Rectal cancer
Rectal cancer is bowel cancer in the last part of the large intestine, where surgery can mean a permanent stoma. Treatment now usually gives all the chemotherapy and radiotherapy first, and about half of people whose tumour disappears completely can keep their rectum and avoid surgery altogether.
Overview
Rectal cancer is staged by pelvic MRI, which shows the depth of invasion, the distance to the mesorectal fascia, extramural venous invasion and nodal disease and so decides who needs treatment before surgery. Total mesorectal excision, described by Heald in 1982, cut local recurrence from a quarter of patients to well under a tenth, and the German CAO/ARO/AIO-94 trial (2004) moved chemoradiation to before surgery, halving local recurrence again. Early tumours (cT1-2, node-negative) go straight to surgery, and small T1 tumours can be removed through the anus.
For locally advanced disease the sequence has been rebuilt as total neoadjuvant therapy: RAPIDO (2020) gave one week of radiotherapy then all the chemotherapy before surgery and cut distant failure and doubled complete responses; PRODIGE 23 (2021) gave induction mFOLFIRINOX before chemoradiation and improved disease-free and, later, overall survival. OPRA (2022) showed that with chemoradiation followed by consolidation chemotherapy about half of patients could avoid surgery through watch and wait without losing disease control, building on the Habr-Gama series from Sao Paulo. PROSPECT (2023) then showed that intermediate-risk tumours suitable for sphincter-sparing surgery can be treated with FOLFOX alone, with radiotherapy reserved for the 9 percent who do not respond.
The 5 to 10 percent of rectal cancers that are mismatch-repair deficient respond so completely to PD-1 blockade that surgery and radiotherapy can be omitted: in the Memorial Sloan Kettering study every patient treated with six months of dostarlimab had a clinical complete response (NEJM 2022, expanded 2025), and AZUR-1 is the registration study. Metastatic rectal cancer is treated as metastatic colorectal cancer, by genotype and sidedness. Open questions are how to select watch and wait safely, whether circulating tumour DNA can guide surveillance, and how to reduce the bowel, sexual and urinary harm that survivors carry.
State of the art
- Total neoadjuvant therapy (RAPIDO, PRODIGE 23, OPRA) has replaced chemoradiation then surgery then chemotherapy as the default for locally advanced disease.
- Watch and wait after clinical complete response spares about half of selected patients the operation, with salvage surgery for the regrowths.
- PROSPECT removed pelvic radiotherapy from the pathway for intermediate-risk tumours.
- Mismatch-repair deficient rectal cancer is treated with immunotherapy alone.
Red cards
From the labels and guidelines behind the standard of care. Your team's thresholds win.- Emergency services nowBleeding or bruising
Bleeding that will not stop, black or bloody stools, or unexplained bruising when platelets are expected to be low.
- Emergency services nowBowel perforation
Sudden severe abdominal pain, a hard or very tender abdomen, or abdominal pain with vomiting and fever. Boxed warning for gastrointestinal perforation on bevacizumab.
- Emergency services nowHypophysitis or adrenal crisis
Persistent headache with extreme tiredness, nausea, dizziness on standing or low blood pressure. Vomiting, severe weakness or collapse is adrenal crisis.
- Good to knowAnti-VEGF class toxicities (hypertension, proteinuria, bleeding, perforation)
The shared side effects of drugs that block blood vessel growth (bevacizumab, ramucirumab and VEGFR kinase inhibitors): high blood pressure, protein leaking into the urine, nosebleeds and more serious bleeding, slow wound healing, and rarely holes in the bowel.
- Good to knowInfusion reactions, hypersensitivity and extravasation
Reactions around the moment a drug is given: chills, fever or breathlessness from antibodies (infusion reactions), true allergy (hypersensitivity, rarely anaphylaxis), and leakage of a damaging drug into tissue around the vein (extravasation).
- Good to knowRadiation necrosis (brain)
Death of brain tissue months to years after radiosurgery or high-dose brain radiotherapy, which can look exactly like tumour growing back on a scan.
