Navigating challenges in implementing watch-and-wait strategies for rectal cancer: From clinical trials to real-world practice

Treatment of locally advanced adenocarcinoma of the rectum has evolved rapidly in recent decades. Multimodality therapy, which combines neoadjuvant chemoradiotherapy (CRT), total mesorectal excision (TME), and adjuvant chemotherapy has improved outcomes compared to historical approaches. While surgery remains a core component, low anterior resection and abdominoperineal resection may have a severe impact on the quality of life, including bowel, urinary, and sexual dysfunction. Recently, patients with no evidence of tumor after completing treatment may be selected for a nonsurgical, watch-and-wait (WW) approach. This paradigm involves extensive surveillance utilizing clinical, endoscopic, and radiologic methods. Artificial Intelligence (AI) is increasingly being applied at multiple stages of rectal cancer care to improve treatment precision and decision-making. AI can integrate clinical data to predict treatment response, improve early detection of disease, and optimize therapy. The WW approach can better identify ideal candidates, facilitate surveillance, and avoid overtreatment or undertreatment. This review explores key concepts in the WW approach as well as the role of AI in its management. AI can support the individualization of cancer care by assessing treatment response, and predicting outcomes to facilitate shared decision-making. These strategies could help expand utilization of the WW approach while increasing organ preservation.