Associate Director & Unit Head, Surgical Oncology, Max Hospital, Gurgaon
Series overview · 10 articles
Diagnosis and Management of Rectum Cancer
September 5, 2026
Colon and rectum cancer, together called colorectal cancer, is the third most common cancer in the world. This guide is based on a Jivo Masterclass by Dr. Kaushal Kishore Yadav, Associate Director and Unit Head of Surgical Oncology at Max Hospital, Gurgaon, and introduces a complete series on diagnosing and managing rectum and colon cancer.
Why Colorectal Cancer Demands Early Attention
Colorectal cancer is the second most common cancer among those whose incidence is rising worldwide. Sixty to seventy percent of patients still present at stage three or stage four, when the disease is already advanced and treatment is longer with fewer options. Changing lifestyle habits mean it is no longer confined to older adults either: patients are now being diagnosed in their thirties and even their twenties. Detecting the disease earlier shortens the treatment course and produces better results.
Recognising the Warning Signs
Fresh bleeding or a change in stool colour, an unexplained drop in haemoglobin, and constipation or diarrhoea that does not resolve within three weeks are the clearest signals to investigate. These should prompt a colonoscopy or CT scan without delay.
Building the Diagnostic Picture
The ideal workup combines colonoscopy with biopsy, an MRI of the pelvis, a CT scan of the thorax and abdomen to check the liver and lungs for spread, a tumour marker blood test, and a PET-CT scan where one is available. A fecal occult blood test can be done even at a primary care level and, while not highly specific, still catches some cases that would otherwise be missed.
Preserving Normal Function Even in Low Rectal Tumours
Rectal cancer spreads upward along its natural embryological lymphatic supply rather than downward. Staying within the correct anatomical plane allows even tumours lying very low in the rectum to be removed with a margin as small as one centimetre, while preserving a normal bowel passage instead of a permanent stoma. A temporary stoma, used for about three months, can later be reversed.
Complete Mesocolic Excision for Colon Cancer
For colon cancer, complete mesocolic excision with central vascular ligation, ligating the feeding vessels at their origin and removing the complete mesocolic fascia with all draining lymph nodes, has been published in international journals and is associated with better survival than the standard technique. Open, laparoscopic and robotic approaches all achieve comparable results, with laparoscopic and robotic surgery offering a shorter hospital stay and faster recovery.
Treating Advanced Disease
Colon cancer in stages one to three has no role for chemotherapy before surgery. Lower rectal cancer with muscle involvement or node-positive disease is treated with chemotherapy and radiotherapy before surgery. Stage four disease is managed mainly with chemotherapy, though limited liver-only or peritoneum-only spread can still be addressed surgically, through liver metastasectomy or cytoreductive surgery combined with HIPEC, which carries roughly a fifty percent survival advantage in colorectal cancer.
In This Series
The articles below cover warning signs and risk factors, the diagnostic workup, sphincter-preserving surgery for low rectal tumours, complete mesocolic excision for colon cancer, open versus laparoscopic versus robotic surgery, managing stage four disease, when chemotherapy or radiotherapy comes before surgery, screening guidelines, and how to refer a patient for treatment in India.
Warning Signs and Risk Factors for Colorectal Cancer | The Diagnostic Workup for Colon and Rectum Cancer: Tests, Scans and Staging | Sphincter-Preserving Surgery for Low Rectal Cancer | Complete Mesocolic Excision with Central Vascular Ligation for Colon Cancer | Open, Laparoscopic and Robotic Surgery for Colon and Rectum Cancer | Managing Stage 4 Colorectal Cancer: Liver and Peritoneal Metastases | When Is Chemotherapy or Radiotherapy Needed Before Rectal Cancer Surgery? | Colorectal Cancer Screening: Who Should Get Tested and When | Referring a Colorectal Cancer Patient for Treatment in India
This article is based on a Jivo Masterclass session conducted by Dr. Kaushal Kishore Yadav, Associate Director & Unit Head, Surgical Oncology, Max Hospital, Gurgaon, India. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
This guide is based on a live Jivo Masterclass: Dr. Kaushal Kishore Yadav taught doctors across Africa on June 15, 2025.
