Oncologic Risk of Rectal Preservation Against Medical Advice After Chemoradiotherapy for Rectal Cancer: A Multicenter Comparative Cross-Sectional Study with Rectal Preservation as Supported by Surgeon

  • Kwang-Seop Song
  • Sung Chan Park
  • Dae Kyung Sohn
  • Jae Hwan Oh
  • Min Jung Kim
  • Ji Won Park
  • Seung-Bum Ryoo
  • Seung-Yong Jeong
  • Kyu Joo Park
  • Heung-Kwon Oh
  • Duck-Woo Kim
  • Sung-Bum KangEmail author
  • Seoul Colorectal Research Group (SECOG)
Original Scientific Report



Rectal preservation against medical advice after neoadjuvant chemoradiotherapy for rectal cancer may increase oncologic uncertainty. This study aimed to compare the oncologic outcomes of patients undergoing rectal preservation as intended by the surgeon, and the outcomes of patients refusing rectal resection against medical advice.


The study population consisted of patients in whom the rectum was preserved after neoadjuvant chemoradiotherapy for clinical stage I–III mid or low rectal cancer between May 2003 and August 2017 (n = 2883); these patients were divided into those in whom rectal preservation was intended by their surgeon (intended rectal preservation, group A, n = 41) and those in whom the rectum was not resected against medical advice (unintended rectal preservation, group B, n = 101), defined as non-operative management or local excision.


The tumor distance, age, and performance status of patients were not significantly different between the groups, while the clinical T stage before chemoradiotherapy was lower in group A than in group B (P < 0.001). During the median follow-up period of 34 months (interquartile range 18.0–72.0 months), the 3-year overall survival in group B (59.7%) was worse than that in group A (90.1%; P < 0.001), and 80.2% of group B patients had residual or unknown disease status.


This study showed that unintended rectal preservation increases oncologic risk after neoadjuvant chemoradiotherapy for rectal cancer regardless of short-term follow-up. Therefore, these findings could be shared with rectal cancer patients who choose to ignore medical advice after chemoradiotherapy to preserve their rectum.


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Human rights and informed consent

Institutional review boards of the three included hospitals reviewed this study and waived the requirement for informed consent on the basis of its retrospective design and minimal risk to the participants. However, method was conducted in accordance with the committee’s approved guidelines to protect patients’ health information.


