Bailey K. Hilty Chu

Background: Circumferential resection margin (CRM) positivity is a validated predictor of local recurrence and survival in rectal cancer and reflects multidisciplinary care quality. The National Accreditation Program for Rectal Cancer (NAPRC), launched in 2017, standardizes rectal cancer care, but national oncologic outcome data remain limited. Study Design: We performed a retrospective National Cancer Database analysis of clinical stage I–III rectal adenocarcinoma (2015–2022) treated with curative-intent proctectomy using a stacked difference-in-differences design. Hospitals accredited between 2018–2021 were compared with inverse probability of treatment weighting–matched non-accredited hospitals. The primary endpoint was annual hospital-level CRM positivity (CRM 60 days. Models included hospital, calendar year, and accreditation year fixed effects with robust standard errors clustered by hospital. Results: Among 58,510 patients treated at 800 hospitals, 57 hospitals (7.1%) achieved accreditation, exposing 2,716 patients to accreditation. CRM positivity declined from 14.9% to 12.0% at accredited hospitals versus 14.4% to 12.6% at non-accredited hospitals, yielding a −1.1 percentage point difference-in-differences (95% CI 0.2–2.0; p=0.03), corresponding to an 8.7% relative reduction. CEA measurement increased from 84.0% to 89.5% versus 84.0% to 85.3%, a +4.2 percentage point difference-in-differences (95% CI 3.6–4.8; p<0.001). There was no significant differential change in treatment delays (+0.7 percentage points; p=0.15). Conclusions: NAPRC accreditation was associated with reduced CRM positivity and increased adherence to pre-treatment CEA testing without prolonging treatment initiation. These findings suggest structured multidisciplinary accreditation is associated with measurable improvements in rectal cancer surgical quality at the national level.

Background: Chronic anastomotic leaks following low anterior resection (LAR) with primary anastomosis and diverting loop ileostomy (DLI) pose a complex management challenge. Optimal strategies for evaluating and managing chronic leaks remain poorly defined, particularly regarding the timing and safety of stoma reversal. Methods: We conducted a retrospective study of patients with stage I-III rectal cancer who underwent LAR with DLI between 2011-2022 and subsequently developed a chronic anastomotic leak, defined as a defect persisting beyond 30 days on imaging or endoscopy. Demographic, procedural, and outcome data were abstracted from the electronic medical record. Patterns of imaging and procedural evaluation, time to clinical disposition (defined as DLI reversal, conversion to colostomy, or decision to maintain DLI), and clinical decision-making factors were analyzed. Results: Nineteen patients met inclusion criteria. During their clinical course, 68.4% of patients underwent percutaneous drainage, with management guided by serial abdominopelvic computed tomography (CT). Gastrografin enemas and endoscopies were performed for anastomotic assessments but demonstrated limited predictive value, as one patient with a normal study developed postoperative pelvic sepsis, while three patients with persistent defects achieved successful reversal. The median time to clinical disposition was 367 days. Ten patients remained with a permanent ostomy, while nine underwent attempted reversal, of whom seven (36.8%) achieved durable bowel continuity. Discussion: Management of chronic anastomotic leaks was individualized, influenced by imaging findings, patient preferences, and surgeon judgment. These findings highlight the limitations of relying solely on structural assessments and underscore the need for integrated, patient-centered frameworks to guide evidence-based reversal decisions.

Nonoperative management, or watch-and-wait, is an increasingly utilized treatment strategy for locally advanced rectal cancer both in the United States and internationally. Studies demonstrate acceptable oncologic outcomes for patients with clinical complete response (cCR) and close surveillance compared with those who undergo surgery after neoadjuvant therapy, but this strategy relies on multiple key factors to achieve optimal outcomes. Implementing watch-and-wait raises new challenges throughout the course of rectal cancer care, from treatment decision-making and offering watch-and-wait, throughout the course of surveillance which involves patients, providers, systems, and policy.

