Conversations in rectal cancer treatment: a qualitative study of multidisciplinary clinician perspective into non-operative management decision-making discussions

Abstract

For select patients with locally advanced rectal cancer (LARC) who achieve a clinical complete response after neoadjuvant therapy, non-operative management (NOM) offers an alternative to surgery but introduces uncertainty and an intensive surveillance burden. Decisions between NOM and surgery are preference-sensitive and evolve as treatment response becomes clearer. How clinicians operationalize shared decision-making (SDM) for NOM remains poorly understood. We aimed to characterize clinician communication strategies and decision processes surrounding NOM, focusing on risk framing and management of uncertainty. Eighteen colorectal surgeons, medical oncologists, and radiation oncologists from two academic medical centers completed 30–60-min semi-structured interviews. Transcripts were coded inductively and analyzed using constant comparison methods and iterative codebook development. Clinicians described discussions about NOM as a longitudinal, multidisciplinary process that unfolds across multiple encounters and clinical specialties, with medical oncologists and surgeons contributing at different points along the treatment trajectory. Complex information was organized through evidence-based explanations and various risk-framing approaches, allowing patients to engage in iterative deliberation while setting clear expectations about the conditional nature of NOM and the demands of ongoing surveillance. The timing and emphasis of discussions varied by treatment phase and clinical role, which supported gradual patient understanding but also created the potential for unrealistic expectations when recommendations from the treatment team were not clearly aligned. Decision-making about NOM for LARC unfolds over time under clinical uncertainty and across specialties. Structured, phase-specific communication and improved interprofessional alignment may strengthen shared decision-making in this preference-sensitive context.