Question
How to manage a patient without cCR following LC-CRT who wishes to pursue W+W against medical advice (which in my experience is becoming an increasingly common issue)?
Answer
Answered by Greg Wynn:
I agree this scenario is more common than it used to be – and for good reason. I suppose the key issue here is trying to quantify the chance of achieving a clinical complete response. Sometimes this only becomes clear after the initial period of watch and wait. The principles are set out below, but the key is good communication and guiding the patient through the different possible outcomes of management whilst addressing what they are likely to do in each setting. Patients will need to be properly informed of the risks involved and this will need to be documented clearly with copies sent to the patient. Regular review of this decision-making pathway and the underlying rationale for this is necessary in addition to the regular clinical follow-up.
- Discuss trials like TRIGGER that might allow the patient to pursue their goals whilst having the security of research monitoring.
- Offer a second opinion from a trusted colleague and/or transfer care to a clinician with a specialist interest in the area.
- Assuming that there has been a good on-going response to chemoradiotherapy (at least MRTRG2 on the 12 week post-treatment MRI), then a watch and wait strategy is reasonable so long as clinical and endoscopic findings correlate with the scans.
- On-going assessments with MRI and endoscopy, performed and reviewed by the same clinician, 3-monthly for the first year, 6 monthly during the second year and annually thereafter, assuming no evidence of re-growth.
- Have a clear plan for suspicion of regrowth. Local excision should be reserved for those unfit or unwilling to consider radical surgery. Exenteration may have to be considered, but outcomes for salvage are generally good if intervention is timely.
Answered by Fraser Smith:
There are a number of issues here.
Where has this patient read about or heard about W+W? It would be important to analyse the source of their information and see why it has made them so strongly opposed to surgery.
Why does the patient not want radical surgery? Is there one thing in particular that scares them? Are they stoma averse – if so why? Have they seen a stoma nurse? Sometimes pts do not understand that modern stoma technology is vastly improved from stomas they may have seen in elderly relative etc.
Do they actually need a permanent stoma – some people could be referred to a centre of expertise in coloanal anastomoses and thus spared an APR.
Have they been counselled on the potential worse QoL with a coloanal vs an APR and permanent colostomy?
Have they been told about colostomy irrigation and the ability not to wear a full stoma bag at all times?
Who has said they do not have a complete response? Although the classical Habr Gama cCR is largely understood to be the only definition of cCR, other groups have also included patients with shallow ulcers or features otherwise consistent with incomplete response. Who has done the assessment – is it a person with a special interest in W+W or a duty endoscopist that does not understand the process?
How long after nCRT has the response been assessed? Features can change over time.
Lastly, even when all of the above has been explored and explained – some people just do not want surgery. In that case, as long as you have counselled the patient and explained that if the tumour continues to grow if may affect their outcome or lead to more extensive surgery such as extent or even make them inoperable, then at the end of the day it is their choice.
I would recommend sending them for a second opinion to an “expert” in W+W as this may influence their decision making.
Question
What would you do in Middle rectal cancer, young patient with partial response (ulcer with fibrosis) in a 50 years old patient at 12 weeks after Long course Neoadjuvant Chemoradiotherapy?
Answer
Answered by Greg Wynn:
The gold-standard for residual mucosal abnormalities would be radical surgery in this scenario, but as always, the patient should be informed as to the possibility of an evolving complete clinical response and the balance of risks that an operative versus a non-operative approach might pose to that particular patient. Local excision would only be considered at a later stage if re-growth was suspected and the patient was not suitable for radical surgery. Following full discussion and clear documentation, a patient wanted to pursue a watch and wait strategy, then I refer you to the answer above.
Answered by Fraser Smith:
Issue here from a watch and wait point of view is that mid rectal likely unable to do DRE. Some groups do include shallow ulcers as possible cCr as long as MR TRG looks favourable and the patient understands fully that it is an inexact science. The difficulty here is that pathology studies have shown that in patients with residual ulcers there may also be significant residual disease and it is a less sensitive and specific endpoint than true cCR, however there is no 100% guarantee of pCR with any method – bear in mind that there is an approximate 30% regrowth even with cCR. So in this case, the patient has resectable disease that should not need a permanent stoma. It is the role of the clinician to discuss the risks and benefits of surgery vs W+W in this scenario and allow the patient to make a choice. I think it would be important to state that at present the main body of data uses only complete response, rather than partial response, as the criterion to offer watch and wait. Again, should the patient be motivated to consider W+W in this scenario then referral to an “expert centre” for a second opinion/ discussion in a scenario would be advised.
Question
How does contact RT differ from brachytherapy and why is it not considered as primary Rx for the rectal cancer (since can deliver up to 30gy locally) rather than for residual disease post NCRT?
Answer
Answered by Fraser Smith:
Contact radiotherapy is actually a form of brachytherapy except it uses low energy X rays rather than radioactivity. Contact therapy can be used as primary treatment for small early cancers with or without additional external beam in patients who refuse or who are too medically unfit for surgery and indeed is in the UK NICE criteria for this. The reason it cannot be used for all rectal cancers is the maximum size of the treatment applicator is 3cm and so it cannot include larger cancers. Also, the depth of penetration is limited and so while it gives massive doses of radiation in the 1st cm or so, it falls off significantly. The advantage of this though is that it spares surrounding tissues, unlike external beam – which is why much higher doses of radiation can be used with contact therapy.
A further advantage of contact therapy over HDR brachy is that it can be given in an outpatient ambulatory setting, treatment takes about 2 minutes and is generally more comfortable for patients. HDR brachy needs to be done in theatre, takes longer and is generally reserved for tumours >3cm or more bulky disease.
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