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Non-operative Management (NOM) of Rectal Cancer: Literature Review and Translation of Evidence into Practice

  • Radiation Therapy and Radiation Therapy Innovations in Colorectal Cancer (P Lee and A Raldow, Section Editors)
  • Published:
Current Colorectal Cancer Reports

Abstract

Purpose of Review

Despite mounting interest in the non-operative management (NOM, also known as watchful waiting) of rectal adenocarcinoma, limited guidance exists regarding appropriate patient selection and procedures. In this literature review targeting patients with operable adenocarcinoma of the rectum, we sought to evaluate NOM in terms of patient selection, management approaches, and outcomes with regard to both quality of life (QoL) and oncologic outcomes.

Recent Findings

Despite a lack of randomized evidence comparing NOM (performed via active surveillance following neoadjuvant chemotherapy and radiation) to neoadjuvant therapy followed by planned surgery, given that the vast majority of local, regional, and distant recurrences occur early in follow-up, the available evidence points to similar oncologic outcomes and possible QoL improvement. Due to the high chance of surgical salvage in the case of locoregional recurrence, close multidisciplinary follow-up is essential.

Conclusions

Under the care of an experienced multidisciplinary lower gastrointestinal team, NOM is feasible, is safe, and has the potential for improved QoL. A potential algorithm for clinically implementing NOM is described within this review.

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Abbreviations

5-FU:

Fluorouracil

ADC:

Apparent diffusion coefficient

CAPOX:

Capecitabine and oxaliplatin

CEA:

Carcinogenic embryonic antigen

cCR:

Complete clinical response

CRT:

Chemoradiation

CT:

Computed tomography

CTV:

Clinical target volume

CXB:

Contact brachytherapy

DRE:

Digital rectal exam

DWI:

Diffusion-weighted imaging

EMVI:

Extramural vascular invasion

FOLFOX:

Folinic acid, 5-FU, oxaliplatin

GTV:

Gross tumor volume

HDR:

High-dose rate

LE:

Local excision

LCRT:

Long-course chemoradiation

MRI:

Magnetic resonance imaging

NOM:

Non-operative management

pCR:

Pathologic complete response

PICOS:

Population, Intervention, Comparator, Outcome, and Study design

PRISMA-S:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses Literature Search Extension

PRO:

Patient-reported outcome

PTV:

Planning target volume

QoL:

Quality of life

RT:

Radiation therapy

RCT:

Randomized controlled trial

TEM:

Transanal endoscopic microsurgery

TME:

Total mesorectal excision

TNT:

Total neoadjuvant therapy

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Acknowledgments

We would like to thank Rebecca Wilcox, MD, Director of Gastrointestinal Pathology at the University of Vermont, for her thorough read of this manuscript’s first draft.

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Authors and Affiliations

  1. Division of Radiation Oncology, University of Vermont Larner College of Medicine, Burlington, VT, USA

    Christopher J. Anker & Nataniel H. Lester-Coll

  2. University of Vermont Cancer Center, 111 Colchester Ave., Burlington, VT, 05401, USA

    Christopher J. Anker, Steven Ades, Nataniel H. Lester-Coll & Peter A. Cataldo

  3. Department of Radiology, University of Vermont Larner College of Medicine, Burlington, VT, USA

    Dmitriy Akselrod

  4. Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT, USA

    Steven Ades

  5. Dana Medical Library, Department of Reference and Education, University of Vermont, Burlington, VT, USA

    Nancy A. Bianchi

  6. Department of Surgery, University of Vermont Larner College of Medicine, Burlington, VT, USA

    Peter A. Cataldo

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  1. Christopher J. Anker
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Correspondence to Christopher J. Anker.

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Appendices

Appendix 1. Literature search strategy for non-operative management (NOM) of rectal adenocarcinoma

figure a

Appendix 2. Study selection flowsheet for the non-operative treatment (NOM) of rectal adenocarcinoma

figure b

Appendix 3

Table 4 PRISMA-S Checklist
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Anker, C.J., Akselrod, D., Ades, S. et al. Non-operative Management (NOM) of Rectal Cancer: Literature Review and Translation of Evidence into Practice. Curr Colorectal Cancer Rep 17, 23–41 (2021). https://doi.org/10.1007/s11888-020-00463-2

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