Last reviewed: 12 May 2021
Last updated: 29 Mar 2021



History and exam

Key diagnostic factors

  • increasing age
  • rectal bleeding
  • change in bowel habit
  • rectal mass
  • positive family history
  • abdominal mass

Other diagnostic factors

  • anemia
  • male sex
  • abdominal pain
  • weight loss and anorexia
  • abdominal distension
  • palpable lymph nodes

Risk factors

  • increasing age
  • adenomatous polyposis coli mutation
  • Lynch syndrome (hereditary nonpolyposis colorectal cancer)
  • MUTYH/MYH-associated polyposis
  • hamartomatous polyposis syndromes
  • inflammatory bowel disease
  • obesity
  • acromegaly
  • limited physical activity
  • lack of dietary fiber

Diagnostic investigations

1st investigations to order

  • complete blood count
  • liver biochemistry
  • renal function
  • colonoscopy
  • CT colonography
  • double-contrast barium enema
  • CT scan of chest, abdomen, and pelvis

Investigations to consider

  • MRI pelvis rectal cancer protocol
  • transrectal endoscopic ultrasound (TRUS)
  • biopsy
  • carcinoembryonic antigen (CEA)
  • PET scan

Emerging tests

  • advanced optical imaging techniques

Treatment algorithm


Regional Chief of Surgery

MedStar Health




DES declares that he has no competing interests.

Associate Program Director

Department of Surgery

MedStar Franklin Square Medical Center




DML declares that he has no competing interests.

Co-Director of Medical Oncology

Director of Immuno-Oncology 

MedStar Franklin Square Medical Center

Harry and Jeanette Weinberg Cancer Institute




PPK declares that she has no competing interests.

Department of Radiation Oncology

MedStar Franklin Square Medical Center




KANC declares that she has no competing interests.

Dr David E. Stein, Dr David M Lisle, Dr Pallavi P Kumarm and Dr Kamila A Nowak-Choi would like to gratefully acknowledge Dr Juan L. Poggio, Dr Jascha Rubin, Dr Najjia Mahmoud, Dr Emily Carter Paulson, Dr Gary Atkin, Dr Anne Ballinger, Dr Mark O'Hara, Dr Mark Harrison, and Dr Robert Glynne-Jones, previous contributors to this topic.


JLP, JR, NM, ECP, MOH, GA, and AB declare that they have no competing interests. MH is the chair of the Mount Vernon Upper GI Tumour Site Specific Group and a member of the National Cancer Research Institute anal, rectal, and advanced colorectal groups. He has also received honoraria for speaking and has been supported to attend international meetings in GI cancer from Roche. He has also received research funding from Pfizer for a trial in rectal cancer. RGJ is the chief medical adviser to the charity Bowel Cancer UK. He has received honoraria for lectures from Roche, Sanofi, and Pfizer. He has received funding for the EXTRA study, involving capecitabine and radiotherapy in anal cancer, published in the International Journal of Radiation Biology Physics. RGJ has also received funding and free cetuximab for an ongoing phase I/II study integrating cetuximab into chemoradiation in rectal cancer, and has an agreement from Roche to supply bevacizumab for 3 months to 60 patients in one randomised phase II study as neoadjuvant chemotherapy in rectal cancer (BACCHUS). He has also been supported by Roche to attend international meetings in GI cancer.

Peer reviewersVIEW ALL

Consultant Colorectal Surgeon

St Mark's Hospital and Academic Institute

Northwick Park




SC declares that she has no competing interests.

Chief of Staff


Department of Colorectal Surgery

Cleveland Clinic




SW declares that he has no competing interests.

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