Medscape is available in 5 Language Editions – Choose your Edition here.


Rectal Cancer

  • Author: Burt Cagir, MD, FACS; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
Updated: Mar 11, 2016

Practice Essentials

Rectal cancer is a disease in which cancer cells form in the tissues of the rectum; colorectal cancer occurs in the colon or rectum. Adenocarcinomas comprise the vast majority (98%) of colon and rectal cancers; more rare rectal cancers include lymphoma (1.3%), carcinoid (0.4%), and sarcoma (0.3%).

The incidence and epidemiology, etiology, pathogenesis, and screening recommendations are common to both colon cancer and rectal cancer. The image below depicts the staging and workup of rectal cancer.

Diagnostics. Staging and workup of rectal cancer p Diagnostics. Staging and workup of rectal cancer patients.

Signs and symptoms

Bleeding is the most common symptom of rectal cancer, occurring in 60% of patients. However, many rectal cancers produce no symptoms and are discovered during digital or proctoscopic screening examinations.

Other signs and symptoms of rectal cancer may include the following:

  • Change in bowel habits (43%): Often in the form of diarrhea; the caliber of the stool may change; there may be a feeling of incomplete evacuation and tenesmus
  • Occult bleeding (26%): Detected via a fecal occult blood test (FOBT)
  • Abdominal pain (20%): May be colicky and accompanied by bloating
  • Back pain: Usually a late sign caused by a tumor invading or compressing nerve trunks
  • Urinary symptoms: May occur if a tumor invades or compresses the bladder or prostate
  • Malaise (9%)
  • Pelvic pain (5%): Late symptom, usually indicating nerve trunk involvement
  • Emergencies such as peritonitis from perforation (3%) or jaundice, which may occur with liver metastases (< 1%)

See Clinical Presentation for more detail.


Perform physical examination with specific attention to the size and location of the rectal tumor in addition to possible metastatic lesions, including enlarged lymph nodes or hepatomegaly. In addition, evaluate the remainder of the colon.

Examination includes the use of the following:

  • Digital rectal examination (DRE): The average finger can reach approximately 8 cm above the dentate line; rectal tumors can be assessed for size, ulceration, and presence of any pararectal lymph nodes, as well as fixation to surrounding structures (eg, sphincters, prostate, vagina, coccyx and sacrum); sphincter function can be assessed
  • Rigid proctoscopy: This examination helps to identify the exact location of the tumor in relation to the sphincter mechanism

Laboratory tests

Routine laboratory studies in patients with suspected rectal cancer include the following:

  • Complete blood count
  • Serum chemistries
  • Liver and renal function tests
  • Carcinoembryonic antigen (CEA) test
  • Cancer antigen (CA) 19-9 assay, if available: May be useful for monitoring the disease
  • Histologic examination of tissue specimens

Screening tests may include the following:

  • Guaiac-based FOBT
  • Stool DNA screening (SDNA)
  • Fecal immunochemical test (FIT)
  • Rigid proctoscopy
  • Flexible sigmoidoscopy (FSIG)
  • Combined glucose-based FOBT and flexible sigmoidoscopy
  • Double-contrast barium enema (DCBE)
  • Computed tomography (CT) colonography
  • Fiberoptic flexible colonoscopy (FFC)

Imaging studies

If metastatic rectal cancer is suspected, the following radiologic studies may be obtained:

  • CT scanning of the chest, abdomen, and pelvis
  • Endorectal ultrasonography
  • Endorectal or pelvic magnetic resonance imaging (MRI)
  • Positron emission tomography (PET) scanning: Not routinely indicated

See Workup for more detail.


A multidisciplinary approach that includes colorectal surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer. Surgical technique, use of radiotherapy, and method of administering chemotherapy are important factors. 

Strong considerations should be given to the intent of surgery, possible functional outcome, and preservation of anal continence and genitourinary functions. The first step involves achievement of cure, because the risk of pelvic recurrence is high in patients with rectal cancer, and locally recurrent rectal cancer has a poor prognosis.


