What is rectal cancer?
Rectal cancer is a malignant tumour arising from the cells lining the rectum (the last 12–15 cm of the large bowel before the anus). It accounts for approximately 30% of all cancers of the lower digestive tract. Treatment differs significantly from colon cancer due to anatomical proximity to the sphincter and pelvic organs.
Modern treatment is multimodal — combining neoadjuvant chemoradiotherapy (when needed), surgical resection with Total Mesorectal Excision (TME), and adjuvant chemotherapy. The aim is complete excision with preservation of sphincter function whenever possible.
How common is it?
Rectal cancer accounts for approximately 30% of cancers of the lower digestive tract. In Greece, around 2,000 new cases are diagnosed annually. It affects men slightly more often than women (1.5:1), with peak incidence between 60 and 70 years.
Modern multimodal approaches and TME technique have radically improved outcomes — 5-year survival exceeds 70% for early-stage tumours, while local recurrence has decreased from 30% (decades ago) to under 10% today.
How does it present?
The main symptoms of rectal cancer include:
- Bright red rectal bleeding mixed with stool.
- Change in bowel habits (alternating constipation and diarrhea).
- Tenesmus — feeling of incomplete evacuation, frequent urge to defecate.
- Change in stool calibre (thin "ribbon-like" stools).
- Mucus or discharge from the rectum.
- Pelvic pain or sense of pressure (advanced disease).
- Unexplained weight loss, fatigue.
- In advanced disease: pelvic pain, urinary or sexual symptoms.
How is it diagnosed?
Diagnosis and staging include:
- Digital rectal examination — gives initial impression of size and distance from the anus.
- Rigid or flexible sigmoidoscopy with biopsies — confirms diagnosis.
- Complete colonoscopy — excludes synchronous lesions in the rest of the colon.
- MRI of the pelvis — the most important investigation for local staging (T, N, mesorectal margin).
- Abdominal-pelvic and chest CT — staging for distant metastases.
- Endorectal ultrasound — for early lesions (T1–T2).
- PET-CT in complex cases.
- Tumour markers (CEA), mutation analysis.
Which factors increase risk?
Risk factors for rectal cancer overlap with those for colon cancer, but there are some distinctive features.
- Family history of colorectal cancer.
- Hereditary syndromes (Lynch syndrome, FAP).
- Personal history of colorectal polyps.
- Inflammatory bowel disease.
- Age >50 years.
- Male sex (slightly more common).
- Obesity, sedentary lifestyle.
- Diet rich in red and processed meat.
- Smoking — particularly associated with rectal cancer.
- Heavy alcohol consumption.
Modern therapeutic options
Treatment of rectal cancer is multidisciplinary and individualised. The choice depends on tumour location (upper, middle, lower rectum), stage, response to neoadjuvant therapy and patient characteristics. The aim is curative resection with sphincter preservation whenever possible.
Robotic Low Anterior Resection (rLAR + TME)
Cutting-edge technique for sphincter-preserving operations. The Da Vinci system offers exceptional three-dimensional visualisation of the narrow pelvic anatomy and articulated instruments for precise mesorectal dissection. Better functional outcomes (continence, sexual function) and equivalent oncological outcomes compared to laparoscopic.
Laparoscopic LAR + TME
International standard for tumours of the upper and middle rectum. Performed with all oncological principles (TME), with reduced postoperative pain and faster recovery compared to open surgery. Excellent oncological outcomes when performed by specialised teams.
Abdominoperineal Resection (APR)
For very low tumours infiltrating the sphincter, where sphincter preservation is not feasible. Includes resection of the rectum and anus with a permanent colostomy. Performed laparoscopically or robotically. Modern technique (extralevator APR) offers excellent oncological outcomes.
Transanal Resection (TAMIS / TES)
For early T1 tumours without lymph node involvement, selected patients. Performed transanally, without abdominal incisions, with full preservation of sphincter and continence. Excellent option in suitable cases.
Frequently asked questions
Will I need a permanent colostomy?
For 75–80% of patients, sphincter preservation is possible (LAR). A permanent colostomy (APR) is required only for very low tumours infiltrating the sphincter. A temporary protective ileostomy is often required for 2–3 months to protect the anastomosis.
Will I have chemoradiotherapy before surgery?
Yes, for locally advanced tumours (T3–T4 or N+). Modern protocols include either short-course radiotherapy (5 days) followed by surgery, or long-course chemoradiotherapy (5 weeks) followed by surgery. Recently, Total Neoadjuvant Therapy (TNT) is increasingly used.
How will continence be affected after surgery?
Most patients experience transient "low anterior resection syndrome" (LARS) — increased stool frequency, urgency. With pelvic floor rehabilitation and gradual adaptation, symptoms improve significantly over 12–18 months. The robotic approach offers better long-term functional outcomes.
What is TME and why is it so important?
Total Mesorectal Excision (TME) is the modern surgical technique that removes the rectum within its intact mesorectal envelope. It is the most important advance in rectal cancer surgery of recent decades — it has reduced local recurrence from 30% to <10% and significantly improved survival.