GET THE FACTS

The colon and rectum are parts of the body’s digestive system and together form a long, muscular tube called the large intestine. The colon is the first 6 feet of the large intestine and the rectum is the last 8-10 inches. The last part of the rectum contains the rectal sphincter or anus. The rectal sphincter is the muscle that controls defecation. Preservation of the rectal sphincter during surgery for rectal cancer is necessary in order to maintain control of bowel function. Treatment approaches differ between cancers of the colon or rectum, and are therefore discussed separately.

Pathology Report

Staging: In order to understand the best treatment options available for treatment of rectal cancer, it is important to first determine where the cancer has spread in the body. The initial spread of rectal cancer occurs circumferentially around the rectum and laterally into the adjacent fat and muscles. Rectal cancer can then invade nearby organs and spread through the lymph and blood systems. Rectal cancer cells may spread via the blood throughout the body to the liver, lungs and other organs.

Computed Tomography (CT) Scan: A CT scan is a technique for imaging body tissues and organs, during which X-ray transmissions are converted to detailed images, using a computer to synthesize X-ray data. A CT scan is conducted with a large machine positioned outside the body that can rotate to capture detailed images of the organs and tissues inside the body.

Magnetic Resonance Imaging (MRI): MRI uses a magnetic field rather than X-rays, and can often distinguish more accurately between healthy and diseased tissue. MRI gives better pictures of tumors located near bone than CT, does not use radiation as CT does, and provides pictures from various angles that enable doctors to construct a three-dimensional image of the tumor.

Colonoscopy: A colonoscopy may be used to identify whether a second cancer is present in the colon or rectum prior to surgery. During a colonoscopy, a long flexible tube that is attached to a camera is inserted through the anus, allowing physicians to examine the internal lining of the colon and rectum for polyps or other abnormalities. The physician may perform a biopsy during a colonoscopy in order to collect samples of suspicious tissues or cells for closer examination.

Endorectal Ultrasound (EUS): Endorectal ultrasound (EUS) involves the use of a special probe that is inserted into the rectum to help determine the thickness of the cancer. By determining the thickness of the cancer, EUS can help determine the stage.


SURGERY

Upon completion of the clinical staging evaluation, surgery is performed to remove the cancer, along with part of the normal adjacent tissues of the rectum. Surgery also helps to further determine the level of spread within the rectal wall and abdomen. The type of surgery performed depends on the size and the location of the cancer.

Some patients may be treated with radiation therapy and/or chemotherapy prior to surgery. Giving these treatments before surgery may reduce the risk of cancer recurrence and help to shrink the cancer prior to surgery.

Following surgical removal of rectal cancer, a final “pathologic” stage will be given. This is based on extent of spread of cancer after looking at the removed tissue under a microscope. All new treatment information concerning rectal cancer is categorized and discussed by the stage. In order to learn more about the most recent information available concerning the treatment of rectal cancer, click on the appropriate stage.

Stage I: Cancer is confined to the rectum.

Stage II: cer may penetrate the wall of the rectum into the surrounding fat or muscles or other adjacent organs, but does not invade any local lymph nodes.

Stage III: Cancer invades one or more of the local lymph nodes, but has not spread to other distant organs.

Stage IV: Cancer has spread to distant locations in the body, which may include the liver, lungs, bones or other sites.

Stages

Stage 1

Overview

The colon and rectum are parts of the body’s digestive system and together form a long, muscular tube called the large intestine. The colon is the first 6 feet of the large intestine and the rectum is the last 8-10 inches. The last part of the rectum contains the rectal sphincter or anus. The rectal sphincter is the muscle that controls defecation. Preservation of the rectal sphincter during surgery for rectal cancer is necessary in order to maintain control of bowel function. Treatment approaches differ between cancers of the colon or rectum, and are therefore discussed separately. A separate section has been created for Colon Cancer.

Surgical Treatment

Adenocarcinoma of the rectum is relatively uncommon and is usually curable by surgical removal of the cancer. Different types of surgery may be recommended depending on the location and specific characteristics of the cancer.

Stage 2

Overview

Following surgical removal of rectal cancer, the cancer is referred to as Stage II rectal cancer if the final pathology report shows that the cancer has penetrated the wall of the rectum, but does not invade any of the local lymph nodes and cannot be detected in other locations in the body.