Radical resection of the rectum is the mainstay of therapy. The timing of surgical resection is dependent on the size, location, extent, and grade of the rectal carcinoma. Operative management of rectal cancer may include the following:

  • Transanal excision: For early-stage cancers in a select group of patients
  • Transanal endoscopic microsurgery: Form of local excision that uses a special operating proctoscope that distends the rectum with insufflated carbon dioxide and allows the passage of dissecting instruments
  • Endocavity radiotherapy: Delivered under sedation via a special proctoscope in the operating room
  • Sphincter-sparing procedures: Low anterior resection, coloanal anastomosis, abdominal perineal resection

Adjuvant medical management

Adjuvant medical therapy may include the following:

  • Adjuvant radiation therapy
  • Intraoperative radiation therapy
  • Adjuvant chemotherapy
  • Adjuvant chemoradiation therapy
  • Radioembolization


The National Comprehensive Cancer Network guidelines recommend the use of as many chemotherapy drugs as possible to maximize the effect of adjuvant therapies for colon and rectal cancer.

The following agents may be used in the management of rectal cancer:

  • Antineoplastic agents (eg, fluorouracil, vincristine, leucovorin, irinotecan, oxaliplatin, cetuximab, bevacizumab, panitumumab)
  • Vaccines (eg, quadrivalent human papillomavirus [HPV] vaccine)

See Treatment and Medication for more detail.



Colon and rectal cancer incidence was negligible before 1900. The incidence of colorectal cancer has been rising dramatically following economic development and industrialization. Currently, colorectal cancer is the third leading cause of cancer deaths in both males and females in the United States.[1, 2]

Adenocarcinomas comprise the vast majority (98%) of colon and rectal cancers. Other rare rectal cancers, including carcinoid (0.4%), lymphoma (1.3%), and sarcoma (0.3%), are not discussed in this article. Squamous cell carcinomas may develop in the transition area from the rectum to the anal verge and are considered anal carcinomas. Very rare cases of squamous cell carcinoma of the rectum have been reported.[1, 3]

Approximately 20% of colon cancers develop in the cecum, another 20% in the rectum, and an additional 10% in the rectosigmoid junction. Approximately 25% of colon cancers develop in the sigmoid colon.[1]

The incidence and epidemiology, etiology, pathogenesis, and screening recommendations are common to both colon cancer and rectal cancer. These areas are addressed together.

An image depicting the staging and workup of rectal cancer can be seen below.

Diagnostics. Staging and workup of rectal cancer p Diagnostics. Staging and workup of rectal cancer patients.


The mucosa in the large intestine regenerates approximately every 6 days. Crypt cells migrate from the base of the crypt to the surface, where they undergo differentiation and maturation, and ultimately lose the ability to replicate.

The significant portions of colorectal carcinomas are adenocarcinomas. The adenoma-carcinoma sequence is well described in the medical literature.[1, 4] Colonic adenomas precede adenocarcinomas. Approximately 10% of adenomas will eventually develop into adenocarcinomas. This process may take up to 10 years.[1]

Three pathways to colon and rectal carcinoma have been described:

  • Adenomatous polyposis coli ( APC) gene adenoma-carcinoma pathway
  • Hereditary nonpolyposis colorectal cancer (HNPCC) pathway
  • Ulcerative colitis dysplasia

The APC adenoma carcinoma pathway involves several genetic mutations, starting with inactivation of the APC gene, which allows unchecked cellular replication at the crypt surface. With the increase in cell division, further mutations occur, resulting in activation of the K-ras oncogene in the early stages and p53 mutations in later stages. These cumulative losses in tumor suppressor gene function prevent apoptosis and prolong the cell's lifespan indefinitely. If the APC mutation is inherited, it will result in familial adenomatous polyposis syndrome.

Histologically, adenomas are classified in three groups: tubular, tubulovillous, and villous adenomas. K-ras mutations and microsatellite instability have been identified in hyperplastic polyps. Therefore, hyperplastic polyps may also have malignant potential in varying degrees.[5]

The other common carcinogenic pathway involves mutation in DNA mismatch repair genes. Many of these mismatched repair genes have been identified, including hMLH1, hMSH2, hPMS1, hPMS2, and hMSH6. Mutation in mismatched repair genes negatively affects the DNA repair. This replication error is found in approximately 90% of HNPCC and 15% of sporadic colon and rectal cancers.[1, 6] A separate carcinogenic pathway is also described in inflammatory bowel disease (IBD). Chronic inflammation such as in ulcerative colitis can result in genetic alterations which then lead into dysplasia and carcinoma formation.[1]



United States

Colon and rectal cancer is the third most common cancer in both females and males. The American Cancer Society (ACS) estimates that 95,270 new cases of colon cancer and 39,220 new cases of rectal cancer will occur in 2016; 23,110 cases of rectal cancer are expected in men and 16,110, in women.[2] For estimates of deaths, the ACS combines colon and rectal cancers; approximately 49,190 deaths from colorectal cancer are expected to occur in 2016.[2]

Both colon and rectal cancer incidences, as well as mortality rates, have been decreasing for the last several decades, from 66.3 per 100,000 population in 1985 to 45.5 in 2006.[2] The rate of decrease accelerated from 1998-2006 (to 3% per year in men and 2.2% per year in women), in part because of increased screening, allowing the detection and removal of colorectal polyps before they progress to cancer. The lifetime risk of developing a colorectal malignancy is approximately 6% in the general US population. This decrease is due to a declining incidence and improvements in both early detection and treatment.


