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Treatment for rectal cancer is based largely on the stage (extent) of the cancer, although other factors can also be important.

People with rectal cancers that have not spread to distant sites are usually treated with surgery. Additional treatment with radiation and chemotherapy (chemo) may also be used before or after surgery.

Treating stage 0 rectal cancer

Stage 0 rectal cancers have not grown beyond the inner lining of the rectum. Removing or destroying the cancer is typically all that is needed. You can usually be treated with surgery such as a polypectomy (removing the polyp), local excision, or transanal resection and should need no further treatment.

Treating stage I rectal cancer

Stage I rectal cancers have grown into deeper layers of the rectal wall but have not spread outside the rectum itself.

This stage includes cancers that were part of a polyp. If the polyp is removed completely during colonoscopy, with no cancer in the edges, no other treatment may be needed. If the cancer in the polyp was high grade (see Colorectal cancer stages) or if there were cancer cells at the edges of the polyp, you might be advised to have more surgery. More surgery may also be advised if the polyp couldn’t be removed completely or if it had to be removed in many pieces, making it hard to see if there were cancer cells at the edges (margins).

For other stage I cancers, surgery is usually the main treatment. Some small stage I cancers can be removed through the anus without cutting the abdomen, using transanal resection or transanal endoscopic microsurgery (TEM). For other cancers, a low anterior resection (LAR), proctectomy with colo-anal anastomosis, or an abdominoperineal resection (APR) may be done, depending on exactly where the cancer is within the rectum. (These operations are discussed in detail in the surgery section).

Additional therapy typically is not needed after these operations, unless the surgeon finds the cancer is more advanced than was thought before surgery. If it is more advanced, a combination of chemo and radiation therapy is usually given. 5-FU is the chemo drug most often used.

If you are too sick to have surgery, you may be treated with radiation therapy, although this has not been proven to be as effective as surgery.

Treating stage II rectal cancer

Many stage II rectal cancers have grown through the wall of the rectum and might extend into nearby tissues. They have not yet spread to the lymph nodes.

Most people with stage II rectal cancer will be treated with chemotherapy, radiation therapy, and surgery, although the order of these treatments might be different for some people. For example, here’s a common approach to treating these cancers:

  • Many people get both chemo and radiation therapy (called chemoradiation) as their first treatment. The chemo given with radiation is usually either 5-FU or capecitabine (Xeloda).
  • This is usually followed by surgery, such as a low anterior resection (LAR), proctectomy with colo-anal anastomosis, or abdominoperineal resection (APR), depending on where the cancer is in the rectum. If the chemo and radiation therapy shrink the tumor enough, sometimes a transanal resection can be done instead of a more invasive LAR or APR. This might avoid having to do a colostomy. But not all doctors agree with this method, as it doesn’t let the surgeon check the nearby lymph nodes for cancer.
  • Additional chemo is then given after surgery, usually for a total of about 6 months. The chemo may be the FOLFOX regimen (oxaliplatin, 5-FU, and leucovorin), 5-FU and leucovorin, CapeOx (capecitabine plus oxaliplatin) or capecitabine alone, based on what’s best suited to your health needs.

Another option might be to get chemotherapy alone first, followed by chemo plus radiation therapy, and then followed by surgery.

If someone can’t have chemo plus radiation for some reason, surgery (such as an LAR, proctectomy with colo-anal anastomosis, or APR) might be done first. This might be followed by chemotherapy, and sometimes radiation therapy.

Treating stage III rectal cancer

Stage III rectal cancers have spread to nearby lymph nodes but not to other parts of the body.

Most people with stage III rectal cancer will be treated with chemotherapy, radiation therapy, and surgery, although the order of these treatments might differ for some.

Most often, chemo is given along with radiation therapy (called chemoradiation) first. This may shrink the cancer, often making surgery more effective for larger tumors. It also lowers the chance that the cancer will come back in the pelvis. Giving radiation before surgery also tends to lead to fewer problems than giving it after surgery.

This is followed by surgery to remove the rectal tumor and nearby lymph nodes, usually by low anterior resection (LAR), proctectomy with colo-anal anastomosis, or abdominoperineal resection (APR), depending on where the cancer is in the rectum. If the cancer has reached nearby organs, a more extensive operation known as pelvic exenteration may be needed.

After surgery, chemo is given, usually for about 6 months. The most common regimens include FOLFOX (oxaliplatin, 5-FU, and leucovorin), 5-FU and leucovorin, CapeOx (capecitabine plus oxaliplatin), or capecitabine alone. Your doctor may recommend one of these if it is better suited to your health needs.

Another option might be to get chemotherapy alone first, followed by chemo plus radiation therapy, and then followed by surgery.

For people who can’t have chemo plus radiation for some reason, surgery (such as an LAR, proctectomy with colo-anal anastomosis, or APR) might be the first treatment. This might be followed by chemotherapy, sometimes along with radiation therapy.

Treating stage IV rectal cancer

Stage IV rectal cancers have spread to distant organs and tissues such as the liver or lungs. Treatment options for stage IV disease depend to some extent on how widespread the cancer is.