FROM THE LIVE Q&A
Dr. Chanda Stephen
Many doctors at a first or second-level hospital see colorectal cancer patients they cannot treat, and even the most advanced hospital available to them locally cannot treat these cases either. What should a doctor in this position do?
Dr. Kaushal Kishore Yadav
Nothing stops a doctor from referring the complex case to an Indian oncologist in parallel, so the patient has a second treatment pathway. Many patients from African countries who present to India face the same underlying problem: the evaluation, diagnosis and route to treatment usually takes a long time in the home country, and by the time they present to us the disease is already at an advanced stage, sometimes stage four with limited options.
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Frequently Asked Questions
Confirmed that no CT scan is available for him to order at his level-one facility. What workup can still be done in that situation?▼
For a patient with a change in bowel habit and an otherwise unexplained low haemoglobin level, send a colonoscopy first. Do a colonoscopy and CT scan whenever there is real suspicion, and don't delay. Even at a primary level, a fecal occult blood test can be done; it is not very specific and may miss some cases, but it can still help.
Shared what is available at his own facility: a fecal occult (or immunochemical) blood test can be sent as a general surgeon at his primary or general hospital, but what happens beyond that?▼
That test is the only early reading that can be done at that level; genetic-level investigation is not available in that setup. For colonoscopy, the patient has to go to a tertiary hospital and bring the results back. At least the fecal occult blood test is available, and even though it is not very specific, it can help catch some cases.
Asked whether sphincter-preserving surgery (intersphincteric resection) can really be done even for a distal rectal cancer, one lying very low in the rectum.▼
Yes. Rectal cancer spreads upward along its natural embryological lymphatic supply rather than downward, so staying strictly within that anatomical plane allows the tumour to be removed completely, following guidelines that show even a minimal distal margin of one centimetre is adequate. An intraoperative frozen section can confirm all microscopic cancer cells have been cleared, and this makes it possible to go between the internal and external anal sphincter even for the lowest-lying tumours, preserving a normal passage instead of requiring a permanent stoma.
Followed up: in a setup where frozen section pathology is not available, how can a surgeon be confident of a clear margin, and how should the patient be followed afterward?▼
Follow the natural avascular surgical plane, doing sharp dissection between the internal and external sphincter. On gross examination, aim for about one centimetre of margin at the lowest extent of the tumour, or three to five centimetres higher up depending on where the tumour is located. Stay within the correct surgical plane and the margin should come back clear; the final histopathology report, once it arrives, confirms this.
Working in a region with very limited healthcare infrastructure, asked what to do when none of the described tests (MRI, CT, PET-CT, tumour markers) are available locally.▼
Do whatever is genuinely achievable under your own control. If something cannot be done locally, it is better to refer the patient to a centre where it can be done with precision, because cancer gives only one real chance to get the treatment pathway right.
In This Series: Diagnosis and Management of Rectum Cancer
- 1.Diagnosis and Management of Rectum Cancer
- 2.Warning Signs and Risk Factors for Colorectal Cancer
- 3.The Diagnostic Workup for Colon and Rectum Cancer: Tests, Scans and Staging
- 4.Sphincter-Preserving Surgery for Low Rectal Cancer
- 5.Complete Mesocolic Excision with Central Vascular Ligation for Colon Cancer
- 6.Open, Laparoscopic and Robotic Surgery for Colon and Rectum Cancer
- 7.Managing Stage 4 Colorectal Cancer: Liver and Peritoneal Metastases
- 8.When Is Chemotherapy or Radiotherapy Needed Before Rectal Cancer Surgery?
- 9.Colorectal Cancer Screening: Who Should Get Tested and When
- 10.Referring a Colorectal Cancer Patient for Treatment in India