Treatments for rectal cancer

The following are treatment options for rectal cancer. Treatments offered for rectal cancer depend on the stage of rectal cancer. Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment plan.

Surgery is the standard treatment for stage 0 rectal cancer.

A local excision (local resection) is usually done to remove the tumour or polyp and a small amount of tissue around it. The type of local excision is often a polypectomy and it is done during a colonoscopy or a sigmoidoscopy. A local transanal excision may be used for small tumours in the rectum that are close to the anus. If cancer cells are found in the tissue removed with the tumour, a bowel resection is done. The type of bowel resection depends on the location of the tumour.

Surgery is the main treatment for stage 1 rectal cancer.

Surgery usually involves a bowel resection. The type of bowel resection depends on the location of the tumour.

In some cases, a local transanal excision or transanal endoscopic microsurgery (TEM) can be done to remove a small, low-grade tumour and tissue around it. A bowel resection is usually chosen over these surgeries because they have a greater risk of recurrence, and it will be harder to completely remove the cancer if it comes back (recurs).

Depending on the type of surgery done, a temporary or permanent colostomy may be needed. The colostomy creates an opening from the colon to the outside of the body through the abdominal wall. It creates a new path for food waste (stool or poop) to leave the body and may be done after a bowel resection.

Surgery is the main treatment for stage 2 rectal cancer. Other treatments such as chemotherapy, radiation therapy or chemoradiation may also be used before or after surgery.

A bowel resection is the surgery that is done. The type of bowel resection depends on the location of the tumour. Depending on the type of surgery done, a temporary or permanent colostomy may be needed. The colostomy creates an opening from the colon to the outside of the body through the abdominal wall. It creates a new path for stool to leave the body.

Chemoradiation combines radiation therapy with chemotherapy. The 2 treatments are given during the same time period. Chemoradiation may be given before surgery. It is usually given as 25 to 30 treatments of radiation and chemotherapy with 5-fluorouracil (Adrucil, 5-FU) or capecitabine (Xeloda) over a period of 5 to 6 weeks. Sometimes chemoradiation is given after surgery.

Radiation therapy is almost always offered for stage 2 rectal cancer. It may be given alone or as part of chemoradiation. External radiation therapy is the most common type of radiation used, but brachytherapy may be used in some cases.

Radiation therapy alone may be given before surgery. Five treatments of radiation therapy may be given, which is sometimes called a short course of radiation. Sometimes radiation therapy is given alone after surgery.

If you can’t have chemotherapy, a long course of radiation therapy alone may be used. A long course of radiation therapy is usually 25 to 30 treatments.

Chemotherapy may be given alone after surgery. If radiation therapy or chemoradiation was not used before surgery, chemotherapy may be given in addition to chemoradiation after surgery.

Chemotherapy is usually given for about 6 months, but the length of chemotherapy depends on the amount of radiation or chemoradiation used before surgery.

The types of chemotherapy used include:

• FOLFOX – leucovorin (folinic acid), 5-fluorouracil and oxaliplatin (Eloxatin)
• 5-fluorouracil with leucovorin
• CAPOX (also called XELOX) – capecitabine and oxaliplatin
• capecitabine alone

Surgery is the main treatment for stage 3 rectal cancer. Other treatments such as chemotherapy, radiation therapy or chemoradiation may also be used before or after surgery.

A bowel resection is the surgery that is done. The type of bowel resection depends on the location of the tumour. Depending on the type of surgery done, a temporary or permanent colostomy may need to be done.The colostomy creates an opening from the colon to the outside of the body through the abdominal wall. It creates a new path for stool to leave the body. Chemoradiation or radiation therapy alone may be given before surgery.

Chemoradiation combines radiation therapy with chemotherapy. The 2 treatments are given during the same time period. Chemoradiation may be given before surgery. It is usually given as 25 to 30 treatments of radiation and chemotherapy with 5-fluorouracil or capecitabine over a period of 5 to 6 weeks. Sometimes chemoradiation is given after surgery.

Radiation therapy is almost always offered for stage 3 rectal cancer. It may be given alone or as part of chemoradiation. External radiation therapy is the most common type of radiation used, but brachytherapy may be used in some cases.

Radiation therapy may be given alone before surgery. Five treatments of radiation therapy may be given, which is sometimes called a short course of radiation. Sometimes radiation therapy is given alone after surgery.

If you can’t have chemotherapy, a long course of radiation therapy alone may be used. A long course of radiation therapy is usually 25 to 30 treatments.

Chemotherapy may be given alone after surgery. If radiation therapy or chemoradiation is not used before surgery, chemotherapy is usually also given after surgery.

Chemotherapy is usually given for about 6 months, but the length of chemotherapy depends on the amount of radiation or chemoradiation used before surgery.

The types of chemotherapy used include:

• FOLFOX – leucovorin, 5-fluorouracil and oxaliplatin
• 5-fluorouracil with leucovorin
• CAPOX (also called XELOX) – capecitabine and oxaliplatin
• capecitabine alone

Treatment options are often the same for both stage 4 and recurrent rectal cancer. Stage 4 means that the cancer has spread to one or more other organs. If rectal cancer comes back (recurs), it usually comes back in a distant site such as the liver.

Treatments and the order they are used depend on if the cancer can be removed with surgery (resectable) or can’t be removed with surgery (unresectable).

