Rectal Cancer Treatment
Treatment at MD Anderson’s Gastrointestinal Center combines the latest technology and research with a multidisciplinary team approach tailored to your unique needs.
Our team of surgeons use minimally invasive techniques, including advanced robotic surgery, that reduce recovery time and maximize quality of life. MD Anderson also offers clinical trials for patients at every disease stage, from newly diagnosed small tumors to patients with stage IV cancer.
Rectal cancer treatment plans
At MD Anderson, doctors use several factors to develop treatment plans for rectal cancer, including the disease’s stage, its features on a molecular level and features identified by specialized MRI techniques.
Rectal cancer may be treated with surgery alone; a combination of surgery and chemotherapy; or with surgery, chemotherapy and radiation therapy together.
Patients with early-stage rectal cancer may only need surgery. If the cancer is more advanced, they may receive chemotherapy and radiation therapy before surgery. In some cases, these treatments are so effective that surgery is no longer needed.
Other times, patients receive chemotherapy after surgery. This is meant to kill cancer cells that might have escaped the primary tumor and moved to other parts of the body, as well as to prevent cancer from recurring.
If rectal cancer has spread, or metastasized, to distant parts of the body, some patients can still be cured. With new treatments, rectal cancer that has spread can often be managed like a chronic condition and care is meant to prolong and preserve quality of life. Treatments for all patients with metastatic rectal cancer can include surgery, radiation therapy, cryotherapy, microwave treatment, and cancer drugs like chemotherapy, targeted therapy and immunotherapy.
Surgery
Surgery is the most common treatment for rectal cancer, especially if it has not spread. Like many cancers, surgery for rectal cancer is most successful when done by a surgeon with a great deal of experience in the procedure. At MD Anderson, these procedures are performed by surgeons who are specialized in rectal cancer surgery and are national and international leaders in the field. Surgeons around the country often refer their patients to MD Anderson surgeons for their expertise, especially for the most difficult cases.
At MD Anderson, most rectal cancer surgeries can be performed using minimally invasive techniques, such as robotic or laparoscopic surgery. These procedures require only a few small cuts. They offer less pain and faster recovery time compared to traditional open surgery. Surgeons at MD Anderson specialize in performing advanced robotic minimally invasive surgery.
Depending on the tumor’s size and location in the rectum, patients may experience changes in their bowel movements after surgery. These can be either temporary or permanent. In some cases, waste in the colon is diverted through an opening in the abdomen and into an external bag. This procedure, called a colostomy, is performed at the same time as the surgery to remove the tumor.
The type of surgery rectal cancer patients undergo depends on the stage and location of the tumor and they include:
Polypectomy: A colonoscope, which is a long tube with a camera on the end, is inserted into the rectum and guided to the polyp. Tiny tools or a wire loop removes the polyp. A polypectomy is ideal for very early, low-risk cancers found within polyps and is usually performed during colonoscopy.
Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD): If a polyp is too large to be removed by traditional polypectomy, an EMR or ESD may be performed. The doctor will use small instruments inserted through a colonoscope to perform detailed surgery from inside the rectum. The polyp and some surrounding tissue will be removed. With this type of advanced endoscopic procedure, major surgery can sometimes be avoided. Gastroenterologists at MD Anderson are experts at performing these specialized, advanced endoscopic procedures.
Proctectomy: This is the most common type of surgery for rectal cancer. The surgeon will remove a part of the rectum, along with surrounding tissue containing lymph nodes. Usually, the colon can be brought down and connected to the remaining rectum (called a low anterior resection) or directly to the anus (a proctectomy with coloanal anastomosis). These sphincter-preserving surgeries allow patients to retain control of their bowel movements. Surgeons at MD Anderson are specialized in sphincter-preserving surgery. In some cases, surgery for rectal cancer requires removal of the anus as well as the rectum with creation of a colostomy (an aominoperineal resection). Surgeons at MD Anderson will most commonly perform these operations with minimally invasive robotic surgery to help patients recover more quickly.
Transanal excision: This is usually performed as a minimally invasive procedure (Transanal Minimally Invasive Surgery or TAMIS) using special surgical instruments and a video camera that is inserted through the anus and into the rectum. It is typically used to remove small early-stage rectal cancers. In some early-stage rectal cancers that are close to the anus, this surgery may be performed directly, without the aid of a video camera.
Pelvic exenteration: Sometimes rectal cancers can grow into surrounding structures within the pelvis. In these cases, surgery should completely remove the tumor and other structures involved with the tumor. A pelvic exenteration is a highly specialized operation that involves removing these structures, such as the rectum, part of the colon, reproductive organs, or the bladder. Once these structures are removed, your surgical team performs reconstructive surgery. This may involve creating new pathways for waste to leave your body. Pelvic exenteration is performed by a highly specialized team of colorectal surgeons, urologists and plastic surgeons. It is a life-changing procedure that requires expert medical care.
