NCCN Guidelines for Patients
Rectal Cancer, Version 1.2017
Metastases at diagnosis
Option 3 starts with chemotherapy followed by short-
course radiation. This option is only for rectal cancers
with 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.
Option 4 starts with chemoradiation. Chemotherapy
by itself is not received at this time. Chemoradiation
is described under Option 2.
Option 5 starts with short-course radiation.
Chemotherapy is not received at this time. Short-
course radiation is described under Option 3.
After neoadjuvant treatment, the extent of the cancer
will be assessed. This assessment helps to plan the
best surgical method. Imaging tests will be used. The
most commonly used tests are MRI, CT, and EUS.
There may be a clinical trial of other imaging tests
that you may join.
Primary treatment is the main method used to
rid your body of cancer. Surgery is often used.
Surgery should occur as soon as possible after
chemotherapy. After short-course radiation, surgery
can occur within 1 to 2 weeks.
A transabdominal resection is advised. A
metastasectomy may also be done to remove the
distant cancer. Both surgeries can be done during
one operation. They can also be done apart in two
Local treatment to the liver or lung may be added
to surgery. Another option is local treatment instead
of metastasectomy. However, NCCN experts
prefer metastasectomy over local treatment. Local
treatment includes ablation and SBRT.
Radiation during surgery (IORT) within the pelvis
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 cancers.
Not all treatment centers provide IORT. Instead, you
may receive external radiation, brachytherapy, or
both. These treatments can be started soon after
surgery. Don’t start adjuvant treatment until radiation
Pathology and imaging
A pathologist will test the tissue removed during
surgery. He or she will assess the current extent of
the cancer in removed tissue. Based on test results,
a pathologic stage will be assigned.
Before adjuvant treatment, imaging is needed.
Imaging can show how well treatment worked.
CT scans of your chest, abdomen, and pelvis are