What is rectal cancer staging?
Rectal cancer staging is used to give you more details about the location of your rectal cancer and if it has spread. There are four stages of rectal cancer, and your care team will use your specific rectal cancer stage to help guide your care in a multidisciplinary team setting, which includes surgeons, radiologists, medical and radiation oncologists, pathologists, genetic counselors, nurses and cancer center administrators.
Rectal cancer is often grouped with colon cancer under the term colorectal cancer. These two types of cancer have similar stages. However, treatment options for each stage may be different.
Rectal cancer stages
When you're first diagnosed with rectal cancer, your doctor will put your cancer into one of several stages, ranging from 0 to 4. Stage 0 rectal cancer is the earliest stage of the disease and is considered precancerous, while stage 4 is the most advanced type of rectal cancer.
Within some stages, there may also be a letter after the stage number, such as A, B or C, to specify features of the cancer. Usually, the higher the number and letter of your rectal cancer stage, the more the cancer has spread within and outside the rectum.
Rectal cancer staging is important because it gives you and your care team the information you need to make informed choices about your next steps. Your treatment options will vary depending on how advanced your cancer is.
A guide called the TNM (tumor, node, metastasis) system is used to help stage cancer:
- Tumor (T): Rectal cancer staging looks at the tumor's position in the bowel wall or the depth of invasion.
- Node (N): This category indicates whether cancer has spread to nearby lymph nodes, which are small, bean-shaped structures that are part of the body's immune system.
- Metastasis (M): If the cancer has spread into other tissues or organs, called metastasis, it makes it harder to treat the cancer.
Learn more about each stage:
Visual of rectal cancer stages
Stage 0 rectal cancer
Stage 0 rectal cancer is the earliest—and most treatable—stage of this type of cancer. Your care team may use “high-grade dysplasia” for abnormal tissue in a rectal polyp. This means that precancerous cells have not spread beyond the innermost lining of the rectum.
Removing the rectal polyp that contains the high-grade dysplasia cells prevents cancer from forming. Doctors can often remove all the high-grade dysplasia in the polyp and the recovery time is minimal.
Treatment
The most common treatment option for high-grade dysplasia in a polyp is a procedure called a polypectomy. During a polypectomy, your doctor will insert a scope into the rectum to remove the rectal polyp(s).
Most of the time, you won’t need other treatments like chemotherapy or radiation. However, your provider may recommend additional screenings and follow-ups to provide ongoing peace of mind.
Survival rate
The National Cancer Institute reports the survival rates for rectal cancer together with colon cancer. Survival after complete removal of a polyp, even with high-grade dysplasia, is no different than the normal population.
Stage 1 rectal cancer
In stage 1, rectal cancer has begun to spread into deeper layers of the tissue, but it’s still only located within the wall of the rectum. It isn’t found in other tissues, organs or lymph nodes.
During this stage, cancer cells may be found in three layers of tissue:
- The mucosa or inner lining of the rectum
- The next layer below the lining, known as the submucosa
- The muscle tissue in the rectum
Stage 1 rectal cancer has a high five-year survival rate and is considered very treatable. In most people with this stage of rectal cancer, the first step in treatment is surgery; often, no other treatments are needed.
Treatment
The goal of an operation for stage 1 rectal cancer is to remove all the cancerous cells in the rectum. Depending on the specific tumor, there may be minimally invasive options for your procedure. The two most common minimally invasive surgeries for stage 1 rectal cancer are:
- Local transanal resection or excision: With this procedure, your doctor will remove the cancer and some of the cells around it using surgical instruments inserted into the anus and rectum. This is most common for stage 1 rectal cancer that’s located lower in the rectum.
- Transanal endoscopic surgery: Some stage 1 rectal cancers located higher in the rectum need endoscopic surgery. During this procedure, the surgical team inserts a scope with a 3D view through the anus into the rectum to get a better view of the cancer. Long, thin operating instruments are placed alongside the scope to operate.
Survival rate
Stage 1 rectal cancer is considered a type of localized colorectal cancer. Data from the National Cancer Institute shows that the survival rate for this type of cancer at five years is 91%.
Stage 2 rectal cancer
When rectal cancer progresses to stage 2, the cancerous cells have now invaded through multiple layers of rectal tissue into the fat surrounding the rectum and possibly into nearby tissues. Unlike later stages of the condition, cancer in stage 2 has not yet spread to any lymph nodes, including those near the tumor.
