Key Concepts

• The method chosen to screen a patient for colorectal cancer (CRC) should be individualized based on patient comorbidities and life expectancy, access, cost, baseline risk, compliance, and tolerance for invasive procedures due to differing costs, sensitivities, and cadences of the various options.
• Defining the anatomic location where the sigmoid colon transitions to the rectum is increasingly determined by cross-sectional imaging due to its reproducibility and is less dependent on endoscopic localization alone, as body habitus and gender can influence the location of the peritoneal reflection.
• Proper tumor localization and staging is essential to establishing treatment recommendations; understanding the pitfalls of each staging modality is important to avoid under- or overtreatment.
• Magnetic resonance imaging (MRI) using a rectal cancer protocol is now standard of care for locally advanced rectal tumors. Endorectal ultrasound (ERUS) is being used less commonly as it is more operator dependent, less reproducible, and invasive for the patient; however, ERUS remains an important staging modality for early stage rectal tumors when determining eligibility for local excision.
• A combination of histologic and radiographic factors should be used to risk stratify CRC; higher-risk tumors should be considered for more aggressive neoadjuvant treatments; however, patient frailty or comorbidities may limit these treatment options and should be individualized.
• Preoperative optimization and preparation of the colorectal cancer patient is essential to maximizing postoperative and oncologic outcomes; a variety of tools, including guidelines and checklists, are available to assist the surgical team in this endeavor.