Although the incidence of colon and rectal cancer varies considerably by country, an estimated 944,717 cases were identified worldwide in 2000. High incidences of colon and rectal cancer cases are identified in the US, Canada, Japan, parts of Europe, New Zealand, Israel, and Australia. Low colorectal cancer rates are identified in Algeria and India. The majority of colorectal cancers still occur in industrialized countries. Recent rises in colorectal cancer incidence have been observed in many parts of the Japan, China (Shanghai) and in several Eastern European countries.[1]



The American Cancer Society estimates that in 2015, colorectal cancer will account for 8% of cancer deaths in men and 9% of cancer deaths in women. In the US, mortality rates have been decreasing in both sexes for the past 2 decades. (The 1- and 5-year rates for patients with colon and rectal cancer are 83% and 64%, respectively.) When colorectal cancers are detected early and localized, the 5-year survival rate is 90%.[2]

A review of eight trials by Rothwell et al found allocation to aspirin reduced death caused by cancer. Individual patient data were available from seven of the eight trials. Benefit was apparent after 5 years of follow-up. The 20-year risk of cancer death was also lower in the aspirin group for all solid cancers. A latent period of 5 years was observed before risk of death was decreased for esophageal, pancreatic, brain, and lung cancers. A more delayed latent period was observed for stomach, colorectal, and prostate cancer. Benefit was only seen for adenocarcinomas in lung and esophageal cancers. The overall effect on 20-year risk of cancer death was greatest for adenocarcinomas.[7]

A study by Banks et al showed the benefit of aspirin in preventing colon adenocarcinoma among patients with hereditary risk of colorectal cancer. In a study of 861 patients, 600 mg of aspirin daily for a mean of 25 months substantially reduced cancer incidence after 55.7 months among carriers of hereditary colorectal cancer. Further studies are needed to determine the ideal dosage and duration.[8]

In a review of 51 randomized controlled trials, Rothwell et al found that aspirin reduced the short-term incidence of cancer and the short- and long-term risk of cancer death. The authors conclude that their results support the use of daily aspirin for cancer prevention.[9]


The incidence of colorectal cancer tends to be higher in Western nations than in Asian and African countries; however, within the United States, minor differences in incidence exist among whites, African Americans, and Asian Americans. Five-year survival rates are lower among blacks (55%) than whites (66%). Among religious denominations, colorectal cancer occurs more frequently in the Jewish population.[2]

A study by Yothers et al found that black patients with resected stage II and stage III colon cancer had worse overall and recurrence-free survival compared with white patients who underwent the same therapy.[10]

A study of racial disparities in mortality rates between black and white individuals with colorectal cancer by Robbins et al showed earlier and larger reductions in death rates for whites from 1985-2008.[11] This racial disparity could be decreased with greater education to the black population regarding colorectal cancer prevention and access to treatment, including colonoscopies and polypectomies.


The incidence of colorectal malignancy is slightly higher in males than in females. The overall age-adjusted incidence of colorectal cancer in all races was 48.9 per 100,000 for males and 37.1 per 100,000 for females in 2008-2012, yielding a male-female ratio of 1.32:1. Mortality rates for colorectal cancer were also higher in males (18.6 per 100,000) than in females (13.1 per 100,000) in 2008-2012.[12] Left colon carcinomas were more likely to be observed in males and right colon carcinomas were more likely to be observed in females.[2]


The incidence of colorectal cancer starts to increase after age 35 and rises rapidly after age 50, peaking in the seventh decade. More than 90% of colon cancers occur after age 50. However, cases have been reported in young children and adolescents.[1] The incidence rates of colorectal cancer increased by 1.8% per year in adults younger than age 50 from 2007 to 2011.[2]

Contributor Information and Disclosures

Burt Cagir, MD, FACS Clinical Professor of Surgery, The Commonwealth Medical College; Attending Surgeon, Assistant Program Director, Robert Packer Hospital; Attending Surgeon, Corning Hospital

Burt Cagir, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.


