• Stage 0 rectal cancer
  
• Stage I rectal cancer
  
• Stage II rectal cancer
  
• Stage III rectal cancer
  
• Stage IV rectal cancer
  
• Recurrent rectal cancer
  

The National Cancer Institute specifies the following treatments as standard care for rectal cancer as of July 1999. You should consider calling the NCI periodically at (800) 4-CANCER or visiting their web site at http://cancernet.nci.nih.gov/clinpdq/soa.html to obtain updated standards of care.

Stage 0 rectal cancer

Stage 0 is the most superficial of rectal tumors, limited to the mucosa without invasion of a deeper layer of the bowel wall. It is readily and successfully treated with surgery that may be minimally invasive.

Treatment options:

• Local excision or simple removal of polyps, always with the goal of achieving clear outer margins on the removed tissue--showing only normal cells on all edges--indicating that all of the tumor has been removed.
• Surgical removal of the rectum for large lesions not amenable to local excision, generally without colostomy.
• Removal of tumors by electrofulguration, a means of burning away tissue.
• Internal (endocavitary) irradiation using one of the various specialized devices available.
• External radiotherapy is uncommonly used for this stage.

Stage I rectal cancer

This stage describes a tumor that has invaded the wall of the rectum, but has not penetrated through the entire wall. This stage may be equivalent to Dukes A or Modified Astler-Coller A and B1. There is no exact one-to-one correspondence among these staging systems.

Treatment options recommended by the National Cancer Institute:

• Surgery to remove the tumor and rejoin the two remaining pieces of bowel, when tumor location ensures that enough rectal tissue will remain to perform such rejoining after tumor removal.
• For tumors that are too low to allow rejoining remaining pieces of bowel, or bowel and anus, surgery to remove the tumor and all anal and rectal tissue, and creation of an ostomy, called abdominoperineal resection.
• One of the two surgical procedures described above to remove the tumor, or local surgery through the anus, with or without external-beam irradiation plus fluorouracil (5-FU) before or after surgery.
• A mesorectal excision, that is, en bloc resection of the rectal tumor and its local lymph nodes with an enveloping fascia.
• Internal (endocavitary) irradiation without surgery, with or without external beam irradiation. Note that special equipment and experience are required to achieve results that are as good as surgery in selected patients. The National Cancer Institute lists eligible patients to be those with:
• Tumors less than 3 centimeters in size
• Well-differentiated tumors
• Disease without deep ulceration, tumor fixation, or palpable lymph nodes
• In very select patients, electrofulguration, a means of burning away tissue, may be as effective as surgery.

Stage II rectal cancer

This stage describes a tumor that has invaded through the entire wall of the bowel wall, but has not spread to lymph nodes, although the National Cancer Institute states that, "the uterus, vagina, parametria, ovaries, or prostate are sometimes involved." This stage may be equivalent to Dukes B or Modified Astler-Coller B2 and B3, although there is no exact one-to-one correspondence among these staging systems.

Patients diagnosed at this stage are encouraged by the National Cancer Institute to join a clinical trial. Treatment within a clinical trial may give you access to better treatment prior to FDA approval, before it becomes available to the general public.

Treatment options recommended by the National Cancer Institute:

• Surgery to remove the tumor entirely, rejoining the remaining pieces of bowel, or bowel and anus, if possible (sphincter preservation). This surgery might include creation of an internal pouch to retain feces. Adjuvant chemotherapy and/or radiotherapy, preferably through participation in a clinical trial, are recommended.
• Surgery to remove all of the rectum and anus (abdominoperineal resection) and construction of a stoma to pass feces. Adjuvant chemotherapy and/or radiotherapy, preferably through participation in a clinical trial, are recommended.
• Partial or total removal of certain pelvic tissue when, rarely, bladder, uterus, vagina, or prostate are involved. Adjuvant chemotherapy and/or radiotherapy, preferably through participation in a clinical trial, are recommended.
• Preoperative radiotherapy with or without chemotherapy, followed by surgery that attempts to preserve sphincter function. Adjuvant chemotherapy, preferably through participation in a clinical trial, should be used in conjunction with surgery.
• Intra-operative electron beam radiotherapy (IORT) targeted to the sites of remaining disease following surgical removal might be used if the tumor could not be entirely removed. This technique is still considered experimental by some researchers.
• Radiobiologically effective pelvic radiotherapy of approximately 50 Greys (Gy) is recommended when radiotherapy is used.

