A team of doctors and scientists from the Champalimaud Clinical Centre in Lisbon, Portugal, and the Netherlands Cancer Institute in Amsterdam, has shown that patients with "low" rectal cancer (that is, very close to the anus) who show no sign of their tumors after a course of radio- and chemotherapy can safely choose to postpone invasive and complication-prone surgical procedures. These results have been published in the journal Annals of Surgery .
Agreeing instead to submit to a very close and strict surveillance of their condition during a period of at least two years, in a "Watch-and-Wait" strategy, they might even totally evade surgery without any negative impact on their health outcome, since the majority (around two-thirds) of these patients does not show any regrowth of the tumor after the first two years of "Watch-and-Wait".
What's most important, according to the scientists, is that of the remaining patients (around one-third), whose tumor does regrow within those first years and who undergo exactly the same surgical procedure as was initially planned for them, 97% show the same outcome as if the surgery had been performed immediately after radio-chemotherapy. In other words, no precious time will have been wasted by waiting and watching the patient.
Surgery still is, today, the frontline classical treatment protocol for rectal cancer cases - which represent about 30% of all colorectal cancers, or about six million new cases per year worldwide, according to 2018 estimates. But the fact is that, for certain particularly complicated locations of the tumor in the rectum, a previous course of radio-chemotherapy before surgery is required. Why? Because in these cases, it is necessary to reduce the size of the tumor that might already be invading the pelvic wall structures or even other organs.
This pre-operative treatment comes with its own side effects, increasing the probability of urinary and sexual dysfunction, worse bowel function or even deficient healing process. These could, in turn, have devastating post-operatory consequences, such as suture defects leading to peritonitis.
For rectal tumors located less than seven centimeters from the anus, the patient is often submitted to radiochemotherapy during five weeks, having a subsequent recovery period of another eight to ten weeks before the surgical intervention." Nuno Figueiredo, head of the Champalimaud Surgical Centre and a colorectal surgeon at the Digestive Cancer Unit of the Champalimaud Clinical Centre
Nuno Figueiredo is one of the co-authors of the new study together with his colleagues Marit Van der Sande and Geerard Beets, from the Netherlands Cancer Institute.
Moreover, in more than half of these low rectal cancer cases - which represent 30% to 40% of all rectal cancers, that is, around two million new cases per year worldwide, according to the same 2018 estimates -, the surgery may require removal of the rectum and surrounding tissue (abdominoperineal amputation), a condition that implies permanently redirecting the colon towards an incision made in the abdomen (colostomy). In these cases, the patient is fitted for life with a "bag" to collect stools directly through that artificial orifice.
For all the above reasons, surgery is potentially a very invasive procedure in low rectal cancer. But what if there was a non-invasive option to surgery that did not put eligible patients' lives at risk? The new study shows that this may actually be the case. Unnecessary surgery?
The Watch-and-Wait strategy for rectal cancer was pioneered by surgeon Angelita Habr-Gama at the University of São Paulo, Brazil, some 20 years ago. Habr-Gama observed that, when patients with low rectal cancer were irradiated to prepare them for surgery due to the proximity of the tumor to the anus, histology results (biopsy) of the tissue harvested during the surgery often showed absolutely no trace of cancer cells. And she wondered whether the surgery, with its cohort of potential complications and life-long impact on patients' quality of life, had actually been necessary in those cases.
In the mid-2000's, surgeons in the Netherlands started proposing the alternative protocol to eligible patients. And in 2013, the Champalimaud Clinical Center and the University of Manchester in the UK were some of the first institutions in the world to follow suit. "Today, 53 centers around the world are using the same Watch-and-Wait protocol", says Figueiredo. "And in 2013, we created the International Watch-and-Wait Database to collect all the data generated by these centers." Related Stories
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