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

This article outlines the nationwide implementation of the W&W strategy in the Netherlands, highlighting the encountered barriers at policy, institutional and patient levels.

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.

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.

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.

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.