Moreover, in more than half of these low rectal cancer cases - which represent 30% to 40% of all rectal cancers, that is, around two million new cases per year worldwide, according to the same 2018 estimates -, the surgery may require removal of the rectum and surrounding tissue (abdominoperineal amputation), a condition that implies permanently redirecting the colon towards an incision made in the abdomen (colostomy). In these cases, the patient is fitted for life with a "bag" to collect stools directly through that artificial orifice.

For all the above reasons, surgery is potentially a very invasive procedure in low rectal cancer. But what if there was a non-invasive option to surgery that did not put eligible patients' lives at risk? The new study shows that this may actually be the case.

Unnecessary surgery?

The Watch-and-Wait strategy for rectal cancer was pioneered by surgeon Angelita Habr-Gama at the University of São Paulo, Brazil, some 20 years ago. Habr-Gama observed that, when patients with low rectal cancer were irradiated to prepare them for surgery due to the proximity of the tumor to the anus, histology results (biopsy) of the tissue harvested during the surgery often showed absolutely no trace of cancer cells. And she wondered whether the surgery, with its cohort of potential complications and life-long impact on patients' quality of life, had actually been necessary in those cases.

In the mid-2000's, surgeons in the Netherlands started proposing the alternative protocol to eligible patients. And in 2013, the Champalimaud Clinical Center and the University of Manchester in the UK were some of the first institutions in the world to follow suit. "Today, 53 centers around the world are using the same Watch-and-Wait protocol", says Figueiredo. "And in 2013, we created the International Watch-and-Wait Database to collect all the data generated by these centers."

The protocol consists in performing, eight to ten weeks after the chemoradiotherapy course, a series of diagnostic tests before deciding if surgery is warranted. "We use clinical and radiological observations to decide whether surgery is needed or not", says Figueiredo. "We perform three exams: digital rectal examination, endoscopy and magnetic resonance imaging." And if the patient's clinical response is "complete" - that is, if the tumor does not show up in any of these exams -, the patient is then told that they can enter the Watch-and-Wait (W&W) protocol. "One hundred percent of our patients at the Champalimaud Center choose this option", Figueiredo points out.

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