Intraoperative Radiation Therapy (IORT): Radiation therapy is sometimes given during surgery in cases of rectal cancers that have grown beyond the rectum and into surrounding structures. This technique allows a stronger dose of radiation to be given directly to the area around the tumor while reducing the risk for side effects. Surgeries that utilize IORT are performed in a specialized operating room specifically designed for this purpose.
Metastectomy: If rectal cancer has spread to other parts of the body such as the lung, liver, ovaries or distant lymph nodes, it may be possible to perform surgery to remove those tumors. At MD Anderson, a multidisciplinary team of doctors including surgeons, medical oncologists and radiation oncologists performs a detailed review to make the recommendation for the best option for treatment when metastasis is identified.
Peritoneal cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: Rectal cancer can spread into the abdominal cavity. During peritoneal cytoreductive surgery, the surgeons remove all visible tumors from the lining of the abdomen. In some cases, this procedure is paired with Hyperthermic Intraperitoneal Chemotherapy, or HIPEC. HIPEC involves filling the abdominal cavity with chemotherapy drugs that have been heated. Also known as “hot chemotherapy,” HIPEC is performed after the surgeon removes tumors or lesions from the abdominal area. Learn more about HIPEC.
Chemotherapy
Chemotherapy drugs kill cancer cells, control their growth or relieve disease-related symptoms. Chemotherapy may involve a single drug or a combination of two or more drugs, depending on the type of cancer and how fast it is growing.
Targeted Therapy
Targeted therapy drugs are designed to stop or slow the growth or spread of cancer. This happens on a cellular level. Cancer cells need specific molecules (often in the form of proteins) to survive, multiply and spread. These molecules are usually made by the genes that cause cancer, as well as the cells themselves. Targeted therapies are designed to interfere with, or target, these molecules or the cancer-causing genes that create them.
Radiation therapy
Radiation therapy uses powerful, focused beams of energy to kill cancer cells. There are several different radiation therapy techniques. Doctors can use these to accurately target a tumor while minimizing damage to healthy tissue.
The types of radiation used to treat rectal cancer include:
- 3D conformal radiation therapy, a treatment that uses three-dimensional scans to determine the exact shape and size of the tumor. The radiation beams are shaped by tiny metal leaves that are arranged to fit the tumor dimensions.
- Intensity modulated radiation therapy (IMRT), which focuses multiple radiation beams of different intensities directly on the tumor for the highest possible dose.
- Brachytherapy: Tiny radioactive seeds are placed in the body close to the tumor. Learn more about brachytherapy.
- Proton therapy: A type of radiation therapy that uses protons to target cancer and reduce damage to normal tissue. Since other treatments have proven just as or more effective in most situations, proton therapy is used to treat rectal cancer only in limited cases. Learn more about proton therapy.
- Intraoperative radiation therapy (IORT): IORT is used to treat an exposed tumor during cancer surgery. Surrounding healthy organs and tissues are protected by lead shields or moved out of the radiation field.
Immunotherapy
The immune system finds and defends the body from infection and disease. Cancer is a complex disease that can evade and outsmart the immune system. Immunotherapy improves the immune system’s ability to eliminate cancer.
There are two types of immunotherapy currently used to treat rectal cancer:
- Immune checkpoint inhibitors stop the immune system from turning off before cancer is completely eliminated. Learn more about immune checkpoint inhibitors.
- Monoclonal antibodies attach to specific proteins on the surface of cancer cells or immune cells. They either mark the cancer as a target for the immune system or boost the ability of immune cells to fight the cancer.
Angiogenesis inhibitors
Angiogenesis is the process of creating new blood vessels. Some cancerous tumors are very efficient at this process. New blood vessels increase blood supply to a tumor, allowing it to grow rapidly. Angiogenesis inhibitors, or anti-angiogenic therapy, disrupt the creation of these blood vessels.
Clinical trials
Clinical trials are a key component of MD Anderson's mission to end cancer. Patients may volunteer to participate in these research studies, which help doctors improve cancer prevention, diagnosis and treatment.
Some clinical trials allow patients to receive experimental medications or treatments, though not all patients are eligible.
If you're interested, ask your doctor if you might be a candidate for a clinical trial.
Rectal cancer surgery: Your treatment options and what to expect
Rectal cancer can impact many of the body’s most basic functions. So, it’s important to find a surgeon who understands the balance between treating your cancer and preserving the body's functions and quality of life.
To learn about the different types of rectal surgery and what to expect, we spoke with Yi-Qian Nancy You, M.D., a colon and rectal cancer surgeon.
What types of surgery are used to treat rectal cancer?
There are three types of surgery used to treat rectal cancer.
- Transanal local excision: This procedure treats very early-stage rectal cancers. During this procedure, a surgeon removes a small area of the rectum wall that contains the early tumor through instruments that are passed through the anus.
