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Overview

The rectum is the last part of the large bowel, which connects to the anus. Rectal cancer develops when the cells lining the inner surface of this area multiply uncontrollably. Most rectal cancers develop over years from benign growths called polyps; for this reason, it is possible to detect them at an early stage.

Although rectal cancer is considered together with colon cancer under the heading of “colorectal cancer”, its narrow anatomical position within the pelvis gives it particular features in terms of diagnosis, surgical technique and radiotherapy. Early diagnosis can increase both the chance of controlling the disease and the options for preserving the anal muscles and bowel function.

Many international organisations recommend that colorectal cancer screening should start at the age of 45 for people at average risk. If there is a family history, an inherited syndrome or inflammatory bowel disease, screening may start earlier and is planned individually [4].

Symptoms and Risk Factors

Which symptoms suggest rectal cancer?

Blood in the stool or bleeding from the anus
A persistent change in bowel habit; diarrhoea, constipation or a change in the shape of the stool
A frequent need to open the bowels or a feeling of incomplete emptying after opening the bowels
Pain, cramps or bloating in the abdomen or around the anus
Unexplained weight loss, loss of appetite or marked tiredness
Iron deficiency and low blood count (anaemia)

These complaints can also occur in benign conditions such as piles (haemorrhoids) or a tear in the anus (anal fissure). However, symptoms that are new, recurrent or last for several weeks should be assessed by a doctor, especially in people over 45 or with a family history. Severe bleeding, fainting, increasing abdominal pain, vomiting or being unable to pass wind or stool require urgent assessment.

Who is at higher risk?

Increasing age, a history of colorectal cancer or advanced polyps in first-degree relatives, inherited conditions such as Lynch syndrome and familial adenomatous polyposis, and long-standing inflammatory bowel diseases (ulcerative colitis or Crohn’s disease) increase the risk. Smoking, high alcohol consumption, obesity, physical inactivity and a diet rich in processed meat are also among the modifiable risk factors. Having a risk factor does not necessarily mean that cancer will develop.

Diagnosis and Staging

The main method of diagnosis is colonoscopy (examination of the bowel with a thin tube that has a camera at its tip). During the procedure, the location of the tumour is seen, other polyps or tumours present at the same time are looked for, and a biopsy (tissue sample) is taken from suspicious tissue. The definitive diagnosis is made by pathological examination.

Which tests are carried out after diagnosis?

Pelvic rectal MRI: Assesses the depth of the tumour in the bowel wall, its distance from the mesorectal fascia and neighbouring structures, the lymph nodes and tumour spread around blood vessels. It is the main imaging method for planning local treatment [1,2].
CT of the chest and abdomen: Looks for spread to the lungs, liver and other areas [1,2].
CEA blood test: Does not establish the diagnosis; the baseline value and its course after treatment can help with follow-up in suitable patients [1,4].
Tumour biomarkers: Assessment of DNA mismatch repair (MMR) proteins or microsatellite instability (MSI) in the tumour tissue is recommended for all patients. The results can affect the likelihood of Lynch syndrome and the choice of treatment in some advanced stages [1,2,4].

Staging does not only answer the question “what stage is it?”. The distance of the tumour from the anus, its proximity to the circumferential surgical margin, the lymph nodes, extramural spread and the presence of distant metastases determine the order of treatment. For this reason, it is important that the images are assessed at a multidisciplinary meeting that includes specialists in colorectal surgery, radiology, medical oncology, radiation oncology and pathology.

Treatment Options

Treatment is personalised, taking into account the stage and location of the tumour, its biological characteristics, the person’s general condition, bowel function and patient preferences.

Very early-stage disease

In suitably selected, small and superficial tumours, local removal through the anus may be performed. However, because the lymph nodes are not removed with this procedure, the size, depth and cellular grade of the tumour, vascular and nerve involvement and the surgical margins are carefully assessed. If pathology shows a higher risk than expected, completion radical surgery or other treatments may be needed.

Locally advanced disease and treatment before surgery

In some stages of rectal cancer, chemotherapy and radiotherapy may be given before surgery. This treatment plan is called “total neoadjuvant therapy”. The aim is to shrink the tumour, treat possible cancer cells at an early stage and increase the success of the operation. In some patients, the likelihood of preserving the anus and the continuity of the bowel may also increase.

Not every patient with rectal cancer needs to receive these treatments. The treatment plan is prepared individually, taking into account the location and stage of the tumour, the MRI findings and the patient’s general health [1–4].