Chemotherapy is usually offered for stage 4 or recurrent rectal cancer. It may be used as the main treatment for unresectable tumours in the rectum or metastases in the liver. It may also be given before surgery to shrink tumours to make the cancer easier to remove. If the cancer is resectable, chemotherapy is usually given after surgery, to kill any cancer cells that may be left behind and prevent the cancer from coming back.

How long chemotherapy is given depends on the type of chemotherapy used, the cancer’s response to the drug or drug combination and if surgery is done. If the cancer is resectable, chemotherapy is usually given for 6 months. If the cancer is unresectable, chemotherapy may be used as long as the cancer responds or until the disease progresses.

When deciding which chemotherapy drug or drug combination to use, your overall health and the possible side effects of the drugs will be considered. A targeted therapy drug may be given with the chemotherapy.

Common chemotherapy drugs include:

• capecitabine
• irinotecan (Camptosar)
• oxaliplatin
• 5-fluorouracil with leucovorin
• raltitrexed (Tomudex)
• trifluridine and tipiracil (Lonsurf)

Common chemotherapy drug combinations include:

• FOLFIRI – leucovorin, 5-fluorouracil and irinotecan
• FOLFOX – leucovorin, 5-fluorouracil and oxaliplatin
• FOLFOXIRI – leucovorin, 5-fluorouracil, oxaliplatin, irinotecan
• CAPOX (also called XELOX) – capecitabine and oxaliplatin
• CAPIRI – capecitabine and irinotecan

Hepatic arterial infusion may be used to treat liver metastases when cancer has only spread to the liver and it can’t be removed with surgery. It delivers chemotherapy directly to liver tumours through the main artery of the liver (called the hepatic artery). Floxuridine (FUDR) is the most common chemotherapy drug used for hepatic arterial infusion.

Targeted therapy is usually offered for stage 4 or recurrent rectal cancer. It is usually given with chemotherapy, but it may be used alone. Targeted therapy drugs used for stage 4 or recurrent rectal cancer include:

• bevacizumab (Avastin, Mvasi) is usually given with FOLFIRI or FOLFOX or CAPOX
• cetuximab (Erbitux) is usually given alone or with irinotecan or with FOLFIRI
• panitumumab (Vectibix) is usually given alone or with FOLFIRI or FOLFOX
• encorafenib (Braftovi) is given with cetuximab
• regorafenib (Stivarga) may be given if the cancer progresses after other treatments

Immunotherapy may be offered for stage 4 or recurrent rectal cancer. Immune checkpoint inhibitors, ipilimumab (Yervoy), nivolumab (Opdivo) and pembrolizumab (Keytruda), are used for metastatic colorectal cancer which has a high microsatellite instability (changes to DNA in the cells).

Chemoradiation combines radiation therapy with chemotherapy. The 2 treatments are given during the same time period. Chemoradiation may be given before surgery to shrink a rectal tumour so it can be removed with surgery. Radiation therapy is combined with 5-fluorouracil or capecitabine. How much radiation is given depends on the location of the tumour and where the cancer has spread. If you have already received radiation to the pelvis, you may not be able to have radiation again.

Surgery may be offered for stage 4 or recurrent rectal cancer. Whether or not surgery is an option will depend on the location of the tumour and your overall health.

A local excision (local resection) may be done to remove a local recurrence of cancer or to relieve symptoms such as pain.

A bowel resection is done to remove cancer in the rectum if it wasn’t done previously. It may also be used to treat a blockage in the intestine (bowel obstruction). The type of bowel resection depends on the location of the tumour or blockage.

Surgery to remove metastatic tumours is done when the cancer has spread to only one distant organ, such as the liver or lung. The type of surgery done will depend on where the cancer has spread.

A pelvic exenteration may be done in some cases to treat rectal cancer that has spread to many areas in the pelvis. Find out more about pelvic exenteration.

A colostomy creates an opening from the colon to the outside of the body through the abdominal wall. It creates a new path for stool to leave the body and may be done after a bowel resection. The colostomy may be temporary or permanent. Find out more about colostomy and ileostomy.

A diverting colostomy is a colostomy that doesn’t remove part of the intestine. It may be used to treat a bowel obstruction by creating a passage so stool can leave the body before it reaches the blocked part of the intestine.

A stent placement may be done to treat or prevent bowel obstruction. The doctor can place a mesh-like metal tube (called a stent) in the intestine to open it so stool can flow normally. Stents are often used to relieve symptoms of advanced cancer.

Radiofrequency ablation (RFA) may be used to treat liver metastases that can’t be removed with surgery. RFA uses a high-frequency electrical current to destroy cancer cells. Find out more about radiofrequency ablation.

Radiation therapy may be offered for stage 4 or recurrent rectal cancer. It may be given alone or as part of chemoradiation. External radiation therapy is the most common type of radiation used.

Radiation therapy may be used alone to control symptoms of advanced cancer such as pain and bleeding. Radiation therapy to the abdomen or pelvis may be used for unresectable rectal cancer. It may also be used to treat bone or brain metastases.

You may want to consider a type of care to make you feel better without treating the cancer itself. This may be because the cancer treatments don’t work anymore, they’re not likely to improve your condition or they may cause side effects that are hard to cope with. There may also be other reasons why you can’t have or don’t want cancer treatment.

Talk to your healthcare team. They can help you choose care and treatment for advanced cancer.

Talk to your doctor about clinical trials open to people with rectal cancer in Canada. Clinical trials look at new ways to prevent, find and treat cancer. Find out more about clinical trials.