Oral Presentation Clinical Oncology Society of Australia Annual Scientific Meeting 2018

A pilot study of patients' preferences for upfront resection versus a ‘watch and wait’ approach after neoadjuvant long course chemoradiation for locally advanced rectal cancer: what is avoiding surgery worth? (#20)

Ashray Gunjur 1 , Grace Chazan 1 , Genni Newnham 1 , Sue-Anne Mclachlan 1
  1. St. Vincent's Hospital Melbourne, Fitzroy, VIC, Australia

Background: In patients with locally-advanced rectal cancer (LARC) who have a clinical complete response (cCR) to neoadjuvant chemoradiation (NACR), it may be reasonable to adopt a ‘watch-and-wait’ (WaW) strategy rather than proceed to rectal cancer resection. Potential benefits of upfront resection must be weighted against the morbidity and inconvenience of the surgery and a temporary or permanent stoma. Our aim was to pilot a patient reported questionnaire designed to determine the local recurrence risk (LRR) acceptable to avoid upfront resection, as well as the overall survival (OS) benefits that make upfront resection justified.

Methods:  20 participants who had NACR and resection for LARC completed the questionnaire. Patients were asked to imagine they had achieved a cCR post their experience of NACR. A hypothetical time trade-off task was used to determine the LRR patients would accept to adopt a WaW strategy (versus a baseline 8% LRR with upfront resection), and the survival benefit that would be needed to justify choosing upfront resection over WaW.

Results: Most patients were male (85%) with a median age of 58 (IQR 46-70) years. 60% continued to have a stoma. The median acceptable LRR to adopt a WaW strategy was 20% (IQR 10-35%). Patients required a median 2.0 (IQR 1.0-3.0) extra years of survival (scenario baseline survival 7 years), and they required an extra 10% (IQR 4%-19%) and 7% (IQR 5%-10%) chance of surviving 7 years over baseline 70% and 90% survival rates respectively, to justify upfront resection over a WaW strategy.

Conclusion: In this first attempt to elicit patient preferences for WaW over upfront rectal cancer resection, LARC patients seemed willing to tolerate moderate risks of local recurrence to avoid upfront resection, and required substantial survival gains to justify this surgery. Further validation of the questionnaire is required to determine a possible effect of framing.