Surgical treatment

The aim of surgical treatment is to remove the cancerous section of bowel safely together with the surrounding lymph nodes. For tumours of the middle and lower rectum, a surgical technique called “total mesorectal excision” (TME) is used, which allows the tissues surrounding the tumour to be removed as a single unit.

In suitable patients, the operation can be performed using laparoscopic or robotic methods. However, more important than the surgical method is that the tumour is removed without leaving diseased tissue behind, that safe surgical margins are achieved and that the procedure is carried out in accordance with the principles of oncological surgery. The most suitable method is determined taking into account the characteristics of the tumour, the patient’s general condition and the experience of the surgical team [1,2].

Clinical complete response and the ‘watch and wait’ approach

In selected patients in whom signs of the tumour have completely disappeared on examination, endoscopy and MRI after treatment before surgery, close follow-up without surgery may be considered in experienced centres. This approach is not a standard “leaving without treatment”. In the first years it requires frequent rectal examination, colonoscopy, MRI and systemic imaging; because regrowth may occur at the tumour site, salvage surgery must be performed in good time. The decision should be made after discussing the uncertainties and alternatives in detail with the patient [1–3].

What is sphincter-preserving surgery?

The muscles around the anus allow stool to be held and passed in a controlled way. If the tumour has not spread to these muscles and the cancerous tissue can be removed safely, the anus can be preserved. In this way, the patient can continue to open their bowels by the normal route.

Whether the anus can be preserved does not depend only on the distance of the tumour from the anus. The relationship of the tumour with the anal muscles, its response to the treatment given, the patient’s existing bowel control and the expected quality of life after surgery are assessed together. The priority is the safe and complete removal of the cancerous tissue.

Will I need a stoma (bag)?

A stoma is the opening of the bowel onto the abdominal wall, with stool collected in a special bag outside the body. Not every patient who has rectal cancer surgery needs a stoma.

In some operations in which the anus is preserved, a temporary stoma may be created to allow the newly made bowel join to heal safely. Once healing is complete and the join has been confirmed to be safe, the stoma can usually be closed with a second operation.

If the tumour has spread to the anal muscles or if it is not possible to rejoin the bowel safely, a permanent stoma may be needed. This decision is made by weighing up together the safe treatment of the cancer, reducing the risk of complications after surgery and preserving the patient’s quality of life.

The idea of a stoma can be worrying at first. However, with the right education and support, stoma care can be learned; patients can continue with their daily lives, work and social activities. Meeting a stoma nurse before the operation, marking the stoma site and receiving care education make the adjustment process easier.

Recovery and Follow-up

Today, special care programmes that speed up recovery are used after rectal cancer surgery. These programmes include preparation before surgery, effective pain control, early eating and drinking, and getting the patient walking as early as possible.

The length of hospital stay and the time to return to daily life are not the same for everyone. The operation performed, additional treatments received, age, general health and the individual speed of recovery affect this period.

Can there be changes in bowel, urinary and sexual function?

It is normal for bowel habits to change for a while after rectal surgery. In some patients the following may occur:

Frequent passing of small amounts of stool
Needing to go to the toilet again at short intervals
A sudden feeling of urgency
Opening the bowels at night
Difficulty controlling wind or stool

These changes may be seen.

These complaints are called “low anterior resection syndrome”. In most patients the complaints decrease over time. Adjusting the diet, using suitable medicines, pelvic floor exercises and, in some patients, bowel irrigation can help bring the complaints under control.

Surgery and other treatments for rectal cancer can sometimes also affect urinary and sexual function. Such complaints are nothing to be ashamed of or to hide. Telling your doctor about them at check-ups allows appropriate support and treatment to be planned.

Why is regular follow-up important?

It is important to continue with regular check-ups after treatment has been completed. The aims of follow-up are:

To detect at an early stage if the disease recurs
To assess the development of new polyps or tumours with colonoscopy
To identify bowel, urinary and sexual function problems related to treatment
To monitor the patient’s nutrition, daily life and general health.

The follow-up programme may include examination, a blood test called CEA, computed tomography, colonoscopy and, if necessary, rectal MRI. The frequency of these check-ups is determined individually according to the stage of the disease and the treatment given.

In patients who are followed closely without surgery, that is, those in a “watch and wait” programme, check-ups are more frequent and more detailed [1,5].