Stage III rectal cancer

Stage III rectal cancer is characterized by tumor invasion of one or more lymph nodes. This stage may be equivalent to Dukes C or Modified Astler-Coller C1-C3. There is no absolute one-to-one correspondence among these staging systems.

Patients diagnosed at this stage are encouraged by the National Cancer Institute to join a clinical trial. Treatment within a clinical trial may give you access to better treatment prior to FDA approval, before it becomes available to the general public.

Treatment options:

• Surgery to remove entirely the diseased rectum, rejoining the remaining pieces of bowel, or bowel and anus, if possible. This surgery might include creation of an internal reservoir to retain feces. Adjuvant chemotherapy and/or radiotherapy, preferably through participation in a clinical trial, should be used following surgery.
• Surgery to remove all of the rectum and anus (abdominoperineal resection) and construction of a stoma to pass feces. Adjuvant chemotherapy and/or radiotherapy, preferably through participation in a clinical trial, are recommended.
• Partial or total removal of certain pelvic tissue when, rarely, bladder, uterus, vagina, or prostate are involved. Adjuvant chemotherapy and/or radiotherapy, preferably through participation in a clinical trial, are recommended.
• Preoperative radiotherapy with or without chemotherapy, followed by surgery that attempts to preserve sphincter function. Adjuvant chemotherapy following surgery, preferably through participation in a clinical trial, is recommended.
• Intra-operative electron beam radiotherapy (IORT) targeted to the sites of remaining disease might be used.
• Radiobiologically effective pelvic radiotherapy of approximately 50 Gy is recommended when radiotherapy is used.
• Radiotherapy and/or chemotherapy to control painful or uncomfortable symptoms. This option is recommended by the National Cancer Institute and some of our medical reviewers as of July 1999, but was not recommended by all of our medical reviewers.

Stage IV rectal cancer

Patients diagnosed at this stage are encouraged by the National Cancer Institute to join a clinical trial. Treatment within a clinical trial may give you access to better treatment prior to FDA approval, before it becomes available to the general public.

Treatment options:

• Surgical removal or bypassing of tumors that are obstructing the bowel or other organs. This approach is used for patients who have been selected as suitable candidates for having their painful or uncomfortable symptoms reduced by surgery. Sometimes it is not surgery intended for cure, but instead for temporarily reducing painful symptoms, bleeding from the tumor, or impending obstruction of the rectum.
• Potentially curative surgery to remove certain tumors that have spread to the liver, lung, or ovaries might be indicated in certain carefully screened patients.
• Radiotherapy intended to control symptoms.
• Chemotherapy intended to control symptoms and possibly to extend survival time.

Recurrent rectal cancer

Recurrent rectal cancer may be found in a single site, such as a single liver tumor or several small liver tumors in one lobe, or it may recur as widespread disease affecting several organs, including bones such as ribs, spine, or pelvis.

Patients with a recurrence of extensive disease should consider joining a clinical trial. Treatment within a clinical trial may give you access to better treatment before it becomes available to the general public.

Treatment options:

• Surgical removal of a recurrent tumor that is very near the site of original disease may be curative in selected patients; in others, it may serve only to reduce symptoms.
• Curative surgery to remove liver tumors for patients in whom liver involvement has been assessed and found to be limited to three or fewer tumors. Five-year cure rate for complete removal of certain liver tumors is 20 to 30 percent in carefully selected patients.
• Curative surgery to remove single lung or ovarian metastases.
• Radiotherapy to control symptoms.
• Chemotherapy to control symptoms.