Your care team will likely recommend surgery to remove as much cancer as possible. Your surgery may include the removal of additional tissues beyond just rectal tissue. Chemotherapy with drugs that are proven to kill colorectal cancer cells may be added to the treatment plan.
Stage 2 rectal cancer is grouped into three substages, stage 2A, 2B and 2C:
- Stage 2A: Rectal cancer has grown through all the layers of rectal tissue and reached the outer layer.
- Stage 2B: The cancer has spread through the outermost layer of the rectum but isn’t affecting nearby tissues.
- Stage 2C: Cancer cells are now found in multiple layers of the rectum, through the outer layer and in nearby organs or tissues.
Treatment
Rectal tumors that have reached stage 2 are too deeply invaded to remove with transanal surgery. Your team may also talk with you about combining surgery with other treatments, including chemotherapy and radiation. Some surgical options for stage 2 rectal cancer include:
- Anterior resection: If your tumor is located in the upper part of your rectum, your surgeon may use an incision in your abdomen to remove part of the rectum, including the cancer. Then, your colon is reattached to the bottom part of the rectum that remains.
- Proctectomy with coloanal anastomosis: Your surgeon may use an incision in your abdomen to remove all the rectum, including the cancer. Then, your colon is reattached to the anus, with or without a small pouch created to replace the rectum. This is called a coloanal anastomosis.
- Abdominoperineal resection (APR): This surgical procedure uses an incision in the abdomen and around the anus to remove the rectum, the anus and the muscles of the pelvic floor. With this procedure, a permanent colostomy is needed. With a colostomy, your surgeon reconnects the colon to an opening in the abdomen to pass stool into a closed, air-tight plastic bag.
Survival rate
Because the cancer may have spread outside the rectum at this stage, it’s classified as regional colorectal cancer. National Cancer Institute data shows a five-year survival rate of 72%.
Stage 3 rectal cancer
Stage 3 rectal cancers have spread into at least one lymph node, regardless of whether the tumor has grown through the rectal wall. The cancer has not spread to any other organs at this stage. Additional types of treatment after an operation are used to treat stage 3 rectal cancer fully.
Your care team will work with you to plan your treatment options based on your cancer substage. The three substages for stage 3 rectal cancer are 3A, 3B and 3C. These specific substages help describe how far rectal cancer has spread and how many lymph nodes are affected by cancer.
- Stage 3A: This stage includes rectal cancer that has grown into but not through the muscle layers of the rectum and involves up to three lymph nodes. It also includes cancer that has spread only through the lining of the rectum but not the muscle and involves up to six lymph nodes.
- Stage 3B: Stage 3B includes rectal cancer that has gone through the rectal wall into abdominal tissue and spread to as many as three lymph nodes; cancer that has spread to as far as the outer wall of the rectum and up to six lymph nodes; and rectal cancer in two layers of tissue and seven or more lymph nodes.
- Stage 3C: This type of stage 3 rectal cancer is found in the abdominal lining and up to six lymph nodes, through the rectum wall and seven or more lymph nodes or in nearby organ tissue and at least one lymph node.
Treatment
To care for stage 3 rectal cancer, the most common treatment plan combines chemotherapy, radiation therapy and surgery. Different people will have these in different orders, depending on the features of the rectal cancer and the goals of the treatment.
For example, you may have chemotherapy and radiation therapy at the same time, which can help make rectal tumors smaller. This means an operation is more likely to completely remove the tumor and to reconnect the two separate segments of the intestine. Other people may have only chemotherapy first, followed by a combination of chemotherapy and radiation before the operation.
Surgical procedures for stage 3 rectal cancer include proctectomy with coloanal anastomosis, anterior resection and abdominoperineal resection.
Survival rate
Stage 3 rectal cancer is considered regional colorectal cancer. For this stage, the National Cancer Institute data shows a survival rate of 72% at five years.
Stage 4 rectal cancer
Stage 4 rectal cancer has reached the most advanced stage. While earlier stages only involve the rectum, nearby organs and lymph nodes, stage 4 rectal cancers have spread to parts of the body far away from the original tumor in the rectum. Some common places that rectal cancer spreads include the liver, lungs or ovaries. You may hear the terms “distant cancer” or “metastatic cancer” to describe this stage.
Because stage 4 rectal cancer is advanced and affects other areas of the body, multiple treatments and combinations of therapies may be needed to control the cancer. Some stage 4 rectal cancers have spread too much to benefit from surgery.