Frequently Asked Questions

What does the stage of rectal cancer mean?

The stage shows how far the disease has progressed in the rectal wall and whether it has spread to nearby lymph nodes or other organs. Various tests are used for staging, chiefly rectal MRI and computed tomography.

According to current guidelines, the treatment decision is not made by looking only at the stage of the disease. The location of the tumour in the rectum, its relationship with the anal muscles, the risk features seen on MRI, its biological make-up and the patient’s general health are also assessed together. For this reason, the treatment plans of two patients with the same stage may differ [1,2,4].

Can rectal cancer be completely cured?

Yes. The likelihood of a complete cure is high, especially while the disease is confined to the bowel and the surrounding lymph nodes. In more advanced stages too, long-term disease control and, in some patients, complete recovery can be achieved by giving chemotherapy, radiotherapy and surgery in the appropriate order.

The success of treatment depends on the stage of the disease, the biological characteristics of the tumour, its response to treatment and the patient’s general health. For this reason, general statistics found on the internet do not show the outcome for an individual patient with certainty [1,4]. For this reason, the outcome for each patient should be assessed individually.

Does everyone get a bag after rectal cancer surgery?

No. Not every patient who has rectal cancer surgery needs a stoma, that is, a bag. The need for a stoma is determined by the location of the tumour, its relationship with the anal muscles, the type of operation performed and the safety of the bowel join.

Some patients do not need a stoma at all. In some patients it is created temporarily to protect the healing of the bowel join and can be closed later. A permanent stoma may be needed in the smaller number of patients whose tumour has spread to the anal muscles or in whom a safe bowel join is not possible.

Why is radiation or drug treatment given before surgery?

In some rectal cancers, radiotherapy and chemotherapy may be given before surgery. The aim of these treatments is to shrink the tumour, increase control of the disease in the area where it is located and treat at an early stage cancer cells that cannot yet be detected with imaging methods.

Not every patient receives the same treatment. The type and sequence of treatment are determined taking into account the location and stage of the tumour, the MRI findings and the patient’s general health.

If I have a complete response to treatment, might I not need surgery?

In some selected patients in whom signs of the tumour have completely disappeared after treatment before surgery, very close follow-up may be considered instead of surgery. However, this approach is not suitable for every patient.

The decision of “complete response” is not made on the basis of the biopsy result alone. Rectal examination, endoscopy and high-quality rectal MRI are assessed together. If follow-up without surgery is chosen, check-ups must be regular, frequent and long-term. It is important that surgery can be carried out in good time if the tumour grows back.

How long does treatment take?

The length of treatment varies according to the stage of the disease and the treatments to be given.

In patients with early-stage disease who need only surgery, the operation and the initial recovery period can usually be completed within 1–3 months. If chemotherapy is needed after surgery, this period may be longer.

In locally advanced rectal cancer requiring chemotherapy and radiotherapy before surgery, treatment takes longer. When chemotherapy, radiotherapy, reassessment of the response to treatment and surgery are considered together, the whole process may take about 6–9 months in most patients.

Radiotherapy may be given for about 1 week in some patients, and for about 5–6 weeks together with chemotherapy in others. The chemotherapy part usually lasts 3–4 months, depending on the medicines used and the treatment plan. After the treatments are completed, the response of the tumour is assessed with examination, endoscopy and rectal MRI, and the timing of surgery or of a close follow-up programme is decided [1–4].

These periods are approximate. The response to treatment, side effects of the medicines, recovery after surgery and the need for additional treatment can change the total time.

Is rectal cancer hereditary?

Most rectal cancers are not an inherited disease passed directly from mother or father. However, some patients may have inherited predispositions such as Lynch syndrome.

Current recommendations support the assessment of MMR or MSI tests, which give guidance on Lynch syndrome, in the tumour tissue of patients diagnosed with colorectal cancer. If a suspicious finding is detected in the test result, genetic counselling and a blood test may be recommended [2,6].

Identifying an inherited condition is important not only for the patient’s treatment but also for determining at what age and how often family members should be screened. However, having rectal cancer in the family does not mean that other family members will necessarily develop cancer.

How should I eat during treatment?

There is no single eating plan that applies to everyone with rectal cancer. The nutrition plan should be prepared individually according to the treatment to be given, bowel habits, whether there is a stoma, weight and any other conditions.

