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To view the medical therapy of familial adenomatous polyposis (FAP), click [[Familial adenomatous polyposis medical therapy|'''here''']]<br>
To view the medical therapy of familial adenomatous polyposis (FAP), click [[Familial adenomatous polyposis medical therapy|'''here''']]<br>
To view the medical therapy of hereditary nonpolyposis colorectal cancer (HNPCC), click [[Hereditary nonpolyposis colorectal cancer medical therapy|'''here''']]<br><br>
To view the medical therapy of hereditary nonpolyposis colorectal cancer (HNPCC), click [[Hereditary nonpolyposis colorectal cancer medical therapy|'''here''']]<br><br>
{{CMG}} {{AE}}  Saarah T. Alkhairy, M.D.; Elliot B. Tapper, M.D.
{{CMG}} {{AE}}  {{RAK}}; Saarah T. Alkhairy, M.D.; Elliot B. Tapper, M.D.


==Overview==
==Overview==
Line 10: Line 10:
==Medical Therapy==
==Medical Therapy==


The mainstay of treatment for colorectal cancer is surgical resection; however, chemotherapy and radiotherapy have proven to also play an important role in therapy depending on the stage at diagnosis.
The mainstay of treatment for colorectal cancer is surgical resection; however, chemotherapy and radiotherapy have proven to also play an important role in treatment depending on the stage at diagnosis.<ref name="pmid28560805">{{cite journal| author=Ma B, Gao P, Wang H, Xu Q, Song Y, Huang X et al.| title=What has preoperative radio(chemo)therapy brought to localized rectal cancer patients in terms of perioperative and long-term outcomes over the past decades? A systematic review and meta-analysis based on 41,121 patients. | journal=Int J Cancer | year= 2017 | volume= 141 | issue= 5 | pages= 1052-1065 | pmid=28560805 | doi=10.1002/ijc.30805 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28560805  }} </ref>
=== Neoadjuvant chemotherapy or chemoradiotherapy ===
Neoadjuvant chemotherapy or chemoradiotherapy is recommended among patients with advanced rectal cancer.<ref name="pmid28560805" />
* Preoperative chemoradiotherapy is recommended for patients with clinical T3N0 or T4N0 tumors.
* T1 or T2 rectal cancer patients, with a suspicion of lymph node involvement on MRI, may also benefit from neoadjuvant chemoradiotherapy.


The following table indicates which treatment should be performed for each stage of colorectal carcinoma.<ref>[http://www.cancer.gov/types/colorectal/patient/colon-treatment-pdq#section/all]</ref><ref>{{Cite journal
*
 
Neoadjuvant chemoradiotherapy may be used to treat locally advanced colon cancer patients; however, studies have yet to prove the effectiveness of this regimen due to:<ref name="pmid22632848">{{cite journal| author=Cukier M, Smith AJ, Milot L, Chu W, Chung H, Fenech D et al.| title=Neoadjuvant chemoradiotherapy and multivisceral resection for primary locally advanced adherent colon cancer: a single institution experience. | journal=Eur J Surg Oncol | year= 2012 | volume= 38 | issue= 8 | pages= 677-82 | pmid=22632848 | doi=10.1016/j.ejso.2012.05.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22632848  }} </ref>
* Increased chemotherapy related toxicity
* Difficulty of targeting specific portions of the colon via radiation (the rectum does not move as much as the colon and is easier to target)
 
=== Adjuvant chemotherapy ===
Adjuvant chemotherapy is recommended for patients with advanced, node-positive, colon cancer.
 
=== Postoperative radiotherapy ===
Postoperative radiotherapy is not routinely recommended for colon cancer since it could lead to [[radiation enteritis]].
 
It's use among patients with rectal cancer is advised for patients with transmural invasion or local invasion to lymph nodes.
 
It may also be used to target [[metastasis|metastatic]] tumor deposits if they compress vital structures and/or cause pain.
 
