John Saleh's experience with rectal cancer was transformed by the watch-and-wait approach at Winship Cancer Institute, sparing him from surgery and leading to remission.
Patrick Sullivan, MD, FACS
Localized rectal cancer has traditionally been treated with Total Neoadjuvant Therapy (TNT) — chemotherapy in combination with radiation followed by radical surgical resection of the rectum. While this strategy is typically effective in achieving control of the tumor, there is a high likelihood that patients will have to live with a permanent stoma.
At Winship Cancer Institute of Emory University, Saleh met with colorectal surgeon Patrick Sullivan, MD, FACS, medical oncologist, Olatunji B. Alese, MD, Winship’s director of gastrointestinal oncology, and radiation oncologist Pretesh Patel, MD.
The doctors presented Saleh with two treatment options: conventional TNT followed by surgery, or TNT followed by a newer watch and wait protocol. With the watch and wait approach, the patient is given a six-month course of chemotherapy and radiation followed by close monitoring with imaging and blood tests. If the cancer responds to these treatments, surgery may not be needed. The decision for watch and wait is typically made after completion of TNT and follow-up rectal examination, scans and endoscopy.
“If you had 100 patients with locally advanced rectal cancer and treated them with chemotherapy and radiation for about six months in total, and you watch those patients, about half of them will have a complete clinical response,” Dr. Sullivan says. “Those patients then go on for watch and wait.”
Olatunji B. Alese, MD
Saleh opted for TNT followed by watch and wait. Following the completion of TNT, he entered a rigorous surveillance program involving regular, scheduled assessments utilizing high-resolution magnetic resonance imaging, endoscopic evaluation of the rectum and serial measurements of serum carcinoembryonic antigen (CEA) levels. The frequency and duration of these surveillance modalities were determined based on established protocols and the evolving clinical picture. The critical decision point within this strategy was the assessment of clinical response. A complete clinical response was defined by the absence of a radiographically or endoscopically detectable tumor within the rectum, coupled with a normalization of CEA levels.
Saleh recently finished up the last of his twice-yearly CT scans, MRIs and colonoscopies that he has been having for the past five years. His medical team told him that his cancer was considered cured.
Going forward, Saleh will get an annual colonoscopy for the next three or four years. After that, he will get one every three or four years.
“As the only National Cancer Institute-designated Comprehensive Cancer Center in the state of Georgia, we are always at the forefront when it comes to adopting and developing innovative new treatments,” says Dr. Alese. “We are fully invested in not just making sure that our patients are among the first to benefit from recent advances, but also in helping to write the clinical guidelines.”