BACKGROUND: Nonoperative management for rectal cancer is increasingly used, offering organ preservation for patients with a clinical complete response after neoadjuvant therapy. However, patients undergoing nonoperative management face a heightened risk of local regrowth and undergo intensive surveillance. Despite growing interest in nonoperative management, the patient experience and factors contributing to suboptimal surveillance are not well characterized. OBJECTIVE: To explore patient perceptions, priorities, barriers, and facilitators related to care while undergoing nonoperative management after total neoadjuvant therapy for rectal cancer. DESIGN: Qualitative descriptive study using semistructured Zoom interviews that explored the patient experience with nonoperative management. Inductive thematic analysis was performed on interview transcripts. SETTING: Single academic institution. PATIENTS: Purposively sampled adults diagnosed with stage I to III rectal adenocarcinoma who completed total neoadjuvant therapy, achieved a clinical complete or near complete response, and elected nonoperative management were included. MAIN OUTCOME MEASURES: Patient perceptions and priorities in rectal cancer care for those on nonoperative management, as well as the barriers and facilitators to achieving recommended surveillance. RESULTS: Fifteen patients (8 women, 13 White individuals, median age 66 years [range, 56–81 years]) who were a median of 5 years from their decision to pursue nonoperative management participated in this study. Local regrowth occurred in 5 patients, 4 experienced distant metastases, and 1 had a permanent stoma. Treatment team recommendations strongly influenced treatment choice. Facilitators of surveillance included trusting, communicative provider relationships, positive patient outlook, and social support. Frequent appointments and uncertainty surrounding recurrence contributed to anxiety, which interfered with engagement in surveillance. LIMITATIONS: This study is limited by selection bias and focus on a single-institution experience. CONCLUSIONS: Patients undergoing nonoperative management generally reported positive experiences supported by provider relationships and social networks. However, emotional burden and social and logistical demands posed significant barriers to surveillance. These findings can inform shared decision-making and highlight the need for system-level interventions to support patients throughout nonoperative management. See Video Abstract. TRATAMIENTO NO QUIRÚRGICO DEL CÁNCER RECTAL: ESTUDIO CUALITATIVO SOBRE LAS PERCEPCIONES, PRIORIDADES, OBSTÁCULOS Y FACILITADORES DE LOS PACIENTES EN RELACIÓN CON LA VIGILANCIA: ANTECEDENTES: El tratamiento no quirúrgico del cáncer rectal se utiliza cada vez más, ya que permite preservar el órgano en pacientes con una respuesta clínica completa tras la terapia neoadyuvante. Sin embargo, los pacientes sometidos a tratamiento no quirúrgico se enfrentan a un mayor riesgo de recidiva local y son objeto de una vigilancia intensiva. A pesar del creciente interés por el tratamiento no quirúrgico, la experiencia de los pacientes y los factores que contribuyen a una vigilancia subóptima no están bien caracterizados. OBJETIVO: Explorar las percepciones, prioridades, barreras y facilitadores de la atención de los pacientes mientras se someten a un tratamiento no quirúrgico después de una terapia neoadyuvante total para el cáncer rectal. DISEÑo: Estudio descriptivo cualitativo mediante entrevistas semiestructuradas por Zoom que exploraron la experiencia de los pacientes con el tratamiento no quirúrgico. Se realizó un análisis temático inductivo de las transcripciones de las entrevistas. ENTORNO: Una sola institución académica. PACIENTES: Adultos seleccionados deliberadamente diagnosticados con adenocarcinoma rectal en estadio I-III que completaron la terapia neoadyuvante total, lograron una respuesta clínica completa o casi completa y optaron por el tratamiento no quirúrgico. PRINCIPALES MEDIDAS DE RESULTADO: Percepciones y prioridades de los pacientes en la atención del cáncer rectal para aquellos en tratamiento no quirúrgico, así como las barreras y los facilitadores para lograr la vigilancia recomendada. RESULTADOS: Participaron quince pacientes (8 mujeres, 13 blancos, edad media de 66 años [rango: 56-81 años]), con una mediana de 5 años desde su decisión de seguir un tratamiento no quirúrgico. Se produjo un recidiva local en 5 pacientes, 4 experimentaron metástasis a distancia y 1 tuvo un estoma permanente. Las recomendaciones del equipo de tratamiento influyeron considerablemente en la elección del tratamiento. Los facilitadores de la vigilancia incluyeron la confianza, las relaciones comunicativas con los proveedores, la actitud positiva de los pacientes y el apoyo social. Las citas frecuentes y la incertidumbre en torno a la recurrencia contribuyeron a la ansiedad, lo que interfirió en la participación en la vigilancia. LIMITACIONES: Este estudio tiene limitaciones debido al sesgo de selección y al hecho de centrarse en la experiencia de una sola institución. CONCLUSIONES: Los pacientes sometidos a un tratamiento no quirúrgico informaron en general de experiencias positivas respaldadas por la relación con el proveedor y las redes sociales. Sin embargo, la carga emocional y las exigencias sociales y logísticas supusieron importantes obstáculos para la vigilancia. Estos resultados pueden servir de base para la toma de decisiones compartida y ponen de relieve la necesidad de intervenciones a nivel del sistema para apoyar a los pacientes a lo largo del tratamiento no quirúrgico. (AI-generated translations )

