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Honghong Zheng,1,* Zhehong Li,2,* Shuai Zheng,1 Jianjun Li,1 Ji Yang,1 Enhong Zhao1 1Department of Gastrointestinal Surgery, The Affiliated Hospital of Chengde Medical University, Chengde, 067000, People’s Republic of China; 2Department of Orthopedic, The Affiliated Hospital of Chengde Medical University, Chengde, 067000, People’s Republic of China*These authors contributed equally to this workCorrespondence: Enhong Zhao, The Affiliated Hospital of Chengde Medical University, No. 36 Nanyingzi St., Chengde, 067000, People’s Republic of China, Email zhenghh1215@163.comPurpose: Patients with middle-aged and elderly rectal cancer (MERC) usually have poor prognosis after surgery. This study aimed to develop a nomogram to achieve individualized prediction of overall survival (OS) in patients with MERC and to guide follow-up and subsequent diagnosis and treatment plans.Patients and Methods: A total of 349 patients were randomly assigned to the training and validation cohorts in a 7:3 ratio. Multivariate Cox regression analysis was performed using the results of univariate Cox regression analysis to confirm independent prognostic factors of OS. Thereafter, the nomogram was built using the “rms” package. Subsequently, discriminative ability and calibration of the nomogram were evaluated using receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA). Integrated discrimination improvement (IDI), net reclassification improvement (NRI), and the area under the ROC curves (AUC) were compared between the nomogram and the tumor-node-metastasis (TNM) staging system (8th edition). Finally, we established a predictive model to assess the survival benefit of patients with MERC by calculating nomogram scores for each patient.Results: Six variables were identified as independent prognostic factors and included in the nomogram: smoking history, family history, hematochezia, tumor size, N stage, and M stage. Based on these factors, we successfully constructed a nomogram and evaluated its discriminative and predictive abilities using ROC curves, calibration curves, and DCA. ROC curves, IDI, and NRI showed that the nomogram had outstanding clinical utility compared with the TNM staging system (8th edition) for OS prediction. The predictive model successfully distinguished between high-, medium-, and low-risk MERC patients.Conclusion: Our nomogram provided a more satisfactory survival prediction ability than the TNM staging system (8th edition) for MERC patients. In addition, the nomogram was able to accurately categorize patients into different risk groups after surgery.Keywords: nomogram, rectal cancer, web-based nomogram, overall survival, prognosis