A “watch and wait” approach to certain types of rectal cancer is helping spare select patients from surgery while preserving a higher quality of life.
Patients who can benefit from watch and wait include those with early stage small tumors and those with more advanced cancer who are elderly, frail or have comorbidities and would otherwise require an ostomy.
“In the last 15 years or so, rectal cancer care has evolved. We now give patients total neoadjuvant therapy — not only chemotherapy with radiation therapy, but also stronger chemotherapy alone,” said Carrie Peterson, MD, colorectal surgeon and MCW faculty member. “Patients tolerate these therapies better before surgery than afterward. “We are also finding patients are better able to get all the chemotherapy they need without any breaks, delays or reduced doses. Therefore, we think this will decrease the chance the tumor will come back.”
The other benefit: Tumors shrink more, allowing surgeons to perform more sphincter-preserving surgeries, which are special operations where a permanent colostomy isn’t necessary. In some cases, they can eliminate surgery altogether because tumors can no longer be detected after completing total neoadjuvant therapy. Patients still need careful monitoring to detect possible recurrences (called “watch and wait”) — usually every three months for the first two years and then every six months for years three to five years thereafter.
“Before we implemented this approach, we observed a clinically complete response in only about 10% of rectal cancer patients. With total neoadjuvant therapy, we are seeing tumors disappear in 30-60% of patients,” Dr. Peterson said. “Studies offer sufficient data to indicate that watch and wait is a safe approach for the appropriate patient.”
Alleviating Worry in Rectal Surgery Patients
Rectal surgery is a major concern for patients. Even with sphincter-sparing techniques, they can experience permanently altered bowel movements, including multiple movements per day, and clustering – having numerous bowel movements within a short period. Incontinence and leakage can also occur. Overall, rectal surgery can have a significant impact on quality of life, social functioning and self-perception.
Close Follow-up Care
Physicians are especially vigilant about the “watch” part of the strategy. Follow-up entails office visits, CT and MRI scans to check the lymph nodes of the rectum, as well as periodic endoscopies.
Froedtert Hospital is recognized by the National Accreditation Program for Rectal Cancer as an Accredited Rectal Cancer Program. That means it meets strict national standards for surgical quality, providing multidisciplinary specialty care overseen by a qualified rectal cancer program director, review of cases before and after treatment, and a quality improvement process that heightens efficiency, standardizes care, and enhances outcomes.
“We have found 'watch and wait' to be a promising approach as long as patients agree to follow-up care,” Dr. Peterson said. “If we catch a recurrence quickly, the outcome is the same as if we had done surgery at the outset. Patients aren’t harmed by waiting.”
For Our Referring Physicians: Academic Advantage of Rectal Cancer Services
The Froedtert & MCW health network gives patients and their referring physicians a distinct advantage.
Contact our physician liaison team for more information about our Colorectal Cancer Program or if you would be interested in meeting with any of the colorectal cancer team members.
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