@article{18d649effb86462d84ac482a28b770f9,
title = "Nationwide implementation of Watch-and-Wait in rectal cancer patients in the Netherlands: Encountered barriers and lessons learned in 20 years",
abstract = "Background: The Watch-and-Wait (W\&W) approach for rectal cancer aims to improve quality of life by avoiding total mesorectal excision in patients with a clinical complete response after neoadjuvant treatment. Over the past two decades, W\&W has gained increasing acceptance and is now incorporated into several national guidelines. However, successful and safe implementation outside highly specialised centres encounters barriers at multiple levels. Objective: To describe the nationwide implementation of the W\&W strategy for rectal cancer in the Netherlands and to identify key barriers at policy, institutional, and patient levels. Methods: This article outlines the nationwide implementation of the W\&W strategy in the Netherlands, highlighting the encountered barriers at policy, institutional and patient levels. Results: W\&W evolved from an innovative approach in specialised {\textquoteleft}expert{\textquoteright} centres to a nationally recognised treatment offered across 18 high-volume hospitals. This was achieved by systematically addressing barriers at each level. Policy-level barriers, such as the absence of standardised criteria for response assessment and follow-up, were addressed by developing MRI and endoscopy guidelines and structured surveillance protocols. Institutional-level barriers, including logistical challenges and financial incentives favouring surgery, were overcome through intensive multidisciplinary collaboration. At patient level, shared decision-making was key to align patient preferences with oncological safety, while careful patient selection supported optimal outcomes. Conclusion: The Dutch experience demonstrates that implementation of W\&W is feasible and sustainable when guided by expert centres and supported by national protocols, collaboration, and quality assurance. These lessons may support other countries in integrating organ-preserving strategies into standard rectal cancer care.",
keywords = "Nationwide implementation, Organ preservation, Rectal cancer, Watch-and-Wait",
author = "C. Ceuppens and Grotenhuis, \{B. A.\} and Lambregts, \{D. M.J.\} and M. Maas and Geubels, \{B. M.\} and Beets-Tan, \{R. G.H.\} and Beets, \{G. L.\} and Huibregtse, \{I. L.\} and \{van Leerdam\}, M. and \{van Triest\}, B. and J. Melenhorst and Breukink, \{S. O.\} and Sonneveld, \{D. J.A.\} and \{van den Broek\}, \{J. J.\} and Peeters, \{K. C.M.J.\} and Boonstra, \{J. J.\} and \{van Westreenen\}, \{H. L.\} and \{de Vos Tot Nederveen Cappel\}, \{W. H.\} and Burger, \{J. W.A.\} and Bloemen, \{J. G.\} and Talsma, \{A. K.\} and Bosker, \{R. B.\} and Tuynman, \{J. B.\} and R. Hompes and C. Hoff and Koopal, \{S. A.\} and A. Pronk and Schiphorst, \{A. H.W.\} and \{de Wilt\}, \{J. H.W.\} and Bremers, \{A. J.A.\} and Wasowicz, \{D. K.\} and Zimmerman, \{D. D.E.\} and Schreurs, \{W. H.\} and Dunker, \{M. S.\} and M. Vermaas and Doornebosch, \{P. G.\} and Martijn, \{M. P.W.Intven\} and Crolla, \{R. M.P.H.\} and S. Festen and M. Verseveld and R. Roomer and E. Verdaasdonk and Brokelman, \{W. J.A.\} and \{Dutch Watch-and-Wait Consortium\}",
note = "Funding Information: A key barrier during the early implementation phase was the lack of infrastructure for central image review and standardised quality assurance, resulting in variation in interpretation and limited feedback mechanisms. A national image-exchange platform was used to set up a system for second reading of restaging MRI scans by an expert radiologist at the principal expert centre after initial assessment by the local radiologist. During the first year the central review was performed systematically, and thereafter upon request by the local team, in the case of equivocal diagnosis. Additional to response assessment, image quality was also evaluated and structured feedback was provided where relevant, for educational purposes. The same process was applied to flexible sigmoidoscopy, for which local endoscopists were instructed to capture and send at least five images of the residual lesion or scar. The MRI and endoscopic findings after central expert reassessment were shared with the local centre. In cases of diagnostic uncertainty, patients were referred to the expert centre for in-person assessment. To support consistent adoption, the principal expert centre conducted a site visit at the initiation, and sometimes also later on at the request of either the participating centre or the coordinating centre. Other aspects of quality assurance included annual meetings with the participating centres to share their experience, to evaluate difficult cases and to review scientific updates. To ensure high-quality implementation of W\&W and adherence to standardised protocols, a structured audit and benchmarking system was deemed to be essential [ 17 ]. In the Netherlands, this was centrally coordinated through the dedicated implementation project funded by the Dutch Cancer Society (KWF). Publisher Copyright: {\textcopyright} 2026 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license. http://creativecommons.org/licenses/by/4.0/",
year = "2026",
month = jul,
day = "1",
doi = "10.1016/j.healthpol.2026.105622",
language = "English",
volume = "169",
journal = "Health Policy",
issn = "0168-8510",
publisher = "Elsevier Ireland Ltd",
}