WATCH-AND-WAIT management for patients with Stage II–III rectal cancer increased substantially between 2006 and 2023, with adoption accelerating particularly after 2019 and rising across all age groups, according to a large US cohort study.
The retrospective study analysed National Cancer Database records for 101,001 patients diagnosed with rectal cancer between 2006 and 2023. All patients had received neoadjuvant chemoradiation at Commission on Cancer-accredited hospitals across the USA.
Researchers aimed to establish how frequently patients underwent intentional organ preservation through watch-and-wait management rather than proctectomy. As nonsurgical management can occur for reasons unrelated to organ preservation, the investigators estimated baseline rates before identifying additional uptake attributable to the watch-and-wait strategy.
Of the 101,001 patients included, 84,324 underwent surgery, while 16,677 received nonsurgical management. Baseline nonsurgical management rates remained stable until 2014, before two distinct acceleration points emerged in 2014 and 2019.
Annual percentage changes in nonsurgical management reached 9.83% between 2015 and 2018 and 21.71% between 2019 and 2023, compared with a nonsignificant change of −0.45% between 2006 and 2014.
Age was also associated with adoption. Baseline nonsurgical management increased from 6.73% among patients younger than 50 years to 28.15% among those aged 80 years and older. Older patients demonstrated earlier uptake, with the oldest age group exceeding a 5-percentage point increase above baseline by 2015. Patients younger than 50 years reached this threshold in 2019.
Overall, watch-and-wait management increased from 2.30% of patients in 2015 to 32.94% in 2023. Increasing diagnosis year (odds ratio: 6.23; 95% confidence interval: 5.48–7.09) and older age (odds ratio: 4.25; 95% confidence interval: 3.98–4.54) were independently associated with nonsurgical management.
The findings demonstrated growing adoption of organ preservation, with the most pronounced acceleration occurring from 2019 onwards. The researchers interpreted this trend as suggesting increasing evidence-concordant implementation of watch-and-wait management.
However, wider adoption also reinforces the importance of appropriate clinical decision-making. Careful patient selection, accurate assessment of treatment response, and rigorous surveillance monitoring remain essential considerations when pursuing organ preservation.
For clinicians managing patients with Stage II–III rectal cancer, these findings highlight the changing landscape of treatment strategies and the increasing role of nonsurgical management. As watch-and-wait adoption continues to expand, maintaining robust assessment and follow-up practices will be crucial to ensuring safe oncological outcomes.
Reference
Keeling SS et al. Organ preservation with watch and wait in patients with rectal cancer. JAMA Netw Open. 2026;9(10):e2640267.
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