Nationwide implementation of Watch-and-Wait in rectal cancer patients in the Netherlands: Encountered barriers and lessons learned in 20 years

Abstract

BACKGROUND: The Watch-and-Wait (W&W) approach for rectal cancer aims to improve quality of life by avoiding total mesorectal excision in patients with a clinical complete response after neoadjuvant treatment. Over the past two decades, W&W has gained increasing acceptance and is now incorporated into several national guidelines. However, successful and safe implementation outside highly specialised centres encounters barriers at multiple levels. OBJECTIVE: To describe the nationwide implementation of the W&W strategy for rectal cancer in the Netherlands and to identify key barriers at policy, institutional, and patient levels. METHODS: This article outlines the nationwide implementation of the W&W strategy in the Netherlands, highlighting the encountered barriers at policy, institutional and patient levels. RESULTS: W&W evolved from an innovative approach in specialised 'expert' centres to a nationally recognised treatment offered across 18 high-volume hospitals. This was achieved by systematically addressing barriers at each level. Policy-level barriers, such as the absence of standardised criteria for response assessment and follow-up, were addressed by developing MRI and endoscopy guidelines and structured surveillance protocols. Institutional-level barriers, including logistical challenges and financial incentives favouring surgery, were overcome through intensive multidisciplinary collaboration. At patient level, shared decision-making was key to align patient preferences with oncological safety, while careful patient selection supported optimal outcomes. CONCLUSION: The Dutch experience demonstrates that implementation of W&W is feasible and sustainable when guided by expert centres and supported by national protocols, collaboration, and quality assurance. These lessons may support other countries in integrating organ-preserving strategies into standard rectal cancer care.