Colorectal Cancer – Treatment Options
In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that usually includes or combines different types of treatments. This is called a multidisciplinary team. For colorectal cancer, this generally includes a surgeon, medical oncologist, radiation oncologist, and a gastroenterologist. A gastroenterologist is a doctor who specializes in the function and disorders of the gastrointestinal tract. Cancer care teams include a variety of other health care professionals, such as physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, counselors, dietitians, and others.
Descriptions of the common types of treatments used for colorectal cancer are listed below, followed by a brief outline of treatment options listed by stage. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care.
Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patient’s preferences and overall health. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Talk with your doctor about the goals of each treatment and what you can expect while receiving the treatment. These types of talks are called “shared decision making.” Shared decision making is when you and your doctors work together to choose treatments that fit the goals of your care. Shared decision making is particularly important for colorectal cancer because there are different treatment options.
Studies have shown that these various treatment approaches provide similar benefits regardless of the patient’s age. However, older adults may have unique treatment challenges. In order to tailor the treatment to each patient, all treatment decisions should consider such factors as:
- The patient’s other medical conditions
- The patient’s overall health
- Potential side effects of the treatment plan
- Other medications that the patient already takes
- The patient’s nutritional status and social support
Below are explanations about each main type of colorectal cancer treatment.
Surgery is the removal of the tumor and some surrounding healthy tissue during an operation. It is often called surgical resection. This is the most common treatment for colorectal cancer. Part of the healthy colon or rectum and nearby lymph nodes will also be removed. While both general surgeons and specialists may perform colorectal surgery, many people talk with specialists who have additional training and experience in colorectal surgery. A surgical oncologist is a doctor who specializes in treating cancer using surgery. A colorectal surgeon is a doctor who has received additional training to treat diseases of the colon, rectum, and anus. Colorectal surgeons used to be called proctologists.
In addition to surgical resection, surgical options for colorectal cancer include:
Laparoscopic surgery. Some patients may be able to have laparoscopic colorectal cancer surgery. With this technique, several viewing scopes are passed into the abdomen while a patient is under anesthesia. Anesthesia is medicine that blocks the awareness of pain. The incisions are smaller and the recovery time is often shorter than with standard colon surgery. Laparoscopic surgery is as effective as conventional colon surgery in removing the cancer. Surgeons who perform laparoscopic surgery have been specially trained in that technique.
Colostomy for rectal cancer. Less often, a person with rectal cancer may need to have a colostomy. This is a surgical opening, or stoma, through which the colon is connected to the abdominal surface to provide a pathway for waste to exit the body. This waste is collected in a pouch worn by the patient. Sometimes, the colostomy is only temporary to allow the rectum to heal, but it may be permanent. With modern surgical techniques and the use of radiation therapy and chemotherapy before surgery when needed, most people who receive treatment for rectal cancer do not need a permanent colostomy.
Radiofrequency ablation (RFA) or cryoablation. Some patients may have surgery on the liver or lungs to remove tumors that have spread to those organs. Other ways include using energy in the form of radiofrequency waves to heat the tumors, called RFA, or to freeze the tumor, called cryoablation. Not all liver or lung tumors can be treated with these approaches. RFA can be done through the skin or during surgery. While this can help avoid removing parts of the liver and lung tissue that might be removed in a regular surgery, there is also a chance that parts of tumor will be left behind.
Side effects of surgery
Before surgery, talk with your health care team about the possible side effects from the specific surgery you will have and ask how side effects can be prevented or relieved. In general, the side effects of surgery include pain and tenderness in the area of the operation. The operation may also cause constipation or diarrhea, which usually goes away after a while. People who have a colostomy may have irritation around the stoma. If you need to have a colostomy, the doctor, nurse, or an enterostomal therapist, who is a specialist in colostomy management, can teach you how to clean the area and prevent infection.
Many people need to retrain their bowel after surgery. This may take some time and assistance. You should talk with your doctor if you do not regain good control of bowel function.
