Non-operative management of rectal adenocarcinoma in a safety-net system: a decade of real-world outcomes outside watch-and-wait eligibility.

Recent guidelines increasingly support watch-and-wait (W&W) strategies for locally advanced rectal cancer (LARC) following favorable response to neoadjuvant therapy. However, these strategies have largely been validated in highly selected trial populations and require intensive surveillance that may be difficult to implement in underserved settings. Limited data exist on outcomes among patients affected by adverse social determinants of health, particularly in safety-net hospital systems. We evaluated outcomes of patients with LARC in an underserved setting who were managed non-operatively out of necessity, rather than according to W&W guidelines. Most of the presented cohort would not have met eligibility criteria for contemporary W&W trials and received care that largely predated widespread adoption of W&W, allowing assessment of whether comparable outcomes are achievable in a higher-risk, real-world population. This retrospective study included patients with LARC managed non-operatively with definitive intent at a single safety-net hospital system over a decade. All patients received radiotherapy and systemic chemotherapy. Clinical characteristics, treatment details, and oncologic outcomes were abstracted. Forty-nine patients were identified with a median follow-up of 25 months (range, 8-90 months). The cohort was 55% male and racially/ethnically diverse (63% Hispanic, 20% White, 12% Black). Most patients (69%) were uninsured. Reasons for non-operative management included patient preference (49%), suspicion of low-burden metastatic or non-regional nodal disease (35%), and medical comorbidities (16%). The majority (76%) received long-course chemoradiotherapy (50-55 Gy with concurrent capecitabine); the remainder received short-course radiotherapy (25 Gy/5 fractions). Local failure did not differ significantly between regimens (P=0.51). Two-year local control, progression-free survival, and overall survival were 59%, 43%, and 67%, respectively. Eighteen patients (37%) achieved an initial complete or near-complete clinical response, of whom 5 developed local recurrence. Distant-only metastasis was the most common recurrence pattern. Despite inclusion of higher-risk patients who would not meet standard W&W criteria, radiotherapy-based non-operative management achieved meaningful local control, with regrowth rates among responders comparable to prospective trials. These findings support the feasibility of organ-preserving approaches in safety-net populations even when adherence to W&W surveillance protocols remains challenging.