IMPLEMENTATION OF NON-OPERATIVE MANAGEMENT / ORGAN PRESERVATION FOR LOCALLY ADVANCED RECTAL CANCER IN CANADA: A NATIONAL SURVEY OF CLINICAL PRACTICE

Purpose:

Non-operative management/organ preservation (NOM/ OP) strategies can achieve oncologic outcomes similar to those involving total mesorectal excision (TME), and they are being increasingly offered to patients with locally-advanced rectal cancer. Our study aimed to describe the implementation of these strategies in Canada.

Materials and Methods:

Through non-probabilistic convenience sampling we recruited a clinical expert representative from each of the 44 Canadian centres that offer radiotherapy, systemic therapy and surgery. Representatives completed an electronic survey to describe NOM/OP strategies for patients with locally-advanced rectal cancer at their centres in terms of availability, patient selection, treatment protocols, response assessments, surveillance, quality assurance resources and perceived challenges. A primary OP strategy was defined as one where neoadjuvant therapy is administered with the explicit initial goal of achieving a complete clinical response (cCR) or a near-complete clinical response (nCR), thereby avoiding an immediate TME. A secondary OP strategy was defined as one where a cCR or nCR allows for previously unplanned avoidance of an immediate TME due to an initial explicit goal of proceeding with surgery.

Results:

From June to August 2023, 40/44(91%) of representatives responded: 24/40(60%) radiation oncologists, 13/40(32.5%) surgeons and 3/40(7.5%) medical oncologists. All provinces were represented: Atlantic (NFL/PEI/NS/NB) 4/40(10%), Quebec 10/40(25%), Ontario 15/40(37.5%), Prairies (MB/SK/AB) 5/40(12.5%), British Columbia 6/40(15%). Of the responding centres, 31/40(77.5%) offered some form of NOM/OP, with 20/40(50%) offering both primary and secondary, 11/40(27.5%) offering only secondary, 8/40(20%) offering neither and 1/40(2.5%) not clarifying. Of the 31 centres offering NOM/OP, 58.6% always/frequently did so after a cCR (17/29 responses) and 14.3% always/frequently did so after a nCR (4/28 responses). Of the 20 centres offering primary OP, 17/20(85%) always/frequently used long course chemoradiation followed by consolidation chemotherapy and 6/20(30%) always/ frequently used long course chemoradiation alone. Standardized criteria for response assessments were used by 18/20(90%) centres for MRI (with 12/20, 60% having synoptic templates) and by 12/20(60%) centres for endoscopy (with only 1/20, 5% having a synoptic template). Among all respondents, the most commonly reported challenges to implementing primary OP were access to MRI (21/40, 52.5%), clinic time/space for the number of required assessments (18/40, 45%), access to timely surgery when required (16/40, 40%), lack of comfort/familiarity with long-term outcomes of supporting evidence (15/40, 37.5%), and staff capacity for the number of required assessments (14/40, 35%).

Conclusions:

Canadian centres are increasingly using non-operative management / organ preservation strategies, but variability exists in their availability, implementation and structure.