Radiation therapy is the use of high-energy x-rays to destroy cancer cells. It is commonly used for treating rectal cancer because this tumor tends to recur near where it originally started. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time.
External-beam radiation therapy. External-beam radiation therapy uses a machine to deliver x-rays to where the cancer is located. Radiation treatment is usually given 5 days a week for several weeks. It may be given in the doctor’s office or at the hospital.
Stereotactic radiation therapy. Stereotactic radiation therapy is a type of external-bean radiation therapy that may be used if a tumor has spread to the liver or lungs. This type of radiation therapy delivers a large, precise radiation dose to a small area. This technique can help save parts of the liver and lung tissue that might otherwise have to be removed during surgery. However, not all cancers that have spread to the liver or lungs can be treated in this way.
Other types of radiation therapy. For some people, specialized radiation therapy techniques, such as intraoperative radiation therapy or brachytherapy, may help get rid of small areas of cancer that can not be removed with surgery.
Intraoperative radiation therapy. Intraoperative radiation therapy uses a single, high dose of radiation therapy given during surgery.
Brachytherapy. Brachytherapy is the use of radioactive “seeds” placed inside the body. In 1 type of brachytherapy with a product called SIR-Spheres, tiny amounts of a radioactive substance called yttrium-90 are injected into the liver to treat colorectal cancer that has spread to the liver when surgery is not an option. Limited information is available about how effective this approach is, but some studies suggest that it may help slow the growth of cancer cells.
Radiation therapy for rectal cancer. For rectal cancer, radiation therapy may be used before surgery, called neoadjuvant therapy, to shrink the tumor so that it is easier to remove. It may also be used after surgery to destroy any remaining cancer cells. Both approaches have worked to treat this disease. Chemotherapy is often given at the same time as radiation therapy, called chemoradiation therapy, to increase the effectiveness of the radiation therapy.
Chemoradiation therapy is often used in rectal cancer before surgery to avoid colostomy or reduce the chance that the cancer will recur. One study found that chemoradiation therapy before surgery worked better and caused fewer side effects than the same radiation therapy and chemotherapy given after surgery. The main benefits included a lower rate of the cancer coming back in the area where it started, fewer patients who needed permanent colostomies, and fewer problems with scarring of the bowel where the radiation therapy was given.
Radiation therapy is typically given in the United States for rectal cancer over 5.5 weeks before surgery. However, for certain patients (and in certain countries), a shorter course of 5 days of radiation therapy before surgery is appropriate and/or preferred.
A newer approach to rectal cancer is currently being used for certain people. It is called total neoadjuvant therapy (or TNT). With TNT, both chemotherapy and chemoradiation therapy are given for about 6 months before surgery. This approach is still being studied to determine which patients will benefit most.
Side effects of radiation therapy
Talk with your doctor about the possible side effects of your radiation therapy regimen. Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. It may also cause bloody stools from bleeding through the rectum or blockage of the bowel. Most side effects go away soon after treatment is finished.
Sexual problems, as well as infertility (the inability to have a child) in both men and women, may occur after radiation therapy to the pelvis. Before treatment begins, talk with your doctor about the chances that the treatment will affect sexual health and fertility and the available options for preserving fertility.
Therapies using medication
Systemic therapy is the use of medication to destroy cancer cells. This type of medication is given through the bloodstream to reach cancer cells throughout the body. Systemic therapies are generally prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication.
Common ways to give systemic therapies include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).
The types of systemic therapies used for colorectal cancer include:
- Targeted therapy
Each of these types of therapies is discussed below in more detail. A person may receive 1 type of systemic therapy at a time or a combination of systemic therapies given at the same time. They can also be given as part of a treatment plan that includes surgery and/or radiation therapy.
The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. It is also important to let your doctor know if you are taking any other prescription or over-the-counter medications or supplements. Herbs, supplements, and other drugs can interact with cancer medications. Learn more about your child’s prescriptions by using searchable drug databases.
Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells.
A chemotherapy regimen, or schedule, usually consists of a specific number of cycles given over a set period of time. A patient may receive 1 drug at a time or a combination of different drugs given at the same time.
Chemotherapy may be given after surgery to eliminate any remaining cancer cells. For some people with rectal cancer, the doctor will give chemotherapy and radiation therapy before surgery to reduce the size of a rectal tumor and reduce the chance of the cancer returning.
Many drugs are approved by the U.S. Food and Drug Administration (FDA) to treat colorectal cancer in the United States. Your doctor may recommend 1 or more of them at different times during treatment. Sometimes these are combined with targeted therapy drugs (see “Targeted therapy” below).
- Capecitabine (Xeloda)
- Fluorouracil (5-FU)
- Irinotecan (Camptosar)
- Oxaliplatin (Eloxatin)
- Trifluridine/tipiracil (Lonsurf)
Some common treatment regimens using these drugs include:
- 5-FU alone
- 5-FU with leucovorin (folinic acid), a vitamin that improves the effectiveness of 5-FU
- Capecitabine, an oral form of 5-FU
- FOLFOX: 5-FU with leucovorin and oxaliplatin
- FOLFIRI: 5-FU with leucovorin and irinotecan
- Irinotecan alone
- XELIRI/CAPIRI: Capecitabine with irinotecan
- XELOX/CAPEOX: Capecitabine with oxaliplatin
- Any of the above with 1 of the following targeted therapies (see below): cetuximab (Erbitux), bevacizumab (Avastin), or panitumumab (Vectibix). In addition, FOLFIRI may be combined with either of these targeted therapies (see below): ziv-aflibercept (Zaltrap) or ramucirumab (Cyramza).
Side effects of chemotherapy
Chemotherapy may cause vomiting, nausea, diarrhea, neuropathy, or mouth sores. However, medications to prevent these side effects are available. Because of the way drugs are given, these side effects are less severe than they have been in the past for most people. In addition, patients may be unusually tired, and there is an increased risk of infection. Neuropathy, which causes tingling or numbness in feet or hands, may also occur with some drugs. Significant hair loss is an uncommon side effect with many of the drugs used to treat colorectal cancer, except irinotecan.
If side effects are particularly difficult, the dose of the drug may be lowered or a treatment session may be postponed. If you are receiving chemotherapy, you should talk with your health care team about any side effects regularly and ask which symptoms and side effects your doctor should know about right away. The side effects from chemotherapy usually go away after treatment is finished.
Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.
Not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. This helps doctors better match each patient with the most effective treatment whenever possible. In addition, research studies continue to find out more about specific molecular targets and new treatments directed at them. These drugs are becoming more important in the treatment of colorectal cancer. Learn more about the basics of targeted treatments.
Studies have shown that older patients are able to benefit from targeted therapies, similar to younger patients. In addition, the expected side effects are usually manageable in both older and younger patients.
For colorectal cancer, the following targeted therapies may be options.
Anti-angiogenesis therapy. Anti-angiogenesis therapy is focused on stopping angiogenesis, which is the process of making new blood vessels. Because a tumor needs the nutrients delivered by blood vessels to grow and spread, the goal of anti-angiogenesis therapies is to “starve” the tumor.
Bevacizumab (Avastin). When bevacizumab is given with chemotherapy, it increases the length of time people with advanced colorectal cancer live. In 2004, the FDA approved bevacizumab along with chemotherapy as the first treatment, or first-line treatment, for advanced colorectal cancer. Recent studies have shown it is also effective as second-line therapy along with chemotherapy. There are 2 drugs similar to bevacizumab, bevacizumab-awwb (Mvasi) and bevacizumab-bvzr (Zirabev), that have also been approved by the FDA to treat advanced colorectal cancer. These are called biosimilars.
Regorafenib (Stivarga). This drug is used to treat people with metastatic colorectal cancer who have already received certain types of chemotherapy and other targeted therapies.