  1. 1.
    Song JH, Jeong JU, Lee JH et al (2017) Preoperative chemoradiotherapy versus postoperative chemoradiotherapy for stage II-III resectable rectal cancer: a meta-analysis of randomized controlled trials. Radiat Oncol J. Google Scholar
  2. 2.
    Seshadri RA, Kondaveeti SS, Jayanand SB et al (2013) Complete clinical response to neoadjuvant chemoradiation in rectal cancers: can surgery be avoided? Hepatogastroenterology. Google Scholar
  3. 3.
    Appelt AL, Pløen J, Harling H et al (2015) High-dose chemoradiotherapy and watchful waiting for distal rectal cancer: a prospective observational study. Lancet Oncol 16:919–927. CrossRefGoogle Scholar
  4. 4.
    Garcia-Aguilar J, Renfro LA, Chow OS et al (2015) Organ preservation for clinical T2N0 distal rectal cancer using neoadjuvant chemoradiotherapy and local excision (ACOSOG Z6041): results of an open-label, single-arm, multi-institutional, phase 2 trial. Lancet Oncol. Google Scholar
  5. 5.
    Silberfein EJ, Kattepogu KM, Hu CY et al (2010) Long-term survival and recurrence outcomes following surgery for distal rectal cancer. Ann Surg Oncol. Google Scholar
  6. 6.
    Renehan AG, Malcomson L, Emsley R et al (2016) Watch-and-wait approach versus surgical resection after chemoradiotherapy for patients with rectal cancer (the OnCoRe project): a propensity-score matched cohort analysis. Lancet Oncol. Google Scholar
  7. 7.
    Rullier E, Rouanet P, Tuech JJ et al (2017) Organ preservation for rectal cancer (GRECCAR 2): a prospective, randomised, open-label, multicentre, phase 3 trial. Lancet. Google Scholar
  8. 8.
    Maas M, Lambregts DMJ, Nelemans PJ et al (2015) Assessment of clinical complete response after chemoradiation for rectal cancer with digital rectal examination, endoscopy, and MRI: selection for organ-saving treatment. Ann Surg Oncol. Google Scholar
  9. 9.
    Perez RO, Habr-Gama A, Pereira GV et al (2012) Role of biopsies in patients with residual rectal cancer following neoadjuvant chemoradiation after downsizing: can they rule out persisting cancer? Color Disease. Google Scholar
  10. 10.
    Ellis CT, Samuel CA, Stitzenberg KB (2017) Innovation or disparity? National trends in nonoperative management of rectal adenocarcinoma. J Clin Oncol. Google Scholar
  11. 11.
    Wang Y, Cummings B, Catton P et al (2005) Primary radical external beam radiotherapy of rectal adenocarcinoma: long term outcome of 271 patients. Radiother Oncol. Google Scholar
  12. 12.
    Kang SB, Park JW, Jeong SY et al (2010) Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): Short-term outcomes of an open-label randomised controlled trial. Lancet Oncol. Google Scholar
  13. 13.
    Yoo S-G, Oh JH, Kim DY et al (2013) Preoperative short-course concurrent chemoradiation therapy followed by delayed surgery for locally advanced rectal cancer: a phase 2 multicenter study (KROG 10-01). Int J Radiat Oncol Biol Phys 86:34–39CrossRefGoogle Scholar
  14. 14.
    Lee JH, Kim JG, Oh ST et al (2014) Two-week course of preoperative chemoradiotherapy followed by delayed surgery for rectal cancer: a phase II multi-institutional clinical trial (KROG 11-02). Radiother Oncol 110:150–154. CrossRefGoogle Scholar
  15. 15.
    Yeo SG, Kim DY, Kim TH et al (2010) Local excision following pre-operative chemoradiotherapy-induced downstaging for selected cT3 distal rectal cancer. Jpn J Clin Oncol. Google Scholar
  16. 16.
    Habr-Gama A, Perez RO, Nadalin W et al (2004) Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results. Ann Surg 240:711Google Scholar
  17. 17.
    Han KS, Sohn DK, Kim DY et al (2016) Endoscopic criteria for evaluating tumor stage after preoperative chemoradiation therapy in locally advanced rectal cancer. Cancer Res Treat. Google Scholar
  18. 18.
    Habr-Gama A, Perez RO, São Julião GP et al (2011) Factors affecting management decisions in rectal cancer in clinical practice: results from a national survey. Tech Coloproctol. Google Scholar
  19. 19.
    São Julião GP, Smith FM, Macklin CP et al (2014) Opinions have changed on the management of rectal cancer with a complete clinical response to neoadjuvant chemoradiotherapy. Color Disease. Google Scholar
  20. 20.
    Landrum MB, Keating NL, Lamont EB et al (2012) Reasons for underuse of recommended therapies for colorectal and lung cancer in the veterans health administration. Cancer. Google Scholar
  21. 21.
    Keating NL, Landrum MB, Klabunde CN et al (2008) Adjuvant chemotherapy for stage III colon cancer: do physicians agree about the importance of patient age and comorbidity? J Clin Oncol. Google Scholar
  22. 22.
    Rogers SO, Gray SW, Landrum MB et al (2010) Variations in surgeon treatment recommendations for lobectomy in early-stage non-small-cell lung cancer by patient age and comorbidity. Ann Surg Oncol. Google Scholar
  23. 23.
    Margolis ML, Christie JD, Silvestri GA et al (2003) Racial differences pertaining to a belief about lung cancer surgery: results of a multicenter survey. Ann Intern Med. Google Scholar
  24. 24.
    Gordon HS, Street RL, Sharf BF et al (2006) Racial differences in trust and lung cancer patients’ perceptions of physician communication. J Clin Oncol. Google Scholar
  25. 25.
    Cykert S, Dilworth-Anderson P, Monroe MH et al (2010) Factors associated with decisions to undergo surgery among patients with newly diagnosed early-stage lung cancer. J Am Med Assoc. Google Scholar
  26. 26.
    Habr-Gama A, Smith FM, Oliva Perez R et al (2015) Avoiding radical surgery improves early survival in elderly patients with rectal cancer, demonstrating complete clinical response after neoadjuvant therapy. Dis Colon Rectum. Google Scholar
  27. 27.
    Oh BY, Huh JW, Lee WY et al (2018) Are we predicting disease progress of the rectal cancer patients without surgery after neoadjuvant chemoradiotherapy? Cancer Res Treat. Google Scholar
  28. 28.
    Abrams MJ, Koffer PP, Leonard KL (2016) The emerging non-operative management of non-metastatic rectal cancer: a population analysis. Anticancer Res 36:1699–1702Google Scholar
  29. 29.
    Cassidy RJ, Switchenko JM, Cheng E et al (2017) Health care disparities among octogenarians and nonagenarians with stage II and III rectal cancer. Cancer. Google Scholar
  30. 30.
    Lee DY, Teng A, Pedersen RC et al (2017) Racial and socioeconomic treatment disparities in adolescents and young adults with stage II–III rectal cancer. Ann Surg Oncol. Google Scholar
  31. 31.
    Smith JJ, Garcia-Aguilar J (2015) Advances and challenges in treatment of locally advanced rectal cancer. J Clin, OncolCrossRefGoogle Scholar
  32. 32.
    Stijns RCH, Tromp MSR, Hugen N, de Wilt JHW (2018) Advances in organ preserving strategies in rectal cancer patients. Eur J Surg, OncolCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2019

Authors and Affiliations

  • Kwang-Seop Song
    • 1
  • Sung Chan Park
    • 1
  • Dae Kyung Sohn
    • 1
  • Jae Hwan Oh
    • 1
  • Min Jung Kim
    • 2
  • Ji Won Park
    • 2
  • Seung-Bum Ryoo
    • 2
  • Seung-Yong Jeong
    • 2
  • Kyu Joo Park
    • 2
  • Heung-Kwon Oh
    • 3
  • Duck-Woo Kim
    • 3
  • Sung-Bum Kang
    • 3
    Email author
  • Seoul Colorectal Research Group (SECOG)
  1. 1.Center for Colorectal Cancer, Research Institute and HospitalNational Cancer CenterGoyangRepublic of Korea
  2. 2.Department of Surgery, Seoul National University College of MedicineSeoul National University HospitalSeoulRepublic of Korea
  3. 3.Department of Surgery, Seoul National University College of MedicineSeoul National University Bundang HospitalSeongnamRepublic of Korea

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