QS139 - Watch-and-Wait Practices for Locally Advanced Rectal Cancer: A Survey of the American Society of Colon and Rectal Surgeons (ASCRS) Members

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Purpose/Background: Approximately 30% of patients with locally advanced rectal cancer (LARC) achieve a clinical complete response (cCR) following total neoadjuvant therapy and may be candidates for watch-and-wait (WW)1. However, WW usage varies and may be underutilized2. There is limited understanding of when and how WW is being offered to patients, as well as the barriers and facilitators that affect its use.

Methods/Interventions: A 34-question anonymous online survey was distributed to all surgeon members of the American Society of Colon and Rectal Surgeons (ASCRS) in September 2024. Questions included whether surgeons offer WW for curative intent in LARC patients who have achieved a cCR or a near clinical complete response (nCR), barriers to offering WW, and variability in counseling patients on the risks and benefits of WW.

Results/Outcomes: The survey was sent to 3,106 ASCRS-member surgeons, yielding 188 complete responses (6% response rate). 94% offer WW to eligible patients however, 49% do not offer W&W to patients with nCR. Of those offering WW to patients with cCR, 99% offer it for low rectal cancers, 86% mid rectal cancers, and 40% for upper rectal cancers. For patients with nCR, 51% offer WW for low rectal cancers, 9% for mid rectal cancers, and 9% for upper rectal cancers.
Amongst those offering WW, most (78%) introduce WW during the initial surgical consultation. Patient factors making clinicians more likely to recommend WW include older patient age and multiple comorbidities. Conversely younger age, lack of social support, traveling long distances for treatment, concern for compliance, low health literacy, and limited insurance coverage reduced the likelihood surgeons would recommend WW.
Amongst surgeons who offer WW, the most common barrier to offering WW is lack of administrative support and access to endoscopy. Amongst those surgeons who do not offer WW (n=11), inadequate training on the risks and benefits of WW, concerns about decreased surgical volume, and oncologic safety were commonly listed barriers to offering WW.
Over 20% of clinicians find the discussions with patients about WW difficult, and 82% do not use educational tools to help facilitate discussions. Furthermore, 77% of respondents believe that a validated decision aid designed to educate patients on the options of W&W and surgery would benefit their patients.

Conclusion/Discussion: While most respondents offer WW, variability in patient selection may contribute to disparities in access. Additionally, limited administrative support and institutional resources highlight the barriers to implementing WW. Surgeons also face difficulties in navigating discussions with patients, which could suggest a need for the development of a validated decision aid to assist surgeons in guiding discussions with patients as they decide between surgery and WW. Understanding practice patterns and factors influencing decision-making may help guide future efforts to standardize care and improve patient outcomes.