Organ Preservation in Rectal Cancer Management: A Prospective GRECCAR Snapshot.

BACKGROUND: Organ preservation strategies, including watch and wait and local excision, are increasingly adopted in rectal cancer management. Total neoadjuvant therapy improves complete response rates, potentially expanding organ preservation indications. OBJECTIVE: To evaluate the real-world implementation of organ preservation strategies and short-term oncologic outcomes in patients with non-metastatic mid- and low-rectal cancer in France. DESIGN: Prospective, multicenter, observational cohort study. SETTINGS: Twenty-seven French GRECCAR centers were included. PATIENTS: Patients with biopsy-proven, non-metastatic rectal adenocarcinoma (<12 cm from anal verge) treated with neoadjuvant therapy managed with organ preservation intent across 27 French GRECCAR centers (October 2022-March 2023) were included. Patients were categorized into selective (early-stage) or opportunistic (advanced-stage) strategies and managed with either watch-and-wait or local excision. MAIN OUTCOME MEASURES: Rates of organ preservation, watch and wait vs local excision use, and oncologic outcomes at 1 and 2 years, including overall survival, disease-free survival, local recurrence-free survival, total mesorectal excision-free survival, and distant metastasis. RESULTS: Of the 457 patients, 117 (26%) underwent organ preservation, more frequently with the selective strategy (51% vs. 18.1%; p < 0.001). Watch and wait was the predominant organ preservation method (78% vs. 22%), used similarly across both groups (p = 0.728). Total neoadjuvant therapy was the most common neoadjuvant regimen (67%), predominantly via induction chemotherapy (56%). Overall survival at 2 years exceeded 95% across groups. No significant differences between watch and wait and local excision in disease-free survival, local recurrence-free survival or total mesorectal excision-free survival. Local regrowth occurred in 14 watch-and-wait patients and 3 after local excision, mostly within the first year, with salvage surgery successfully performed. Distant metastases were more frequent in patients treated under the opportunistic strategy. LIMITATIONS: The short follow-up period limits the assessment of long-term outcomes and late recurrences. CONCLUSIONS: In this nationwide French cohort, organ preservation strategies-supported by total neoadjuvant therapy-were feasible and safe across tumor stages. Both watch and wait and local excision demonstrated comparable short-term oncologic outcomes, supporting their role as viable options within individualized, response-adapted treatment pathways. See Video Abstract.