In light of the recently published OPRA trial, could one consider organ preservation as a standard treatment option for appropriately selected patients treated with total neoadjuvant therapy for locally advanced rectal cancer?

I think that it is NOT appropriate to consider watch and wait as a standard therapy. The OPRA trial did not test that concept- they just showed that they get pretty good results at 3 years using this technique when compared to historical data. They have not done any type of randomized comparison demonstrating that W and W is as good as resection for the entire population defined in OPRA (although, it seems to work pretty well for some of the W and W patients). OPRA looked at outcomes in two groups of patients using different TNT approaches. In addition, there was only data presented on a large group of patients to 3 years. There could easily be a meaningful drop off in survival with more complete follow-up. The OPRA trial is an important st...

Multidisciplinary teams could establish watch and wait as an option. The key component is the surgical expertise to recognize local regrowth. If that is in place, there does not appear to be an oncologic downside to offering that option. The salvage rates are extremely high among patients whose tumor regrows after they achieve a cCR. The problem is that defining W&W as a standard based on a randomized trial will probably never happen. That is because patients with a CR to TNT (30% of patients) will not likely randomize to surgery versus watch and wait. The LC, DFS, DM, and OS differences for statistical comparison are likely small based on several large retrospective data sets, the OPRA trial compared to historical controls, so the sample s...