EP105 - Multidisciplinary Clinicians’ Attitudes Towards Non-Operative Management of Rectal Cancer – A Qualitative Study

Purpose/Background: When patients with locally-advanced rectal cancer (LARC) reach a complete clinical response after neoadjuvant treatment, non-operative management (NOM) is an option that can avoid further long-term bowel, bladder, and sexual dysfunction from surgery or avoid a permanent colostomy. Incorporating changes in care requires physician and patient buy-in. We explored the attitudes and beliefs regarding NOM of medical oncologists, radiation oncologists, and colorectal surgeons.

Methods/Interventions: One experienced interviewer conducted semi-structured interviews exploring clinician perspectives about NOM for LARC using videoconference. Interviews were transcribed and de-identified. We analyzed the data using inductive thematic analysis, creating codes to capture concepts in the text. Two researchers coded the transcripts, with the third as a reviewer. We identified relationships and connections between codes through constant comparisons.

Results/Outcomes: Participants from two Midwest academic medical centers included 18 clinicians: 3 medical oncologists, 3 radiation oncologists, and 12 colorectal surgeons. Clinical experience among participants ranged from 44% having < 10 years of practice, 34% with 10-20 years, and 22% with >20 years. Participants reported their race as White (83%) and Asian (17%). Overall mean age was 46.5 years (range: 34-58), and 33% were female and 67% male.

While clinicians shared positive attitudes towards NOM, notably that patients desire it, NOM spares patients morbidity, and potential for NOM can provide hope, clinicians also shared hesitations within their positive statements. When expressing positive attitudes, clinicians shared some caveats: there must be an experienced team, high quality imaging, and a set surveillance protocol. Clinicians also shared their worries about risk, as well as possible downsides for the patient and surgeons.

Risk aversion: Radiation oncologists and surgeons shared their perceptions about medical oncologists' worries and medical oncologists corroborated the concerns related to caring for patients with surgically unsalvageable recurrence. Medical oncologists and surgeons both expressed hesitation due to the lack of long-term outcomes data.

Patient downsides: Medical oncologists focus on the intensity of surveillance balancing this against the surgical alternative, which may include a colostomy. A radiation oncologist, however, shared that the intense surveillance may involve less time off work than other treatments, like a prolonged recovery from surgery. Clinicians raise the idea of cost or insurance coverage affecting patients, while not knowing specifics. Surgeons recognize the benefits of avoiding surgical morbidity and recovery while considering the possibility of late complications of pelvic radiation for NOM patients.

Surgeon downsides: Surgeons shared several downsides, even if they did not affect the surgeon personally, including: reimbursement, lower surgical volumes negatively affecting fellowship and early faculty experience in rectal cancer, and surgeon schedule challenges when planning for surgery when there may be a complete response.

Conclusion/Discussion: While clinicians view NOM positively due to patient preference, providing hope, and sparing patients surgery or a colostomy, attitudes are hesitantly positive because NOM involves more than just buy-in - clinicians consider longer term risks, patient downsides, clinician downsides, and an experienced team for NOM care.

Multidisciplinary Clinicians' Attitudes Towards Non-Operative Management