Ziv-aflibercept (Zaltrap) and ramucirumab (Cyramza). Either of these drugs can be combined with FOLFIRI chemotherapy as a second-line treatment for metastatic colorectal cancer.
Epidermal growth factor receptor (EGFR) inhibitors. Researchers have found that drugs that block EGFR may be effective for stopping or slowing the growth of colorectal cancer.
Cetuximab (Erbitux). Cetuximab is an antibody made from mouse cells that still has some of the mouse structure.
Panitumumab (Vectibix). Panitumumab is made entirely from human proteins and is less likely to cause an allergic reaction than cetuximab.
Recent studies show that cetuximab and panitumumab do not work as well for tumors that have specific mutations, or changes, to a gene called RAS. ASCO recommends that all people with metastatic colorectal cancer who may receive an EFGR inhibitor have their tumors tested for RAS gene mutations. If a tumor has a mutated form of the RAS gene, ASCO recommends that they do not receive EFGR inhibitors. Furthermore, the FDA now recommends that both cetuximab and panitumumab only be given to people with a tumor with non-mutated, sometimes called wild-type, RAS genes.
Tumor-agnostic treatment. Larotrectinib (Vitrakvi) is a type of targeted therapy that is not specific to a certain type of cancer but focuses on a specific genetic change called an NTRK fusion. This type of genetic change is found in a range of cancers, including colorectal cancer. It is approved as a treatment for colorectal cancer that is metastatic or cannot be removed with surgery and has worsened with other treatments.
The tumor may also be tested for other molecular markers, including BRAF, HER2 overexpression, and others. These markers do not have FDA-approved targeted therapies yet, but there may be opportunities in clinical trials that are studying these molecular changes.
Side effects of targeted therapies
Talk with your doctor about possible side effects for a specific medication and how they can be managed. The side effects of targeted treatments can include a rash to the face and upper body, which can be prevented or reduced with various treatments.
Immunotherapy, also called biologic therapy, is designed to boost the body’s natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function.
Checkpoint inhibitors are an important type of immunotherapy used to treat colorectal cancer.
Pembrolizumab (Keytruda). Pembrolizumab targets PD-1, a receptor on tumor cells, preventing the tumor cells from hiding from the immune system. Pembrolizumab is used to treat metastatic colorectal cancers that have a molecular feature called microsatellite instability (MSI-H) or mismatch repair deficiency (dMMR).
Nivolumab (Opdivo). Nivolumab is used to treat people who are 12 or older and have MSI-H or dMMR metastatic colorectal cancer that has grown or spread after treatment with chemotherapy with a fluoropyrimidine (such as capecitabine and fluorouracil), oxaliplatin, and irinotecan.
Nivolumab and ipilimumab (Yervoy) combination. This combination of checkpoint inhibitors is approved to treat patients who are 12 or older and have MSI-H or dMMR metastatic colorectal cancer that has grown or spread after treatment with chemotherapy with a fluoropyrimidine, oxaliplatin, and irinotecan.
Side effects of immunotherapies
Different types of immunotherapy can cause different side effects. The most common side effects of immunotherapy may include fatigue, rash, diarrhea, nausea, fever, muscle pain, bone pain, joint pain, abdominal pain, itching, vomiting, cough, decreased appetite, and shortness of breath. Talk with your doctor about possible side effects for the immunotherapy recommended for you.
Physical, emotional, and social effects of cancer
Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.
Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive palliative care along with treatment for the cancer often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.
Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation therapy.
Before treatment begins, talk with your doctor about the goals of each treatment in the treatment plan. You should also talk about the possible side effects of the specific treatment plan and palliative care options.
During treatment, your health care team may ask you to answer questions about your symptoms and side effects and to describe each problem. Be sure to tell the health care team if you are experiencing a problem. This helps the health care team treat any symptoms and side effects as quickly as possible. It can also help prevent more serious problems in the future.