There are three substages in stage 4 rectal cancer:
- Stage 4A: Your rectal cancer has spread to only one distant area of the body.
- Stage 4B: In this stage of rectal cancer, cancer cells have spread to more than one distant area of the body.
- Stage 4C: In the most advanced substage of rectal cancer, the cancer is found in distant places in the abdominal wall and other areas or organs in the body.
Treatment
Treatment for stage 4 rectal cancer can be complex, and it requires a multidisciplinary team of specialists. Your rectal cancer team will create a treatment plan to care for your cancer based on many factors, including genetic testing, tumor biology, likely response to chemotherapy, radiation therapy, targeted therapies, immunotherapy, surgery, ablation (the removal or destruction of tissue) or embolization (blocking or reducing blood flow to tissue).
Most people with stage 4 rectal cancer will be treated first with chemotherapy. Today, there are several chemotherapy drugs used for rectal cancer. If one type of chemotherapy doesn’t work for you, your team may try another. When the cancer has spread to the liver and lung (metastases), you may require surgery, ablation or different chemotherapy agents.
The order of treatments varies. If you have surgery, you may have chemotherapy both before and after the procedure. Surgical procedures like proctectomy with coloanal anastomosis, anterior resection and abdominoperineal resection can remove cancer in the rectum. If surgery isn’t an option, therapies like ablation could be used to help destroy the tumor.
Another treatment option for stage 4 rectal cancer is immunotherapy. Immunotherapy uses your immune system to target cancer cells with specific features or genetic changes.
Survival rate
At stage 4, rectal cancer is classified as distant colorectal cancer. According to the National Cancer Institute, the five-year survival rate for distant colorectal cancer is 13%.
Recurrent rectal cancer
Recurrent rectal cancer is the term used when rectal cancer returns after your treatment. When rectal cancer returns to its original location in the rectum or other areas of the body, it’s important to have an experienced team by your side. Recurrent rectal cancer requires specialized care because it can be difficult to treat.
Like your initial treatment, your care team will consider several options to tailor your care to the size, type and location of the recurrent rectal cancer. Your treatment plan could include chemotherapy, radiation therapy and surgery, even if you didn’t have some of these treatments in your initial care.
Treating recurrent rectal cancer
The location of your recurrent rectal cancer will guide your care. The two types of recurrence are:
- Local recurrence: A local recurrence of rectal cancer is cancer that returns near the original area in the rectum. Treatment may require more extensive surgery than previous surgeries and may include more chemotherapy and radiation.
- Distant recurrence: Distant recurrent rectal cancer is rectal cancer that develops in another area of the body away from the rectum. The treatment options for this type of recurrence are similar to those for stage 4 rectal cancer. If your cancer doesn’t respond to these traditional treatments, talk with your care team about other options, such as clinical trials.
Rectal cancer survival rate
Survival rate data can help you learn more about what to expect with your stage of rectal cancer and provide an estimate of how many people with that stage of cancer are living five years after their diagnosis. The average five-year survival rate for all stages of rectal cancer is 63%, based on data reported by the National Cancer Institute.
In the early stages of rectal cancer, the condition is considered highly treatable and it has a high five-year survival rate. While the survival rate for the most advanced stage of rectal cancer is lower, advances in treatments and options like clinical trials continue to provide hope for all people with the condition.
- Localized: Localized rectal cancer includes stage 0 and stage 1, where cancer hasn’t spread outside the rectum. The five-year survival rate is about 91%.
- Regional: Regional rectal cancer means that cancer has spread to nearby organs or lymph nodes, including stage 2 and stage 3 rectal cancer. The five-year survival rate is 72%.
- Distant: When rectal cancer spreads to areas in the body away from the rectum, it’s called distant rectal cancer or stage 4 cancer. The five-year survival rate is 13%.
Personalized support at any stage
When you’re fighting rectal cancer, you not only need care for your physical symptoms but also for the emotional, social, mental and spiritual impact of cancer.
Our specialized cancer teams and extensive network of cancer centers are there for you with support at every turn. With access to numerous treatments, research, education and support services, you’ll feel confident in your path forward.
From navigating your care choices to connecting with others sharing a similar journey, you won’t have to fight rectal cancer alone. We’re here for you, from diagnosis to survivorship, and we offer support designed for the needs of your family and caregivers, too.