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Rectal cancer

Key sources
The following summarized guidelines for the evaluation and management of rectal cancer are prepared by our editorial team based on guidelines from the American Society of Colon and Rectal Surgeons (ASCRS 2024; 2022; 2020; 2015; 2014), the European Society of Medical Oncology (ESMO 2023; 2020; 2017), the American Society of Clinical Oncology (ASCO 2023), the American College of Physicians (ACP 2023), the American Gastroenterological Association (AGA 2023; 2021), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES/ESCP/EAES 2023), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES/ASCRS 2023), the College of American Pathologists (CAP/AMP/FCC 2022), the American Society for Radiation Oncology (ASTRO 2021), the American College of Gastroenterology (ACG 2021; 2019; 2015), the U.S. Preventive Services Task Force (USPSTF 2021; 2016), the Hereditary Haemorrhagic Telangiectasia Working Group (HHT-WG 2020), the US Multi-Society Task Force on Colorectal Cancer (USMSTF 2020; 2017; 2016), the British Society of Gastroenterology (BSG 2019; 2018), the World Society of Emergency Surgery (WSES 2018), the American College of Surgeons (ACS 2018), and the American Society for Gastrointestinal Endoscopy (ASGE 2014).
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Guidelines

1.Screening and diagnosis

Indications for screening, general population, aged 45-49 years, ACP: avoid obtaining screening for CRC in asymptomatic 45-49 years old average-risk adults. Discuss the uncertainty around the benefits and harms of screening in this population.
D
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  • Indications for screening (general population, aged 50-75 years)

  • Indications for screening (general population, aged 76-85 years)

  • Indications for screening (high-risk individuals, family history)

  • Indications for screening (high-risk individuals, hereditary cancer syndromes)

  • Indications for screening (high-risk individuals, IBD)

  • Indications for screening (high-risk individuals, PSC)

  • Indications for screening (high-risk individuals, HHT)

  • Choice of screening tests (primary choice)

  • Choice of screening tests (alternative choices)

  • Indications for testing (lower gastrointestinal bleeding)

  • Indications for testing (chronic constipation)

  • Indications for testing (chronic diarrhea)

  • Indications for screening (risk stratification)

2.Classification and risk stratification

Staging: use the AJCC TNM system for staging RC.
B

3.Diagnostic investigations

History and physical examination
As per ASCRS 2020 guidelines:
Elicit cancer-specific history, including disease-specific symptoms, associated symptoms, and family history, and obtain perioperative risk assessment in patients with RC.
B
Perform a complete physical examination, including an assessment of the distance of the distal extent of the tumor from the anal verge and the tumor's relation to the sphincter complex.
B

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  • Laboratory tests

  • Imaging for staging (pelvic MRI)

  • Imaging for staging (EUS)

  • Imaging for staging (thoracoabdominal CT/MRI)

  • Imaging for staging (PET)

  • Evaluation in emergency settings

4.Diagnostic procedures

Diagnostic colonoscopy: perform rigid rectoscopy and preoperative colonoscopy to the cecal pole, or virtual colonoscopy in case of obstruction, to exclude synchronous colonic tumors in patients with RC. Perform completion colonoscopy within 6 months of surgery if not performed preoperatively.
B

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  • Biopsy and histopathology (general principles)

  • Biopsy and histopathology (technical considerations)

  • Molecular testing (dMMR/MSI status)

  • Molecular testing (specific gene mutations)

  • Molecular testing (DPD deficiency)

5.Medical management

Management of nonmetastatic disease, neoadjuvant therapy, indications, ASCRS: offer total neoadjuvant therapy in patients with stage II-III mid or low rectal adenocarcinoma.
B

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  • Management of nonmetastatic disease (neoadjuvant therapy, regimens)

  • Management of nonmetastatic disease (neoadjuvant therapy, assessment of response)

  • Management of nonmetastatic disease (neoadjuvant therapy, interval to surgery)

  • Management of nonmetastatic disease (local excision)

  • Management of nonmetastatic disease (radical resection)

  • Management of nonmetastatic disease (adjuvant therapy, indications)

  • Management of nonmetastatic disease (adjuvant therapy, technical considerations)

  • Management of metastatic disease (general principles)

  • Management of metastatic disease (surgical resection)

  • Management of metastatic disease (systemic therapy, first-line)

  • Management of metastatic disease (systemic therapy, maintenance)

  • Management of metastatic disease (systemic therapy, second-line)

  • Management of metastatic disease (systemic therapy, subsequent lines)

  • Management of metastatic disease (palliative interventions)

  • Management of metastases (general principles)

  • Management of metastases (perioperative treatment)

  • Management of metastases (liver metastases)

  • Management of metastases (peritoneal metastases)

  • Management of metastases (lung metastases)

  • Management of acute complications (general principles)

  • Management of acute complications (obstruction)

  • Management of acute complications (perforation)

  • Management of acute complications (unstable patients)

  • Management of acute complications (antibiotic therapy)

6.Surgical interventions

Technical considerations for surgery, preoperative care, ESCP/SAGES/EAES
Consider performing mechanical bowel preparation, administering oral antibiotics, and performing enema before minimally invasive rectal surgery.
C
Perform mechanical bowel preparation and administer oral antibiotics before minimally invasive colorectal surgery if there is an intention to localize the lesion intraoperatively.
A

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  • Technical considerations for surgery (perioperative care)

  • Technical considerations for surgery (choice of surgical approach)

  • Technical considerations for surgery (postoperative care)

7.Preventative measures

Aspirin for primary prevention
As per ACG 2021 guidelines:
Consider initiating low-dose aspirin to reduce the risk of CRC in 50-69 years old patients with ≥ 10% CVD risk over the next 10 years, no increased risk for bleeding, and willing to take aspirin for at least 10 years.
C
Do not use aspirin as a substitute for CRC screening.
D

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  • Aspirin for secondary prevention

  • Primary prevention in IBD

  • Primary prevention in PSC

  • Primary prevention in T2DM

  • Agents with no evidence for benefit

8.Follow-up and surveillance

Surveillance after curative-intent therapy
As per ESMO 2023 guidelines:
Obtain radiological evaluation every 8-12 weeks, including (in most cases) CT or MRI, as well as serum CEA level measurements in patients with metastatic disease receiving active treatment.
B
Obtain more intense monitoring initially with a radiological assessment with CT (or MRI) and measurements of CEA level every 3 months during the first 2 years and every 6 months thereafter in patients with a radically resected metastatic disease with potential for cure.
A