“Watch-and-wait” or “Lost to follow-up”? Real-World Adherence with Surveillance for Nonoperative Management of Rectal Cancer

Abstract

Abstract Purpose Due to potential for local regrowth in patients undergoing nonoperative management (NOM) of rectal adenocarcinoma, current guidelines recommend close surveillance as part of any “watch-and-wait” paradigm. These regimens require many visits, which may impose significant burden on patients. There is a paucity of data regarding optimal frequency of examinations. We sought to determine adherence with recommended surveillance, identify predictors of poor adherence, and describe the impact of adherence on oncologic outcomes during the first two years after clinical complete response (cCR). Methods This is an analysis of a prospectively-maintained registry of rectal cancer patients, initially seen between June 2016 and October 2021, who opted for NOM following cCR after treatment with radiation and chemotherapy. Surveillance was per-protocol and entailed periodic luminal exams and cross-sectional imaging. Adherence was quantified as the percentage of recommended examinations completed annually or until local regrowth was identified. Results Of 255 patients that received radiation and chemotherapy, 107 patients were found to have cCR and met criteria for inclusion. Of these, 65 patients had a sustained cCR and were eligible for a second year of surveillance. Fifty-four patients (50.5%) were fully adherent with the minimum number of recommended surveillance exams during the first year of NOM, and 22 patients (34%) during the second year. Local regrowth was identified in 31 patients (29%), all but two of whom subsequently underwent an R0 resection. Conclusions Less than half of patients were fully adherent with the minimum number of recommended surveillance exams during the first two years of nonoperative management. Improving real-world adherence to facilitate optimal oncologic outcomes requires the least burdensome, yet safe regimen, as well as collaborative systems-based practices.