See all on the product pages:BevacizumabCAPOX (capecitabine, oxaliplatin)CetuximabDostarlimabFOLFIRI (5-FU, leucovorin, irinotecan)FOLFOX (5-FU, leucovorin, oxaliplatin)·Printable cards in the navigator
Anatomy and lymph node drainage
- Right colon (MSI-high, BRAF commoner)
- Left colon and sigmoid
- Rectum
- Anal canal (HPV squamous)
- Appendix
- Peritoneum and omentum (mesothelioma, peritoneal spread)
- Nodes: pericolic
- Nodes: mesenteric root
- Nodes: para-aortic
- Nodes: mesorectal
- Nodes: lateral pelvic and inguinal (anal)
Right-sided tumours behave differently from left-sided and rectal ones; the colon drains along its mesenteric vessels, the rectum into the mesorectum and pelvic side wall.
- Right colon (MSI-high, BRAF commoner)
- Left colon and sigmoid
- RectumLow rectal cancer (within 5 cm of the anal verge; the sphincter is at risk) · Mid and upper rectal cancer (anterior resection with anastomosis) · Locally advanced rectal cancer (cT3-4 or node-positive on MRI; total neoadjuvant therapy) · Mismatch-repair deficient rectal cancer (immunotherapy alone, no surgery) · Rectal cancer in clinical complete response under watch and wait
- Anal canal (HPV squamous)Low rectal cancer (within 5 cm of the anal verge; the sphincter is at risk)
- Appendix
- Peritoneum and omentum (mesothelioma, peritoneal spread)
- pericolic
- mesenteric root
- para-aortic
- mesorectal
- lateral pelvic and inguinal (anal)
Same organ: Peritoneal mesothelioma, Colorectal cancer, Mismatch-repair deficient (MSI-high) colorectal cancer, BRAF V600E-mutant colorectal cancer, HER2-amplified colorectal cancer, KRAS G12C-mutant colorectal cancer, Early-onset colorectal cancer (under 50), Anal cancer (squamous cell carcinoma), Appendiceal cancer and pseudomyxoma peritonei, Small intestine cancer (small bowel adenocarcinoma)
About a third of colorectal cancers start in the rectum, the last 15 cm of the bowel; because the rectum sits in the narrow pelvis next to the bladder, sexual organs and sphincter, local recurrence, stomas and function matter more than for colon cancer.
- MRIStandard of care
Nothing recorded yet.
Nothing recorded yet.
Also on OnCo: Symptoms and red flags · Early detection roadmap.
Cases by country
No country-level case numbers. This cancer is not mapped to a GLOBOCAN site.
One section per setting: the options named, what each is for, the trials behind them, the recorded trade-offs and the questions to ask.
Total mesorectal excision, increasingly robotic or laparoscopic; transanal local excision for small, well-differentiated T1 tumours; no radiotherapy.
Total neoadjuvant therapy: short-course radiotherapy then CAPOX or FOLFOX (RAPIDO), or induction mFOLFIRINOX then chemoradiation (PRODIGE 23); chemoradiation then consolidation chemotherapy when organ preservation is the goal (OPRA); surgery or watch and wait for complete responders.
Six cycles of FOLFOX with chemoradiation only if the tumour shrinks by less than 20 percent (PROSPECT), then total mesorectal excision.
Six months of dostarlimab or another PD-1 antibody with non-operative management for complete responders; surgery reserved for the rare non-responder.
As metastatic colorectal cancer: doublet chemotherapy with bevacizumab or, for RAS and BRAF wild-type left-sided tumours, an anti-EGFR antibody; primary tumour managed by symptoms; liver-limited disease resected.
