Survival and Quality of Life Drive Treatment Preferences in Rectal Cancer

Key Clinical Summary: 

• Design/Context: PrefCoRe assessed preferences among over 1,000 participants regarding treatment strategies after clinical complete response in locally advanced rectal cancer.
• Key Outcomes: Survival and quality of life were the most influential factors in decision-making, while the choice between watch-and-wait and surgery alone was not the dominant determinant.
• Clinical Relevance: These findings emphasize the need for individualized, shared decision-making in rectal cancer, incorporating multiple patient-centered factors beyond treatment modality alone.

Andrew Renehan, MD, PhD, The Christie NHS Foundation Trust, Manchester, United Kingdom, discusses findings from the PrefCoRe study evaluating patient preferences for watch-and-wait versus surgery after clinical complete response in locally advanced rectal cancer.

Results demonstrated that survival and quality of life are the primary drivers of decision-making, underscoring the complexity of treatment preferences.

Transcript: 

Good afternoon, my name is Professor Andrew Renehan from the University of Manchester in the United Kingdom. This is a collaborative piece of work that was published very recently in the European Journal of Cancer in the area of locally advanced rectal cancer. The title was “quantifying preferences for watch and wait compared with surgery after clinical complete response in locally advanced rectal cancer.”

Specifically, the methodology here may not be that familiar to everybody. It was a discrete choice experiment, and the acronym for the project was PrefCoRe. This was a collaborative piece of work with my decision-making colleagues in the division of health economics at the University of Manchester and also a collaborator, another health economist, from the University of Washington in Seattle.

Rectal cancer treatment has really changed a lot in the last 5 to 7 years where there are a whole variety of different options in the nonmetastatic setting from early stage to more advanced stage. Specifically, the drive among many trials in the last 5 or so years has been towards organ preservation– this is where we can avoid major surgery, which is the backbone of treatment of rectal cancer, which is associated with a lot of morbidity and also the probability of having a permanent stoma in anything from 30 to 40 percent of cases. 

There are a variety of different mechanisms now of achieving organ preservation, or what is also called clinical complete response. These can be achieved through conventional chemoradiotherapy, which is often called long-course, through to more recent developments such as total neoadjuvant therapy (TNT). Very recently, we’ve had exciting news in the area of immunotherapy and also contact brachytherapy in the form of Papillon treatment. When a clinical complete response is achieved, we follow our patients quite intensively with a surveillance program called watch-and-wait, because we know that between 25 and 35 percent of patients may go on to have a regrowth within the lumen of the rectum, called a local regrowth, and they may require salvage surgery. 

There are a lot of complexities here, and this is a challenge when we try to explore patient preferences. In this area, and in other areas of cancer, we’ve traditionally asked patients after they’ve had their treatment what their preferences were. The questions are often driven by binary-type choices, surgery versus radiotherapy, for example. However, at a real-world level, this is far more complicated, and people as human beings take a lot of other things into account and this is what the methodology of discrete choice experiments can do. Rather than dealing with binary data, it deals with things over a continuous set of outputs and we can develop regression models based on these outputs. We can do this across very large cohorts of participants. We also recognize that when we use patients who have experienced the condition, while this has certain advantages because they have lived experience, there is a lot of evidence in the literature to suggest that there are biases associated with this type of assessment. These are a form of survivorship bias, where people who survive their treatment are inclined to give a preference towards the treatment that they chose, because they have survived. 

This approach that we used has been used in many other areas of cancer, and particularly by the group that I work with, we’ve used it extensively in the area of cancer screening, for example. This takes into account a lot of preferences and a lot of ways that patients and people who may develop cancer may  think. To take this into account, the modeling has to derive attributes, and then within each attribute, derive levels. In this particular study, we did a lot of background work, thanks to the lead health economist on this project, Dr Garima Dalal, who is the first author and unfortunately is not able to attend today.

We interviewed both patients and clinicians in this area, and we derived 7 attributes. These included the chance of local regrowth, the chance of distant disease, follow-up, time to stoma, issues related to the intensity of surveillance—that is, frequency—and then the last 2 were overall survival and quality of life. We used an online methodology to capture our participants. These were adult participants, there were over 800 non-cancer participants and over 350 participants who had had previous experience of cancer, not necessarily rectal cancer, it could be cancer of any sort. We collected a lot of detail in relation to their characteristics, their education, and their background, and there were a lot of similarities across these two groups.

We ran the survey for approximately 6 to 8 weeks, captured the data, and then analyzed it using regression models, random and fixed logit models, which allowed us to assess heterogeneity and variability. There were some surprising findings. Specifically, the model showed that the question of watch-and-wait versus surgery was not a crucial factor in decision-making, and in fact this came out very much as 50/50. The 2 factors that ranked the highest were survival and quality of life. All of the other attributes contributed to the ranking of preferences, and this demonstrated that there is a complexity and a dynamic process that goes on when patients have to make these decisions.

Looking forward, it would be useful to repeat this in other populations. This was a UK population, so it would be useful to reproduce it elsewhere, to look at ethnicities, and to extend this work to other cancers. For example, in esophageal cancer there are also options such as watch-and-wait, and similar approaches could be applied. Some of this has already been explored, for example in the Dutch SANO trial, which we discussed in the paper.

Overall, this is a novel study. We believe it is the first discrete choice experiment of this type in this area. It reflects the complexity of decision-making, but it also provides new insights that weren’t previously available and importantly, it gives us something to discuss with our patients when they are faced with these difficult and complex decisions.  

Source: 

Dalal G, Wright SJ, Malcomson L, et al. Quantifying preferences for watch-and-wait compared with surgery after a clinical complete response in locally advanced rectal cancer: A discrete choice experiment (PrefCoRe). Eur J Cancer. Published online: February 18, 2026. doi:10.1016/j.ejca.2026.116589