Douglas R Trostle, MD, MBA, FACS Chairman of Surgery, The Guthrie Clinic

Douglas R Trostle, MD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association of Clinical Endocrinologists, American Association for Physician Leadership, American College of Surgeons, Pennsylvania Medical Society, Society for Surgery of the Alimentary Tract, American Association of Endocrine Surgeons, American Society of General Surgeons, American College of Surgeons Oncology Group

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

N Joseph Espat, MD, MS, FACS Harold J Wanebo Professor of Surgery, Assistant Dean of Clinical Affairs, Boston University School of Medicine; Chairman, Department of Surgery, Director, Adele R Decof Cancer Center, Roger Williams Medical Center

N Joseph Espat, MD, MS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American College of Surgeons, American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Clinical Oncology, Americas Hepato-Pancreato-Biliary Association, Association for Academic Surgery, Central Surgical Association, Chicago Medical Society, International Hepato-Pancreato-Biliary Association, Pancreas Club, Sigma Xi, Society for Leukocyte Biology, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Surgical Oncology, Society of University Surgeons, Southeastern Surgical Congress, Southern Medical Association, Surgical Infection Society

Disclosure: Nothing to disclose.

Additional Contributors

Philip Schulman, MD Chief, Medical Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center

Philip Schulman, MD is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, American Society of Hematology, Medical Society of the State of New York

Disclosure: Nothing to disclose.


Elizabeth Cirincione, MD Director of Colon and Rectal Surgery, Department of Surgery, Nassau University Medical Center

Disclosure: Nothing to disclose.

Wendy Hu, MD Consulting Staff, Department of Hematology/Oncology and Bone Marrow Transplantation, Huntington Memorial Medical Center

Wendy Hu, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Blood and Marrow Transplantation, American Society of Hematology, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

  1. Giovannucci E, Wu K. Cancers of the colon and rectum. Schottenfeld D, Fraumeni J, eds. Cancer. Epidemiology and Prevention. 3rd ed. Oxford University Press; 2006.

  2. American Cancer Society. Cancer Facts & Figures 2016. American Cancer Society. Available at Accessed: March 4, 2016.

  3. Anagnostopoulos G, Sakorafas GH, Kostopoulos P, et al. Squamous cell carcinoma of the rectum: a case report and review of the literature. Eur J Cancer Care (Engl). 2005 Mar. 14(1):70-4. [Medline].

  4. Potter JD. Colorectal cancer: molecules and populations. J Natl Cancer Inst. 1999 Jun 2. 91(11):916-32. [Medline]. [Full Text].

  5. Leggett BA, Devereaux B, Biden K, Searle J, Young J, Jass J. Hyperplastic polyposis: association with colorectal cancer. Am J Surg Pathol. 2001 Feb. 25(2):177-84. [Medline].

  6. Wheeler JM, Bodmer WF, Mortensen NJ. DNA mismatch repair genes and colorectal cancer. Gut. 2000 Jul. 47(1):148-53. [Medline]. [Full Text].

  7. Rothwell PM, Fowkes GR, Belch JF, Ogawa H, Warlow CP, Meade TW. Effect of daily aspirin on long-term risk of death due to cancer: analysis of individual patient data from randomized trials. Lancet. Dec 7/2010; Early online publication. [Full Text].

  8. Burn J, Gerdes AM, Macrae F, et al. Long-term effect of aspirin on cancer risk in carriers of hereditary colorectal cancer: an analysis from the CAPP2 randomised controlled trial. Lancet. 2011 Dec 17. 378(9809):2081-7. [Medline]. [Full Text].

  9. Rothwell PM, Price JF, Fowkes FG, Zanchetti A, Roncaglioni MC, Tognoni G, et al. Short-term effects of daily aspirin on cancer incidence, mortality, and non-vascular death: analysis of the time course of risks and benefits in 51 randomised controlled trials. Lancet. 2012 Apr 28. 379(9826):1602-12. [Medline].

  10. Yothers G, Sargent DJ, Wolmark N, et al. Outcomes Among Black Patients With Stage II and III Colon Cancer Receiving Chemotherapy: An Analysis of ACCENT Adjuvant Trials. J Natl Cancer Inst. 2011 Oct 19. 103(20):1498-1506. [Medline]. [Full Text].

  11. Robbins AS, Siegel RL, Jemal A. Racial disparities in stage-specific colorectal cancer mortality rates from 1985 to 2008. J Clin Oncol. 2012 Feb 1. 30(4):401-5. [Medline].