Neoadjuvant Therapy: Neoadjuvant therapy refers to treatment given prior to surgery. Many patients with Stage II rectal cancer receive neoadjuvant chemotherapy and radiation therapy; the goals are to reduce the risk of cancer recurrence and to shrink the cancer prior to surgery. If patients are in poor health and are unable to tolerate chemotherapy and/or radiation therapy, surgery may be the initial treatment.

Surgical Treatment: The standard surgical procedures used to remove Stage II rectal cancer include low anterior resection (LAR) or an abdominoperineal resection (APR). The choice of operation depends on the location of the rectal cancer.

An LAR involves an incision across the abdomen and removal of the cancerous part of the rectum along with some surrounding tissue and lymph nodes. This is often done for cancers that are in the upper part of the rectum. Lower cancers may be treated with removal of the rectum along with extensive removal of surrounding tissues (total mesorectal excision). Depending on where the cancer was and how much of the rectum was removed, the colon may be reconnected to the remaining part of the rectum or to the anus. When possible, the surgery will allow a patient to continue to pass waste through the anus. Some patients, however, may require a temporary or permanent colostomy (an artificial opening that allows waste to pass from the colon to the outside of the body).

If the cancer is very low in the rectum (near the anus), a patient may need to have an abdominoperineal resection (APR). This involves an incision in the abdomen and an incision around the anus. Because both the rectum and the anus are removed, an APR requires a permanent colostomy.

Adjuvant Therapy: The goal of providing additional treatment after surgery (adjuvant therapy) is to reduce the risk of cancer recurrence by eliminating any remaining cancer. For patients who received neoadjuvant (before-surgery) chemotherapy and radiation therapy, additional chemotherapy is often given after surgery. If patients did not receive neoadjuvant therapy, they may be treated with both chemotherapy and radiation therapy after surgery.

Laparoscopic Surgery: Laparoscopic surgery is used for many types of surgery with the short-term advantages of less pain, fewer wound complications, quicker post-operative recovery, and shorter hospital stays. Instead of making one long incision in the abdomen, the surgeon makes several smaller incisions.

Improved Approaches to Radiation Therapy: As the technology for radiation therapy has evolved, important advances have been made in the ability of physicians to precisely target the area of the cancer. The goal is to deliver effective doses of radiation to the cancer while sparing healthy tissue to the extent possible. One newer approach to delivering radiation therapy is intensity modulated radiation therapy (IMRT). IMRT starts with a three-dimensional image of the cancer, and allows physicians to deliver different doses of radiation to different areas. The potential advantages for patients include both better tumor control and fewer side effects.

Managing Side Effects: Techniques designed to prevent or control the side effects of cancer and its treatments are called supportive care. Side effects not only cause patients discomfort, but also may prevent the delivery of therapy at its planned dose and schedule. In order to achieve optimal outcomes from treatment and improve quality of life, it is imperative that treatment is delivered as planned and that side effects resulting from cancer and its treatment are appropriately managed.

Stage 3

Overview

Following surgical removal of rectal cancer, the cancer is referred to as Stage III rectal cancer if the final pathology report shows that the cancer has invaded any of the local lymph nodes, but cannot be detected in other locations in the body.

Neoadjuvant Therapy: Neoadjuvant therapy refers to treatment given prior to surgery. Many patients with Stage III rectal cancer receive neoadjuvant chemotherapy and radiation therapy; the goals are to reduce the risk of cancer recurrence and to shrink the cancer prior to surgery. If patients are in poor health and are unable to tolerate chemotherapy and/or radiation therapy, surgery may be the initial treatment.

Surgical Treatment: The standard surgical procedures used to remove Stage III rectal cancer include low anterior resection (LAR) or abdominoperineal resection (APR). The choice of operation depends on the location of the rectal cancer.

Adjuvant Therapy: The goal of providing additional treatment after surgery (adjuvant therapy) is to reduce the risk of cancer recurrence by eliminating any remaining cancer. For patients who received neoadjuvant (before-surgery) chemotherapy and radiation therapy, additional chemotherapy is often given after surgery. If patients did not receive neoadjuvant therapy, they may be treated with both chemotherapy and radiation therapy after surgery.

Laparoscopic Surgery: Laparoscopic surgery is used for many types of surgery with the short-term advantages of less pain, fewer wound complications, quicker post-operative recovery, and shorter hospital stays. Instead of making one long incision in the abdomen, the surgeon makes several smaller incisions.

