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NCCN Guidelines for Patients



Rectal Cancer, Version 1.2017


Metastatic disease

Metastases at diagnosis

Option 3

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

Option 4 starts with chemoradiation. Chemotherapy

by itself is not received at this time. Chemoradiation

is described under Option 2.

Option 5

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

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

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 therapy

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

is finished.

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