Current nutrition guidelines recommend that weight loss and malnutrition during cancer treatment should be recognised early. Taking in enough energy, protein and fluid can help treatment to be better tolerated and support recovery [7].

If diarrhoea, constipation, loss of appetite, nausea or unintentional weight loss develops, you should talk to your doctor and a dietitian. As every patient’s needs are different, unnecessary and very restrictive diets should be avoided. Herbal products and food supplements can interact with chemotherapy medicines, so they should not be used without consulting your doctor.

When is a temporary stoma closed?

There is no fixed period for closing a temporary stoma that applies to everyone. First of all, the bowel join must have healed safely, there must be no infection or leak, and the patient must be fit for another operation.

Ongoing treatments such as chemotherapy and the patient’s general health can also affect when the stoma is closed. Before the closure procedure, the bowel join may be checked by examination, colonoscopy or imaging methods.

Current stoma surgery guidelines also recommend that the closure decision should be made individually for each patient and that stoma care education should be part of the treatment process [8].

Is sexual life affected after rectal cancer treatment?

The nerves around the rectum are closely linked to urinary and sexual function. Surgery, radiotherapy and other treatments can, in some patients, cause reduced sexual desire, erection or ejaculation problems in men, and vaginal dryness or pain during intercourse in women.

Whether these problems arise varies according to the patient’s age, the treatment given and their function before treatment. Some complaints may decrease over time; others may require medication, pelvic floor rehabilitation or specialist support.

Current follow-up and quality-of-life guidelines recommend that urinary and sexual function should be specifically assessed at check-ups. For this reason, it is important for patients to share these complaints with their doctors [5]. If necessary, support can be obtained from urology, gynaecology, physiotherapy or sexual health services.

Does bleeding from the anus definitely mean cancer?

No. Bleeding from the anus also has benign causes such as haemorrhoids and an anal fissure. However, bleeding should not simply be put down to “piles”.

If the bleeding recurs, or is accompanied by a change in bowel habit, unexplained weight loss, tiredness or anaemia, you should see a doctor. The cause of the bleeding should be established by examination and, if necessary, colonoscopy.

When can I return to normal life after surgery?

The time to return to daily life varies from person to person. Most patients can gradually resume light daily activities within a few weeks. However, the timing of heavy lifting, driving, exercise and return to work differs according to the operation performed and the speed of recovery.

It is important to increase activities gradually and to follow your doctor’s advice. If fever, increasing pain, marked abdominal swelling, persistent vomiting, discharge from the wound or a serious bowel problem develops, you should contact your healthcare team.

What you should know

In rectal cancer, the most appropriate treatment is planned by a multidisciplinary team according not only to the stage of the disease but also to the location of the tumour in the rectum, the MRI findings, its biological characteristics and the person’s priorities.

Scientific References

The information on this page has been prepared on the basis of current international guidelines and high-level scientific studies.

ESMO Clinical Practice Guideline: Localised Rectal Cancer (2025)
ASCRS Clinical Practice Guideline: Management of Rectal Cancer—2023 Supplement
ASTRO Clinical Practice Guideline Focused Update: Radiation Therapy for Rectal Cancer (2025)
NCI Rectal Cancer Treatment (PDQ®), health professional version
ASCRS Clinical Practice Guideline: Surveillance and Survivorship Care After Curative Treatment (2021)
National Cancer Institute. Genetics of Colorectal Cancer (PDQ®). Updated: 21 March 2025. https://www.cancer.gov/types/colorectal/hp/colorectal-genetics-pdq
Muscaritoli M, Arends J, Bachmann P, et al. ESPEN practical guideline: Clinical nutrition in cancer. Clinical Nutrition.2021;40(5):2898–2913. https://pubmed.ncbi.nlm.nih.gov/33946039/
Davis BR, Valente MA, Goldberg JE, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for Ostomy Surgery. Diseases of the Colon & Rectum. 2022;65(10):1173–1190. https://www.ascrsu.com/ascrs/view/ASCRS-Toolkit/2851081/all/Ostomy_Surgery__2022_

Important Information: The information on this page has been prepared for general information purposes, drawing on current scientific literature and international guidelines. The clinical characteristics of every patient are different; the information given here does not replace a personal medical assessment, diagnosis or treatment recommendation. People with suspected rectal cancer, symptoms or risk factors should see a doctor for a personal assessment. The treatment plan should be drawn up taking into account both current guidelines and the assessment of a multidisciplinary team.