In a series of interviews, we will be previewing this year’s ACPGBI annual meeting in Dublin, 1-3 July. We talked to Professor Per Nilsson, Consultant Colorectal Surgeon and Senior Lecturer at Karolinska University Hospital, Sweden and current President of the European Society of Coloproctology. Per will deliver the Colorectal Disease Lecture on ‘Watch and wait’ and surgery for regrowth after neoadjuvant radiotherapy for rectal cancer. Here he discusses the benefits and current evidence.
“The apparent benefits of the ‘Watch and wait’ protocol is that in some patients it is possible that they will not have to undergo surgery and in a proportion of patients we can avoid a permanent stoma,” explained Professor Nilsson. “Even though it is possible to perform an anterior resection with an anastomosis to restore bowel continuity, we know that both radiotherapy and surgery do cause some functional problems. The hypothesis of watch and wait is that if a patient only receives radiotherapy the functional outcomes maybe better than if a patient has both treatments.”
According to Professor Nilsson, there is a lack of high-grade evidence, in the form of randomised controlled trials and meta-analyses, to demonstrate that watch and wait is more effective than radiotherapy and surgery. However, he stated that there is a growing body of surgical experience and evidence – such as data from case series and registries from across the world – that suggests that this approach is working.
Regarding those patients who achieve a complete clinical response and those who experience local regrowth, Professor Nilsson explained there are still many questions to be answered, such as a patient’s sensitivity to radiotherapy. Nevertheless, he added that smaller tumours have a better response and are more likely to be eradicated than larger tumours, and therefore more likely that the patient will have a complete response following radiotherapy or chemoradiotherapy than if the patient has a larger lesion. There is no evidence to suggest the location of a tumour – whether it is distal or proximal – has an impact on outcome, although it is easier to assess the response in a distal tumour, he added.
“If the patient has a smaller lesion, they have a better chance of a complete response and there is a reduced chance of regrowth, compared with a larger lesion that appears to have a complete response because the ‘perceived’ complete response, did not occur,” he said. “I would say the size of the lesion is the most important predictive factor that we have today.”
According to the literature, approximately 90-95% patients who experience local regrowth can still be treated with surgery, although there are some patients who not only develop local regrowth but also experience distal metastasis. A course of re-radiotherapy is something, he added, that is selectively used, not in the re-growth situation but in a small number of patients who have undergone pre-operative radiotherapy and surgery.
“The are some techniques that are under discussion such as local radiotherapy or contact radiotherapy that could be used on some selected patients with regrowth but those are not as yet established treatments and remain at the moment ‘experimental’ therapies. However, in the future, there could be radiation techniques that might make it possible to treat regrowth, but these techniques are still ‘developmental’ at the moment.”
Professor Nilsson stated that in Scandinavia and The Netherlands in particular, the watch and wait approach has been used more selectively in patients. Patients have received neoadjuvant therapy according to guidelines and only in those patients where a clinical complete response occurs, a watch and wait approach has been used. This selective use of wait and watch is because we try to decrease the use of pre-operative radiotherapy, as there has been a tendency to overuse pre-operative radiotherapy.
“Now, in the smaller lesions it has been suggested that we should increase our use of neoadjuvant radiotherapy with the aim of achieving a complete response, however, this is a bit of a dilemma because the same patients who you were thinking not to give radiotherapy, perhaps we should in order to achieve a complete response. However, if we increase radiotherapy for the earlier tumours not all of them will have complete response and we will have to perform surgery. They will then have received a non-beneficial neoadjuvant radiotherapy – a course of treatment that will have given them side-effects with no benefit. We have not yet figured out how to put this contradiction into practice. We need to establish new algorithms and pathways for the management of patients with T2 or T3 tumours. As a medical and cancer community, we have to challenge our existing algorithms, pathways and standards and rethink how we should approach the earlier tumours.”
He emphasised that the watch and wait approach – that is potentially very beneficial for patients – also increases the demands on both the consulting surgeon and the patient because it is very important that the patient is fully informed and educated on the treatments, possible side-effects and risks.
“Surgeons must always be well educated on all the treatments they are offering patients and have a frank and full discussion with them outlining all the options and risks – with the option of neoadjuvant radiotherapy for rectal cancer – this has increased the importance of these discussions,” he concluded. “During my presentation Dublin will focus on the importance of surveillance and detection of regrowth, as well as highlight what to do in instances of regrowth and what issues the surgeon need to pay particular attention to. I look forward to speaking at the ACPGBI meeting in July on this very important topic.”
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