Radiotherapy plays a role in palliative care of colorectal cancer patients as it decreases the tumor burden in order to relieve or prevent symptoms.
 
=== Stage specific therapy ===
The following table indicates which treatment should be performed for each stage of colorectal cancer.<ref>{{Cite journal
  | author = [[Yasmine Samir Galal]], [[Tarek Tawfik Amin]], [[Abdulelah Khalid Alarfaj]], [[Abdulaziz Abdullah Almulhim]], [[Abdullah Abdulmohsen Aljughaiman]], [[Abdulrhaman Khaled Almulla]] & [[Rehab Ahmed Abdelhai]]
  | author = [[Yasmine Samir Galal]], [[Tarek Tawfik Amin]], [[Abdulelah Khalid Alarfaj]], [[Abdulaziz Abdullah Almulhim]], [[Abdullah Abdulmohsen Aljughaiman]], [[Abdulrhaman Khaled Almulla]] & [[Rehab Ahmed Abdelhai]]
  | title = Colon Cancer among Older Saudis: Awareness of Risk Factors and Early Signs, and Perceived Barriers to Screening
  | title = Colon Cancer among Older Saudis: Awareness of Risk Factors and Early Signs, and Perceived Barriers to Screening
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{| {{table}} cellpadding="4" cellspacing="0" style="border:#c9c9c9 1px solid; margin: 1em 1em 1em 0; border-collapse: collapse;"
{| {{table}} cellpadding="4" cellspacing="0" style="border:#c9c9c9 1px solid; margin: 1em 1em 1em 0; border-collapse: collapse;"


| style="background:#f0f0f0;" align="center" |'''Stage'''
| style="background:#f0f0f0;" align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Stage'''


| style="background:#f0f0f0;" align="center" |'''Treatment'''
| style="background:#f0f0f0;" align="center" style="background:#4479BA; color: #FFFFFF;" + |'''Treatment'''


|-
|-


| '''0 (Carcinoma in situ)'''||Local excision or simple [[polypectomy]]; resection and [[anastomosis]] when the tumor is too large to remove by local excision
| '''0 (Carcinoma in situ)'''||Local excision or simple [[polypectomy]]; resection + [[anastomosis]] (when the tumor is too large to remove by local excision)


|-
|-


| '''1'''||[[Resection]] and [[anastomosis]]
| '''1'''||[[Resection]] + [[anastomosis]]


|-
|-


| '''2'''||[[Resection]] and [[anastomosis]] which may be followed by [[chemotherapy]]
| '''2'''||[[Resection]] + [[anastomosis]] +/- adjuvant [[chemotherapy]]


|-
|-


| '''3'''||[[Resection]] and [[anastomosis]] which may be followed by [[chemotherapy]]; clinical trials of new [[chemotherapy]] regimens after [[surgery]]
| '''3'''||[[Resection]] + [[anastomosis]] +/- adjuvant [[chemotherapy]]; clinical trials of new [[chemotherapy]] regimens after [[surgery]]


|-
|-
Line 80: Line 103:


|}
|}
===Chemotherapy===
 
[[Chemotherapy]] is used to reduce the likelihood of metastasis developing, shrink tumor size, and slow tumor growth. [[Chemotherapy]] is often applied after surgery ([[adjuvant]]), before surgery ([[Neoadjuvant chemotherapy|neo-adjuvant]]), or as the primary therapy if surgery is not indicated ([[Palliative therapy|palliative]]).  The treatments listed here have been shown in [[clinical trial]]s to improve survival and/or reduce [[mortality]] rate and have been approved for use by the US [[Food and Drug Administration]].
===Chemotherapeutic agents===
[[Chemotherapy]] is used to reduce the likelihood of metastasis developing, shrink tumor size, and slow tumor growth.
 
