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Diseases of the Colon & Rectum Volume 58: 8 (2015)
Do We Practice What We Preach With Complete Responders in Rectal Cancer? To the Editor—There is a lack of conclusive long-term studies evaluating risk and benefit in the surgical management of complete pathological response to rectal cancer. The trend in practice is becoming increasingly conservative, especially with an ageing population with increasing comorbidity, with recent data supporting a "watch and wait" approach to complete responders. Decision-analytical modeling predicted no difference in survival in 60-year-old male patients between those managed conservatively and operatively. More interestingly, they predicted a significant improvement in absolute survival in 80-year-old patients managed conservatively.1 Given the trend of the current evidence, we aimed to determine the regional practice in Merseyside. We questioned whether increased age and/or comorbidity influenced the surgeon's decision when complete pathological response was detected. A questionnaire was submitted to all the colorectal cancer surgeons within the greater Merseyside region, in the north west of England. The participants were asked for their practice in managing 3 patient cohorts (60, 70, and 80 years of age) with complete pathological response and of varying comorbid status. They were then asked for their preference should they be faced with the same clinical scenario personally. Ten colorectal cancer units with 33 colorectal surgeons were surveyed. The response rate was 23/33 (70%). Five percent of surgeons would offer surgery to 70- to 80-year-old patients with multiple comorbidities, whereas 22% would if the patient was 60 years of age. Twentyseven percent of surgeons would offer surgery to patients who were 80 years of age who had no medical comorbidities, and 55% would if they were 60 years of age with no comorbidities. Sixty-six percent of surgeons would not want any surgery if they personally had a completely responding rectal cancer. Forty-four percent would want different treatment from what they would offer their patients. One surgeon would not routinely offer surgery but would personally want it. Patients with complete pathological response get different treatment according to surgeon preference in Merseyside. Forty-four percent of surgeons would advise their patients something they would not choose should they be faced personally with the same scenario. More study into the long-term risk and benefit of surgical vs conservative management of complete responders is required so that surgeons can offer a more evidence-based treatment for the patient, a treatment they would wish for themselves.
REFERENCE 1. Smith FM, Rao C, Oliva Perez R, et al. Avoiding radical surgery improves early survival in elderly patients with rectal cancer, demonstrating complete clinical response after neoadjuvant therapy: results of a decision-analytic model. Dis Colon Rectum. 2015;58:159–171.
H. M. Joshi, M.R.C.S.(Engl.) N. Ormsby, M.R.C.S. R. Rajaganeshan, M.D., F.R.C.S.(Gen. Surg.) Liverpool, Merseyside, United Kingdom
The Author Replies To the Editor—I was delighted and fascinated to read your interesting study based on our recent publication in Diseases of the Colon & Rectum.1 First, it is of interest that such a high proportion of surgeons in Merseyside would not offer surgery to patients in any of the age and comorbidity categories that you describe, when surgery is probably still regarded as standard of care internationally in this context. Interestingly, a recent questionnaire-based study of UK surgeons that I was involved in showed that between 2007 and 2013 the number of surgeons likely to offer "watch and wait" to apparent complete clinical response had risen from 42% to 78%.2 This shows that the technique seems to be gaining general acceptance in the UK despite its controversial status. What your study does not allude to is the proportion of patients who were informed about "watch and wait" as an option at the time of diagnosis and as a part of their informed consent process. Informing patients at an early time point would potentially allow them to be placed into trials of more intensive neoadjuvant regimes aimed at increasing the rates of response3 and allow the administration of radiation +/– chemotherapy in earlier rectal cancers that would otherwise not receive this. In particular, your locality to the world expert in this area, Professor Arthur Sun Myint at the Clatterbridge Cancer Centre, would facilitate the use of contact radiation therapy either definitively or as a boost in addition to standard treatment.4 What is also very interesting from your study is that 44% of surgeons would advise patients to have a procedure that they would not have themselves! Maybe the take-home message from your study is that it is the patients and not their surgeon who should decide to be treated by "watch and wait" and that informed consent about this as a treatment option should be standard of care to all patients with rectal cancer right at the start of their cancer pathway to give them this choice.5 My own opinion after the publication of our statistical model is that it is a technique most suitable for elderly and comorbid patients and motivated patients of all ages who would like to avoid an abdominoperineal resection at
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
