Letter to Editor on “Quality of life and functional outcomes after rectal sparing approaches following neoadjuvant therapy for rectal cancer: a prospective cohort multicentre study”

To the Editor, Gavaruzzi et al provide prospective, multicenter patient-reported evidence that directly informs the most difficult part of rectal organ preservation: counseling patients not only on oncologic safety but on the functional “price” of different rectum-sparing strategies[1]. This commentary was prepared in accordance with the TITAN 2025 guideline to promote transparent and responsible reporting[2]. Using the ReSARCh cohort, the authors longitudinally assessed global and colorectal-specific quality of life (QoL) alongside bowel function and continence at baseline (post-neoadjuvant therapy) and at 6 and 12 months, comparing watch-and-wait (WW) with local excision (LE), and performing a clinically relevant comparison among complete clinical responders (cCR)[1]. The overarching message is appropriately balanced: both WW and LE are compatible with generally preserved QoL trajectories over 12 months, supporting rectal preservation as a meaningful goal in selected responders. This aligns with broader prospective experience showing that patients managed with WW can maintain good QoL, albeit with nontrivial bowel/sexual dysfunction in subsets – especially when salvage surgery becomes necessary[3]. The study’s most actionable contribution is its clear functional differentiation between approaches. LE appears to carry a distinct continence “signature,” with increased fecal incontinence after LE that remains clinically relevant at 12 months and is higher than WW among cCR patients[1]. This finding reinforces that organ preservation is not synonymous with “no functional harm,” and that adding transanal surgery after (chemo)radiation can compound pelvic floor and sphincter dysfunction – an observation consistent with prior syntheses of rectal-preserving pathways[4]. Notably, the authors also show that despite worse incontinence frequency after LE, the perceived continence-related QoL impact can be similar between groups, highlighting the importance of expectation-setting and shared decision-making[1]. Two translational points follow. First, in an era where total neoadjuvant therapy has increased the pool of patients eligible for non-operative management, these PRO data complement oncologic evidence and help define when WW should be preferred over “routine” LE in cCR patients[5]. Second, future rectum-sparing trials should treat continence endpoints (and patient preference) as co-primary decision drivers rather than secondary outcomes, with longer follow-up to capture late radiation effects and functional adaptation[1]