The treatments listed here have been shown in [[clinical trial]]s to improve survival and/or reduce [[mortality]] rate and have been approved for use by the US [[Food and Drug Administration]]:<ref>[http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancer-treating-by-stage-colon]</ref>
 
==== Stage 0 & 1 ====
Resection without the use of chemotherapy is recommended for these stages.


====Stage 2====
====Stage 2====
The main options for [[adjuvant chemotherapy]] for this stage include [[5-FU]] and [[leucovorin]] (alone) OR [[capecitabine]], but other combinations may also be used
The main options for [[adjuvant chemotherapy]] for this stage include:
* [[5-FU]] + [[leucovorin]]  
* [[capecitabine]] (alone)


====Stage 3====
====Stage 3====


The main options for [[adjuvant chemotherapy]] for this stage are ([[5-FU]], [[leucovorin]] and [[oxaliplatin]]) OR ([[capecitabine]] and [[oxaliplatin]]) are used most often, but some patients may receive [[5-FU]] and [[leucovorin]] OR [[capecitabine]] alone based on their age and health needs
The main options for [[adjuvant chemotherapy]] for this stage include:
* [[5-FU]]+ [[leucovorin]] + [[oxaliplatin]]
* [[capecitabine]] + [[oxaliplatin]]


====Stage 4====
====Stage 4====
Most patients with stage IV cancer will get [[chemotherapy]]. The most commonly used regimens include the following<ref>[http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancer-treating-by-stage-colon]</ref>:
The most commonly used regimens include the following:
*[[Leucovorin]], [[5-FU]], and [[oxaliplatin]]  
*[[Leucovorin]] + [[5-FU]] + [[oxaliplatin]]  
*[[Leucovorin]], [[5-FU]], and [[irinotecan]]  
*[[Leucovorin]] + [[5-FU]] + [[irinotecan]]  
*[[Capecitabine]] and [[oxaliplatin]]  
*[[Capecitabine]] + [[oxaliplatin]]  
*Any of the above combinations plus either [[bevacizumab]] or [[cetuximab]] (but not both)
*Any of the above combinations plus either [[bevacizumab]] or [[cetuximab]] (but not both)
*[[5-FU]] and [[leucovorin]], with or without [[bevacizumab]]
*[[5-FU]] + [[leucovorin]]
*[[Capecitabine]], with or without [[bevacizumab]]
**With or without [[bevacizumab]]
*[[Leucovorin]], [[5-FU]], [[oxaliplatin]], and [[irinotecan]]
*[[Capecitabine]]
*[[Irinotecan]], with or without [[cetuximab]]
**With or without [[bevacizumab]]
*[[Cetuximab]] alone
*[[Leucovorin]] + [[5-FU]] + [[oxaliplatin]] + [[irinotecan]]
*[[Panitumumab]] alone
*[[Irinotecan]]
*[[Regorafenib]] alone
**With or without [[cetuximab]]
*[[Cetuximab]]  
**Alone
*[[Panitumumab]]  
**Alone
*[[Regorafenib]]  
**Alone


=====Radiation therapy=====
===Support therapies===
[[Radiotherapy]] is not used routinely in colon cancer since it could lead to [[radiation enteritis]]. It is also difficult to target specific portions of the colon.  It is more commonly performed in rectal cancer since the rectum does not move as much as the colon and is easier to target.   
Cancer diagnosis very often results in an enormous change in the patient's psychological well-being.   


Indications include:
Various support resources are available from hospitals and other agencies which provide [[counseling]], social service support, [[cancer support group]]s, and other services. 
*[[Colon cancer]]
:*Pain relief and palliation
:*Targeted at [[metastasis|metastatic]] tumor deposits if they compress vital structures and/or cause pain
*[[Rectal cancer]]
:*[[Neoadjuvant chemotherapy|Neoadjuvant]] - given before surgery in patients with tumors that extend outside the rectum or have spread to [[Lymph nodes|regional lymph nodes]] in order to decrease the risk of recurrence following surgery or to allow for less invasive surgical approaches
:*[[Adjuvant]] - where a tumor perforates the rectum or involves regional lymph nodes (AJCC T3 or T4 tumors or Duke's B or C tumors)
:*[[Palliative therapy|Palliative]] - to decrease the tumor burden in order to relieve or prevent symptoms


