EP240 - Choosing Not to Cut: National Trends and Disparities in Nonoperative Rectal Cancer Management

Purpose/Background: Nonoperative management (Watch and Wait) for rectal cancer is an evolving approach aimed at organ preservation in patients achieving complete clinical response after neoadjuvant therapy. While growing evidence supports its oncologic safety in selected patients, national trends in its adoption remain underexplored. This study evaluates temporal trends in WW use between 2004 and 2023 using population-level data.

Methods/Interventions: We conducted a retrospective cohort study using data from the National Cancer Database (NCDB) between 2004 and 2023. Patients with locally advanced rectal cancer who received neoadjuvant therapy were included and stratified into two groups: those undergoing total mesorectal excision (TME) and those managed with a nonoperative “watch-and-wait” (WW) approach. Trends in adoption of WW were analyzed across five time intervals. Demographic and clinical characteristics were compared between groups using chi-square tests, with statistical significance set at p< 0.001.

Results/Outcomes: Among 92,912 patients included, 31,049 (33.4%) were managed nonoperatively, while 61,863 (66.6%) underwent surgery following neoadjuvant therapy. Adoption of WW increased substantially over time, from 8.7% in 2004–2007 to 42.3% in 2020–2023. Compared to the surgical group, WW patients were more likely to be aged ≥80 (18.2% vs. 6.1%) and treated at community cancer programs (8.6% vs. 6.3%). The WW group also had alower comorbidity burden, with a Charlson-Deyo Score 0 (77.5% vs. 78.2%). Medicaid-insured patients (48.4% vs. 36.8%) and those in the lowest income quartile (29.8% vs. 29.9%) were more likely to receive WW. Differences were also observed by race: non-Hispanic Black (10.6% WW vs. 8.4% surgery) and Hispanic patients (12.1% WW vs. 11.3%) were slightly more likely to undergo WW compared to non-Hispanic White patients. Stage III tumors constituted the majority in both groups.

Conclusion/Discussion: While the increasing adoption of WW reflects evolving management strategies for rectal cancer, its higher use among older, minority, and socioeconomically disadvantaged patients may also reflect disparities in access to surgical care. Further investigation is needed to determine whether WW is consistently applied based on oncologic appropriateness or if structural factors are influencing treatment decisions.

Trends in the Adoption of the Watch and Wait Approach


Univariate Analysis of Demographic Characteristics Among Rectal Cancer Patients Managed with Surgery vs. Watch-and-Wait