D
Diseases of the Colon & Rectum Volume 58: 8 (2015)
Do We Practice What We Preach With Complete Responders in Rectal Cancer? To the Editor—There is a lack of conclusive long-term studies evaluating risk and benefit in the surgical management of complete pathological response to rectal cancer. The trend in practice is becoming increasingly conservative, especially with an ageing population with increasing comorbidity, with recent data supporting a "watch and wait" approach to complete responders. Decision-analytical modeling predicted no difference in survival in 60-year-old male patients between those managed conservatively and operatively. More interestingly, they predicted a significant improvement in absolute survival in 80-year-old patients managed conservatively.1 Given the trend of the current evidence, we aimed to determine the regional practice in Merseyside. We questioned whether increased age and/or comorbidity influenced the surgeon's decision when complete pathological response was detected. A questionnaire was submitted to all the colorectal cancer surgeons within the greater Merseyside region, in the north west of England. The participants were asked for their practice in managing 3 patient cohorts (60, 70, and 80 years of age) with complete pathological response and of varying comorbid status. They were then asked for their preference should they be faced with the same clinical scenario personally. Ten colorectal cancer units with 33 colorectal surgeons were surveyed. The response rate was 23/33 (70%). Five percent of surgeons would offer surgery to 70- to 80-year-old patients with multiple comorbidities, whereas 22% would if the patient was 60 years of age. Twentyseven percent of surgeons would offer surgery to patients who were 80 years of age who had no medical comorbidities, and 55% would if they were 60 years of age with no comorbidities. Sixty-six percent of surgeons would not want any surgery if they personally had a completely responding rectal cancer. Forty-four percent would want different treatment from what they would offer their patients. One surgeon would not routinely offer surgery but would personally want it. Patients with complete pathological response get different treatment according to surgeon preference in Merseyside. Forty-four percent of surgeons would advise their patients something they would not choose should they be faced personally with the same scenario. More study into the long-term risk and benefit of surgical vs conservative management of complete responders is required so that surgeons can offer a more evidence-based treatment for the patient, a treatment they would wish for themselves.
REFERENCE 1. Smith FM, Rao C, Oliva Perez R, et al. Avoiding radical surgery improves early survival in elderly patients with rectal cancer, demonstrating complete clinical response after neoadjuvant therapy: results of a decision-analytic model. Dis Colon Rectum. 2015;58:159–171.
H. M. Joshi, M.R.C.S.(Engl.) N. Ormsby, M.R.C.S. R. Rajaganeshan, M.D., F.R.C.S.(Gen. Surg.) Liverpool, Merseyside, United Kingdom
The Author Replies To the Editor—I was delighted and fascinated to read your interesting study based on our recent publication in Diseases of the Colon & Rectum.1 First, it is of interest that such a high proportion of surgeons in Merseyside would not offer surgery to patients in any of the age and comorbidity categories that you describe, when surgery is probably still regarded as standard of care internationally in this context. Interestingly, a recent questionnaire-based study of UK surgeons that I was involved in showed that between 2007 and 2013 the number of surgeons likely to offer "watch and wait" to apparent complete clinical response had risen from 42% to 78%.2 This shows that the technique seems to be gaining general acceptance in the UK despite its controversial status. What your study does not allude to is the proportion of patients who were informed about "watch and wait" as an option at the time of diagnosis and as a part of their informed consent process. Informing patients at an early time point would potentially allow them to be placed into trials of more intensive neoadjuvant regimes aimed at increasing the rates of response3 and allow the administration of radiation +/– chemotherapy in earlier rectal cancers that would otherwise not receive this. In particular, your locality to the world expert in this area, Professor Arthur Sun Myint at the Clatterbridge Cancer Centre, would facilitate the use of contact radiation therapy either definitively or as a boost in addition to standard treatment.4 What is also very interesting from your study is that 44% of surgeons would advise patients to have a procedure that they would not have themselves! Maybe the take-home message from your study is that it is the patients and not their surgeon who should decide to be treated by "watch and wait" and that informed consent about this as a treatment option should be standard of care to all patients with rectal cancer right at the start of their cancer pathway to give them this choice.5 My own opinion after the publication of our statistical model is that it is a technique most suitable for elderly and comorbid patients and motivated patients of all ages who would like to avoid an abdominoperineal resection at
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
D
