Miguel Cunha interviews Aiwen Wu, Professor of Gastrointestinal Surgery from Peking University Cancer Hospital & Institute in Beijing, China ahead of his talk on 'watch and wait' for rectal cancer at the upcoming Global Reach webinar.

He is experienced in the surgical treatment of gastrointestinal malignancies and advocates organ preservation strategy including 'watch and wait' policy for rectal cancer following neoadjuvant treatment. He has led a series of clinical trials on colorectal cancer and contribute to nearly 100 publications and many congress presentations.

Miguel Cunha: Firstly, let me say it is a pleasure to interview you both prior to ESCP Global Reach webinar on the session: 'Watch and Wait for Rectal Cancer: An Evolving Practice'. I hope this interview works as a teaser for our colleagues to tune in on the 20 November.

I’ve read with great interest your recent research on colorectal cancer. You are definitely in the forefront of investigation on this subject. We know that 'watch and wait' is an approach for patients with low rectal cancer, who have been submitted to neoadjuvant chemoradiotherapy, which can accomplish a clinical complete response.

I believe my first question is challenging, though important to introduce the topic for our readers. In a short sentence, according to current knowledge, can you give us the definition of clinical complete response? Also, what is the best way to identify these patients?

AW: yes, it is a challenging question. The current definition of clinical complete response is ‘no evidence of viable disease’ with current methods including digital examination, endoscopy, MR T2 weighted imaging and DWI, as well as normal CEA level. The best way to identify these patients is to carefully evaluate every patient after neoadjuvant treatment - especially those with low lying rectal cancer and probable poor anal function. Of note, do not make your decision too early as some lesions may gradually disappear 12 week, 16 weeks, or even longer after the neoadjuvant radiation.

MC: In the last few months, we’ve had the opportunity to see different results from large randomised clinical trials on this subject, such as Prodige23, RAPIDO and OPRA. Each one of them comprised differences on the neoadjuvant treatment regimes. What is the most used regime in your countries, and what are the main outcomes?

AW: different modalities are under investigation worldwide including Prodige23, RAPIDO, and OPERA. In our country, chemoradiation following by surgery are most popular. TNT is under investigation, with higher pCR rate of approximately 30%, even for high risk patients. Our centre has developed a risk matrix that facilitates the personalized treatment with either surgery alone, chemotherapy alone, I/O alone, or a combination.

MC: We know that this emerging approach is still debatable, and it is not included in most guidelines. Should the W&W approach be used more widely, with a global-level standard monitorisation, or should it still be restricted to randomized controlled trials?

AW: Yes, I think 'watch and wait' approach should be used more widely, with a global-level standard monitorization, for two reasons: one is that patients have the right to choose, and the other is that a higher and higher pCR rate is being achieved together with the advances of preoperative treatment. Nevertheless, more studies should be performed, including RCTs.

MC: Now turning to the patient’s perspective. In your experience, when a patient who has been given the diagnosis of rectal cancer arrives in your office, do they usually already know about the 'watch and wait' strategy and ask about it, or are you the one who presents this possibility to the patient?

AW: In my experience, the number of patients coming to referral for watch and wait' is increasing. They get the information from various sources. For the patients with low lying rectal cancer, usually I will tell the patient that 'watch and wait' is one of the choices if cCR can be achieved.

MC: When we propose a patient for surgery, we give him/her an informed consent, explaining the risks and benefits of the surgical approach. Concerning ethics, when you propose a patient for 'watch and wait', do you do the same? Can you tell us what you think is the most important information to be included in such consent?

AW: It is a good point. Just like the informed consent before surgery, we should explain the risks and benefits of 'watch and wait' for every patient and/or their relatives. There are two things that I will make clear to them. The first thing, is that the probability of recurrence or metastasis still exists. The second one is that they must comply with the follow-up protocol. We also drafted a template of informed consent for 'watch and wait' for physician’s reference (in Chinese) which was published earlier this year. Detailed information was also given to the patients and their relatives.

MC: If we assume the oncological outcomes are the same for 'watch and wait' and standard surgery, the benefit would therefore be in regard to quality of life and organ-related side effects. How can this be ensured and monitored?

AW: We had a study comparing those who received either 'watch and wait' or surgery. The 'watch and wait' group had a better quality of life and fewer treatment-related side-effects. This is also supported by literature from other groups.

MC: From a broader range, do you think that in the future this approach will be extended to more proximal rectal cancers? Scientifically speaking, why are we not there yet?

AW: Thanks for your great question. Personally, I believe in the future this approach will be extended to more proximal rectal cancer, colon cancers, and even other malignancies. Recently we have reviewed the vanished surgery in the history. That might be the future. Certainly, it needs time and the demand from the patients.

MC: From your point of view, what does the future bring for 'watch and wait' strategy?

AW: In my opinion, with the development of drugs and other armamentariums, more and more pCR specimens may lessen the surgeon’s confidence and promote the research on excluding viable cells in vivo. This would therefore make the future for 'watch and wait' more promising. As a surgeon, I don’t hope that this change come too early, but as an outsider, I do.

MC: Thank you so much for sharing your knowledge with us. We have great expectations for your talk at the upcoming ESCP Global Reach webinar, and are looking forward to it! We’ll all be tuned in on the 20 November. Thank you.

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

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