Sometimes [[chemotherapy]] agents are used to increase the effectiveness of [[Radiation therapy|radiation]] by sensitizing tumor cells if present.
These services help to mitigate some of the difficulties of integrating a patient's medical complications into other parts of their life.<ref name="pmid26327863">{{cite journal| author=Woźniak K, Iżycki D| title=Cancer: a family at risk. | journal=Prz Menopauzalny | year= 2014 | volume= 13 | issue= 4 | pages= 253-61 | pmid=26327863 | doi=10.5114/pm.2014.45002 | pmc=4520372 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26327863  }}</ref>
 
===Support therapies===
Cancer diagnosis very often results in an enormous change in the patient's psychological well-being.  Various support resources are available from hospitals and other agencies which provide [[counseling]], social service support, [[cancer support group]]s, and other services.  These services help to mitigate some of the difficulties of integrating a patient's medical complications into other parts of their life.


==References==
==References==

Latest revision as of 20:12, 10 October 2019

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To view the medical therapy of familial adenomatous polyposis (FAP), click here
To view the medical therapy of hereditary nonpolyposis colorectal cancer (HNPCC), click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2] Associate Editor(s)-in-Chief: Roukoz A. Karam, M.D.[3]; Saarah T. Alkhairy, M.D.; Elliot B. Tapper, M.D.

Overview

Chemotherapy is used to reduce the likelihood of metastasis developing, shrink tumor size, and slow tumor growth. Chemotherapy is often applied after surgery (adjuvant), before surgery (neo-adjuvant), or as primary therapy if surgery is not indicated (palliative). Other therapies include radiation and support therapies.

Medical Therapy

The mainstay of treatment for colorectal cancer is surgical resection; however, chemotherapy and radiotherapy have proven to also play an important role in treatment depending on the stage at diagnosis.[1]

Neoadjuvant chemotherapy or chemoradiotherapy

Neoadjuvant chemotherapy or chemoradiotherapy is recommended among patients with advanced rectal cancer.[1]

  • Preoperative chemoradiotherapy is recommended for patients with clinical T3N0 or T4N0 tumors.
  • T1 or T2 rectal cancer patients, with a suspicion of lymph node involvement on MRI, may also benefit from neoadjuvant chemoradiotherapy.

Neoadjuvant chemoradiotherapy may be used to treat locally advanced colon cancer patients; however, studies have yet to prove the effectiveness of this regimen due to:[2]

  • Increased chemotherapy related toxicity
  • Difficulty of targeting specific portions of the colon via radiation (the rectum does not move as much as the colon and is easier to target)

Adjuvant chemotherapy

Adjuvant chemotherapy is recommended for patients with advanced, node-positive, colon cancer.

Postoperative radiotherapy

Postoperative radiotherapy is not routinely recommended for colon cancer since it could lead to radiation enteritis.

It's use among patients with rectal cancer is advised for patients with transmural invasion or local invasion to lymph nodes.

It may also be used to target metastatic tumor deposits if they compress vital structures and/or cause pain.

Radiotherapy plays a role in palliative care of colorectal cancer patients as it decreases the tumor burden in order to relieve or prevent symptoms.

