• Author
    Mariam Noorulhuda
  • Discovery PI

    Tara Russell

  • Project Co-Author

    Mariam Noorulhuda, Kera Kwan, Armine Kalbakian, Qian Yi Pang, Tara Russell

  • Abstract Title

    Approaches to Active Surveillance for Non-Operative Management in Rectal Cancer: A Multisite Study Across Diverse Care Settings

  • Discovery AOC Petal or Dual Degree Program

    Healthcare Improvement & Health Equity Research

  • Abstract

    Introduction: Watch-and-wait (WW) is an organ-preserving strategy for locally advanced rectal cancer patients who achieve a clinical complete response after total neoadjuvant therapy. Its safety depends on intensive active surveillance with serial imaging and endoscopy to detect tumor regrowth. How surveillance is implemented in practice remains unclear.

    Methods: We recruited surgical, medical, and radiation oncologists from diverse clinical settings as part of a larger study exploring WW implementation and use. Semi-structured interviews were conducted via Zoom, recorded, and transcribed. We examined interview content on individual and institutional surveillance practices, including provider roles, institutional infrastructure, and adherence concerns. Transcripts underwent inductive thematic analysis with mapping to Consolidated Framework for Implementation Research (CFIR) domains.

    Results: We interviewed 26 surgical (n=15), medical (n=6), and radiation (n=5) oncologists from academic (n=7), safety-net (n=8), academic-safety-net hybrid (n=4), Veterans Affairs (n=5), and private practice (n=2) settings. Five themes emerged: (1) diffuse ownership without formal accountability systems, (2) reliance on individual clinician effort, (3) concern about loss to follow-up, (4) protocols not embedded in workflow, and (5) need for infrastructure. In absence of automated systems, surveillance was primarily managed through memory, notes, informal lists, or personal spreadsheets, and providers acknowledged they might not consistently know if patients were lost to follow-up. Across settings, providers identified similar needs including registry-based tracking, EHR-integrated reminders, dedicated coordination support, and clearer assignment of responsibility.

    Active Surveillance Themes and CFIR Domains With Representative Quotes

    Theme/CFIR Domains

    Representative Quotes

    Diffuse Ownership Across Specialties Without Clear Accountability Structure

     

    [Innovation Deliverers - Role Clarity; Inner Setting - Structural Characteristics (Work Infrastructure), Networks & Communication; Implementation Process - Teaming]

     

    “I think all of us are [managing surveillance] together…But I don't think there's, like, one specific person who's assigned. There's no, like, quarterback.” (Radiation oncologist, Academic)
     

    “It's been mostly us in medical oncology, but I don't necessarily think it was because it was clearly communicated to us, or that we volunteered. I think it was just similarly, hey, who saw the patient last?” (Medical oncologist, VA)

    “We kind of are leaving it up to [the medical oncologists] to do the frequent appointments and order the imaging and blood work, but we are the ones that are ordering the endoscopies and scheduling those.” (Surgeon, Safety-net)

    Surveillance as Individual Clinician Effort Rather Than System

     

    [Inner Setting - Available Resources, Structural Characteristics; Implementation Process - Executing]

    “Sheer dedication and documentation in our notebooks…” (Medical oncologist, VA)

    “I have a separate kind of a registry that I track them…A good old Excel sheet.” (Surgeon, Private practice)

    “My own personal reminder lists and spreadsheets and calling patients if I need to…coordination..is..myself,…my MA, and my patient.” (Surgeon, Academic)

    Concern About Loss to Follow-Up

     

    [Outer Setting - Patient Needs & Resources; Inner Setting - Implementation Climate]

    “My biggest issue is just if I have a patient who is reliable through therapy, but then the surveillance window comes, and I just can't get a hold of them… then they're at risk for a missed recurrence, and I'm stressed.” (Surgeon, Safety-net)
     

    “If they don't follow up with their surveillance, then I may not be able to detect their regrowth…our ability to salvage those patients are compromised. So that's my biggest fear.” (Surgeon, VA)

    Protocols Exist but Not Embedded in Workflow

     

    [Inner Setting - Compatibility, Structural Characteristics (Informational Technology Infrastructure)]

    “We have a protocol…but you still have to remember to order everything.” (Radiation oncologist, Academic)

     

    “I would like to see a little bit more standardization…I just want to know what I'm responsible for, and on what timeline, and we all agree on it.” (Medical oncologist, Academic)

    Need for Infrastructure and Tracking Systems

     

    [Inner Setting - Available Resources; Implementation Process - Planning, Reflecting]

    “In an ideal world, it would be, like, built into the EHR and not, like, a separate Excel file…and automatically populates.” (Surgeon, VA)

     

    “It would have to be kind of a thing that, like, was in your face that popped out at you every time you log on to the system…Something that forced you to look at it every time and make sure that they're checking all the boxes.” (Surgeon, Safety-net)

     

     

    Conclusion: Active surveillance for WW relies heavily on individual clinician effort rather than embedded systems. Strengthening surveillance infrastructure may improve reliability and support expansion of organ-preserving care.

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