You’ve persisted through the long and difficult journey of chemotherapy and radiation for your rectal cancer. The doctors call this combination treatment ‘neoadjuvant therapy’ but you thought of it as ‘trying-to-kill-me’ therapy.
But you persisted, and now at long last, your efforts have paid off. Your MRI and FDG PET scan has come back clear of cancer! Yippee!
You may not know what this really means but not seeing cancer on a scan must be a good thing right?
You’re right, it is an awesome thing not to see cancer on a scan. Even oncologists do a little dance in the privacy of their clinic rooms when they see that.
Unfortunately… or fortunately… you’re now faced with a dilemma you never thought you would have to deal with.
The dilemma of having complete response to treatment
Do you remember your surgeon talking about surgery at the beginning of your diagnosis? Through the fog of chemotherapy and radiation, some patients actually forget they need to go through surgery after the dust settles on their ‘neoadjuvant treatment’.
Well, now a days (circa 2023/2024), if you have rectal cancer and your PET scan doesn’t show cancer after treatment, you’ll hear these words – complete metabolic response. And you’ll be given the option of proceeding with surgery or watch-and-wait.
Would you like to proceed with major surgery and have a colostomy (poo bag) for the rest of your life? Or would you like to sit tight and wait to see if the cancer will come back?
WTF.
Yes, it’s OK. Most patients either say it or think it when hit with this curve ball.
It doesn’t help that most typical surgeons don’t give out enough information about the pros and cons of either approach and can’t seem to answer your questions clearly.
It’s because there are no clear answers. There will be in the future. At the time of this writing, randomized trials are underway comparing surgery vs watch-and-wait for rectal cancer and we hope to get some definite answers in a few years.
But for now, we don’t know which is better.
Sorry, I’m just being honest. No point in pretending to know the answers when I don’t. However, I can tell you what we do know and try to make it easier for you to decide which is the better option for you.
The case for radical surgery
I can tell you that surgery is the standard of care (also called best practice/standard therapy) for localized and locally advanced rectal cancer. It has been for years and will still be for quite a few years yet.
The risk of recurrence for each of you is different but generally speaking, having surgery for rectal cancer improves your chances of being alive at 5 years (5 year overall survival) up to 90%. Pretty good odds IMHO.
The downside is you have to go through major surgery and have a permanent colostomy for life.
The case for watch-and-wait
We have no long-term data to know if watch-and-wait is better (or even just as good) as surgery as recurrences can happen up to 5-10 years later. There are also no randomized trials. All that we know so far is only based on retrospective and observational studies.
Despite this, some doctors are willing to offer the option of not having upfront surgery to patients who have no evidence of cancer after neoadjuvant treatment. It’s easy to see why.
An abdomino-peritoneal resection (APR) is major surgery, associated with significant risks. Not having surgery also means you get to keep your bowels intact.
The downside is that we know the risks of cancer regrowth is higher. The numbers differ depending on which study you read but regrowth rates as high as 30% have been reported.
However, studies also note that when cancer regrows in the rectum, >90% of people can proceed with surgery then and can still be cured of cancer.
The problem occurs when cancer regrows somewhere else out of the rectum, for example, in your lymph nodes, lungs or liver. With the watch-and-wait approach, there is an approximately 8% chance that you cancer may come back elsewhere and you will have Stage 4 (metastatic disease) disease.
If this occurs, the chances of you being cured is very slim and treatment is usually palliative – aimed at control of disease rather than cure.
Surgery vs Waiting: Which should you choose?
At this stage, no doctor would dare to make this decision for you. If really pressed, we can only go by current evidence – surgery has been proven to reduce your risk of the cancer coming back. Watch-and-wait is as yet, unproven.
But we’re not the ones who have to live with a colostomy bag the rest of our days.
Undoubtedly, you will have a million questions swirling in your head. But really, it only boils down to one big question:
Do you prefer to maximize your chances of cure but live with a permanent colostomy, or do you prefer to keep your bowels but take the higher risk that the cancer may come back?
Bear in mind that there is a pretty good chance that the cancer will come back in the rectum and surgery is still possible. However, you also take the higher risk (up to 10%) of having stage IV disease if the cancer comes back.
The right answer will depend on your life priorities.
It’s a tough one. Good luck with making your decision and all the best.
You may also be interested in whether taking aspirin regularly reduces your risk of rectal cancer.
Further reading:
- https://academic.oup.com/jnci/article/112/8/771/5701655
- https://linkinghub.elsevier.com/retrieve/pii/S2468-1253(17)30074-2
- https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31078-X/abstract