  12. Surveillance, Epidemiology, and End Results Program. SEER Stat Fact Sheets: Colon and Rectum Cancer. National Cancer Institute. Available at Accessed: May 14, 2015.

  13. Chao A, Thun MJ, Connell CJ, et al. Meat consumption and risk of colorectal cancer. JAMA. 2005 Jan 12. 293(2):172-82. [Medline].

  14. Baron JA, Beach M, Mandel JS, van Stolk RU, Haile RW, Sandler RS, et al. Calcium supplements for the prevention of colorectal adenomas. Calcium Polyp Prevention Study Group. N Engl J Med. 1999 Jan 14. 340(2):101-7. [Medline].

  15. Ferrari P, Jenab M, Norat T, Moskal A, Slimani N, Olsen A, et al. Lifetime and baseline alcohol intake and risk of colon and rectal cancers in the European prospective investigation into cancer and nutrition (EPIC). Int J Cancer. 2007 Nov 1. 121(9):2065-72. [Medline].

  16. Kabat GC, Howson CP, Wynder EL. Beer consumption and rectal cancer. Int J Epidemiol. 1986 Dec. 15(4):494-501. [Medline].

  17. Tsoi KK, Pau CY, Wu WK, Chan FK, Griffiths S, Sung JJ. Cigarette smoking and the risk of colorectal cancer: a meta-analysis of prospective cohort studies. Clin Gastroenterol Hepatol. 2009 Jun. 7(6):682-688.e1-5. [Medline].

  18. Phipps AI, Baron J, Newcomb PA. Prediagnostic smoking history, alcohol consumption, and colorectal cancer survival: The Seattle Colon Cancer Family Registry. Cancer. 2011 Nov 1. 117(21):4948-57. [Medline]. [Full Text].

  19. Johns LE, Houlston RS. A systematic review and meta-analysis of familial colorectal cancer risk. Am J Gastroenterol. 2001 Oct. 96(10):2992-3003. [Medline].

  20. Burt RW. Familial risk and colorectal cancer. Gastroenterol Clin North Am. 1996 Dec. 25(4):793-803. [Medline].

  21. Hampel H. Genetic counseling in patients with familial risk for colorectal cancer. Presented at: NCCN 19th Annual Conference: Clinical Practice Guidelines & Quality Cancer Care; March 13, 2014; Hollywood, Fla.

  22. Mulcahy N. NCCN: Test all colorectal cancers for Lynch syndrome. Medscape Medical News. March 14, 2014. [Full Text].

  23. Henderson D. Home-Based Stool Test Detects 79% of Colorectal Cancers. Medscape Medical News. Available at Accessed: February 10, 2014.

  24. Lee JK, Liles EG, Bent S, Levin TR, Corley DA. Accuracy of Fecal Immunochemical Tests for Colorectal Cancer: Systematic Review and Meta-analysis. Ann Intern Med. 2014. 160:171-181.

  25. de Wijkerslooth TR, Stoop EM, Bossuyt PM, Meijer GA, van Ballegooijen M, van Roon AH, et al. Immunochemical Fecal Occult Blood Testing Is Equally Sensitive for Proximal and Distal Advanced Neoplasia. Am J Gastroenterol. 2012 Jul 31. [Medline].

  26. Nelson H, Petrelli N, Carlin A, Couture J, Fleshman J, Guillem J, et al. Guidelines 2000 for colon and rectal cancer surgery. J Natl Cancer Inst. 2001 Apr 18. 93(8):583-96. [Medline].

  27. Schoen RE, Pinsky PF, Weissfeld JL, Yokochi LA, Church T, Laiyemo AO, et al. Colorectal-Cancer Incidence and Mortality with Screening Flexible Sigmoidoscopy. N Engl J Med. 2012 May 21. [Medline].

  28. [Guideline] United States Preventive Services Task Force. Screening for Colorectal Cancer. AHRQ: Agency for Healthcare Research and Quality. Available at Accessed: May 12, 2015.

  29. Brounts LR, Lehmann RK, Lesperance KE, Brown TA, Steele SR. Improved rates of colorectal cancer screening in an equal access population. Am J Surg. 2009 May. 197(5):609-12; discussion 612-3. [Medline].

  30. Meredith KL, Hoffe SE, Shibata D. The multidisciplinary management of rectal cancer. Surg Clin North Am. 2009 Feb. 89(1):177-215, ix-x. [Medline].

  31. Kapiteijn E, Marijnen CA, Nagtegaal ID, Putter H, Steup WH, Wiggers T. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med. 2001 Aug 30. 345(9):638-46. [Medline].

