EP200 - Adherence To Surveillance: A Key Requirement For Non-Operative Management Candidacy According To Rectal Cancer Clinicians

Purpose/Background: Non-operative management (NOM) is an option offered to some locally advanced rectal cancer (LARC) patients after complete clinical response to neoadjuvant therapy. NOM requires intensive surveillance to identify tumor regrowth, should it occur. Studies show < 50% of rectal cancer patients achieved all National Comprehensive Cancer Network (NCCN) recommended NOM surveillance in the first year, with adherence decreasing over subsequent years. This qualitative study explored patient factors that clinicians consider to establish NOM candidacy.

Methods/Interventions: Surgeons, medical oncologists, and radiation oncologists who treat LARC were recruited from two Midwestern medical centers. Semi-structured interviews were conducted via secure video platform. Providers were asked what makes a patient a good or bad candidate for NOM after clinical complete response. Interviews were audio recoded, transcribed, de-identified, and managed in NVivo. Through inductive thematic analysis, we developed the codebook, coded data, and created summaries to explore concepts across clinician discipline and medical center affiliation.

Results/Outcomes: A multidisciplinary group of clinicians (n=18) participated in the study: 12 surgeons, 3 medical oncologists and 3 radiation oncologists. Average clinician age was 46.5 years (range: 34-58). The majority were male clinicians (67%), and White (83%).

When asked to describe characteristics of a good and bad NOM candidate, all clinicians agreed that the patient's ability to adhere to surveillance was critical. Clinicians particularly considered three influential factors of adherence: the patient's coping and understanding of risk and benefits, ability to access care, and history with care adherence.

Understanding and coping: Most clinicians noted that NOM requires patient commitment to intensive surveillance. Therefore, clinicians evaluated the patient's understanding of NOM and their psychological readiness for it. Surveillance entails frequent appointments, MRIs, exams, and endoscopy. Patients should accept the possible risks of cancer recurrence and need for salvage surgery. Thus, clinicians did not recommend NOM for patients with dementia or mental illness that would affect understanding of NOM risks or adherence to surveillance. Clinicians would not recommend NOM to patients who would experience severe anxiety about disease recurrence.

Ability to access care: Clinicians were less likely to recommend NOM to patients where transportation, medical center proximity, and insurance and finances were of concern. These factors could limit access to close surveillance. The cumulative burden of travel, distance, and cost over 5 years of intense surveillance could influence adherence.

History with care adherence: A history of nonadherence would make clinicians hesitant whether NOM is the best option for the patient. Clinicians cited previously missed appointments, habitual lateness to exams, or difficulty to contact as worrisome factors. Additionally, clinicians also considered how engaged and active a patient has been in their care.

Conclusion/Discussion: Surveillance is a critical component of NOM, in order to expeditiously address tumor regrowth. Factors that clinicians evaluate to predict patients' adherence to surveillance include: readiness for NOM, resources to access care, and previous compliance with care. Understanding clinician's perspective of NOM candidacy is crucial to LARC treatment decision-making.

Patient's factors influencing ability to adhere to NOM surveillance
Representative quotes of the following themes: understanding and coping; ability to access care; and history of care adherence