Is surgery necessary for all patients with rectal cancer who respond to chemoradiation?—No.
Neoadjuvant chemoradiotherapy (CRT) has become the standard of care in T3/T4 or node-positive rectal cancer, with multiple trials demonstrating the advantage of preoperative chemoradiotherapy vs postoperative treatment both in terms of better long-term local control and less toxic effects of chemoradiotherapy. Across the literature the rate of complete pathologic response (pCR) after preoperative chemoradiotherapy has been reported up to 30%.1,2 Undoubtedly therefore, there is a significant group of patients who demonstrate complete clinical response (cCR) after CRT, as defined by no evidence of tumor on clinical, endoscopic, or radiological examinations. Traditionally, such patients would still undergo radical rectal excision and be congratulated when the subsequent pathologic results revealed no residual tumor. However, for some people, this sequence of events seemed problematic, and the appropriateness of such high morbidity surgical intervention was called into question. This issue of watch and wait strategy as opposed to radical surgery in this group has been heavily debated in the literature.
Monson JRT, Arsalanizadeh R. Surgery for Patients With Rectal Cancer—Time to Listen to the Patients and Recognize Reality. JAMA Oncol. Published online December 22, 2016. doi:10.1001/jamaoncol.2016.5380