- Proctectomy: During this surgery, a surgeon removes all or part of the rectum that contains the tumor. Usually, the colon can be brought down and connected to the remaining rectum or directly to the anus in sphincter-preserving surgery. This allows the patient to retain bowel passage through the anus, although the stool frequency and patterns will likely be different. Often to protect the new connection, the surgeon will make a temporary diverting ileostomy bag, a plastic bag that collects waste from the digestive tract and needs to be emptied throughout the day. This is done to divert the stool away from the colon and give the new connection the best chance to heal. If the sphincter can’t be preserved, the surgeon will create a permanent colostomy and insert a colostomy bag, a plastic bag that collects waste from the digestive tract and needs to be emptied throughout the day.
- Pelvic exenteration: This type of surgery is needed if rectal cancer has spread to the surrounding organs within the pelvis. During this highly specialized operation, surgeons will remove the rectum containing the tumor and any part of any adjacent organs that may be also directly involved by the tumor — including other bowel or intestine, reproductive organs, bladder, bone or other tissue — and then perform the reconstruction. Patients who have had a pelvic exenteration often need a colostomy bag.
What is recovery from rectal cancer surgery like? What can patients expect?
Your recovery depends on what type of surgery you undergo. Patients who have a proctectomy typically stay in the hospital for two to five days, or they may have to stay until they have a bowel movement. Patients are usually up and walking around about 24 hours after surgery. Typically, bowel function will return about two to three days following surgery. Pain is the strongest for the first 48 hours and then begins to subside. MD Anderson surgery teams rely on an enhanced recovery process that helps patients recover faster and limit their use of pain medication.
For patients who have undergone a pelvic exenteration, the recovery process is slower. Typically, these patients stay in the hospital for two to three weeks and spend the following months getting their strength back by working with a physical therapist.
Patients who have had a temporary ileostomy or permanent colostomy as a part of their proctectomy or pelvic exenteration may need to stay in the hospital longer as they adjust to using the ostomy bag.
What is life like after rectal cancer surgery? Do patients with an ileostomy or colostomy bag need to make dietary changes?
An ostomy bag may be temporary. Patients may only need it for two to six months, or it may be permanent. Your care team will work with you to show you how to empty the bag and make any other changes. Having an ostomy will require some adjustment and adaptation. However, most importantly, contrary to common belief, patients with ostomy bags can resume an active lifestyle and get back to activities they enjoyed before surgery.
Read how one young patient has learned to live with her ostomy bag.
What other methods are used to treat rectal cancer?
Many rectal cancer patients will need additional treatments, typically a combination of chemotherapy and radiation and typically before surgery. For rectal cancer, it’s important to see a specialized care team with experience treating rectal cancer and who understand all aspects of your rectal cancer treatment. When you’re choosing a care team, look for one that will coordinate your care and enable you to receive the best treatment possible.
Overall, the cancer stage determines the type of treatments a rectal cancer patient received. But an experienced team also takes into account the patient’s tumor molecular characteristics and personal wishes to design a personalized treatment regimen. In addition, MD Anderson is conducting clinical trials to use liquid biopsies to more accurately determine what next steps to take. The biopsies show how cancer has impacted the bloodstream and helps guide the use of chemotherapy after surgery.
1 in 4 new cases of rectal cancer in the U.S. is diagnosed at or under age 50. What should young rectal cancer patients know?
Young rectal cancer patients face a unique set of challenges. They have so many years left ahead of them, but they’re facing big changes as survivors. For these patients, it’s particularly important to select a cancer center like MD Anderson where the doctors are not only experts in treating rectal cancer, but also understand what’s critical to a young patient. At MD Anderson, one-third of all of our new colorectal cancer patients are younger than age 50. Programs like MD Anderson’s Young-Onset Colorectal Cancer Program provide cancer care and connect patients to services they may need in addition to treatment, including genetic testing and counseling, fertility services, wound ostomy service, supportive care and connection to our Adolescent and Young Adult Oncology Program.
What should patients preparing for rectal cancer surgery know?
Look for a care team where the surgeons both perform a high number of rectal cancer surgeries and are also experts in treating rectal cancer and in understanding the best coordination of surgery with other treatments, such as chemotherapy and radiation.
Rectal cancer impacts an area that is key to many bodily functions, so it’s essential to seek a care team that truly understands it and with whom you feel comfortable discussing your worries and concerns.
Often, we see patients who first underwent surgery at another hospital. In many cases, the patient’s cancer has returned and they now need a pelvic exenteration. While MD Anderson surgeons are skilled at performing this complicated surgery, it would be easier on the patient if they sought care from leading experts first. It might be difficult to decide to have more of the rectum removed initially, but it’s better in the long run. At MD Anderson, our doctors understand how to balance this.
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