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Rectal Cancer

NCCN Guidelines for Patients: Rectal Cancer

Navigating cancer can be overwhelming, leaving individuals feeling lost in a sea of information and choices. The NCCN Guidelines for Rectal Cancer Patients is here to help. Receive clear, step-by-step guidance for rectal cancer care based on global healthcare standards.


The goal of this educational document is to empower you to have informed discussions with your doctors about your treatment options. These resources are designed to empower you in meaningful conversations with your medical team, ensuring that you make well-informed decisions about your rectal cancer treatment journey.

Below you can access the official NCCN Guidelines for Patients: Rectal Cancer page, with additional resources and the full downloadable guide. On this page, you will discover the key points from each section.

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Rectal Cancer NCCN Guidelines: Key Points

Rectal Cancer Basics

  • The rectum, the final part of the large bowel, stores stool until it's expelled through the anus. 

  • Many rectal cancers originate in adenomas, which are polyps. 

  • Adenocarcinoma is the most common type of rectal cancer that develops from adenomas. 

  • Cancer can grow beyond the rectal wall and spread to other areas after starting in a polyp. 

  • Cancer cells can metastasize, traveling to different body parts through lymph or blood. 

  • Rectal cancer stage indicates the extent of cancer in the body. 

  • There are five stages of rectal cancer, numbered 0, I (1), II (2), III (3), or IV (4).

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Treatment Planning

  • Inherited syndromes linked to rectal cancer include Lynch syndrome and FAP. 

  • Health history, including family health history, is essential for everyone with rectal cancer. 


Diagnostic procedures such as colonoscopy, biopsy, and pathology reports play a crucial role:

  • Colonoscopy allows examination for polyps and potentially cancerous lesions. 

  • A biopsy is typically done during a colonoscopy to confirm suspected cancer. 

  • Pathology reports include cancer grade, indicating its growth and spread speed. 

  • Recommended blood tests include a complete blood count (CBC), chemistry profile, and carcinoembryonic antigen (CEA) test. 

  • Imaging methods like pelvic MRI and chest/abdomen/pelvis CT scans help determine cancer's extent and spread. 

  • Biomarker testing, including MMR/MSI testing, KRAS/NRAS, BRAF, and HER2 testing, is essential for diagnosis and treatment planning. 

  • Young adults with rectal cancer should receive counseling on fertility-related risks and preservation options like sperm banking, egg freezing, ovarian tissue banking, and ovarian transposition. 

Overview of Treatments


  • Transanal surgery for very early rectal cancers removes tumors through the anus. 

  • Transabdominal surgery, involving abdominal wall cutting, is common for many rectal cancers. It removes the tumor, surrounding tissue, and nearby lymph nodes.

Systemic Therapy and Radiation Therapy: 

  • Systemic therapy includes chemotherapy, targeted therapy, and immunotherapy. 

  • Chemotherapy is the primary systemic therapy for rectal cancer. 

  • Radiation therapy uses high-energy rays, usually external beam radiation therapy (EBRT), for rectal cancer treatment. 

  • Chemotherapy and radiation therapy may be combined, known as chemoradiation. 

Local Therapies for Metastases: 

  • Surgery (resection) is preferred for removing liver or lung metastases whenever possible. 

  • Image-guided ablation destroys small liver or lung tumors, often used with or without surgery for specific cases. 

  • Liver-directed therapies are an option for non-responsive liver tumors, ineligible for resection or ablation. 

  • Stereotactic body radiation therapy (SBRT) treats rectal cancer that has spread to the liver, lungs, or bones. 

Clinical Trials: 

  • Clinical trials offer access to experimental treatments not yet approved by the U.S. FDA, providing hope for future treatments. 

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Non-Metastatic Cancer

Cancerous Polyps: 

  • Pedunculated cancerous polyps, removed in one piece and low risk, often require no further treatment. 

  • Surgery is an option for sessile cancerous polyps, which are more likely to recur after polypectomy. 

Early Rectal Cancer: 

  • Transanal surgery suits very early rectal cancers confined to the second layer of the rectum wall. 

  • Transabdominal surgery is recommended for early rectal cancers that don't meet transanal surgery criteria. 

  • Stage I cancers after transabdominal surgery usually require no further treatment. 

  • Stage II or III cancers post transabdominal surgery often need treatment, including chemotherapy and chemoradiation. 


Locally Advanced Rectal Cancer: 

  • Locally advanced rectal cancer invades nearby areas or lymph nodes. 

  • Treatment typically involves chemotherapy and either long-course chemoradiation or short-course radiation, called total neoadjuvant therapy. Surgery may follow successful treatment. 



  • Stage I rectal cancers require colonoscopies for monitoring. 

  • For cases treated with transanal surgery, proctoscopies are also needed in the first 5 years after surgery. 

  • Surveillance for stage II and III rectal cancer includes physical exams, CEA blood tests, colonoscopies, and CT scans. 

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Metastatic Cancer


  • Metastasis is the spread of cancer cells to distant areas. 

  • If metastases are found at diagnosis, it's stage IV rectal cancer. 

  • Metastases often develop after treatment, termed distant recurrence. 

Treatment for Metastatic Rectal Cancer: 

  • Local therapies can be used for some metastatic cases, including image-guided ablation, intra-arterial liver-directed therapies, and SBRT. 

  • Surgery or ablation is preferred for liver or lung metastases when feasible, but not always possible. 

  • Metastatic cancer not treatable with surgery or local therapies is managed with systemic therapy. 

Supportive Care: 

  • Palliative care is available to manage symptoms and improve comfort, but it doesn't aim to treat cancer directly. 


Cancer Survivorship: 

  • Survivorship addresses unique physical, emotional, and financial concerns of cancer survivors. 

  • Coordination between your oncologist and primary care doctor is crucial for follow-up care. 

  • A written survivorship care plan outlines your recommended post-treatment care. 

  • Leading a healthy post-cancer life involves little to no alcohol, a balanced diet, regular exercise, smoking cessation, and overall health maintenance. 

  • For individuals with ostomies, consider joining support groups or seeking specialized care. 

  • Acupuncture, heat therapy, and duloxetine can help manage nerve damage from chemotherapy. 

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Additional Survivorship Resources Linked Below:

These resources cover various topics relevant to cancer survivors, including: 


  • Anxiety, depression, and distress 

  • Cognitive dysfunction 

  • Fatigue 

  • Pain 

  • Sexual problems 

  • Sleep problems 

  • Healthy lifestyles 

  • Immunizations 

  • Employment, insurance, and disability concerns 

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Contact Us

Facing cancer can be confusing, but you're not alone. Reach out today to start your journey with confidence. Our skilled surgeons provide top-quality care, staying updated on the latest treatments and techniques.

For more information, you can you can access the official NCCN Guidelines for Patients: Rectal Cancer page linked below:

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