Implementation of Organ Preservation for Locally Advanced Rectal Cancer in Canada: A National Survey of Clinical Practice

Abstract

Purpose: Organ preservation (OP) is an increasingly recognized treatment for locally advanced rectal cancer. However, variability in patient selection, treatment regimens, and surveillance can hinder widespread adoption. We conducted a national, cross-sectional survey evaluating how OP is implemented across Canada. Methods: Between June and July 2023, surgeons, radiation oncologists, and medical oncologists with expertise in OP from all 44 Canadian radiation centers completed an electronic survey about the implementation of OP at their centers. Primary OP was defined as administering neoadjuvant therapy with the explicit goal of avoiding surgery. Secondary OP was defined as deferring planned surgery only when there was an unexpected yet sufficient clinical response. Results: Responses from 40 radiation centers (response rate 90.9%) identified that 20 (50.0%) offered primary and secondary OP, 11 (27.8%) offered only secondary, and 8 (20.0%) offered neither. The most common treatment in primary OP was chemoradiation with consolidation chemotherapy (17/20, 89.5%). When assessing the response in primary OP, endoscopic biopsies were more commonly performed with a near-complete response (10/20, 50.0%) than a complete response (4/20, 20.0%). Watch-and-wait surveillance was more frequently offered for a complete response (17/31, 54.8%) than a near-complete response (4/31, 12.9%). Challenges included limited MRI (21/40, 52.5%), clinic time (18/40, 45.0%), timely surgery if required (16/40, 40.0%), and limited familiarity with the protocols and evidence (15/40, 37.5%). Conclusion: OP is recognized nationwide but is inconsistently implemented. Challenges raise concerns about the current feasibility of OP in Canada and highlight the need for less resource-intensive, complex OP protocols.