NCCN Guidelines for Patients
Rectal Cancer, Version 1.2017
Stages II and III
Stages II and III
presents the three treatment options
for stage II and III cancers. More than one type of
treatment is used. These treatments are given in a
sequence to achieve the best outcomes. Treatment
may include radiation with or without chemotherapy,
surgery, and chemotherapy by itself. Across all
treatment, six months of chemotherapy is preferred.
Treatment given before surgery improves results.
This treatment is called neoadjuvant treatment. Its
aim is to reduce the extent of the cancer.
For a long time, the standard of care was
chemoradiation. However, newer research suggests
that short-course radiation may be used in some
cases. Current research is testing the best approach
for neoadjuvant treatment.
Radiation received before surgery has benefits. It
may work better on tissue that hasn’t been exposed
to surgery. Side effects are less as the small intestine
is more easily avoided. Also, the bowel parts to be
re-attached are more likely to be healthy.
Option 1 starts with chemoradiation. A long course of
radiation is advised. Chemotherapy helps radiation
to work better. Capecitabine or infusional 5-FU is
preferred. Side effects of these regimens may be too
much for you. If so, bolus 5-FU/LV may be received.
Option 2 starts with chemotherapy. This is called
induction chemotherapy. FOLFOX or CAPEOX is
preferred for chemotherapy. Otherwise, you may
receive 5-FU/LV or capecitabine. Chemoradiation, as
described for Option 1, should follow.
There may be benefits to option 2. Outcomes may be
better. Side effects may be less severe.
Option 3 starts with short-course radiation.
Chemotherapy isn’t received at this time. This option
is only for T1, T2, or T3 tumors.
Some results of a short radiation course are equal to
a long course. It works well in treating rectal cancer
within and near the rectum. It also extends life as
much as a long course.
Your treatment team should discuss if this is an
option for you. One factor to discuss is the extent
of cancer. Some cancers do not shrink enough for
surgery during a short course. Another factor is the
side effects of short-course radiation.
After neoadjuvant treatment, the cancer will be
re-staged. Staging helps to plan the best surgical
method. Many cancers are down-staged.
Imaging tests will be used for staging. The most
commonly used tests are MRI, CT, and EUS. There
may be a clinical trial of imaging that you may join.
Primary treatment is the main method used to rid
your body of cancer. The goal is to have surgery for
primary treatment. However, some tumors may be
too large for surgery.
A transabdominal resection is advised. The tumor
and lymph nodes should be removed. Surgery
should occur 5 to 12 weeks after chemoradiation.
After short-course radiation, surgery can occur within
1 to 2 weeks.
Radiation during surgery (IORT) may be an option. It
is sometimes used if cancer is in the surgical margin.
It is also used as a boost for T4 and recurrent