Subtypes & biomarkers
top- Low rectal cancer (within 5 cm of the anal verge; the sphincter is at risk)
- Mid and upper rectal cancer (anterior resection with anastomosis)
- Locally advanced rectal cancer (cT3-4 or node-positive on MRI; total neoadjuvant therapy)
- Mismatch-repair deficient rectal cancer (immunotherapy alone, no surgery)
- Rectal cancer in clinical complete response under watch and wait
- Pelvic MRI : T stage, mesorectal fascia involvement, extramural venous invasion, lateral nodes
- Mismatch repair / microsatellite status (immunotherapy alone if deficient)
- RAS, BRAF V600E and HER2 in metastatic disease
- Carcinoembryonic antigen (CEA)
- Circulating tumour DNA after treatment (under study)
- Clinical complete response on endoscopy and MRI
How often this target appears
- 1908Miles describes the abdominoperineal resection with permanent colostomy
- 1982Heald describes total mesorectal excision, cutting local recurrence to under 10 percent
- 2004CAO/ARO/AIO-94: preoperative chemoradiation halves local recurrence
- 2004Habr-Gama reports watch and wait after complete clinical response in Sao Paulo
- 2020RAPIDO: short-course radiotherapy then chemotherapy establishes total neoadjuvant therapy
- 2021PRODIGE 23: induction mFOLFIRINOX improves disease-free survival
- 2022OPRA: about half of patients keep their rectum after total neoadjuvant therapy
- 2022Dostarlimab alone produces complete responses in every mismatch-repair deficient rectal cancer treated
- 2023PROSPECT: FOLFOX with selective chemoradiation is as good as routine chemoradiation
- 2026AZUR-1 confirms non-operative management with dostarlimab in mismatch-repair deficient rectal cancer
Dated changes read from the records linked to this cancer: approvals, regulatory steps, reported trials, guideline versions and milestones. Newest first; no date is inferred.
All 22 changes by month →- 2026-09-17This recordRectal cancerFacts on this page last checked
When this page itself was last checked or edited.
- 2026Trial resultAZUR-1AZUR-1 reported
Primary endpoint (sustained cCR at 12 months) met; rates pending congress presentation.
- 2026MilestoneAZUR-1AZUR-1 confirms non-operative management with dostarlimab in mismatch-repair deficient rectal cancer
A milestone in how this cancer is treated.
- 2025-06RegulatoryDostarlimabDostarlimab: designation granted (US)
Breakthrough Therapy designation, dMMR locally advanced rectal cancer (organ preservation)
- 2023Trial resultPROSPECT (Alliance N1048)PROSPECT (Alliance N1048) reported
5-year disease-free survival 80.
- 2023MilestonePROSPECT (Alliance N1048)PROSPECT: FOLFOX with selective chemoradiation is as good as routine chemoradiation
A milestone in how this cancer is treated.
What is in development for Rectal cancer, drawn from the whole corpus: 9 items. Drugs are grouped by the most advanced trial phase they have reached anywhere; approved treatments sit under standard of care. Technologies are the methods being tested for this cancer, trials are the studies recorded here, and ideas are proposals not yet in a trial.
Technologies being tested · 1
Trials under way · 1
- A Study of Dostarlimab in Participants With Untreated Locally Advanced Rectal Cancer in China · phase 2 · GlaxoSmithKline
Trials reported · 6
- AZUR-1 · phase 2 · 2026 · positive
- CAO/ARO/AIO-94 (German Rectal Cancer Study) · phase 3 · 2004 · positive
- OPRA · phase 2 · 2022 · positive
- PRODIGE 23 · phase 3 · 2021 · positive
- PROSPECT (Alliance N1048) · phase 2/3 · 2023 · positive
- RAPIDO · phase 3 · 2020 · positive
Ideas not yet in a trial · 1
Open problems and what is being done
No validated test predicts which clinical complete responders will regrow under watch and wait.
Long-term bowel, sexual and urinary function after total neoadjuvant therapy is poorly measured.
Whether circulating tumour DNA can safely guide surveillance after organ preservation is untested in randomised trials.
Lateral pelvic node disease is managed differently in Japan and the West with no comparative trial.
Trials
topTrials recruiting now
Country and place are remembered in this browser only. A postcode is sent to OpenStreetMap's Nominatim service to find coordinates when you press the button; nothing else leaves your device.
