Rectal Cancer Treatment Options Overview

by Specialist

There are different types of treatments available for patients with rectal cancer.

There are different types of treatments available to patients with rectal cancer. Some treatments are standard treatments (those currently used), and others are in clinical trials. A clinical trial of a treatment is a study designed to help improve an existing treatment or to get information about a new cancer treatment. When the results of a clinical trial show that a new treatment is better than the standard treatment, this new treatment may then become the standard treatment. Patients may want to consider participating in a clinical trial. Some clinical trials are only open to patients who have not yet started treatment.

The six standard treatments currently used

Surgery

Surgery is the most common treatment for all stages of rectal cancer. The cancer may be removed using one of the following surgical approaches.

  • Polypectomy: If a polyp (a small bulging piece of tissue) is found to contain cancer cells, the polyp is often removed during a colonoscopy.
  • Local excision: If the cancer is located on the inner surface of the rectum and has not spread to the rectal wall, the cancer and a small amount of surrounding normal tissue may be removed.
  • Excision: If the cancer has spread into the rectal wall, then the part of the rectum with the cancer and nearby normal tissue may be removed. Sometimes the tissue between the rectum and the abdominal wall is also removed. And the lymph nodes near the rectum are removed to check for signs of cancer under a microscope.
  • Radiofrequency ablation:A special probe with tiny electrodes is used to kill cancer cells. Sometimes the probe needs to be inserted directly into the skin under local anesthesia only. Sometimes, the probe needs to be inserted through an incision in the abdomen under general anesthesia.
  • Cryosurgery: A treatment that uses an instrument to freeze and destroy abnormal tissue. This treatment is also called cryotherapy.
  • Pelvic organ resection: If the cancer has spread to other organs around the rectum, then the lower colon, rectum, and bladder are removed. For female patients, the cervix, vagina, ovaries, and adjacent lymph nodes may also need to be removed. In male patients, the prostate may also need to be removed. An artificial stoma (opening) is then required to allow urine and stool to drain from the body into a collection bag.

    After the cancer is removed, the surgeon will also:

  • perform an anastomosis (suturing the healthy parts of the rectum together, suturing the remaining rectum to the colon, or suturing the colon to the anus);
    rectal resection anastomosis. The rectum and part of the colon are removed, and then the colon and anus are joined.
  • or
  • Make a stoma (opening) that leads from the rectum to the outside of the body so that the stool can pass. If the cancer is too close to the anus, then this procedure – called a colostomy – is needed. A bag-like device is placed around the stoma to collect stool. Sometimes a colostomy is performed only if the rectum has healed, and then it can be reversed. If the entire rectum is removed, then the colostomy may be permanent.

    Radiation therapy and/or chemotherapy may be given before surgery to reduce the size of the tumor, make the cancer easier to remove, and help with postoperative bowel control. Preoperative treatment is called neoadjuvant therapy. Even if surgery removes all visible cancerous tissue, some patients will need chemotherapy or radiation therapy after surgery to kill any remaining cancer cells. Treatment given after surgery to reduce the risk of cancer recurrence is called adjuvant therapy.

    Radiotherapy

    Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or to stop the growth of cancer cells. There are two types of radiation therapy:

  • Ex vivo radiation therapy uses a machine outside the body to send radiation to the cancer site.
  • In vivo radiation therapy involves sealing radioactive material in a needle, implanted particle, guide wire, or catheter and placing it directly on or near the cancer site.

    The way radiation therapy is administered depends on the staging and staging of the cancer. External radiation therapy is used to treat rectal cancer.

    Preoperative short-term radiation therapy is used for certain types of rectal cancer. This treatment involves less radiation, lower doses, and surgery a few days after radiation therapy is completed than standard treatment.

    Chemotherapy

    Chemotherapy is a treatment that uses drugs to stop the growth of cancer cells, either by killing them or by stopping them from dividing. When chemotherapy drugs are taken orally or given intravenously or intramuscularly, the drugs enter the bloodstream and reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy drugs are placed directly in the cerebrospinal fluid, an organ, or a body cavity (such as the abdominal cavity), the drugs primarily affect cancer cells in these areas (local chemotherapy).

    Hepatic artery chemoembolization is a type of localized chemotherapy that can be used to treat cancer that has spread to the liver. Hepatic artery chemoembolization is done by blocking the hepatic artery (the main artery that supplies blood to the liver) and injecting anti-cancer drugs between the embolus and the liver. The hepatic artery then carries the drug into the liver. Only a small amount of the drug will reach the rest of the body. The embolism may be temporary or permanent, depending on what is used to block the artery. The liver continues to receive some blood from the portal vein of the liver, which carries blood from the stomach and small intestine.

    The type of chemotherapy depends on the type of cancer being treated and its stage.

    For more information, see Drugs approved for the treatment of colon and rectal cancers.

    Active surveillance

    Active surveillance means that the patient’s condition is closely monitored and no treatment is given unless there is a change in test results. It is used to detect early signs of disease progression. In active surveillance, patients undergo specific tests and examinations to check if the cancer lesion is growing. Treatment is given when the cancer begins to grow. Tests include the following:

  • rectal finger exam
  • Magnetic resonance imaging
  • Endoscopy
  • Sigmoidoscopy
  • Computed tomography scan
  • Carcinoembryonic antigen (CEA) testing

    Targeted therapy

    Targeted therapy is a treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells.

