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Rectal cancer treatment by stage

This page was reviewed under our medical and editorial policy by

Maurie Markman, MD, President, Medicine & Science at CTCA.

This page was reviewed on June 9, 2022.

The choice of rectal cancer treatment varies by how early or advanced the cancer is, along with other factors that may be unique to you. Treatment may include:

The stages of rectal cancer range from stage 0 to stage 4. Your cancer care team will recommend one or more of these treatments based on the stage of the cancer. They may also recommend different treatments than you previously had depending on whether the rectal cancer is recurrent, which means it returned after prior treatment.

Rectal cancer stage 0 treatment

At stage 0, the rectal cancer hasn’t spread beyond the rectum’s inner lining. Treatment typically involves excision (surgically removing the tumor) during a colonoscopy. Excision at this stage may involve:

  • A polypectomy (removal of a polyp, or area of abnormal cells)
  • A local excision to remove the area of the rectum with cancer and surrounding tissue where the cancer has spread

Rectal cancer stage 1 treatment

At stage 1, the rectal cancer has spread into deeper layers of the rectal wall, but not outside the rectum. Surgery is the main treatment for stage 1 rectal cancer. Generally, further treatment isn’t needed. However, some cases may warrant chemotherapy with 5-fluorouracil (5-FU) and capecitabine, plus radiation therapy when:

  • Testing after surgery reveals that the cancer is more aggressive
  • A patient is not considered a good candidate for surgery

Rectal cancer stage 2 treatment

At stage 2, rectal cancer has spread beyond the rectum and possibly into nearby tissue, but it’s not yet spread to the lymph nodes. Treatment typically entails a combination of surgery, chemotherapy and radiation therapy. The order in which patients receive these treatments varies.

The types of surgery for stage 2 rectal cancer are based on where the tumor is located:

Low anterior resection (LAR)

This surgery is for cancer in the upper portion of the rectum. For this procedure, the surgeon removes cancer from the rectum and reattaches the remaining healthy tissue to the lower part of the colon.

Proctectomy with colo-anal anastomosis

This surgery is performed on cancer in the middle and lower third of the rectum. During this procedure, the surgeon performs a proctectomy to completely remove the rectum and then connects the colon directly to the anus, which is called colo-anal anastomosis.

Abdominoperineal resection (APR)

This surgery is for cancer in the lower part of the rectum that’s also grown into nearby muscles. More extensive than the other types of surgery, this procedure involves the removal of the rectum, the anus and the tissue surrounding these organs.

Your care team may recommend chemotherapy and radiation therapy prior to surgery. If the chemotherapy and radiation therapy shrink the tumor enough, you may be able to undergo a less invasive surgery. As part of this process, you may receive additional chemotherapy for about six months after your surgery.

Rectal cancer stage 3 treatment

At stage 3, the rectal cancer has spread to nearby lymph nodes, but it’s not yet spread to other organs. Most stage 3 rectal cancer treatments involve chemotherapy, radiation therapy and surgery. Stage 3 surgical procedures are similar to those used for stage 2 rectal cancer. Some patients may receive chemotherapy and radiation therapy if they:

  • Need to shrink the tumor so surgery is less extensive
  • Aren’t considered good candidates for surgery

Rectal cancer stage 4 treatment

At stage 4, the rectal cancer has spread to other organs in the body. Treatment depends on how far the cancer has spread, and to what organs. Some patients undergo surgery to remove the cancer, followed by chemotherapy and/or radiation therapy. Others receive chemotherapy first to shrink the tumor before having it removed surgically. Then they typically receive additional chemotherapy and radiation therapy following surgery.

You may receive chemotherapy along with one of the following treatments:

  • Targeted therapy to cut off the cancer’s blood supply
  • An immunotherapy drug to block key immune cell proteins that could help the cancer spread

You may also receive radiation therapy, chemotherapy or other treatments to help manage stage 4 rectal cancer symptoms. For example, you may have a stent placed to help prop the rectum open if the tumor is blocking it.

Recurrent rectal cancer treatment

Rectal cancer may return after treatment in the initial area, distant body parts or both. Recurrences are more common in the first few years after surgery.

Patients who have a local recurrence may receive more extensive surgery to treat it. They may also receive radiation therapy during or after the surgery along with chemotherapy after surgery. Treatment for patients who have a distant recurrence depends on where the cancer is located and whether surgery is an option. Some patients with a distant recurrence may also receive chemotherapy either before or after surgery.

If the cancer can't be surgically removed, treatment may involve chemotherapy, immunotherapy and/or targeted therapy in various combinations. As with stage 4 rectal cancer, you may need treatment to ease symptoms and to avoid long-term problems. If your cancer is recurrent, you may also be able to participate in a clinical trial.

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