- Watch-and-wait may be an appropriate strategy for select patients with rectal cancer who have demonstrated a complete clinical response (CCR) after neoadjuvant therapy and are compliant with frequent surveillance colonoscopy.
- CCR is widely defined as the absence of any palpable tumor at digital rectal examination and no visible lesion at colonoscopy.
- Data from the International Watch & Wait Database shows that at 3 years, the rate of local tumor regrowth with a watch-and-wait strategy is 25%, and the rate of metastasis is 10%.
- Data from retrospective studies suggests that there are no significant differences in overall survival and local recurrence between patients who underwent surgery and those who were managed via watch-and-wait strategy, but data from randomized trials are needed to confirm the noninferiority of the watch-and-wait strategy versus standard treatment before it can be recommended as a standard practice.
- Organ preservation and watch-and-wait is a normal strategy in selected patients with rectal cancer, who have a clinical complete response after neoadjuvant therapy. The watch-and-wait strategy is associated with a lower morbidity and better quality of life, as compared to immediate major surgery.
- The most challenging issue is to how to exactly determine CCR, and when to assess CCR, and how close to monitor these patients.
- Digital rectal examination, MRI, and endoscopy can be used to evaluate the clinical response.
- Also, there is no uniform consensus on the definition of CCR.CCR is widely defined as the absence of any palpable tumor at digital rectal examination, no visible lesion at colonoscopy—except the flat scar or whitening of the mucosa. These minimum criteria can be complemented by the absence of any residual tumor and draining lymph nodes on imaging with MRI or anorectal ultrasound and negative biopsies from the scar.
- All patients with CCR who are managed with a watch-and-wait strategy should undergo an intensive surveillance to ensure that a timely salvage surgery is feasible.
- Some evidence from retrospective studies suggest that there are no significant differences in overall survival and local recurrence between patients who underwent surgery, and those who are managed according to the watch-and-wait strategy.
- The watch-and-wait strategy can only be offered to patients who will be compliant with frequent visits. Nevertheless, data from randomized trials are needed to confirm the noninferiority of the watch-and-wait strategy versus standard treatment before the strategy can be more widely recommended.
- In Indian context it becomes very difficult for majority of patients to follow a stringent follow up schedule and surveillance strategy due to lack of awareness, lack of finances, logistics and resources.In a developing country like India wait and watch policy in patients with complete clinical response after neoadjuvant therapy is still a distant possibility where a majority of patients still prefer surgery over wait and watch strategy due to the practical reasons mentioned above.
