Nonoperative versus operative approach according to the response to neoadjuvant chemoradiotherapy for rectal cancer: A prospective cohort study. (September 2022)

• Record Type: Journal Article
• Authors: Bulens, Philippe P.; Smets, Lien; Debucquoy, Annelies; Joye, Ines; D'Hoore, André; Wolthuis, Albert; Debrun, Lynn; Dekervel, Jeroen; Van Cutsem, Eric; Dresen, Raphaëla; Vandecaveye, Vincent; Deroose, Christophe M.; Sagaert, Xavier; Haustermans, Karin
• Is Part Of: Clinical and translational radiation oncology. Volume 36(2022)
• Page Start: 113
• Page End: 120
• Publication Date: 2022-09
• Subjects: Rectal cancer -- Organ preservation -- Watch-and-Wait -- Chemoradiotherapy; Cancer -- Radiotherapy -- Periodicals; Oncology -- Periodicals; Cancer -- Radiotherapy; Oncology; Radiation Oncology; Neoplasms -- radiotherapy; Translational Medical Research; Periodicals; Electronic journals; Periodicals; 616.9940642
• DOI: 10.1016/j.ctro.2022.07.009
• Languages: English
• ISSNs: 2405-6308

Abstract

Highlights: Watch-and-wait patients after chemoradiotherapy for rectal cancer have good functional outcome. No survival differences were seen between patients undergoing surgery versus patients in a watch-and-wait protocol. There is a subset of patients that has initial favorable response but will recur with distant metastases afterwards. A previously published model predicting (near)-complete response could not be validated. Abstract: Purpose: To report on organ preservation following chemoradiotherapy (CRT) in a prospective cohort of locally advanced rectal cancer patients. Methods and materials: Fifty-two patients received CRT. MRI and 18 F-FDG-PET/CT were performed prior to CRT. Response assessment was done 6 and 12 weeks after CRT using digital rectal examination, MRI, 18 F-FDG-PET/CT and endoscopy. For clinical complete response or minimal residual disease, a watch-and-wait (W&W) protocol was started. Regrowth-free survival (ReFS), Total Mesorectal Excision-free disease-free survival, distant metastasis-free survival (DMFS) and overall survival (OS) were evaluated using Kaplan-Meier method. Functional outcome was compared with the Wilcoxon signed-rank test using EORTC QLQ-C30, MSKCC BFI, LARS and IIEF-5/FSFI-5 questionnaires. A previously developed prediction model performance was tested using receiver operating characteristic analysis. Results: 29/52 patients entered a W&W protocol. There was no difference in two-year DMFS (81.1 % vs 78.8 %, p = 0.82), two-year OS (96.4 % vs 100 %, p = 0.38) and two-year DFS (77.5 % vs 78.8 %, p = 0.87) between W&W patients and those who underwent surgery at 12 weeks after CRT. Two-year DMFS differed between W&W with local regrowth, W&W with sustained response and patients who had surgery (66.7 % vs 88.0 % vs 78.8 %; p = 0.04). At 6 and 12 months, W&W patients reported good QoL and bowel function. The model validation reached an AUC of 0.627. Conclusion: Good functional outcome in patients with rectal cancer allocated to surveillance after CRT needs to be balanced against potentially worse DMFS in a subset of patients without sustained clinical complete response. Reliable prediction of patients eligible for surveillance programs needs further investigation.