“Watch-and-wait” or “Lost to Follow-up”? Adherence to Nonoperative Management of Rectal Cancer

Introduction: Due to potential for local regrowth in patients undergoing nonoperative management (NOM) of rectal adenocarcinoma, current guidelines recommend offering close surveillance in a “watch-and-wait” paradigm. These regimens require many visits, potentially posing significant burden on patients. There is a paucity of data regarding optimal frequency of examinations. We sought to determine adherence to recommended surveillance, identify predictors of poor adherence, and evaluate its association with on oncologic outcomes during the first 2 y after clinical complete response (cCR). Methods: We analyzed a prospectively maintained registry of rectal cancer patients who opted for NOM following cCR after treatment with radiation and chemotherapy between June 2016 and 2021. Surveillance was per-protocol and entailed periodic luminal exams and cross-sectional imaging. Adherence was quantified as the percentage of recommended examinations completed annually or until local regrowth. Results: Of 255 patients treated with radiation and chemotherapy, 107 patients achieved cCR and met inclusion criteria. Sixty-five had a sustained cCR and were eligible for a second year of surveillance. Fifty-four patients (50.5%) were fully adherent with the minimum number of recommended surveillance exams in the first year of NOM, and 22 (34%) in the second. Local regrowth was identified in 32 patients (30%), of whom 29 underwent surgery, with all but 1 achieving an R0 resection. Conclusions: Less than half of patients adhered fully to recommended surveillance exams in the first 2 y of NOM. Improving real-world adherence to NOM surveillance requires a regimen that balances oncologic safety with patient burden, alongside collaborative systems-based practices.