The primary curative treatment for most rectal cancer is surgical. The earlier the stage of the disease, the better the prognosis. Decisions regarding the extent of palliative surgical treatment are often difficult and sound judgement is needed to avoid inappropriate morbidity.

Some patients may benefit from the use of preoperative therapy. In those patients with clinical stage T3 disease (non-fixed), a short course of preoperative radiotherapy may be beneficial. Although short course preoperative radiotherapy does not immediately shrink tumours, it minimizes the delay to surgery imposed by starting with radical radiotherapy, increases local control, and reduces morbidity as compared to long-course post-operative radiotherapy. In patients with locally unresectable disease, a full 5-week course of preoperative radiotherapy, with or without concomitant chemotherapy, may reduce the size of the cancer, enabling subsequent resection. We encourage the referral of clinical stage T3 (non-fixed) rectal cancers for consideration of preoperative short-course radiotherapy. Unresectable rectal cancer patients may also be referred for consideration of "down-staging" with preoperative radical radiotherapy or chemoradiotherapy.

Patients receiving preoperative radiotherapy, with or without concomitant chemotherapy, are considered for adjuvant therapy in the form of systemic chemotherapy (GIRFF).

Postoperatively, if no preoperative radiation was given, adjuvant chemotherapy and radiation therapy improves local control and survival in Stage II and III rectal cancer (GIFUR2). Patients eligible for adjuvant treatment should be referred as early as possible. Chemotherapy is best done under the supervision of a physician skilled in the management of GI cancer.

Chemotherapy for metastatic rectal cancer can benefit suitable patients. Benefits include palliation of symptoms, delayed progression, and prolonged survival compared with best supportive care.