    Types of targeted therapy for rectal cancer include:

  • Monoclonal antibodies:Monoclonal antibody therapy is a targeted treatment for rectal cancer. Monoclonal antibody therapy uses antibodies produced in the laboratory from a single type of immune cell. These antibodies recognize substrates on cancer cells or normal substrates that help cancer cells grow. The antibodies attach to the substrate and kill the cancer cells, stop the cancer cells from growing, or prevent the cancer cells from spreading. Monoclonal antibodies are given by injection. They can be used alone, or they can deliver drugs, toxins, or radioactive substances directly to cancer cells.

    There are different types of monoclonal antibody therapy:

  • Vascular endothelial growth factor (VEGF) inhibitor therapy:Cancer cells produce a substance called VEGF, which promotes the formation of new blood vessels (angiogenesis) and helps cancer cells grow.VEGF inhibitors block VEGF and stop the formation of new blood vessels. This may kill cancer cells because they need new blood vessels to grow. Bevacizumab and ramolutumab are VEGF inhibitors and angiogenesis inhibitors.
  • Epidermal growth factor receptor (EGFR) inhibitor therapy:EGFR is a protein found on the surface of certain cells, including cancer cells. Epidermal growth factor attaches to the epidermal growth factor receptor on the cell surface, causing the cells to grow and divide. EGFR inhibitors block the receptor, preventing epidermal growth factor from attaching to cancer cells. This stops the cancer cells from growing and dividing. Cetuximab and panitumumab are EGFR inhibitors.
  • Angiogenesis inhibitors:Angiogenesis inhibitors stop the creation of new blood vessels needed for tumor growth.
  • Ziv-aflibercept (abciximab) is a vascular endothelial growth factor decoy that blocks the enzyme needed for neoangiogenesis in tumors.
  • Regofenib is used to treat colorectal cancer that has spread to other parts of the body and has not improved with other treatments. It blocks the activity of certain proteins, including vascular endothelial growth factor. This may help inhibit the growth of cancer cells and possibly kill them. It may also inhibit the production of new blood vessels needed for tumor growth.

    For more information, see Drugs approved for colon and rectal cancers.

    Immunotherapy

    Immunotherapy is a therapy that uses the patient’s immune system to fight cancer. Substances produced by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also known as biologic therapy.

    Immune checkpoint inhibitor therapy is a type of immunotherapy:

  • Immune checkpoint inhibitor therapy: PD-1 is a protein that sits on the surface of T cells and helps control the body’s immune response. When PD-1 attaches to another protein called PDL-1 on cancer cells, it prevents T cells from killing the cancer cells. PD-1 inhibitors attach to PDL-1, causing the T cells to kill the cancer cells. Pammasumab is an immune checkpoint inhibitor.
    Immune checkpoint inhibitors. Checkpoint proteins such as PD-L1 on tumor cells and PD-1 on T cells help suppress the immune response. the binding of PD-L1 to PD-1 prevents T cells from killing tumor cells in the body (left). Blocking the binding of PD-L1 to PD-1 with an immune checkpoint inhibitor (anti-PD-L1 or anti-PD-1) allows T cells to kill tumor cells (right).
    Immunotherapy uses the body’s immune system to fight cancer. This animation explains an immunotherapy treatment that uses immune checkpoint inhibitors to treat cancer.

    For more information, see Drugs approved for colon and rectal cancers.

    Other types of treatments are in clinical trials.

    Information about clinical trials can be found on the NCI website.

    Treatment for rectal cancer may cause side effects.

    For information about side effects of cancer treatment, see our side effects page.

    Patients may want to consider participating in a clinical trial.

    For some patients, participating in a clinical trial may be the best treatment option. Clinical trials are part of the cancer research process. Clinical trials are conducted to test whether a new cancer treatment is safe and effective or better than standard treatment.

    Many of today’s standard treatments for cancer are based on early clinical trials. Patients who participate in clinical trials can receive standard treatments or be among the first to receive new treatments.

    Patients who participate in clinical trials will also help improve future cancer treatments. Even if clinical trials do not produce effective novel treatments, they often answer important questions and help move research forward.

    Patients can participate in a clinical trial before, during, or after cancer treatment.

    Some clinical trials accept only patients who have not yet received treatment. There are also trials that test treatments for patients whose cancer is not getting better. There are also clinical trials that test new ways to stop cancer from coming back or to reduce the side effects of cancer treatment.

    Clinical trials are being conducted in many parts of the country. Information about NCI-supported clinical trials can be found on the NCI’s Clinical Trials Search website. Clinical trials supported by other organizations can be found on the ClinicalTrials.gov website.

    Follow-up testing may also be required.

    Follow-up tests may need to repeat some of the diagnostic tests and staging tests for cancer. Some tests may need to be repeated in order to test the effectiveness of treatment. Depending on the results of these tests, decisions are made about whether treatment needs to be continued, changed, or stopped.

    Some tests sometimes need to be continued after treatment ends. The results of these tests can show if the patient’s condition has changed or if the cancer has returned. These tests are sometimes called follow-up tests.

    After treatment for rectal cancer is finished, blood tests may be needed to measure the amount of carcinoembryonic antigen (a substance in the blood that increases in amount when there is cancer) to see if the cancer has come back.