Nationwide analysis on the role of neoadjuvant radiotherapy and watch and wait in rectal cancer

Introduction: Patients receiving neoadjuvant short-course radiotherapy (SCRT) or chemoradiotherapy (CRT) for primary non-metastasized rectal cancer may achieve a clinical complete response and can be surveilled following the watch and wait strategy. The aim of this study is to investigate the utilization of this strategy using nationwide data from the Netherlands Cancer Registry. Methods: Data from 6968 patients diagnosed with non-metastatic rectal cancer between 2018 and 2020 were analyzed. 3681 patients (54 %) undergoing neoadjuvant SCRT (n = 1404) or CRT (n = 2277) were categorized based on inclusion in the watch and wait strategy or time to surgery post-treatment. Results: Overall 569/3681 (15 %) of patients were successfully managed in the watch and wait strategy at 12 months, 93/1404 (7 %) after SCRT and 476/2277 (21 %) after CRT. Combined with local excisions, organ preservation increases to 633 patients (17 %), to 127 (9 %) after SCRT and 506 (22 %) after CRT. Patients in the watch and wait group showed better baseline performance status and lower tumor stages compared to those undergoing surgery. Kaplan Meier survival analysis showed a 81 % and 95 % 3-year overall survival for patients in the watch and wait group who underwent SCRT or CRT. Conclusion: This population-based nationwide study showed that over half of all non-metastasized rectal cancer patients underwent neoadjuvant treatment. The overall successful one-year organ preservation rate was 17 %, of which 2 % with the addition of local excision. The watch and wait approach has been widely adopted within the national healthcare system as an alternative to surgery for patients with a clinical complete response.