Objective: To investigate perspectives and changes in treatment selection by Chinese surgeons since introduction of the watch-and-wait approach after neoadjuvant therapy for rectal cancer. Methods: A cross-sectional survey was conducted using a questionnaire distributed through the "Wenjuanxing" online survey platform. The survey focused on the recognition and practices of Chinese surgeons regarding the strategy of watch-and-wait after neoadjuvant therapy for rectal cancer and was disseminated within the China Watch-and-Wait Database (CWWD) WeChat group. This group targets surgeons of deputy chief physician level and above in surgical, radiotherapy, or internal medicine departments of nationally accredited tumor-specialist or comprehensive hospitals (at provincial or municipal levels) who are involved in colorectal cancer diagnosis and treatment. From 13 to 16 December 2023, 321 questionnaires were sent with questionnaire links in the CWWD WeChat group. The questionnaires comprised 32 questions encompassing: (1) basic physician characteristics (including surgical volume); (2) assessment methods and criteria for clinical complete response (cCR); (3) patients eligible for watch-and-wait; (4) neoadjuvant therapies and other measures for achieving cCR; (5) willingness to implement watch-and-wait and factors influencing that willingness; (6) risks and monitoring of watch-and-wait; (7) subsequent treatment and follow-up post watch-and-wait; (8) suggestions for development of the CWWD. Descriptive statistics were employed for data analysis, with intergroup comparisons conducted using the χ2 or Fisher's exact probability tests. Results: The response rate was 31.5%, comprising 101 responses from the 321 individuals in the WeChat group. Respondents comprised 101 physicians from 70 centers across 23 provinces, municipalities, and autonomous regions nationwide, 85.1% (86/101) of whom represented provincial tertiary hospitals. Among the respondents, 87.1% (88/101) had implemented the watch-and-wait strategy. The approval rate (65.6%, 21/32) and proportion of patients often informed (68.8%, 22/32) were both significantly higher for doctors in oncology hospitals than for those in general hospitals (27.7%, 18/65; 32.4%, 22/68) (χ2=12.83, P<0.001; χ2=11.70, P=0.001, respectively). The most used methods for diagnosing cCR were digital rectal examination (90.1%, 91/101), colonoscopy (91.1%, 92/101), and rectal T2-weighted magnetic resonance imaging (86.1%, 87/101). Criteria used to identify cCR comprised absence of a palpable mass on digital rectal examination (87.1%, 88/101), flat white scars or new capillaries on colonoscopy (77.2%, 78/101), absence of evident tumor signals on rectal T2-weighted sequences or T2WI low signals or signals equivalent to the intestinal wall (83.2%, 84/101), and absence of tumor hyperintensity on diffusion-weighted imaging with no corresponding hypointensity on apparent diffusion coefficient maps (66.3%, 67/101). As for selection of neoadjuvant regimen and assessment of cCR, 57.4% (58/101) of physicians preferred a long course of radiotherapy with or without induction and/or consolidation capecitabine + oxaliplatin, whereas 25.7% (26/101) preferred immunotherapy in combination with chemotherapy and concurrent radiotherapy. Most (96.0%, 97/101) physicians believed that the primary lesion should be assessed ≤12 weeks after completion of radiotherapy. Patients were frequently informed about the possibility of achieving cCR after neoadjuvant therapy and the strategy of watch-and-wait by 43.6% (44/101) of the responding physicians and 38.6% (39/101) preferred watch-and-wait for patients who achieved cCR or near cCR after neoadjuvant therapy for rectal cancer. Capability for multiple follow-up evaluations (70.3%, 71/101) was a crucial factor influencing physicians' choice of watch-and-wait after cCR. The proportion who patients who did not achieve cCR and underwent surgical treatment was lower in provincial tertiary hospitals (74.2%, 23/31) than in provincial general hospitals (94.5%, 52/55) and municipal hospitals (12/15); these differences are statistically significant (χ2=7.43, P=0.020). The difference between local recurrence and local regrowth was understood by 88.1% (89/101) of respondents and 87.2% (88/101) agreed with monitoring every 3 months for 5 years. An increase in local excision or puncture rates to reduce organ resections in patients with pCR was proposed by 64.4% (65/101) of respondents. Conclusion: Compared with the results of a previous survey, Chinese surgeons' awareness of the watch-and-wait concept has improved significantly. Oncologists in oncology hospitals are more aware of the concept of watch-and-wait.
