Dr Overman on Nonoperative Cancer Management in GI Malignancies

Michael J. Overman, MD, professor, Department of Gastrointestinal Medical Oncology, Division of Cancer Medicine, chair, Division of Executive Committee of the Medical Staff, The University of Texas MD Anderson Cancer Center; associate vice president of research, MD Anderson Cancer Network, discusses the rationale for utilizing a nonoperative management approach over traditional surgery in gastrointestinal (GI) cancers.

The shift towards nonoperative management in GI cancers has been made possible by the advent of immunotherapy, particularly for cancers characterized by DNA mismatch repair deficient (dMMR) or microsatellite instability-high (MSI-H), Overman begins. Overman highlights the role of immunotherapy in driving this transition, citing its remarkable efficacy in these specific subsets of GI malignancies. Traditionally, nonoperative management has been reserved for rare scenarios in GI cancers thatnecessitate regimens capable of producing high response rates and potentially curing cancer without resorting to surgery, he reports.

Notably, dostarlimab-gxly (Jemperli) has demonstrated efficacy in a small cohort of patients with rectal cancer, underscoring the robust activity of immunotherapy in this context. Other publications have shown similar activity, including high responses and pathologic complete responses (pCR) rates with immunotherapy, leading to discussions about the feasibility of nonoperative management approaches in GI cancer, Overman expands.

The integration of PD-1 therapy into neoadjuvant regimens in dMMR rectal cancer exemplifies the translation of these findings into clinical practice, Overman continues. Patients with rectal cancer are key candidates for nonoperative management due to the potential functional repercussions associated with surgery in this setting, such as the need for ostomy bags. This reinforces the importance of preserving organ function whenever feasible, he elucidates.

This paradigm shift towards nonoperative management reflects a concerted effort to optimize patient outcomes while mitigating the adverse impact of invasive surgical interventions, Overman notes. Efforts to use nonoperative approaches are propelled by advances in immunotherapy and a growing ability to tailor treatment to patients’ distinct molecular profiles, he concludes.