If there’s a chance that all of the cancer can be removed (for example, there are only a few tumors in the liver or lungs), the most common treatment options include:

  • Surgery to remove the rectal lesion and distant tumors, followed by chemo (and radiation therapy in some cases)
  • Chemo, followed by surgery to remove the rectal lesion and distant tumors, usually followed by chemo and radiation therapy (chemoradiation)
  • Chemo, followed by chemo and radiation therapy (chemoradiation), followed by surgery to remove the rectal lesion and distant tumors. This might be followed by more chemotherapy.
  • Chemo and radiation therapy, followed by surgery to remove the rectal lesion and distant tumors. This might be followed by chemotherapy.

These approaches may help you live longer and in some cases may even cure you. Surgery to remove the rectal tumor would usually be a low anterior resection (LAR), proctectomy with colo-anal anastomosis, or abdominoperineal resection (APR), depending on where it’s located.

If the only site of cancer spread is the liver, you may be treated with chemo given directly into the artery leading to the liver (hepatic artery infusion). This may shrink the cancers in the liver more effectively than if the chemo is given into a vein (IV) or by mouth.

If the cancer is more widespread and can’t be removed completely by surgery, treatment options depend on whether the cancer is causing a blockage of the intestine. If it is, surgery may be needed right away. If not, the cancer will likely be treated with chemo and/or targeted therapy drugs (without surgery). Some of the options include:

  • FOLFOX: leucovorin, 5-FU, and oxaliplatin (Eloxatin)
  • FOLFIRI: leucovorin, 5-FU, and irinotecan (Camptosar)
  • CapeOX: capecitabine (Xeloda) and oxaliplatin
  • FOLFOXIRI: leucovorin, 5-FU, oxaliplatin, and irinotecan
  • One of the above combinations, plus either a drug that targets VEGF (bevacizumab [Avastin], ziv-aflibercept [Zaltrap], or ramucirumab [Cyramza]), or a drug that targets EGFR (cetuximab [Erbitux] or panitumumab [Vectibix])
  • 5-FU and leucovorin, with or without a targeted drug
  • Capecitabine, with or without a targeted drug
  • Irinotecan, with or without a targeted drug
  • Cetuximab alone
  • Panitumumab alone
  • Regorafenib (Stivarga) alone
  • Trifluridine and tipiracil (Lonsurf)

The choice of regimens depends on several factors, including any previous treatments and your overall health and ability to withstand treatment.

If chemo shrinks the tumors, in some cases it may be possible to consider surgery to try to remove all of the cancer at this point. Chemo may then be given again after surgery.

For cancers that don’t shrink with chemo and widespread cancers that are causing symptoms, treatment is done to relieve symptoms and avoid long-term complications such as bleeding or blockage of the intestines. Treatments may include one or more of the following:

  • Removing the rectal tumor with surgery
  • Surgery to create a colostomy and bypass the rectal tumor (a diverting colostomy)
  • Using a special laser to destroy the tumor within the rectum
  • Placing a stent (hollow plastic or metal tube) within the rectum to keep it open; this does not require surgery
  • Chemo and radiation therapy
  • Chemo alone

If tumors in the liver can’t be removed by surgery because they are too large or there are too many of them, it may be possible to destroy them with ablation or embolization.

Treating recurrent rectal cancer

Recurrent cancer means that the cancer has come back after treatment. It may come back near the area of the initial rectal tumor (locally) or in distant organs, like the lungs or liver. If the cancer does recur, it is usually in the first 2 to 3 years after surgery.

Local recurrence

If the cancer comes back in the pelvis (locally), it is treated with surgery to remove the cancer, if possible. This surgery is often more extensive than the initial surgery. In some cases radiation therapy may be given during the surgery ( this is called intraoperative radiotherapy) or afterward. Chemo may also be given after surgery (as well as radiation therapy aimed at the tumor if it was not used before).

Distant recurrence

If the cancer comes back in a distant part of the body, the treatment will depend on whether it can be removed by surgery.

If the cancer can be removed, surgery is done. Chemo may be given before surgery (see “Treating stage IV rectal cancer” for a list of possible drug regimens). Chemo is given after surgery as well. When the cancer has spread to the liver, chemo may be given through the hepatic artery leading to the liver.

If the cancer can’t be removed by surgery, chemo and/or targeted therapy drugs may be used. The regimen used will depend on what a person has received previously and on their overall health. If the cancer doesn’t shrink with chemo, a different drug combination may be tried.

As with stage IV rectal cancer, surgery, radiation therapy, or other approaches may be used at some point to relieve symptoms and avoid long-term complications such as bleeding or blockage of the intestines.

These cancers can often be hard to treat, so you might also want to ask your doctor if you are eligible for any clinical trials of newer treatments.

For more on dealing with a recurrence, see When Your Cancer Comes Back: Cancer Recurrence.


Last Medical Review: 10/15/2015
Last Revised: 01/20/2016