  32. Bonjer HJ, Deijen CL, Abis GA, Cuesta MA, van der Pas MH, de Lange-de Klerk ES, et al. A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med. 2015 Apr 2. 372(14):1324-32. [Medline].

  33. Baxter NN, Garcia-Aguilar J. Organ preservation for rectal cancer. J Clin Oncol. 2007 Mar 10. 25(8):1014-20. [Medline].

  34. Rothenberger D, Garcia-Aquilar J. Rectal cancer, local treatment. Current Therapy in Colon and Rectal Surgery. 2nd ed. Philadelphia, Pa: Mosby; 2005.

  35. Peng J, Chen W, Venook AP, et al. Long-term outcome of early-stage rectal cancer undergoing standard resection and local excision. Clin Colorectal Cancer. 2011 Mar 1. 10(1):37-41. [Medline].

  36. Brooks M. Local Excision for Rectal Cancer Increasing, but Inferior. Medscape Medical News. Available at Accessed: December 23, 2013.

  37. Stitzenberg KB, Sanoff HK, Penn DC, Meyers MO, Tepper JE. Practice patterns and long-term survival for early-stage rectal cancer. J Clin Oncol. 2013 Dec 1. 31(34):4276-82. [Medline]. [Full Text].

  38. Weiser MR, Landmann RG, Wong WD, Shia J, Guillem JG, Temple LK, et al. Surgical salvage of recurrent rectal cancer after transanal excision. Dis Colon Rectum. 2005 Jun. 48(6):1169-75. [Medline].

  39. Bullard KM, Rothenberger DA. Colon, rectum, and anus. Schwartz SE, ed. Principles of Surgery. 8th ed. New York, NY: McGraw Hill; 2005.

  40. Li S, Chi P, Lin H, Lu X, Huang Y. Long-term outcomes of laparoscopic surgery versus open resection for middle and lower rectal cancer: an NTCLES study. Surg Endosc. 2011 Oct. 25(10):3175-82. [Medline].

  41. Green BL, Marshall HC, Collinson F, Quirke P, Guillou P, Jayne DG, et al. Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer. Br J Surg. 2012 Nov 6. [Medline].

  42. van Helmond J, Beart RW. Cancer of the rectum: Operative management and adjuvant therapy. Current Therapy in Colon and Rectal Surgery. 2nd ed. Philadelphia, Pa: Mosby; 2005.

  43. Maurer CA, Renzulli P, Kull C, et al. The impact of the introduction of total mesorectal excision on local recurrence rate and survival in rectal cancer: long-term results. Ann Surg Oncol. 2011 Jul. 18(7):1899-906. [Medline].

  44. Fujita S, Akasu T, Mizusawa J, Saito N, Kinugasa Y, Kanemitsu Y, et al. Postoperative morbidity and mortality after mesorectal excision with and without lateral lymph node dissection for clinical stage II or stage III lower rectal cancer (JCOG0212): results from a multicentre, randomised controlled, non-inferiority trial. Lancet Oncol. 2012 Jun. 13(6):616-21. [Medline].

  45. Dhir M, Lyden ER, Wang A, et al. Influence of margins on overall survival after hepatic resection for colorectal metastasis: a meta-analysis. Ann Surg. 2011 Aug. 254(2):234-42. [Medline].

  46. Margalit DN, Mamon HJ, Ancukiewicz M, et al. Tolerability of combined modality therapy for rectal cancer in elderly patients aged 75 years and older. Int J Radiat Oncol Biol Phys. 2011 Dec 1. 81(5):e735-41. [Medline].

  47. Ceelen WP, Van Nieuwenhove Y, Fierens K. Preoperative chemoradiation versus radiation alone for stage II and III resectable rectal cancer. Cochrane Database Syst Rev. 2009 Jan 21. CD006041. [Medline].

  48. Jakobsen A, Ploen J, Vuong T, Appelt A, Lindebjerg J, Rafaelsen SR. Dose-Effect Relationship in Chemoradiotherapy for Locally Advanced Rectal Cancer: A Randomized Trial Comparing Two Radiation Doses. Int J Radiat Oncol Biol Phys. 2012 May 15. [Medline].

  49. Wong RK, Tandan V, De Silva S, Figueredo A. Pre-operative radiotherapy and curative surgery for the management of localized rectal carcinoma. Cochrane Database Syst Rev. 2007 Apr 18. CD002102. [Medline].

  50. Ng K, Ogino S, Meyerhardt JA, et al. Relationship Between Statin Use and Colon Cancer Recurrence and Survival: Results From CALGB 89803. J Natl Cancer Inst. 2011 Oct 19. 103(20):1540-51. [Medline]. [Full Text].

