Treatment options for rectal cancer

Deciding which treatment you need

A team of doctors and other professionals discuss the best treatment and care for you. They are called a multidisciplinary team (MDT).

Doctors choose your treatment after considering your risk of the cancer coming back after treatment. They consider many factors including:

• whether the cancer is in the low, middle or high part of your rectum

• how far it has grown or spread (the stage) - for rectal cancers, doctors use the TNM staging system

• whether your cancer has spread into blood vessels

• whether your cancer has spread into the sheet of tissue surrounding the rectum (mesorectal fascia)

They also consider your general health and fitness level. And they talk to you about your treatment, its benefits and the possible side effects.

Find out about TNM staging for rectal cancer

Surgery

Most people with rectal cancer have surgery. The two main types of surgery are:

• local excision (including trans anal endoscopic microsurgery)

• total mesorectal excision (TME)

A local excision a small operation. You might have a local excision if you have a small early ​stage​ cancer with a low risk of it coming back.

Your surgeon removes the cancer through the back passage opening (anus).

Total mesorectal excision (TME) is the most common type of surgery for rectal cancer. The surgeon removes the part of the rectum that contains cancer, as well as a border (margin) of healthy tissue around it. They also remove the fatty tissue (mesorectum) around the rectum. 

Find out more about surgery for rectal cancer

Your team consider how likely it is that your cancer will come back after surgery and decide if you need:

• surgery on its own

• surgery after radiotherapy with or without chemoradiotherapy

• total neoadjuvant treatment (TNT) - this is radiotherapy and chemotherapy together with an extra course of chemotherapy, all before surgery

• chemotherapy after surgery

Radiotherapy

Radiotherapy uses high energy rays to destroy cancer cells. If your doctor thinks you need radiotherapy, you usually have it before surgery.

You might have:

• external radiotherapy

• internal radiotherapy (brachytherapy)

Some people might have both.

Some people only need a short course of radiotherapy. Doctors call this short course preoperative radiotherapy or SCPRT.

You have daily radiotherapy for 5 days and then have:

• surgery straight away

• delayed surgery (at least 6 weeks after radiotherapy)

You don't usually have radiotherapy after surgery. But your doctor might suggest this if you were diagnosed with rectal cancer as an emergency and had an emergency operation. Or if your rectal cancer comes back soon after your surgery.

Read more about radiotherapy for rectal cancer

Chemotherapy

Chemotherapy uses anti cancer (cytotoxic) drugs to destroy cancer cells. The drugs circulate throughout the body in your bloodstream.

You might have chemotherapy combined with radiotherapy (chemoradiotherapy) before surgery. Or you might have chemotherapy on its own after surgery, to lower the risk of the cancer coming back. This is called adjuvant chemotherapy.

Get more information about chemotherapy for rectal cancer

Chemotherapy and radiotherapy together (chemoradiotherapy)

Chemotherapy combined with radiotherapy is called chemoradiotherapy or chemoradiation. You usually have chemoradiotherapy before surgery. Doctors also call this long course chemoradiotherapy.

Some people have chemoradiotherapy as their only treatment or after surgery. But this is less common.

Chemoradiotherapy before surgery

You might have chemoradiotherapy before surgery if:

• your rectal cancer has spread to nearby structures and tissues

• it might be difficult for your surgeon to remove the rectal cancer with a clear border of tissue (margin)

 You usually have:

• radiotherapy every week day for around 5 weeks

• a chemotherapy drug called fluorouracil (5FU)

• surgery after completing chemoradiotherapy – ask your team when your surgery is likely to be

Find out more about chemoradiotherapy

Total neoadjuvant therapy (TNT)

Total neoadjuvant therapy (TNT) means that you have a combination of treatments before surgery. This might be chemoradiotherapy together with chemotherapy.

You might have:

• chemotherapy followed by chemoradiotherapy

• chemoradiotherapy followed by chemotherapy

Watch and wait

Rectal cancer surgery has possible side effects. So, for some people, seeing how well the cancer responds to other treatment first can be an option. This is called watch and wait.

You have tests and scans after radiotherapy, chemotherapy or chemoradiotherapy.

Watch and wait might be suitable for you if there is no sign of cancer after you have had your first treatment. Your healthcare team monitor you closely. You then have surgery if needed.

Immunotherapy

You might have a type of immunotherapy called dorstalimab if you have certain types of stage 2 or stage 3 rectal cancer and you live in Wales.

Find out about staging in rectal cancer

Your cancer needs to be ​mismatch repair deficient​ (dMMR) or ​microsatellite instability​ high (MSI-H).

Talk to your treatment team if you think this could be a suitable treatment for you.

Find out more about dorstalimab

Planning treatment

The rectal cancer MDT discuss the best treatment and care for you. They talk with you about your options and what the possible benefits and side effects are.

Your doctors make an individual treatment plan for you. They look at many factors to work out the possible risk of your cancer coming back. Knowing whether the cancer is in the low, middle or high part of your rectum can help doctors plan treatment.

Cancer in the upper 3rd of the rectum (high part)

Most people have surgery if they have cancer in the upper part of the rectum.

You might have:

• surgery as your first treatment – there are different types depending on the stage of your cancer

• chemotherapy or chemoradiotherapy after surgery – this is called ​adjuvant treatment. It’s rare to have chemoradiotherapy after TME surgery

You might have treatment before surgery if the cancer has spread through the bowel wall or to nearby ​lymph nodes​. This is called neoadjuvant treatment. You might have:

• chemotherapy

• total neoadjuvant therapy (TNT)

• chemoradiotherapy or short course radiotherapy

Cancer in the lower or middle 3rd of rectum (low or middle part)

Surgery is a common treatment for cancer in the lower or middle part of the rectum.

Treatment before surgery (neoadjuvant treatment) can work very well for some people. If your team think that all the cancer has gone, it is called a complete clinical response. In this case, your team might discuss a watch and wait approach with you. You are monitored very closely with tests and scans to look for any sign of the cancer. 

If you have surgery

You might have:

• surgery as your first treatment – there are different types depending on the stage of your cancer • chemotherapy or chemoradiotherapy after surgery. It’s rare to have chemoradiotherapy after TME surgery

You might have treatment before surgery if cancer has spread through the bowel wall or to nearby ​lymph nodes​. This is called neoadjuvant treatment. You might have:

• chemotherapy • radiotherapy • total neoadjuvant therapy (TNT)

If you don’t have surgery

Your treatment depends on your T stage. This describes the how far the cancer has grown into the bowel wall. As your first treatment you might have:

• radiotherapy – external radiotherapy with or without internal radiotherapy (brachytherapy) • chemoradiotherapy • total neoadjuvant treatment (TNT)

After treatment you have tests. You then might have:

• watch and wait – you are monitored very closely with tests and scans to look for any sign of the cancer • surgery • surgery with chemotherapy after surgery

Having treatment as part of a clinical trial

Doctors are always trying to improve treatments and reduce side effects. Your doctor might ask you to take participate in a clinical trial as part of your treatment. This might be to investigate a new test, a new cancer treatment or to look at different combinations of existing treatments.

Your doctor will tell you if there are any trials that you can enter.

Get information on research and clinical trials for bowel cancer