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OC-006 Oncological outcome following ‘watch and wait’ for clinical complete response after pre-operative chemo-radiotherapy in patients with rectal cancer
  1. A Renehan1,2,
  2. L Malcomson1,
  3. R Emsley3,
  4. S Gollins4,
  5. N Scott5,
  6. ST O’Dwyer2
  7. North West Colorectal Cancer Group
  1. 1Institute of Cancer Sciences, University of Manchester
  2. 2Department of Colorectal Surgery, The Christie NHS Foundation Trust
  3. 3Institute for Population Health, University of Manchester, Manchester
  4. 4Department of Clinical Oncology, North Wales Cancer Treatment Centre, Rhyl
  5. 5Department of Colorectal Surgery, Royal Preston NHS Foundation Trust, Preston, UK

Abstract

Introduction In patients with rectal cancer, management by ‘watch and wait’ (W&W), with potential avoidance of surgical resection (SR), has emerged as a management option following a clinical complete response (cCR) after pre-operative chemoradiotherapy (CRT). However, precise quantification of oncological outcomes after this treatment pathway is unclear.

Method Between 2010 and 2013, we followed a consecutive series of 259 patients with non-metastatic rectal cancer who completed pre-operative CRT (majority: 45 Gy in 25 daily fractions with concurrent fluoropyrimidine-based chemotherapy). Post-CRT, 31 patients (12%) were considered at a multi-disciplinary meeting to have cCR and offered W&W on a protocolised pathway. We supplemented these cases with a registry of 89 patients managed across four cancer treatment centres in the North West of England and North Wales (total cCRs: 120). Primary endpoint was actuarial rate of intraluminal re-growth. Secondary endpoints were non-intraluminal disease-free survival (niDFS) and colostomy-free survival (CFS). Comparisons with standard care (SR) were performed using propensity score matched-treatment analysis and using time-dependent survival analyses to account for differences in times to W&W decision and salvage SR.

Results With a mean follow-up from W&W decision of 23 months, there were 36 (30%) intraluminal re-growths (3-year actuarial rate: 35%). Of the 32 intraluminal re-growths without concomitant distant metastases, 25 (78%) underwent subsequent salvage surgery (R0: 24, R1: 1); and 3 underwent Papillon local radiotherapy. After propensity score matching, there were no deleterious effect on niDFS for patients treated by W&W versus SR (hazard ratio, 95% confidence intervals: 0.562; 0.269 to 1.174). However, there was a significant improvement in 3-year CFS rates for patients treated by W&W versus SR: 83% and 54% (log rank, p < 0.001).

Conclusion Approximately two-thirds of patients with rectal cancer managed by W&W after cCR avoided surgical resection with improvement in colostomy-free survival, without loss of oncological safety. The outcomes from this multi-centred clinical cohort will assist the rectal cancer patient and oncologist with decision making at the outset of long-course CRT.

This study was generously supported by the BDRF.

Disclosure of interest None Declared.

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