Non-operative management of rectal cancer: Highlighting the controversies

Abstract

There remains much ambiguity on what non-operative management (NOM) of rectal cancer truly entails in terms of the methods to be adopted and the best algorithm to follow. This is clearly shown by the discordance between various national and international guidelines on NOM of rectal cancer. The main aim of the NOM strategy is organ preservation and avoiding unnecessary surgical intervention, which carries its own risk of morbidity. A highly specific and sensitive surveillance program must be devised to avoid patients undergoing unnecessary surgical interventions. In many studies, NOM, often interchangeably called the Watch and Wait strategy, has been shown as a promising treatment option when undertaken in the appropriate patient population, where a clinical complete response is achieved. However, there are no clear guidelines on patient selection for NOM along with the optimal method of surveillance.

Keywords: Non-operative; Management; Rectal cancer; Highlighting; Controversies

Core Tip: Patients with locally advanced rectal cancers are ideally treated with neoadjuvant chemoradiation therapy followed by surgical resection. As neoadjuvant treatments evolved, an increasing number of patients showed a complete response to neoadjuvant therapy. The complete response of rectal cancers to neoadjuvant treatment inspired the concept of non-operative management (NOM). Following extensive multidisciplinary team meeting discussion, patients can be considered for NOM. Questions arose regarding patient selection for NOM and the best surveillance program to ensure no red flags for recurrent disease. Another consideration is how patients who develop recurrence be managed.