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Myint et al. Mini-invasive Surg 2018;2:34 I http://dx.doi.org/10.20517/2574-1225.2018.52 Page 7 of 8

with entirely different outcomes. In the absence of data from “hard to do” randomized trials, we need to
consider how best to gather evidence to support the watch and wait approach. Most patients prefer not to
have a stoma if there is a choice. The management of rectal cancer is becoming more complex and all cases
should be discussed at the colorectal MDT before any treatment is offered. All treatment options that are
available should be explained to the patients and their caregivers so that genuine “shared decision making”
[15]
occurs before consent for treatment is obtained . Sufficient time should be given to the patient prior to
making that decision. Clinicians should be aware that some patients cannot handle too much information,
and provision of needed but not excessive information to these patients must be considered. However,
enough information should be given so as to allow the patient to make choices that take into account their
values, which can be quite different from established medical views. In cases where uncertainties exist,
the patients should be encouraged to participate in ongoing clinical trials so that meaningful data can be
generated to help with decision-making in the future.

Following treatment, it is sometimes difficult to assess the clinical response, especially if the clinicians are
not experienced in following a watch and wait strategy. Newer cancer centers that are starting to adopt
these non-surgical treatment plans should work closely with, and take advice from, more experienced
[8]
clinicians at other cancer hospitals. Not all patients with mucosal abnormalities have residual tumors
and clinicians should be aware that not all abnormalities on MRI represent a residual tumor. There are
many uncertainties and clinicians should be encouraged to work closely with oncologists at nearby cancer
centers who have more experience, so as to avoid performing unnecessary salvage surgeries, which can be
devastating for the patient when there is no residual cancer. Litigation could follow, and so the possibility
[16]
of this scenario should be clearly explained to the patient . In cases where there is clinical uncertainty, it
is better to wait a little longer to clarify the situation, to determine whether or not there is regrowth of any
residual tumor, as the regrowth does not progress as quickly as one would expect.

CONCLUSION
The management of rectal cancer is becoming complex, even for early-stage tumors, and all cases should be
presented and discussed in an early rectal MDT. Patients have a right to refuse the MDT recommendations,
and alternative treatment options should be presented and explained to the patients and their caregivers.
Patients should be made aware of any uncertainties about the possible treatments, including lack of data
from relevant randomized trials that might guide rational evidence-based decisions. The rectal cancer
patients should be encouraged to enter into ongoing clinical trials and ongoing trials such as the Organ
[17]
Preservation for Early Rectal Adenocarcinoma trial (OPERA) which may provide some useful data for
decision making in the future.

DECLARATIONS
Author’s contributions
Both authors contributed equally to all.

Availability of data and materials
The data were strictly obtained from medical records according to the privacy policy and ethics code of
our institute. All materials data are from Clatterbridge data base.

Financial support and sponsorship
None.

Conflicts of interest
Gerard JP is the medical advisor for Ariane company. Myint AS has no conflict of interest.