Landmark trials
Expert centres
topExpert centres
New York · cancer center Programme: dMMR rectal organ preservation | United States | 2 | 5,100 | 94,456 | #1 | ||
Baltimore · cancer center | United States | 0 | 2,955 | 41,449 | #10 | ||
Seoul · hospital | South Korea | none recorded | 0 | 464 | 3,248 | #22 | |
Chicago, IL · consortium | United States | none recorded | 1 | 42 | 482 | - | |
Paris · consortium | France | none recorded | 1 | not matched | - | - | |
| China | none recorded | 0 | 2,872 | 31,534 | - | ||
Sydney · cancer center | Australia | none recorded | 0 | 2,222 | 33,278 | - | |
Beijing · hospital | China | none recorded | 0 | 1,784 | 18,230 | - | |
| China | none recorded | 0 | 1,245 | 12,931 | - | ||
Tianjin · cancer center | China | none recorded | 0 | 1,219 | 11,455 | - | |
Beijing · hospital | China | none recorded | 0 | 1,154 | 11,808 | - | |
Pittsburgh, PA · cancer center | United States | 0 | 1,078 | 21,539 | - | ||
| United Kingdom | none recorded | 0 | 693 | 7,168 | - | ||
Gothenburg · hospital | Sweden | none recorded | 0 | 553 | 5,211 | - | |
Shanghai · hospital | China | none recorded | 0 | 539 | 6,491 | - |
These are the things we can measure; they are not a ranking of quality. Each column is a field on the institution record or a count over what OnCo has linked; a centre that treats many patients with Rectal cancer but is thinly recorded here will look small.
Not known: OnCo holds no case-volume or outcome figures for centres, so none are shown. Where a national audit or registry publishes them, the centre's page links to it. Default order: Newsweek rank, then trials for this cancer, then research output.
Questions to ask
topQuestions to ask your oncologist about Rectal cancer
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Why: Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example Pelvic MRI: T stage, mesorectal fascia involvement, extramural venous invasion, lateral nodes, Mismatch repair / microsatellite status, RAS, BRAF V600E and HER2 in metastatic disease, Carcinoembryonic antigen, Circulating tumour DNA after treatment), and what were the results?Why: These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Why: Recognised subtypes for this cancer include Low rectal cancer, Mid and upper rectal cancer, Locally advanced rectal cancer.
- Is germline (inherited) genetic testing recommended for me or my family?Why: Inherited variants can change treatment and matter for relatives.
Early (cT1-2, node-negative)
- For my situation (early (ct1-2, node-negative)), which of the standard options do you recommend and why?Why: Guideline options include: Total mesorectal excision, increasingly robotic or laparoscopic; transanal local excision for small, well-differentiated T1 tumours; no radiotherapy.
Locally advanced, higher risk
- For my situation (locally advanced, higher risk), which of the standard options do you recommend and why?Why: Guideline options include: Total neoadjuvant therapy: short-course radiotherapy then CAPOX or FOLFOX (RAPIDO), or induction mFOLFIRINOX then chemoradiation (PRODIGE 23); chemoradiation then consolidation chemotherapy when organ preservation is the goal (OPRA); surgery or watch and wait for complete responders.
- Am I a candidate for CAPOX (capecitabine, oxaliplatin), FOLFOX (5-FU, leucovorin, oxaliplatin), and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of RAPIDO and PRODIGE 23 apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Intermediate risk, sphincter-sparing surgery planned
- For my situation (intermediate risk, sphincter-sparing surgery planned), which of the standard options do you recommend and why?Why: Guideline options include: Six cycles of FOLFOX with chemoradiation only if the tumour shrinks by less than 20 percent (PROSPECT), then total mesorectal excision.
- Am I a candidate for FOLFOX (5-FU, leucovorin, oxaliplatin), and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of PROSPECT (Alliance N1048) apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Mismatch-repair deficient
- For my situation (mismatch-repair deficient), which of the standard options do you recommend and why?Why: Guideline options include: Six months of dostarlimab or another PD-1 antibody with non-operative management for complete responders; surgery reserved for the rare non-responder.
- Am I a candidate for Dostarlimab, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of AZUR-1 apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Metastatic
- For my situation (metastatic), which of the standard options do you recommend and why?Why: Guideline options include: As metastatic colorectal cancer: doublet chemotherapy with bevacizumab or, for RAS and BRAF wild-type left-sided tumours, an anti-EGFR antibody; primary tumour managed by symptoms; liver-limited disease resected.
