Colorectal cancer

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Treatments for stage 4 or recurrent rectal cancer

Treatment options are usually the same for both stage 4 or recurrent rectal cancer because the cancer has spread outside the rectum. Stage 4 means that the cancer has spread to one or more other organs. Rectal cancer can recur, or come back, in the area where it started (called a local recurrence) or in another part of the body (called metastatic rectal cancer). A local recurrence may be treated differently than metastatic rectal cancer.

The following are treatment options for stage 4 or recurrent rectal cancer. Treatment options and the order they are used depend on if the cancer is resectable (it can be removed with surgery) or unresectable (it can’t be removed). Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment plan.


Chemotherapy is usually offered for stage 4 or recurrent rectal cancer. It may be used as the primary treatment for unresectable stage 4 tumours in the rectum or metastases in the liver. It may also be given before surgery (called neoadjuvant chemotherapy) to shrink tumours to make the cancer resectable or surgery easier. If the cancer is resectable, chemotherapy is usually given after surgery (called adjuvant chemotherapy) to kill any cancer cells 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 chemotherapy and if surgery is done. For resectable rectal cancer, chemotherapy is usually given for 6 months. For unresectable rectal cancer, chemotherapy may be used as long as the cancer responds or until the disease progresses.

When deciding on which chemotherapy drug or drug combination to offer, your doctors will consider your overall health and possible side effects. The chemotherapy drugs used for stage 4 or recurrent rectal cancer with distant metastasis include:

  • FOLFIRI – leucovorin (folinic acid), 5-fluorouracil (Adrucil, 5-FU) and irinotecan (Camptosar)
  • FOLFOX – leucovorin (folinic acid), 5-fluorouracil (Adrucil, 5-FU) and oxaliplatin (Eloxatin)
  • CAPOX (also called XELOX) – capecitabine (Xeloda) and oxaliplatin (Eloxatin)
  • CAPIRI – capecitabine (Xeloda) and irinotecan (Camptosar)
  • capecitabine (Xeloda)
  • irinotecan (Camptosar)
  • 5-fluorouracil (Adrucil, 5-FU) with leucovorin (folinic acid)
  • raltitrexed (Tomudex)
  • trifluridine plus tipiracil hydrochloride (Lonsurf)

FOLFIRI is used most often for stage 4 or recurrent rectal cancer. It is also the standard first-line chemotherapy for metastatic colorectal cancer. You may be given other chemotherapy combinations or single drugs if FOLFIRI can’t be used, if FOLFIRI causes a lot of severe side effects or if the cancer progresses.

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. Hepatic arterial infusion is not used very often because it has to be done in a hospital by a large healthcare team who are trained to give this treatment.

Targeted therapy

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

The targeted therapy drugs used depend on if chemotherapy is also given and if the rectal cancer cells have the KRAS gene mutation. If the rectal cancer cells don’t have the KRAS gene mutation, the tumours are called KRAS wild-type tumours. Targeted therapy drugs used for stage 4 or recurrent rectal cancer include:

  • bevacizumab (Avastin), which is usually given with FOLFIRI or FOLFOX
  • cetuximab (Erbitux), which is usually given with irinotecan (Camptosar) for KRAS wild-type tumours
  • panitumumab (Vectibix), which is usually used alone for KRAS wild-type tumours
  • regorafenib (Stivarga), which is given if the cancer progresses after most other treatments

Bevacizumab (Avastin) with FOLFIRI is used most often for stage 4 or recurrent rectal cancer. It is also the standard treatment for metastatic colorectal cancer.

Doctors don’t usually give targeted therapy before surgery if they think that all of the tumour can be removed and there are no cancer cells in the healthy tissue removed along with the tumour (called negative surgical margins). They may give targeted therapy after surgery.


Chemoradiation combines chemotherapy with radiation therapy. Chemotherapy is given during the same time period as radiation therapy. Some types of chemotherapy make radiation therapy more effective.

Chemoradiation may be given before surgery to shrink a rectal tumour so it can be removed with surgery (is resectable). External beam radiation therapy is combined with 5-fluorouracil (Adrucil, 5-FU) or capecitabine (Xeloda). 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.


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

Local excision, or local resection, is usually done to remove a local recurrence of cancer or to relieve symptoms such as pain (called palliative surgery).

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 (called bowel obstruction). Depending on the location of the tumour or blockage, the surgeon may do a:

  • right hemicolectomy
  • transverse colectomy
  • left hemicolectomy
  • sigmoid colectomy
  • subtotal or total colectomy
  • low anterior resection or abdominoperineal resection with total mesorectal excision

Surgery to remove metastatic tumours may be done when the cancer has spread to only one distant organ (such as the liver or lung) and there are very few metastatic tumours in the organ. The type of surgery done will depend on where the cancer has spread.

Pelvic exenteration may be done in some cases to treat rectal cancer that has spread to many areas in the pelvis. A colostomy and urinary diversion may be needed after pelvic exenteration.

Colostomy or ileostomy may be done to allow the intestine to rest and heal after a bowel resection. This surgery creates a stoma (an artificial opening) from the colon or ileum to the outside of the body through the abdominal wall. The 2 ends of the intestine are joined together after they have healed. Depending on the type of surgery done, the colostomy or ileostomy may be temporary or permanent.

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

Stent placement may be done to treat or prevent bowel obstruction. The doctor can place a metal mesh-like 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 (called palliative therapy).

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. It is done with a special probe or needle inserted into the tumours in the liver. In most cases, the doctor gives the RFA through the skin and into the tumour. In other cases, the doctor may need to make a cut, or incision, in the abdomen to reach the liver. Sometimes the doctor will only make small cuts in the abdomen and use a laparoscope to give the RFA.

Radiation therapy

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

Radiation therapy may be used alone to control symptoms such as pain and bleeding (called palliative radiation therapy). External beam radiation therapy to the abdomen and pelvis may be used for unresectable rectal cancer. It may also be used to treat bone or brain metastases.

Clinical trials

You may be asked if you want to join a clinical trial for rectal cancer. Find out more about clinical trials.


Giving relief.

For example, palliative therapies relieve symptoms but do not cure disease.


A procedure that uses an endoscope (a thin, tube-like instrument with a light and lens) to examine or treat organs inside the abdomen and pelvis.

Cells or tissue may be removed for examination under a microscope. Doctors may also use laparoscopy to perform different surgical procedures in the abdomen and pelvis.

The type of endoscope used for this procedure is called a laparoscope.


Steve Manske Helping young people improve their health

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