目的： 了解中国外科医生对于直肠癌新辅助治疗后等待观察疗法的观点和治疗选择的现状。 方法： 采用横断面调查方法进行问卷调查，通过“问卷星”网络调查平台创建关于直肠癌新辅助治疗后等待观察治疗中国外科医生的再认知和实践调查问卷。调查对象的选择标准：（1）全国范围内，有完善的结直肠癌诊疗资质的（省级或地市级）肿瘤专科医院或综合医院：（2）目标中心的副主任医师及以上的外科、放疗科或内科医生。2023年12月13日至16日，在CWWD微信群中发送调查问卷链接，共发送321份问卷。问卷总共32个问题，内容包括：（1）医生的基本信息（含手术量统计）；（2）临床完全缓解（cCR）的评估方式及标准；（3）等待观察的适用人群；（4）促进cCR的新辅助治疗方式及其他措施；（5）等待观察的实施意愿及影响因素；（6）等待观察的风险与监测；（7）等待观察后续治疗及随访；（8）对于中国等待观察数据库（CWWD）的发展建议。总结上述调查结果，组间比较采用χ2检验或Fisher确切概率法。 结果： 共发送问卷321份，共收到101份反馈，应答率为31.5%，反馈对象来自全国23个省市自治区直辖市、70家中心。来自省级三甲医院的医生占比85.1%（86/101）。已开展等待观察治疗的医生占比87.1%（88/101）。肿瘤专科医院医生对等待观察策略的认可率（65.6%，21/32）和经常告知患者的比例（68.8%，22/32）均高于综合医院医生（27.7%，18/65；32.4%，22/68），差异均有统计学意义（χ2=12.83，P<0.001；χ2=11.70，P=0.001）。直肠指诊（90.1%，91/101）、结肠镜检查（91.1%，92/101）、直肠T2加权像核磁共振（86.1%，87/101）以及扩散加权成像磁共振（85.1%，86/101）是本次调查受访医生判断cCR最常用的诊断方式；cCR的判断标准包括：直肠指诊未触及肿物（87.1%，88/101）、内镜下扁平白色瘢痕及新生毛细血管（77.2%，78/101），直肠核磁T2序列未见明显肿瘤信号或T2WI低信号或与肠壁等信号（83.2%，84/101）、DWI无肿瘤高信号且ADC中无低信号（66.3%，67/101）。在新辅助治疗方案选择和促进cCR的评估方面，57.4%（58/101）的医生首选长程放化疗联合或不联合诱导和（或）巩固CapeOX方案（卡培他滨+奥沙利铂），25.7%（26/101）的医生首选免疫治疗联合化疗及同步放化疗。96.0%（97/101）的医生认为，首次评估原发灶的时间应该在放疗结束后12周内。43.6%（44/101）的医生经常会向患者提示新辅助治疗后cCR的可能及等待观察策略。38.6%（39/101）的医生对于直肠癌新辅助治疗后达到cCR或近cCR的患者首选等待观察。多次随访复查能力（70.3%，71/101）是影响医生选择cCR后等待观察治疗的重要因素。对于临床上未达到cCR的患者，省级三甲肿瘤专科医院中选择手术治疗的比例低于省级综合医院和地市级医院，其比例分别为74.2%（23/31）、94.5%（52/55）和12/15，差异具有统计学意义（χ2=7.43，P=0.020）。88.1%（89/101）的医生了解局部复发和局部再生的区别。87.2%（88/101）的医生认同初始每3个月监测1次，直至5年。64.4%（65/101）的医生认为应该提高局部切除或穿刺比例，减少病理完全缓解患者的器官切除率。 结论： 与前期调查结果相比，中国外科医生对于等待观察理念的认知和实践有显著提高，肿瘤专科医院医生更加倾向于选择等待观察治疗。.