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NCCN Guidelines for Patients



Rectal Cancer, Version 1.2017


Metastatic disease

Metastases at diagnosis

Guide 11

lists nonsurgical options for liver or

lung metastases present at diagnosis. Options are

grouped by whether cancer symptoms are present or


Symptoms absent

Systemic treatment may be an option. The goal of

treatment is to slow down the growth of the cancer.

If treatment works, symptoms may be prevented or

delayed. Part 6 contains lists of chemotherapy that

may be received. Targeted therapy may be added.

For some people, chemotherapy may greatly

shrink the cancer. If it shrinks enough, surgery to

cure the cancer may be an option. Most people

with metastatic rectal cancer won’t be able to have

surgery. Surgery is unlikely if there is widespread

cancer in your liver or lung. If surgery is possible,

tests to assess the tumor size are advised every two

months during chemotherapy.

If taking bevacizumab, it should be stopped 6 weeks

before surgery. It increases your chance for a stroke,

bleeding, and other arterial events. These events

are even more likely if you are older than 65 years.

Bevacizumab can be re-started 6 to 8 weeks after

surgery. Otherwise, it can slow healing.

Surgery should occur as soon as possible after

chemotherapy. After surgery, you may receive more

chemotherapy. Chemotherapy received before and

after surgery should not exceed 6 months. Targeted

therapy may be added.

Symptoms present

There are treatments for a number of symptoms.

Systemic treatment may improve symptoms within

1 to 2 weeks. Likewise, chemoradiation may relieve

symptoms within the pelvis. Infusional 5-FU or

capecitabine is preferred. The side effects of these

regimens may be too much for you. In this case,

bolus 5-FU/LV may be received.

The tumor may have grown so large that it blocks

the flow of stool. Surgery to remove the part of the

rectum with cancer may be an option. Surgery may

also stop bleeding.

Other options to unblock the rectum are a diversion

and stent. A diversion is a type of surgery. It attaches

the colon to the surface of the abdomen, and a “bag”

is needed. A stent is a wire mesh tube. It is placed in

the rectum to allow stool to pass.

Short-course radiation may downsize the rectal

cancer. This option is only for rectal cancers with

T1, T2, or T3 tumors. Your treatment team should

discuss if this is an option for you. Factors to discuss

are the extent of cancer and side effects of short-

course radiation.

After treatment for symptoms, systemic treatment is

advised. Part 6 contains lists of chemotherapy that

may be received. Targeted therapy may be added.

Guide 12

lists important follow-up care for stage

IV cancer. Follow-up care starts when there are

no signs of cancer after surgery. It is also called

survivorship care. This care should address your

whole health and well-being.

Your cancer doctor and primary doctor should work

together to help you. Each doctor can have a role in

survivorship. Talk with your doctors about the care

you want and need so you get the best plan.

Cancer tests

A medical history and physical exam are advised.

Get this care every 3 to 6 months for 2 years. If

results are normal for 2 years, repeat care every 6

months for another 3 years.

CEA blood tests are mainly used to detect the return

of cancer. CEA levels should be tested every 3 to 6

months for 2 years. If results are normal for 2 years,

get tested every 6 months for another 3 years.