Intended for healthcare professionals

Practice Uncertainties

Is “watch-and-wait” after chemoradiotherapy safe in patients with rectal cancer?

BMJ 2018; 363 doi: (Published 13 November 2018) Cite this as: BMJ 2018;363:k4472
  1. Fraser M Smith, consultant general/colorectal surgeon, and chair of Cheshire and Mersey Contact Therapy/Watch and Wait MDT1 4,
  2. Katharine Cresswell, patient and public involvement and engagement project manager2,
  3. Arthur Sun Myint, consultant clinical oncologist and lead clinician in the Papillon Suite, and honorary professor, University of Liverpool3 4,
  4. Andrew G Renehan, professor of cancer studies and surgery, and consultant in colorectal and peritoneal surgery5 6
  1. 1Department of Surgery, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
  2. 2NIHR Biomedical Research Centre Patient and Public Cancer Research Advisory Group, Public Programmes Team, Manchester University NHS Foundation Trust; and Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
  3. 3Clatterbridge Cancer Centre, Bebington, Wirral, UK
  4. 4Institute of Translational Medicine, University of Liverpool, Liverpool, UK
  5. 5Manchester Cancer Research Centre, NIHR Manchester Biomedical Research Centre, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
  6. 6Colorectal and Peritoneal Oncology Centre, Christie NHS Foundation Trust, Manchester, UK
  1. Correspondence to: F M Smith fraser.smith{at}

What you need to know

  • After standard long-course chemoradiotherapy for locally advanced rectal cancer, up to a quarter of patients have no clinically apparent tumour—referred to as a clinical complete response

  • Evidence from observational studies suggests these patients can be considered for a “watch-and-wait” approach with regular surveillance to avoid major surgery

  • Up to a third of patients on a watch-and-wait programme develop tumour regrowth and require salvage surgery; the long term outcomes are uncertain

Colorectal cancer is the third commonest cancer worldwide.1 About a third of these arise in the rectum. Approximately a third of rectal cancers are locally advanced and at high risk of recurrence. Long-course chemoradiotherapy followed by surgical resection is now standard treatment for these tumours in the UK,23 Europe,4 the US,5 and Australia.6 However, surgery is associated with major complications (up to 15%), perioperative mortality (up to 5%), and the need for a permanent stoma in up to a quarter of patients.7

Within the published literature, after chemoradiotherapy 10-25% of patients have no residual tumour on pathological examination after surgical resection.78910 Clinical examination before surgery in these patients has shown an equivalent favourable response, referred to as a clinical complete response. The criteria for defining a clinical complete response include absence of residual ulceration, stenosis, or mass within the rectum during digital rectal examination and endoscopic examination (fig 1).910

Fig 1

Endoscopic images of rectum after chemoradiotherapy for rectal cancer show (A) “white” scar (circled) and (B) telangiectasia changes (arrow). Both are accepted as “normal” and are compatible with a clinical complete response

Nearly 15 years ago, a seminal study from a centre in São Paulo, Brazil reported that 71 patients with clinical complete response were managed without initial surgery. Instead they were managed by a non-surgical “watch-and-wait” …

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