions Several clinical, pathologic, and treatment variables can help to predict which patients are most likely to have pCR after nCRT for rectal cancer. Awareness of these variables can be valuable in counseling patients regarding prognosis and treatment options.

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Surveillance after neoadjuvant therapy in advanced rectal cancer with complete clinical response can have comparable outcomes to total mesorectal excision

Abstract: Active surveillance can be a safe option that avoids the morbidity associated with proctectomy and preserves oncologic outcomes.

Cited by 69 publications

References 17 publications

Wait-and-see treatment strategies for rectal cancer patients with clinical complete response after neoadjuvant chemoradiotherapy: a systematic review and meta-analysis

Wait-and-see treatment strategies for rectal cancer patients with clinical complete response after neoadjuvant chemoradiotherapy: a systematic review and meta-analysis

Nonoperative Management or ‘Watch and Wait’ for Rectal Cancer with Complete Clinical Response After Neoadjuvant Chemoradiotherapy: A Critical Appraisal

Predictors of Pathologic Complete Response Following Neoadjuvant Chemoradiotherapy for Rectal Cancer

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