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10 slides generated from the cancer page, with a quiz from the open benchmark and speaker notes that cite the sources. Arrow keys move between slides; Print gives one slide per page.
Rectal cancer is bowel cancer in the last part of the large intestine, where surgery can mean a permanent stoma. Treatment now usually gives all the chemotherapy and radiotherapy first, and about half of people whose tumour disappears completely can keep their rectum and avoid surgery altogether.
Rectal cancer is staged by pelvic MRI, which shows the depth of invasion, the distance to the mesorectal fascia, extramural venous invasion and nodal disease and so decides who needs treatment before surgery. Total mesorectal excision, described by Heald in 1982, cut local recurrence from a quarter of patients to well under a tenth, and the German CAO/ARO/AIO-94 trial (2004) moved chemoradiation to before surgery, halving local recurrence again. Early tumours (cT1-2, node-negative) go straight to surgery, and small T1 tumours can be removed through the anus.
For locally advanced disease the sequence has been rebuilt as total neoadjuvant therapy: RAPIDO (2020) gave one week of radiotherapy then all the chemotherapy before surgery and cut distant failure and doubled complete responses; PRODIGE 23 (2021) gave induction mFOLFIRINOX before chemoradiation and improved disease-free and, later, overall survival. OPRA (2022) showed that with chemoradiation followed by consolidation chemotherapy about half of patients could avoid surgery through watch and wait without losing disease control, building on the Habr-Gama series from Sao Paulo. PROSPECT (2023) then showed that intermediate-risk tumours suitable for sphincter-sparing surgery can be treated with FOLFOX alone, with radiotherapy reserved for the 9 percent who do not respond.
| Setting | Approach | Guideline |
|---|---|---|
| Early (cT1-2, node-negative) | Total mesorectal excision, increasingly robotic or laparoscopic; transanal local excision for small, well-differentiated T1 tumours; no radiotherapy. | not mapped |
| Locally advanced, higher risk | Total neoadjuvant therapy: short-course radiotherapy then CAPOX or FOLFOX (RAPIDO), or induction mFOLFIRINOX then chemoradiation (PRODIGE 23); chemoradiation then consolidation chemotherapy when organ preservation is the goal (OPRA); surgery or watch and wait for complete responders. | not mapped |
| Intermediate risk, sphincter-sparing surgery planned | Six cycles of FOLFOX with chemoradiation only if the tumour shrinks by less than 20 percent (PROSPECT), then total mesorectal excision. | not mapped |
| Mismatch-repair deficient | Six months of dostarlimab or another PD-1 antibody with non-operative management for complete responders; surgery reserved for the rare non-responder. | not mapped |
| Metastatic | As metastatic colorectal cancer: doublet chemotherapy with bevacizumab or, for RAS and BRAF wild-type left-sided tumours, an anti-EGFR antibody; primary tumour managed by symptoms; liver-limited disease resected. | not mapped |