How to Treat Rectal Cancer

https://www.cancer.org/cancer/....colon-rectal-cancer/

Treatment of Rectal Cancer, by Stage
Treatment for rectal cancer is based largely on the stage (extent) of the cancer, although other factors can also be important.
People with rectal cancers that have not spread to distant sites are usually treated with surgery. Treatment with radiation and chemotherapy (chemo) may also be used before or after surgery..

Treating stage I rectal cancer
Stage I rectal cancers have grown into deeper layers of the rectal wall but have not spread outside the rectum itself.
This stage includes cancers that were part of a polyp. If the polyp is removed completely during colonoscopy, with no cancer in the edges, no other treatment may be needed. If the cancer in the polyp was high grade, or if there were cancer cells at the edges of the polyp, you might be advised to have more surgery.

Treating stage II rectal cancer
Many stage II rectal cancers have grown through the wall of the rectum and might extend into nearby tissues. They have not spread to the lymph nodes.
Many people get both chemo and radiation therapy (called chemoradiation) as their first treatment. The chemo given with radiation is usually either 5-FU or capecitabine (Xeloda).
This is usually followed by surgery, such as a low anterior resection (LAR), proctectomy with colo-anal anastomosis, or abdominoperineal resection (APR), depending on where the cancer is in the rectum. If the chemo and radiation therapy shrink the tumor enough, sometimes a transanal resection can be done instead of a more invasive LAR or APR. This might help you avoid having a colostomy. But not all doctors agree with this method, because it doesn’t let the surgeon check the nearby lymph nodes for cancer.
Additional chemo is then given after surgery, usually for a total of about 6 months. The chemo may be the FOLFOX regimen (oxaliplatin, 5-FU, and leucovorin), 5-FU and leucovorin, CAPEOx (capecitabine plus oxaliplatin) or capecitabine alone, based on what’s best suited to your health needs.

Treating stage III rectal cancer
Stage III rectal cancers have spread to nearby lymph nodes but not to other parts of the body.
Most people with stage III rectal cancer will be treated with chemotherapy, radiation therapy, and surgery, although the order of these treatments might differ.
Most often, chemo is given along with radiation therapy (called chemoradiation) first. This may shrink the cancer, often making it easier to take out larger tumors. It also lowers the chance that the cancer will come back in the pelvis. Giving radiation before surgery also tends to lead to fewer problems than giving it after surgery.
Chemoradiation is followed by surgery to remove the rectal tumor and nearby lymph nodes, usually by low anterior resection (LAR), proctectomy with colo-anal anastomosis, or abdominoperineal resection (APR), depending on where the cancer is in the rectum. If the cancer has reached nearby organs, a more extensive operation known as pelvic exenteration may be needed.
After surgery, chemo is given, usually for about 6 months. The most common regimens include FOLFOX (oxaliplatin, 5-FU, and leucovorin), 5-FU and leucovorin, CAPEOX (capecitabine plus oxaliplatin), or capecitabine alone. Your doctor will recommend the one best suited to your health needs.

Treating stage IV rectal cancer
Stage IV rectal cancers have spread to distant organs and tissues such as the liver or lungs. Treatment options for stage IV disease depend to some extent on how widespread the cancer is.
If the cancer is more widespread and can’t be removed completely by surgery, treatment options depend on whether the cancer is causing a blockage of the intestine. If it is, surgery might be needed right away. If not, the cancer will likely be treated with chemo and/or targeted therapy drugs (without surgery). Some of the options include:
FOLFOX: leucovorin, 5-FU, and oxaliplatin (Eloxatin)
FOLFIRI: leucovorin, 5-FU, and irinotecan (Camptosar)
CAPEOX or CAPOX: capecitabine (Xeloda) and oxaliplatin
FOLFOXIRI: leucovorin, 5-FU, oxaliplatin, and irinotecan
One of the above combinations, plus either a drug that targets VEGF (bevacizumab [Avastin], ziv-aflibercept [Zaltrap], or ramucirumab [Cyramza]), or a drug that targets EGFR (cetuximab [Erbitux] or panitumumab [Vectibix])
5-FU and leucovorin, with or without a targeted drug
Capecitabine, with or without a targeted drug
Irinotecan, with or without a targeted drug
Cetuximab alone
Panitumumab alone
Regorafenib (Stivarga) alone
Trifluridine and tipiracil (Lonsurf)
If the tumor doesn't shrink, a different drug combination may be tried. For people with certain gene changes in their cancer cells, another option after initial chemotherapy might be treatment with an immunotherapy drug such as pembrolizumab (Keytruda).

Written by
The American Cancer Society medical and editorial content team
Last Medical Review: February 21, 2018 Last Revised: October 19, 2018

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