Contemporary cancer research prioritizes clinical endpoints such as overall survival (OS) and disease-free survival (DFS). However, definition of the start

Objective: To evaluate patient-reported outcomes (PROs) in rectal cancer patients who underwent neoadjuvant therapy followed by watch-and-wait. Background: Advancements in rectal cancer therapies have improved oncologic outcomes and increased focus on long-term treatment effects. Watch-and-wait, which aims for organ preservation in patients with a clinical complete response to neoadjuvant therapy, is used more frequently. While watch-and-wait may reduce functional impairments associated with proctectomy, its association with PROs is poorly understood. Methods: We performed a systematic review and meta-analysis of studies reporting PROs for patients with stage I–III rectal adenocarcinoma treated with neoadjuvant therapy and watch-and-wait. Random-effects model meta-analysis was performed when feasible; otherwise, data were synthesized through a narrative review. Results: Twenty-five studies (3139 patients) reported PROs for patients receiving neoadjuvant therapy followed by watch-and-wait (n = 1283), proctectomy (n = 1583), local excision (n = 263), or declined surgery (n = 10). Most studies (64.0%) excluded patients with local regrowth, leaving PRO data for 103 such patients. Fourteen studies compared PROs between treatment groups after neoadjuvant therapy. Meta-analyses demonstrated fewer bowel symptoms and improved quality of life (QoL) in 1/6 subscales for watch-and-wait. Across 24 QoL comparisons, 14 showed improvement in some subscales for watch-and-wait, while 10 found no difference. For 24 symptom scale comparisons, 11 indicated some improvement with watch-and-wait, and 13 found no differences between groups. Conclusions: Watch-and-wait offers the potential to avoid permanent ostomy and surgical morbidity. However, more robust data are needed to assess its association with PROs compared to proctectomy or local excision. Researchers should prioritize publishing QoL data to better inform shared decision-making.

Background: Rural patients, including those with rectal cancer, continue to be underrepresented in research and medically underserved with unique challenges to accessing care. Like the rest of America, rural patients are experiencing rising rates of rectal cancer; however, unlike the rest of the country, they also have rising rectal cancer-related mortality. This study aims to review the literature regarding care for patients with rectal cancer in rural settings, from presentation and diagnosis to treatment algorithms, oncologic outcomes, their unique preferences, and the goals of care. Methods: A literature search was performed on PubMed, on 31 October 2024, using synonyms of “rural” and “rectal cancer” to identify relevant articles. Articles from outside the USA and Canada and those offering only commentary were eliminated during the initial screening/retrieval. A full-text review was performed on the remaining articles; all the studies that did not address the identified primary or secondary outcomes in rural rectal cancer patients were then excluded. All the primary and secondary outcomes are briefly summarized in narrative form, with more detail on the primary outcomes provided in tables. The variability in the key criteria between the studies is also summarized in the tables and appendices provided. Results: Thirty studies were identified that addressed the outcomes of interest in rural rectal cancer patient populations. The total number of participants could not be assessed given the use of overlapping databases. Of the articles, 21 addressed treatment modalities (surgery, chemotherapy, radiation), 13 addressed oncologic outcomes, and a mix of additional studies addressed the diagnostic work up, costs, and patient preferences. The studies addressing treatment demonstrated similar practices in regard to chemotherapy and surgical management, aside from lower rates of minimally invasive surgery, along with decreased neoadjuvant radiotherapy use and increased under-dosing in rural patients. The oncologic outcomes were overall similar to worse for rural patients as compared to urban patients, even for those receiving treatment at high-volume urban centers. Additionally, rural patients have higher healthcare costs for rectal cancer care. Discussion/Conclusions: Rural patients are an at-risk group, with a rising disease burden and worsening rectal cancer outcomes, despite advances in rectal cancer care and improving oncologic outcomes in the general population. Analysis of the situation is complicated due to the underrepresentation of rural patients in research and the lack of uniformity in the definition of “rural”. Moreover, significant gaps in the literature remain, such that the evaluation of guideline-concordant care is incomplete, including an absence of literature about watch-and-wait approaches in rural populations. While regionalization of rectal cancer care has shown promise, the improvements in outcomes may not be commensurate for rural patients. Thus, a specific focus on the impact of this shift for rural patients is necessary to mitigate unintended consequences.