  51. NCCN. Clinical Practice Guidelines in Oncology Symposium: Colon, Rectal and Anal Cancers. Available at

  52. [Guideline] National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Rectal Cancer Version 1.2016. Available at Accessed: March 11, 2016.

  53. Kidwell KM, Yothers G, Ganz PA, Land SR, Ko CY, Cecchini RS, et al. Long-term neurotoxicity effects of oxaliplatin added to fluorouracil and leucovorin as adjuvant therapy for colon cancer: Results from National Surgical Adjuvant Breast and Bowel Project trials C-07 and LTS-01. Cancer. 2012 May 8. [Medline].

  54. Cao S, Bhattacharya A, Durrani FA, Fakih M. Irinotecan, oxaliplatin and raltitrexed for the treatment of advanced colorectal cancer. Expert Opinion on Pharmacotherapy. 2006. 7(6):687-703.

  55. Maughan TS, Adams RA, Smith CG, et al. Addition of cetuximab to oxaliplatin-based first-line combination chemotherapy for treatment of advanced colorectal cancer: results of the randomised phase 3 MRC COIN trial. Lancet. 2011 Jun 18. 377(9783):2103-14. [Medline].

  56. Douillard JY, Siena S, Cassidy J, Tabernero J, Burkes R, Barugel M, et al. Randomized, phase III trial of panitumumab with infusional fluorouracil, leucovorin, and oxaliplatin (FOLFOX4) versus FOLFOX4 alone as first-line treatment in patients with previously untreated metastatic colorectal cancer: the PRIME study. J Clin Oncol. 2010 Nov 1. 28(31):4697-705. [Medline].

  57. Peeters M, Price TJ, Cervantes A, Sobrero AF, Ducreux M, Hotko Y. Randomized phase III study of panitumumab with fluorouracil, leucovorin, and irinotecan (FOLFIRI) compared with FOLFIRI alone as second-line treatment in patients with metastatic colorectal cancer. J Clin Oncol. 2010 Nov 1. 28(31):4706-13. [Medline].

  58. Simkens LH, Koopman M, Mol L, et al. Influence of body mass index on outcome in advanced colorectal cancer patients receiving chemotherapy with or without targeted therapy. Eur J Cancer. 2011 Nov. 47(17):2560-7. [Medline].

  59. Quan D, Gallinger S, Nhan C, Auer RA, Biagi JJ, Fletcher GG, et al. The role of liver resection for colorectal cancer metastases in an era of multimodality treatment: A systematic review. Surgery. 2012 Jun. 151(6):860-70. [Medline].

  60. Cheng X, Chen VW, Steele B, Ruiz B, Fulton J, Liu L, et al. Subsite-specific incidence rate and stage of disease in colorectal cancer by race, gender, and age group in the United States, 1992-1997. Cancer. 2001 Nov 15. 92(10):2547-54. [Medline].

  61. Ebert MP, Tanzer M, Balluff B, et al. TFAP2E-DKK4 and chemoresistance in colorectal cancer. N Engl J Med. 2012 Jan 5. 366(1):44-53. [Medline].

  62. Hendlisz A, Van den Eynde M, Peeters M, Maleux G, Lambert B, Vannoote J, et al. Phase III trial comparing protracted intravenous fluorouracil infusion alone or with yttrium-90 resin microspheres radioembolization for liver-limited metastatic colorectal cancer refractory to standard chemotherapy. J Clin Oncol. 2010 Aug 10. 28(23):3687-94. [Medline].

  63. [Guideline] Kahi CJ, Boland CR, Dominitz JA, Giardiello FM, Johnson DA, Kaltenbach T, et al. Colonoscopy Surveillance After Colorectal Cancer Resection: Recommendations of the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2016 Mar. 150 (3):758-768.e11. [Medline]. [Full Text].

  64. Nielsen A, Munk C, Kjaer SK. Trends in incidence of anal cancer and high-grade anal intraepithelial neoplasia in Denmark, 1978-2008. Int J Cancer. 2012 Mar 1. 130(5):1168-73. [Medline].

  65. FDA: Gardasil approved to prevent anal cancer. U.S. Food and Drug Administration. Available at Accessed: May 12, 2015.

  66. Eu KW, Seow-Choen F, Ho JM, Ho YH, Leong AF. Local recurrence following rectal resection for cancer. J R Coll Surg Edinb. 1998 Dec. 43(6):393-6. [Medline]. [Full Text].