Treatment options by stage
In general, stages 0, I, II, and III are often curable with surgery. However, many people with stage III colorectal cancer, and some with stage II, receive chemotherapy after surgery to increase the chance of eliminating the disease. People with stage II and III rectal cancer will also receive radiation therapy with chemotherapy either before or after surgery. Stage IV is not often curable, but it is treatable, and the growth of the cancer and the symptoms of the disease can be managed. Clinical trials are also a treatment option for each stage.
Stage 0 colorectal cancer
The usual treatment is a polypectomy, or removal of a polyp, during a colonoscopy. There is no additional surgery unless the polyp cannot be fully removed.
Stage I colorectal cancer
Surgical removal of the tumor and lymph nodes is usually the only treatment needed.
Stage II colorectal cancer
Surgery is often the first treatment. People with stage II colorectal cancer should talk with their doctor about whether more treatment is needed after surgery because some people receive adjuvant chemotherapy. Adjuvant chemotherapy is treatment after surgery with the goal of trying to destroy any remaining cancer cells. However, cure rates for surgery alone are quite good, and there are few benefits of additional treatment for people with this stage of colorectal cancer. Learn more about adjuvant therapy for stage II colorectal cancer. A clinical trial is also an option after surgery.
For stage II rectal cancer, radiation therapy is usually given in combination with chemotherapy, either before or after surgery. Additional chemotherapy may be given after surgery as well.
Stage III colorectal cancer
Treatment usually involves surgical removal of the tumor followed by adjuvant chemotherapy. A clinical trial may also an option. For rectal cancer, radiation therapy may be used with chemotherapy before or after surgery, along with adjuvant chemotherapy.
Metastatic (stage IV) colorectal cancer
If cancer spreads to another part in the body from where it started, doctors call it metastatic cancer. Colorectal cancer can spread to distant organs, such as the liver, lungs, the tissue called the peritoneum that lines the abdomen, or a woman’s ovaries. If this happens, it is a good idea to talk with doctors who have experience treating this stage of cancer. Doctors can have different opinions about the best standard treatment plan. Clinical trials might also be an option.
Your treatment plan may include a combination of surgery, radiation therapy, immunotherapy, and chemotherapy, which can be used to slow the spread of the disease and often temporarily shrink a cancerous tumor. Palliative care will also be important to help relieve symptoms and side effects.
At this stage, surgery to remove the portion of the colon where the cancer started usually cannot cure the cancer, but it can help relieve blockage of the colon or other problems related to the cancer. Surgery may also be used to remove parts of other organs that contain cancer, called resection, and can cure some people if a limited amount of cancer spreads to a single organ, such as the liver or a lung.
If the colorectal cancer has spread only to the liver and if surgery is possible—either before or after chemotherapy—there is a chance of complete cure. Even when curing the cancer is not possible, surgery may add months or even years to a person’s life. Determining who can benefit from surgery for cancer that has spread to the liver is often a complicated process that involves multiple doctors with different specialties working together to plan the best treatment option.
For most people, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. You and your family are encouraged to talk about how you feel with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.
Remission and the chance of recurrence
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.
A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions are permanent, it is important to talk with your doctor about the possibility of the cancer returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return.
If the cancer returns after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).
When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence. After this testing is done, you and your doctor will talk about the treatment options. Often the treatment plan will include the treatments described above, such as surgery, chemotherapy, and radiation therapy, but they may be used in a different combination or given at a different pace. Your doctor may suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Generally, the treatment options for recurrent cancer are the same as those for metastatic cancer (see above) and include surgery, radiation therapy, and chemotherapy. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.
People with recurrent cancer often experience emotions such as disbelief or fear. You are encouraged to talk with the health care team about these feelings and ask about support services to help you cope.
If treatment does not work
Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.
This diagnosis is stressful, and for many people, advanced cancer is difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.
People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment can make staying at home a workable option for many families.
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