Colorectal Cancer

Treatment Options by Stage of Cancer

The recommended treatment options for colon and rectal cancer depend primarily on the stage of disease (Table 1). However, many other factors may be considered when choosing the best treatment plan, and your health care team will discuss these details with you. You should talk openly with the members of your treatment team about the options, the side effects of various treatments and how treatment will affect your normal daily activities and quality of life.

Some treatment plans are straightforward. For example, stage 0 and I colon cancers can typically be treated with resection and anastomosis without the need for further treatment unless the surgeon thinks that the tumor was not completely removed or if the pathologist detects cancer cells in the surgical margin. The recommended treatment of stage III colon cancer is also straightforward: surgical resection followed by adjuvant chemotherapy.

For other stages of disease, decision-making can be more complex. Stage II colon cancer is one such example. Surgical resection is the primary treatment for stage II cancer, but many factors must be considered in deciding whether there is benefit to chemotherapy after the operation. The purpose of adjuvant chemotherapy is to reduce the likelihood of recurrence, but adjuvant chemotherapy has been found to be of benefit for only a small percentage (about 5%) of people with stage II disease — people who are at high risk for recurrence. In general, a person is at high risk for recurrence if the tumor is large (T4) and invasive (extends through the wall of the colon into nearby tissues and/or organs):

  • tumor blocked the colon
  • tumor looks very abnormal when examined by the pathologist
  • pathologist did not examine at least 12 lymph nodes
  • surgical margins contained cancer cells

One test is recommended to help determine whether the risk of recurrence warrants adjuvant chemotherapy for stage II colon cancer. This test, microsatellite instability (MSI), reflects the amount of MMR protein in the tumor. Studies have shown that if the amount of MMR protein in the tumor is low (noted as MMR deficient or MSI-high), the risk of recurrence is low, and adjuvant chemotherapy can be safely avoided. Also, the results of studies have suggested that adjuvant treatment with 5-FU alone is not beneficial for people with stage II colon cancer that is MSI-high.

Another test may also help doctors and their patients with stage II colon cancer decide on adjuvant chemotherapy. The test, Oncotype DX (Genomic Health, Redwood, CA), measures the activity of 12 genes in the tumor, and a computerized program calculates a Recurrence Score® of 0 to 100 points. A low score indicates low risk, and a high score indicates high risk of recurrence within 3 years after diagnosis. The Recurrence Score is considered along with other clinical factors, such as the stage and grade of the tumor and the number of lymph nodes involved. More studies are needed before the Oncotype DX test can be recommended for routine practice, but the test is commercially available and testing may be right for some people. Talk with your doctor about whether this test would be useful for you.

Decision-making is also challenging for rectal cancers, for which there are several surgical treatment options, depending on the size and location of the cancer. In some circumstances, the size of the cancer may need to be reduced with use of chemoradiation therapy before it can be removed safely or with less risk to healthy tissue. Surgical procedures can be complicated, and there is often the potential for other organs in the pelvis to be involved. Quality-of-life issues also play an important role in deciding on the type of surgical procedure, especially with regard to the preference to save the anal sphincter and thereby preserve bowel function. A multidisciplinary consultation or a second opinion may be valuable for people with rectal cancer.

Stage IV colon or rectal cancer also involves several considerations, and treatment decisions should be made by a multidisciplinary treatment team that includes surgeons, medical oncologists and radiation oncologists. The optimal treatment depends on the number of metastatic sites, and cure may be a possibility for some patients if the metastatic tumors can be removed. In general, it is highly recommended that patients with stage IV colon or rectal cancer be evaluated by an experienced multidisciplinary team at a comprehensive or clinical cancer center before any treatment is begun.

Treatment of stage IV colorectal cancer also involves monitoring the disease response to treatment. Measurements of carcinoembryonic antigen (CEA) levels in the blood and imaging studies are used to monitor response. Experts recommend measuring the CEA level before the start of chemotherapy and then every 1 to 3 months during active treatment. Imaging studies are usually done after two and four cycles of chemotherapy. If there is evidence that disease has progressed, your doctor can suggest a different drug combination as second-line treatment.

Recurrent Disease

If cancer recurs locally — that is, in the colon or the rectum — a surgical procedure may be done to remove the tumor. Preoperative chemotherapy may be part of the treatment. If the cancer recurs in the liver or lung, treatment is similar to that described for stage IV disease. A surgical procedure may be considered, depending on the location and number of metastatic sites. If a surgical procedure is not an option (because of a person’s overall health or the location of the cancer), chemotherapy plus targeted therapy is the treatment of choice. As is the case for stage IV colorectal cancers, it is highly recommended that people with recurrent disease be evaluated by an experienced multidisciplinary team at a comprehensive or clinical cancer center.

No matter what stage of cancer you have, make sure you know the options and recommended treatments for your particular cancer so that you can make informed decisions about your treatment.

Table 1. Recommended Disease-Directed Treatment Options According to Stage of Colon or Rectal Cancer

  Surgery Chemotherapy Radiation Therapy Other
Colon Cancer
Stage 0 Polypectomy is usually sufficient; surgical resection with anastomosis or local excision may be done, depending on the size and location of the tumor Not needed Not needed Supportive care to manage symptoms
Stage I Resection with anastomosis Not needed Not needed Supportive care to manage symptoms
Stage II Resection with anastomosis Adjuvant chemotherapy if risk of recurrence is high (see text for factors that increase risk of recurrence) Usually not needed, but may be used in special circumstances Supportive care to manage symptoms and treatment-related side effects
Stage III Resection with anastomosis Yes (adjuvant) Usually not needed, but may be used in special circumstances Supportive care to manage symptoms and treatment-related side effects
Stage IV Yes, to relieve symptoms; also may be done with curative intent in combination with other treatments (such as surgical removal or ablative procedures) for the metastatic disease; evaluation by a multidisciplinary team is strongly recommended Yes, with targeted therapy; may be used preoperatively (if indicated), postoperatively, or to shrink the tumor or delay disease progression if an operation is not possible Usually not needed, but may be used in special circumstances Targeted therapy with an EGFR* inhibitor is used only if KRAS mutation testing is negative.

Supportive care to manage symptoms and treatment-related side effects.

Hospice care, when appropriate.
Rectal Cancer
Stage 0 Polypectomy is usually sufficient, but may also be local excision or transanal resection Not needed Not needed Supportive care to manage symptoms
Stage I Yes; the type of operation depends on the size and location of the tumor (the chance of recurrence may be higher with transanal resection) Not needed Not needed Supportive care to manage symptoms
Stage II Yes (after neoadjuvant treatment) Neoadjuvant chemoradiation and sometimes adjuvant chemotherapy if the risk of recurrence is high Neoadjuvant chemoradiation Supportive care to manage symptoms and treatment-related side effects
Stage III Yes (after neoadjuvant treatment) Neoadjuvant chemoradiation and adjuvant chemotherapy Neoadjuvant chemoradiation Supportive care to manage symptoms and treatment-related side effects
Stage IV Yes, to relieve symptoms; also may be done with curative intent in combination with other treatments (such as surgical removal or ablative procedures) for the metastatic disease; evaluation by a multidisciplinary team is strongly recommended Yes, with targeted therapy; used preoperatively (if indicated), postoperatively, or to shrink the tumor or delay disease progression if an operation is not possible May be used in some cases, either to relieve symptoms or as part of curative intent (preoperatively) Targeted therapy with an EGFR* inhibitor is used only if KRAS mutation testing is negative.

Supportive care to manage symptoms and treatment-related side effects.

Hospice care, when appropriate.

*EGFR = epidermal growth factor inhibitor

 

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