Watch and Wait Approach After Neoadjuvant Chemoradiotherapy in Rectal Cancer: Initial Experience in the Indian subcontinent

Patients with locally advanced rectal cancer (LARC) that have a complete clinico-radiological response after neoadjuvant chemoradiation (NACRT) can be offered nonoperative or watch and wait (W&W) management. This study assessed the compliance and outcomes of such patients at our institute. Thirty-six patients with locally advanced low-lying rectal cancers treated between December 2013 and November 2018 and had a near-complete clinical response (ncCR) or complete clinical response (cCR) after completing NACRT and were reluctant to undergo surgery were included. They were followed up at 3 monthly intervals with a combination of pelvic MRI, digital rectal examination, and sigmoidoscopy. Twelve weeks after chemoradiation, 24 (67%) patients had cCR and 12 (33%) had ncCR. All the 36 patients were kept on the W&W protocol. At a median follow-up of 35 (range 17–72) months, six (17%) patients developed local regrowth, one from the cCR group, while five were from the ncCR group. Four of the six patients underwent surgery for local disease (three had sphincter preserving resections and one had abdominoperineal resection), and one of these also had liver metastatectomy. Two of the six patients refused surgery, giving a compliance rate of 94.5%. Three of the 36 patients (8%) had distant metastasis, one had liver metastasis, one had leptomeningeal metastasis, and the third who refused surgery at regrowth developed lung metastasis. Thus, of the 36 patients on the W&W protocol, organ preservation rate was 80%. Local regrowth free DFS was 92.4%, and OAS was 96% at 3 years. W&W approach after cCR and ncCR to NACRT in LARC is acceptable with reasonable compliance and with good outcomes.