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NCCN Guidelines for Patients



Rectal Cancer, Version 1.2017


Nonmetastatic cancer

Stages II and III

Stages II and III

Guide 7

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.

Neoadjuvant treatment

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

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

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

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

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.

Transabdominal resection

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 therapy

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