What is the Watch & Wait strategy?

Watch & Wait is a strategy for rectal cancer patients who achieve a complete clinical response after neoadjuvant chemoradiotherapy. Instead of proceeding with surgery, the tumor is intensively monitored, and surgery is postponed or avoided as long as there are no signs of recurrence.

This approach allows for organ preservation — the rectum is kept, avoiding stoma creation and LARS syndrome.

When does it apply?

The criteria for Watch & Wait include:

Complete clinical response — the tumor is no longer detectable by:
- Clinical examination (digital rectal exam) — no palpable tumor mass
- Endoscopy (rectoscopy) — flat, whitish scar with no visible tumor
- Pelvic MRI — no residual tumor signal (or only fibrosis)
The patient understands and accepts the intensive monitoring program
The multidisciplinary team confirms eligibility

Success rates

30-40% of patients receiving neoadjuvant chemoradiotherapy achieve a complete clinical response
Of these, approximately 70-75% maintain the complete response long-term
25-30% may experience local recurrence, usually in the first 2-3 years
Local recurrence can be treated surgically (salvage surgery) with oncologic outcomes similar to immediate surgery

Monitoring program

Monitoring in the Watch & Wait strategy is intensive, especially in the first 2 years. Per the NCCN 2025 protocol:

Physical exam and CEA (tumor marker)

First 2 years: every 3-6 months
Years 3-5: every 6 months

Digital rectal exam and proctoscopy/flexible sigmoidoscopy

First 2 years: every 3-4 months
Years 3-5: every 6 months

Rectal MRI

Every 6 months, for up to 3 years

Chest and abdomen CT

Every 6-12 months, for 5 years
After MRI monitoring stops (after 3 years), the CT will also include the pelvis

Colonoscopy

At 1 year after treatment, then based on findings

Advantages and risks

Advantages

Avoiding surgery and its associated complications
No stoma (temporary or permanent)
No LARS syndrome
Better quality of life — bowel, sexual and urinary function preserved
Faster recovery and return to normal activities

Risks

Local recurrence in 25-30% of patients
Anxiety related to intensive monitoring and fear of disease return
Long-term monitoring — commitment to frequent visits
The need for salvage surgery if the tumor returns

Active research

Watch & Wait is an approach under continuous research. International studies (including the International Watch & Wait Database — IWWD) collect data to optimize:

Patient selection criteria
Optimal monitoring protocols
Identifying biomarkers that predict complete response
Combining with TNT (Total Neoadjuvant Therapy) to increase the rate of complete response

Important: Watch & Wait is not yet the standard of care in all centers. Discuss with your medical team about your eligibility for this approach.