Gloria Zaffaroni interviews Jung Wook Huh, Professor at Samsung Medical Center, Department of Surgery Seoul, South Korea ahead of his talk on 'watch and wait' for rectal cancer at the upcoming Global Reach webinar.

Rectal cancer management has changed over the last few decades. The current gold standard is radical surgical resection. However, rectal cancer surgery carries short and long term morbidity which could impact on the patients’ quality of life.

With the introduction nCRT, significant improvements have been seen. Several landmark works have demonstrated the benefits of nCRT in rectal cancer, including a significant reduction in local recurrence rates. A part of these patients demonstrated a complete clinical response (cCR), which is defined as no clinical evidence of residual tumor. In addition, a subgroup of patients could have a complete pathological response (pCR) which is defined by the absence of residual tumour in the pathological specimen.

The watch and wait approach consists in a clinical observation in these patients. It has shown excellent outcomes, as long as candidates are carefully selected and appropriately monitored.

Gloria Zaffaroni: Dear Professor Jung Wook, thanks for agreeing to speak at the ESCP Global Reach Webinar: 'Achievement Through Collaboration'. Your topic is 'Watch and Wait for Rectal Cancer: an evolving practice - Current status in Asia-Pacific countries'. Could you give us some information about your speech?

Jung Wook Huh: Thank you for inviting me this wonderful webinar; it is an honor to be here. As you mentioned, the standard management for rectal cancer is total mesorectal excision. Especially in cases of locally advanced rectal cancer, neoadjuvant chemoradiation followed by total mesorectal excision can produce good local control and long-term survival. However, radical surgery can result in postoperative morbidities, including sexual, urinary, and anal sphincter dysfunction, as well as a risk of permanent stoma. After neoadjuvant chemoradiation, patients who are likely to achieve a complete response could be treated with a watch and wait method, potentially avoiding radical resection. Evidence supporting this watch and wait policy has been reported recently. However, a lack of evidence from randomized controlled trials is a major hurdle to the adoption of this approach in clinical practice.

Thus, I designed an international survey on contemporary views of this approach among colorectal surgeons in 19 Asia-Pacific countries on behalf of the Asian-Pacific Federation of Coloproctology (APFCP) last year. The results were published in the Annals of Coloproctology, the official journal of the APFCP. My findings suggested widespread support for the watch and wait approach among the Asian-Pacific surgeons, up to 80% of those surveyed.

GZ: The main challenge with watch and wait is the selection of patients who can be considered for this approach. Do you agree?

JWH: Absolutely. Patient selection is the most important factor in the success of this approach. Although the watch and wait policy has produced promising data, the protocol is undefined and uncertain. Currently, there are no universal guidelines for findings or methods that accurately predict complete response after neoadjuvant chemoradiation. As mentioned, no randomized trials can be performed due to probably ethical issues. Most Asian surgeons agree with this concept; however, we believe that this approach should be administered in a research-based manner, or alternately, in patients with old age, with severe medical issues, or for those who refuse radical surgery. In all cases, informed consent should be obtained after discussing the risks and benefits of this approach with our patients.

GZ: Are there any controversies in the assessment of clinical response?

JWH: For reassessment of chemoradiation response, most Asian surgeons use sigmoidoscopy with biopsy, rectal MRI, and sometimes PET-CT scan. However, the accuracy of restaging after chemoradiation using current imaging modalities is not good, and is insufficient for defining no tumor cells in the spot. Biopsies can also be false-negative. For these reasons, some studies at the molecular level have been performed, but most have been small, with a heterogeneous population, and most importantly, many findings could not be validated by other researchers.

GZ: What strategies do you think are the best to increase the rate of cCR?

JWH: I don’t know exactly. But many studies have shown consistently that the more early-stage tumors are treated, the higher the rate of complete response. According to our survey, 43% of Asian surgeons prefer consolidation chemotherapy during the resting period, as it may increase the CR rate. However, we still await the results of many ongoing studies. Also, improvement in the accuracy of imaging modalities would facilitate treatment decision-making in these patients.

GZ: What will be the cutting edge of your presentation?

JWH: I found high support for the watch and wait policy among Asian-Pacific surgeons from the survey. In total, 80% of surgeons supported and accepted this approach, and 65% have used it in their clinical practice. We received over 400 replies, over 97% of which were from colorectal specialized surgeons and over 90% were from the staff of a university or tertiary hospital, demonstrating the importance and validity of our results. I believe this survey provides a good overview and answers regarding several controversial issues about watch and wait approach among Asian-Pacific surgeons currently.

 ESCP Global Reach Webinar: 'Achievement Through Collaboration', Friday 20 November 2020 >

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