Question
The surveillance of complete responders is involved and costly and is the biggest barrier to centres offering it routinely to patients as a treatment option. Does Gina have any advice on approaching this issue? Should it remain ‘experimental’ and only offered if part of a carefully monitored programme, or can the individual clinician try to just look after a complete response patient with the standard service and system around them? Thanks
Answer
This is an excellent question. We have known for some time that a watch and wait protocol appears to be cheaper than subjecting patients to radical surgery. A recent publication from Prof. Beets group in the Netherlands has confirmed these findings1. A standard follow-up programme would involve 3-monthly clinical, endoscopic and MRI assessment for the first year, 6-monthly for the second year and annually thereafter for 5 years. The issue of whether it is “experimental” is much debated. In the UK, we would normally offer chemoradiotherapy in the neoadjuvant setting with the expectation of proceeding to surgery afterwards. However, many clinicians would counsel the patient about possible complete or near-complete responses after the first stage of treatment and what should be done if that occurs. If the clinician is up-to-date with the literature and presents the available data to the patient in an unbiased way, then I think it is perfectly reasonable to let the patient decide which specific benefits and risks are important to them. If necessary, the patient can be offered a second opinion and then be subsequently managed by a team that are experienced in watch and wait strategies. There is good evidence that even in the event of re-growths, the outcomes are good after salvage surgery2,3.
- Hupkens et al. Oncological Outcomes and Hospital Costs of the Treatment in Patients With Rectal Cancer: Watch-and-Wait Policy and Standard Surgical Treatment. Dis Colon Rectum.2020;63:598-605.
- Renehan et al. Watch-and-wait approach versus surgical resection after chemoradiotherapy for patients with rectal cancer (the OnCoRe project): a propensity-score matched cohort analysis. Lancet Oncol.2016;17:174-183.
- van der Sande et al. Management and Outcome of Local Regrowths in a Watch-and-wait Prospective Cohort for Complete Responses in Rectal Cancer. Ann Surg.2020 Feb 7.
Question
This topic generates much discussion in our MDT and your thoughts / comments would be welcomed. What is the role of adjuvant chemotherapy in (fit) patients with high risk rectal cancer who have undergone neo-adjuvant long-course chemo-radiotherapy followed by surgery and the pathological stage is now favourable and does not meet criteria for consideration of adjuvant chemotherapy (however there remains concerns regarding adverse initial radiological stage [ie T4N1/2V1])? Many thanks.
Answer
Thank you for a great question. This area remains controversial as it makes perfect sense to assess the need for adjuvant chemotherapy on the initial stage of the rectal cancer as this should represent the risk of metastatic disease. However, many trials have failed to show any benefit from additional post-operative treatment for cancers treated with neoadjuvant chemoradiotherapy and radical surgery. The issues are complex, as clinical and radiological staging are not always accurate and we know that patients tolerate chemotherapy much better in the neoadjuvant setting with many unable to tolerate any significant adjuvant therapy due to the impact of surgery. In our unit, we do not feel that adjuvant chemotherapy is this setting gives us a significant benefit to most patients, but this does depend on the age and fitness of the patient, what reposnse they’ve had to their neoadjuvant treatment and whether they have come through their surgery without complications. We feel that if at all possible, the focus for high risk rectal cancers should be on total neoadjuvant therapy, so that surgery should be the final treatment in the majority of patients.
Question
Question to Mr Wynn, I know post resection MR rectum won’t be as good as Pre resection MR, but could the clips be removed with a biopsy forceps after few days, before the Pt had MR rectum? Just a thought. Many thanks
Answer
Yes, that is possible – although I would wait for 2 weeks as most endoscopically placed clips would fall out within this period and the risk of recurrent bleeding is less. However, it is still a further intervention for the patient and if bleeding was a major issue during the initial EMR, then by definition, the polyp was relatively advanced. I think the main take-home message is to try not to interfere with a significant rectal polyp during the index endoscopy so that an accurate assessment of the tumour can be made with MRI (along with carefully taken biopsies). The presence of clips is just one factors that makes life difficult for our radiology colleagues. Sometimes polyps are removed entirely at endoscopy and the location is not clearly documented, making interpretation of the MRI impossible. Worse still, the piecemeal removal of an early cancer……remember that during the UK TEMS study in 2009, about a quarter of rectal polyps initially deemed benign actually contained an early cancer.
Question
Is there still a role for ERUS in rectal large polyps? Or should we just move definitively towards assessment-staging MRI even for large polyps in the rectum?
Answer
Yes, there is still a role for endo-rectal ultrasound for the assessment of rectal polyps. This is, however, user-dependent and as MRI gets better and better at assessing the early stages of cancer, the indications for ERUS become increasingly narrow. The differentiation between benign and T1 versus T2 cancers is still better with ERUS in experienced hands, but it will depend on local resources and the size and location of the tumour. Ultimately, the overall objective of the diagnostic phase will determine whether MRI is sufficient to answer the question being posed: Is this a big biopsy or is this potentially definitive treatment? MRI remains the first investigation of significant rectal polyps in most centres in the UK.
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