Quality of Life and Functional Outcomes After Watch-and-Wait for Locally Advanced Rectal Cancer: A Meta-Analysis

Introduction

Watch-and-wait (W&W), which involves total neoadjuvant therapy followed by close observation, has emerged as an alternative to total mesorectal excision for patients with locally advanced rectal cancer who achieve a clinical or near-complete response. This approach aims to preserve bowel function and avoid the morbidity associated with radical surgery.

Methods

This systematic review and meta-analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane guidelines. Eligible studies included randomized trials and observational studies of patients with locally advanced rectal cancer treated with total neoadjuvant therapy, followed by either W&W or total mesorectal excision. The primary outcome was quality of life (QoL), assessed using validated instruments (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30, Quality of Life Questionnaire-CR29, Fecal Incontinence Quality of Life). Secondary outcomes included bowel function among patients without an ostomy, using validated measures such as Cleveland Clinic Florida Fecal Incontinence Scores, Vaizey, Memorial Sloan Kettering Cancer Center, and low anterior resection syndrome scores. A comprehensive search of PubMed, EMBASE, Medline, and Web of Science (Sept 2023-May 2025) was performed without language or date restrictions. Abstract/full-text screening, data extraction, and risk of bias assessments were conducted independently by two reviewers. Meta-analyses used inverse-variance weighting under a random-effects model. Data unsuitable for meta-analysis were synthesized narratively.

Results

Of 617 screened studies, 28 were reviewed in full and 9 met inclusion criteria (total 923 patients). Meta-analysis of five studies (n = 601) with no statistically significant difference in overall QoL between groups (pooled mean difference = 0.10, 95% confidence interval: −0.19 to 0.39, P = 0.49). However, pooled analysis of fecal incontinence scores from four studies (n = 384) showed a significant advantage for W&W (pooled mean difference = −1.10, 95% confidence interval: −1.50 to −0.73, P < 0.001). Qualitative synthesis of low anterior resections syndrome scores outcomes favored W&W.

Conclusions

W&W, offers a functional advantage without compromising QoL. The decision to pursue W&W should be individualized, considering both the potential functional benefits and the oncological risks.