- Am I a candidate for FOLFOX (5-FU, leucovorin, oxaliplatin), FOLFIRI (5-FU, leucovorin, irinotecan), Bevacizumab or related drugs, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Any stage
- Are there clinical trials I could join, for example of AZUR-1, A Study of Dostarlimab in Participants With Untreated Locally Advanced Rectal Cancer in China, Dostarlimab, Signatera?Why: Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Why: Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Why: Supportive care improves quality of life and helps patients complete treatment.
- I read that “No validated test predicts which clinical complete responders will regrow under watch and wait”. How does that affect my plan?Why: Open problems are where trials and second opinions matter most.
- I read that “Long-term bowel, sexual and urinary function after total neoadjuvant therapy is poorly measured”. How does that affect my plan?Why: Open problems are where trials and second opinions matter most.
Newly diagnosed? Read the first 60 days with Rectal cancer, then print the one-page appointment sheet with room for the answers.
Print this page for your appointment (your browser's print command). These prompts are for discussion; your clinical team knows your case.
Direct links plus the targets, companies, and technologies of this cancer's products.
technologies
13targets
3drugs
10companies
8pathways
1terms
9trials
7ideas
1people
4Latest papers
topQuery for this cancer: (TITLE:"Rectal cancer" OR ABSTRACT:"Rectal cancer" OR TITLE:"Rectal adenocarcinoma" OR ABSTRACT:"Rectal adenocarcinoma" OR TITLE:"Cancer of the rectum" OR ABSTRACT:"Cancer of the rectum" OR TITLE:"Locally advanced rectal cancer" OR ABSTRACT:"Locally advanced rectal cancer" OR TITLE:"Rectum cancer" OR ABSTRACT:"Rectum cancer") AND (treatment OR therapy OR trial OR survival OR diagnosis). Results are unfiltered search hits about Rectal cancer, not a curated reading list.
Similar pages
not linked directly; found by shared links- CancerMismatch-repair deficient (MSI-high) colorectal cancer
Shares A Study of Dostarlimab in Participants With Untreated Locally Advanced Rectal Cancer in China, AZUR-1, Andrea Cercek, Clinical complete response (cCR) and the tag subtype-page.
- CancerEarly-onset colorectal cancer (under 50)
Shares RAPIDO, Total neoadjuvant therapy (TNT, rectal cancer), Organ preservation (watch-and-wait, bladder-sparing, larynx preservation), Colorectal cancer (KEGG map) and the tag subtype-page.
- CancerKRAS G12C-mutant colorectal cancer
Shares Panitumumab, FOLFIRI (5-FU, leucovorin, irinotecan), Colorectal cancer (KEGG map), FOLFOX (5-FU, leucovorin, oxaliplatin) and the tag subtype-page.
- CancerBRAF V600E-mutant colorectal cancer
Shares Colorectal cancer (KEGG map), FOLFOX (5-FU, leucovorin, oxaliplatin), CAPOX (capecitabine, oxaliplatin), Microsatellite instability (MSI-H) / mismatch repair deficiency (dMMR) and the tag subtype-page.
- CancerHER2-amplified colorectal cancer
Shares FOLFIRI (5-FU, leucovorin, irinotecan), Colorectal cancer (KEGG map), FOLFOX (5-FU, leucovorin, oxaliplatin), VEGF / VEGFR and the tag subtype-page.
- CancerExtrahepatic cholangiocarcinoma (perihilar and distal)
Shares Hepatectomy (liver resection), FOLFOX (5-FU, leucovorin, oxaliplatin), Microsatellite instability (MSI-H) / mismatch repair deficiency (dMMR), MRI and the tag subtype-page.
- CancerEarly hepatocellular carcinoma (BCLC 0 and A)
Shares Hepatectomy (liver resection), MRI, Robotic & minimally invasive surgery, Bevacizumab and the tag subtype-page.
- CancerIntrahepatic cholangiocarcinoma
Shares Hepatectomy (liver resection), FOLFOX (5-FU, leucovorin, oxaliplatin), MRI, Capecitabine and the tag subtype-page.