The first 60 days: 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. Below, week by week, is what OnCo's record of Rectal cancer says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
Ask which of these were tested and what the results were; see the report reader for what each value means.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- RadiologistNamed in the standard of care for: Early (cT1-2, node-negative).
- SurgeonNamed in the standard of care for: Early (cT1-2, node-negative), Locally advanced, higher risk, Intermediate risk, sphincter-sparing surgery planned, Mismatch-repair deficient and 1 more.
- Medical oncologistNamed in the standard of care for: Early (cT1-2, node-negative), Locally advanced, higher risk, Intermediate risk, sphincter-sparing surgery planned, Mismatch-repair deficient and 1 more.
- Clinical oncologist (radiotherapy)Named in the standard of care for: Early (cT1-2, node-negative), Locally advanced, higher risk, Intermediate risk, sphincter-sparing surgery planned.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
Total mesorectal excision, increasingly robotic or laparoscopic; transanal local excision for small, well-differentiated T1 tumours; no radiotherapy.
Six cycles of FOLFOX with chemoradiation only if the tumour shrinks by less than 20 percent (PROSPECT), then total mesorectal excision.
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 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.
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?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?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?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?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?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?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?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?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?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?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?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?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?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of AZUR-1 apply to someone like me?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?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?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?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?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?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?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?Open problems are where trials and second opinions matter most.
Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Rectal cancer: the full pageRectal 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.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
- Total mesorectal excision (TME): The standard rectal cancer operation: the rectum is removed together with its surrounding fatty envelope (the mesorectum) in one intact package, which is where local recurrences used to come from.
- Abdominoperineal resection: Removing the rectum and anus together, leaving a permanent colostomy.
- Total neoadjuvant therapy (TNT, rectal cancer): Giving all the chemotherapy and radiotherapy for rectal cancer before surgery rather than splitting it around the operation.
- Stoma (colostomy, ileostomy, urostomy): An opening made in the abdominal wall so bowel or urine empties into a bag; may be temporary while a join heals, or permanent when the rectum, anus or bladder has been removed.
- Clinical complete response (cCR): No sign of tumour on examination, endoscopy, and MRI after treatment, without surgery to confirm it.
- Organ preservation (watch-and-wait, bladder-sparing, larynx preservation): Curing a cancer with drugs and radiotherapy so that the organ (rectum, bladder, larynx, limb) does not have to be removed, keeping surgery in reserve for the minority whose cancer regrows.
- Hepatectomy (liver resection): Cutting out the part of the liver containing tumour.
- Microsatellite instability (MSI-H) / mismatch repair deficiency (dMMR): Microsatellite instability is the mark of a broken DNA spell-checker (loss of MLH1, MSH2, MSH6 or PMS2) that leaves thousands of mutations, so the tumour displays abnormal proteins that T cells can recognise.
- Chemoradiation (chemoradiotherapy, CRT): Radiotherapy given at the same time as chemotherapy, which sensitises the cancer to radiation.
Every term links to the glossary.