Stage specific therapy

The following table indicates which treatment should be performed for each stage of colorectal cancer.[3][4][5][6]

Stage Treatment
0 (Carcinoma in situ) Local excision or simple polypectomy; resection + anastomosis (when the tumor is too large to remove by local excision)
1 Resection + anastomosis
2 Resection + anastomosis +/- adjuvant chemotherapy
3 Resection + anastomosis +/- adjuvant chemotherapy; clinical trials of new chemotherapy regimens after surgery
4 (and recurrent colon cancer) Local excision for tumors that have recurred; resection with or without anastomosis; surgery to remove parts of other organs where the cancer may have recurred or spread (chemotherapy can be given to shrink the tumor, radiofrequency ablation or cryosurgery for patients who can not have surgery, chemoembolization of the hepatic artery); radiation therapy or chemotherapy may be offered as palliative therapy, chemotherapy and/or targeted therapy with a monoclonal antibody or an angiogenesis inhibitor; clinical trials of chemotherapy and/or targeted therapy

Chemotherapeutic agents

Chemotherapy is used to reduce the likelihood of metastasis developing, shrink tumor size, and slow tumor growth.

The treatments listed here have been shown in clinical trials to improve survival and/or reduce mortality rate and have been approved for use by the US Food and Drug Administration:[7]

Stage 0 & 1

Resection without the use of chemotherapy is recommended for these stages.

Stage 2

The main options for adjuvant chemotherapy for this stage include:

Stage 3

The main options for adjuvant chemotherapy for this stage include:

Stage 4

The most commonly used regimens include the following:

Support therapies

Cancer diagnosis very often results in an enormous change in the patient's psychological well-being.

Various support resources are available from hospitals and other agencies which provide counseling, social service support, cancer support groups, and other services.

These services help to mitigate some of the difficulties of integrating a patient's medical complications into other parts of their life.[8]

References

  1. ↑ 1.0 1.1 Ma B, Gao P, Wang H, Xu Q, Song Y, Huang X; et al. (2017). "What has preoperative radio(chemo)therapy brought to localized rectal cancer patients in terms of perioperative and long-term outcomes over the past decades? A systematic review and meta-analysis based on 41,121 patients". Int J Cancer. 141 (5): 1052–1065. doi:10.1002/ijc.30805. PMID 28560805.
  2. ↑ Cukier M, Smith AJ, Milot L, Chu W, Chung H, Fenech D; et al. (2012). "Neoadjuvant chemoradiotherapy and multivisceral resection for primary locally advanced adherent colon cancer: a single institution experience". Eur J Surg Oncol. 38 (8): 677–82. doi:10.1016/j.ejso.2012.05.001. PMID 22632848.
  3. ↑ Yasmine Samir Galal, Tarek Tawfik Amin, Abdulelah Khalid Alarfaj, Abdulaziz Abdullah Almulhim, Abdullah Abdulmohsen Aljughaiman, Abdulrhaman Khaled Almulla & Rehab Ahmed Abdelhai (2016). "Colon Cancer among Older Saudis: Awareness of Risk Factors and Early Signs, and Perceived Barriers to Screening". Asian Pacific journal of cancer prevention : APJCP. 17 (4): 1837–1846. PMID 27221862.
  4. ↑ Samir Pathak, Sanjay Pandanaboyana, Ian Daniels, Neil Smart & K. R. Prasad (2016). "Obesity and colorectal liver metastases: Mechanisms and management". Surgical oncology. 25 (3): 246–251. doi:10.1016/j.suronc.2016.05.021. PMID 27566030.
  5. ↑ Masato Watanabe, Masanori Tada, Takafumi Satomi, Daichi Chikazu, Masashi Mizumoto & Hideyuki Sakurai (2016). "Metastatic rectal adenocarcinoma in the mandibular gingiva: a case report". World journal of surgical oncology. 14 (1): 199. doi:10.1186/s12957-016-0958-6. PMID 27473859.
  6. ↑ Vivek Subbiah & Howard Jack West (2016). "Jaundice (Hyperbilirubinemia) in Cancer". JAMA oncology. 2 (8): 1103. doi:10.1001/jamaoncol.2016.1236. PMID 27416009.
  7. ↑ [1]
  8. ↑ Woźniak K, Iżycki D (2014). "Cancer: a family at risk". Prz Menopauzalny. 13 (4): 253–61. doi:10.5114/pm.2014.45002. PMC 4520372. PMID 26327863.


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