  67. Thong MS, Mols F, Lemmens VE, et al. Impact of preoperative radiotherapy on general and disease-specific health status of rectal cancer survivors: a population-based study. Int J Radiat Oncol Biol Phys. 2011 Nov 1. 81(3):e49-58. [Medline].

  68. Bipat S, Glas AS, Slors FJ, Zwinderman AH, Bossuyt PM, Stoker J. Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging--a meta-analysis. Radiology. 2004 Sep. 232(3):773-83. [Medline].

  69. Boisen MK, Johansen JS, Dehlendorff C, Larsen JS, Osterlind K, Hansen J, et al. Primary tumor location and bevacizumab effectiveness in patients with metastatic colorectal cancer. Ann Oncol. 2013 Jul 17. [Medline].

  70. Kumar A, Scholefield JH. Endosonography of the anal canal and rectum. World J Surg. 2000 Feb. 24(2):208-15. [Medline].

  71. Lipton LR, Johnson V, Cummings C, et al. Refining the Amsterdam Criteria and Bethesda Guidelines: testing algorithms for the prediction of mismatch repair mutation status in the familial cancer clinic. J Clin Oncol. 2004 Dec 15. 22(24):4934-43. [Medline].

  72. Lynch HT, de la Chapelle A. Hereditary colorectal cancer. N Engl J Med. 2003. 348:919â€"932.

  73. Phang PT, Wong WD. Preoperative evaluation of the rectal cancer patient: Assessment of operative risk and strategy. Current Therapy in Colon and Rectal Strategy. 2nd ed. Philadelphia, Pa: Mosby; 2005.

Diagnostics. Staging and workup of rectal cancer patients.
Staging and treatment. Rectal cancer treatment algorithm (surgery followed by adjuvant chemotherapy and radiotherapy). Initial stages are Endorectal ultrasound staging (uT).
Table 1. Comparison of AJCC Definition of TNM Staging System to Dukes Classification.
Rectal Cancer Stages TNM Staging Duke Staging 5-Year Survival
Stage I T1-2 N0 M0 A >90%
Stage II A T3 N0 M0 B 60%-85%
B T4 N0 M0 60%-85%
Stage III A T1-2 N1 M0 C 55%-60%
B T3-4 N1 M0 35%-42%
C T1-4 N2 M0 25%-27%
Stage IV T1-4 N0-2 M1 5%-7%
Table 2. Acceptable Minimal Distal and Proximal Resectional Margins for Rectal Cancer. [26]
Resection Margins Proximal Resection Margin(cm) Distal Resection Margin (cm)
Ideal Margins 5 cm or more 2 cm or more
Minimally acceptable margins 5 cm or more 1 cm or more
Table 3. Colorectal Chemotherapeutic Regimens


FOLFOX (every 2 weeks) Oxaliplatin 85 mg/m2 day 1

Leucovorin 200 mg/m2 day 1

5-FU 400 mg/m2 IV Bolus day 1 and 2

5-FU 600 mg/m2 IV Infusion day 1 and 2 (22 hours)


(every 2 weeks)

(4 cycles)

Oxaliplatin 85 mg/m2 day 1

Leucovorin 200 mg/m2 day 1

5-FU 400 mg/m2 IV Bolus day 1 and 2

5-FU 2400 mg/m2 IV Infusion day 1 (46 hours)


(Every 2 weeks)

(4 cycles)

Oxaliplatin 85 mg/m2 day 1

Leucovorin 400 mg/m2 day 1

5-FU 400 mg/m2 IV Bolus day 1 and 2

5-FU 1200 mg/m2 IV Infusion day 2 days


(Twice daily x 14 days)

(every 3 weeks)

Oxaliplatin 130 mg/m2 day 1

Capecitabine 850 mg/m2 PO BID for 14 days


(every 2 weeks)

Irinotecan 165 mg/m2 day 1

Leucovorin 200 mg/m2 day 1

5-FU 400 mg/m2 IV Bolus day 1 and 2

5-FU 600 mg/m2 IV Infusion day 1 and 2 (22 hours)


(every 2 weeks)

Irinotecan 180 mg/m2 day 1

Oxaliplatin 85 mg/m2 day 1

Leucovorin 200 mg/m2 day 1

5-FU 3200 mg/m2 IV Infusion day (48 hours)

Bevacizumab 5-10 mg/kg IV every 2 weeks with chemotherapy
Cetuximab 400 mg/m2 IV day 1, then 250 mg/m2 IV weekly
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.