Exploring perceptions, barriers, and facilitators to non-operative management of rectal cancer: Developing a “Watch and Wait” approach

Lead Researcher(s):  Frances Wright

Lead Institution: Sunnybrook Research Institute

Co-Investigators: Andrea M. Covelli, Erin Kennedy, Fayez A. Quereshy

ARCC Program Area(s): Health Systems, Services, and Policy

Funding Term: 2018-2019

Project Summary:

The standard of care for stage 2/3 rectal cancer is neoadjuvant chemo-radiation, followed by proctectomy. Post-operative complications can include anastomotic leak, anorectal, urinary, and sexual dysfunction, all of which potentially decrease patients’ overall quality of life.  Studies have shown that 15-25% of patients have a complete clinical response after completion of neoadjuvant therapy, which has led some clinicians to endorse non-operative management (NOM) over proctectomy.  A survey study we previously completed demonstrated that most patients are interested in, and would advocate for NOM, whereas oncologists appear to be reluctant to offer this option.

The purpose of this study was to identify the values, perceptions, barriers and facilitators to NOM. It was designed to provide critical information for developing  strategies to implement a ‘watch-and-wait’ approach to stage 2/3 rectal cancers, thereby providing patients with a treatment option that potentially avoids surgical morbidity and may improve quality of life.

This qualitative study explored oncologists’ experiences treating rectal cancer and identified their perceptions and values around NOM as an option for their patients. Medical, surgical and radiation oncologists who routinely treat rectal cancer were recruited via purposive and snowball sampling. Oncologists were sampled from academic and high volume rectal cancer centres across Canada. They varied in length of practice and gender.

Semi-structured interviews were conducted via telephone with the same interviewer: Participants included 20 surgeons, 12 radiation and 8 medical oncologists with a median length of years practice of 10 years. Data saturation was achieved after 40 interviews.

The results demonstrated that surgical, radiation and medical oncologists who are experts in the treatment of rectal cancer across Canada almost uniformly discard watchful waiting as an equivalent alternative. Oncologists felt that NOM should not be offered as a standard of care. Most felt that there is insufficient data supporting NOM and more notably expressed significant concerns around worse oncologic outcomes. However, what was particularly absent from this perspective was the potential improvement in treatment-related morbidity and overall functional outcomes for those select patients with a complete clinical response. While not the same as oncologic outcomes, it has been well-established that patients also value both short and long term quality-of-life related outcomes in their treatment decision-making.  Future work on patient preferences is needed.