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Session: ePoster: Rectal Cancer 3 (Sun1230)

EP471 - When Patients Say No – Outcomes of Opting Against Recommended Treatment After Total Neoadjuvant Therapy for Stage II/III Rectal Cancer

Sunday, May 11, 2025
1:13 PM – 1:18 PM PT
Location: Monitor 10, Sails Pavilion, Upper Level

    ePoster Presenter(s)

  • Scarlett B. Hao, MD (she/her/hers)

    Fellow
    Corewell Health Beaumont
    East Carolina University Brody School of Medicine
    Royal Oak, MI, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no financial relationships with ineligible companies.

    • Author(s)

  • Jacob Applegarth, MD

    Resident
    Corewell Health East, William Beaumont University Hospital
    Royal Oak, MI, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no financial relationships with ineligible companies.

  • EM

    Erin Mueller, n/a

    medical student
    Oakland University William Beaumont School of Medicine
    Rochester, Michigan, United States

    Disclosure information not submitted.

  • HW

    Harry Wasvary, MD

    Chief department colon and rectal surgery
    Corewell health William Beaumont university hospital
    Royal oak, Michigan, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no financial relationships with ineligible companies.

  • MZ

    Matthew Ziegler, MD

    program director
    Corewell Health / Royal Oak
    Royal Oak, Michigan, United States

    Disclosure information not submitted.

    • Senior Author(s)

  • BK

    Bradley Krasnick, MD

    Colon and Rectal Surgeon
    Corewell Health William Beaumont University Hospital
    Royal Oak, Michigan, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no financial relationships with ineligible companies.

All of the relevant financial relationships listed below have been mitigated.
Scarlett B. Hao, MD: This individual has no financial relationships with ineligible companies.
Jacob Applegarth, MD: This individual has no financial relationships with ineligible companies.
Harry Wasvary, MD: This individual has no financial relationships with ineligible companies.
Bradley Krasnick, MD: This individual has no financial relationships with ineligible companies.
Image or Table (Do Not add text here):

Purpose/Background: Patients with stage II/III rectal cancer, upon completion of total neoadjuvant therapy (TNT), may be recommended total mesorectal excision (TME) or a watch-and-wait (WW) approach depending on their clinical tumor response. However, in shared decision-making, patients may ultimately decide for surgery when it is not recommended or against surgery when it is recommended. This study aimed to describe the tumor response outcomes of patients with LARC who pursue and do not pursue the recommended approach following TNT.

Methods/Interventions: We performed a descriptive retrospective cohort study of all adult patients diagnosed with AJCC clinical stage 2 or 3 disease between 2021-2023 who were treated at a single tertiary care center with TNT. Patients with inflammatory bowel disease, genetic syndromes such as FAP or HNPCC, additional primary tumors including colon, those who did not receive both chemoradiation and systemic chemotherapy, and those without evaluation of a clinical response to therapy were excluded. Patients were sorted into subgroups based on tumor response and compliance with recommended subsequent approach (TME versus WW). Primary outcomes were clinical complete response (cCR) and pathologic complete response (pCR) out of the entire cohort and by subgroup.

Results/Outcomes: Out of 151 patients with stage II/III rectal cancer, 66 met inclusion criteria. The cohort was 43.9% female (n=29) and predominantly Caucasian (n=55, 83.3%). 48.5% (n=32) were recommended WW after completion of TNT. Four of these patients opted instead for TME; of these, two had a sterile specimen. Of the remaining 34 who were recommended TME, four opted to pursue WW against recommendation. Of these four, three remain alive greater than a year after completion of TNT (range 16-26 months of post-treatment follow-up), although only one had eventual radiographic cCR. The fourth died of progression of disease. Of the 30 patients who underwent TME, 8 had a sterile specimen. Inclusive of patients who underwent surgery with a sterile specimen, 38 out of 66 patients achieved either cCR or pCR (57.6%).

Conclusion/Discussion: In the modern era of shared decision-making, it is unavoidable that patients may opt to go against physician recommendations. Our rate of combined clinical and pathologic responses suggests that optimal outcomes can still be achieved even when patients refuse to proceed with recommendation. Additional insight into the reasoning behind patient decision-making when selecting WW or TME, including patient-related demographic factors predictive of non-compliance, can inform physician-patient counseling. Future analysis is planned to better answer this question.