Stage 4

Overview

Following clinical evaluation of rectal cancer, the cancer is referred to as Stage IV rectal cancer if the final evaluation shows that the cancer has spread to distant locations in the body, which may include the liver, lungs, bones, or other sites.

Treatment of Extensive Stage IV Rectal Cancer

While some patients have a single site of metastatic cancer that can be treated with curative intent, the majority of patients with Stage IV rectal cancer have more widespread cancer that cannot be completely removed with surgery.

If the cancer is extensive but not causing symptoms, treatment oven involves chemotherapy. Several different chemotherapy regimens are available, and the choice of which to use will depend on factors such as your health and previous treatment history. In some cases, chemotherapy may shrink the cancer enough that surgery to remove it becomes possible.

Chemotherapy may be given in combination with other drugs known as targeted therapies. Targeted therapies are anticancer drugs that interfere with specific pathways involved in cancer cell growth or survival. Some targeted therapies block growth signals from reaching cancer cells; others reduce the blood supply to cancer cells; and still others stimulate the immune system to recognize and attack the cancer cell. Depending on the specific “target”, targeted therapies may slow cancer cell growth or increase cancer cell death.

If patients are experiencing symptoms from their rectal cancer, they may also receive treatments such as radiation therapy, surgery, or stenting to relieve problems such as bowel obstruction.

Recurrent Rectal Cancer

Recurrent rectal cancer is cancer that has returned or progressed following initial treatment with surgery, radiation therapy and/or chemotherapy. Patients experiencing progression of rectal cancer have been perceived to have few treatment options. However, certain patients can still be cured of their cancer and others derive meaningful palliative benefit from additional treatment.

  • Treatment of Pelvic Recurrence of Rectal Cance:
    Patients treated for rectal cancer may experience a recurrence of cancer near the original site of the cancer. Depending on the extent of recurrent disease, surgery may involve local excision with or without bowel resection, abdominoperineal resection, or pelvic exenteration (removal of most structures in the pelvis). Patients may also be treated with chemotherapy and radiation therapy.
  • Treatment of Metastatic Rectal Cancer
    Recurrent rectal cancer may also involve distant sites in the body such as the liver or lung. When the site of metastasis is a single organ, such as the liver, and the cancer is confined to a single defined area within the organ, patients may benefit from local treatment—such as surgery—directed at that single site of recurrence or metastasis. This local treatment may be accompanied by systemic (whole-body) treatment such as chemotherapy. When cancer is more extensive and surgery is not possible, systemic therapy is the primary approach to treatment.
  • Treatment of the Liver
    When the cancer has spread only to the liver and it’s possible to completely surgically remove all liver metastases, surgery is the preferred treatment. Although surgery offers some patients the chance for a cure, a majority of patients with liver metastases are not candidates for surgery because of the size or location of their tumors or their general health. Some of these patients may become candidates for surgery if initial treatment with chemotherapy shrinks the tumors sufficiently. If the tumors continue to be impossible to remove surgically, other liver-directed therapies may be considered. These other therapies include radiofrequency ablation (use of heat to kill cancer cells), cryotherapy (use of cold to kill cancer cells), delivery of chemotherapy directly to the liver, and radiation therapy.
  • Systemic Treatments
    Several different chemotherapy regimens are available, and the choice of which to use will depend on factors such as your health and previous treatment history. In some cases, chemotherapy can shrink the cancer enough that initially inoperable cancer becomes possible to surgically remove.
  • Managing Side Effects
    Techniques designed to prevent or control the side effects of cancer and its treatments are called supportive care. Side effects not only cause patients discomfort, but also may prevent the delivery of therapy at its planned dose and schedule. In order to achieve optimal outcomes from treatment and improve quality of life, it is imperative that treatment is delivered as planned and that side effects resulting from cancer and its treatment are appropriately managed.

Radiation Therapy for Rectal Cancer

Radiation therapy, or radiotherapy, is a common way to treat rectal cancer. Doctors who specialize in treating cancers with radiation are known as radiation oncologists. Radiation therapy involves the use of high-energy x-rays to kill cancer cells. For many rectal cancers, radiation therapy is used after surgery to destroy any cancer cells that may remain in the area of the operation. In advanced stages of rectal cancer, radiation therapy is often given before surgery to shrink the cancer, or instead of surgery when an operation cannot be performed. Radiation therapy is also commonly given in combination with anti-cancer drugs (chemotherapy). Chemotherapy has the ability to kill cancer cells directly and make radiation therapy more effective in killing cancer cells.