Colorectal cancer medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Elliot B. Tapper, M.D., Saarah T. Alkhairy, M.D.

Overview

The following table indicates which treatment should be performed for each stage of colorectal carcinoma.

Stage	Treatment
0 (Carcinoma in situ)	Local excision or simple polypectomy; resection and anastomosis when the tumor is too large to remove by local excision
1	Resection and anastomosis
2	Resection and anastomosis
3	Resection and anastomosis which may be followed by chemotherapy; clinical trials of nre 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, readiofrequency ablation or cryosurgery for patients who cannnot 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

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 the primary therapy if surgery is not indicated (palliative). Other therapies include radiation and support therapies.

Medical Therapy

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 (neo-adjuvant), or as the primary therapy if surgery is not indicated (palliative). 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.

Adjuvant chemotherapy One regimen involves the combination of infusional 5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX)

• 5-fluorouracil (5-FU) or Capecitabine (Xeloda®)
• Leucovorin (LV, Folinic Acid)
• Oxaliplatin (Eloxatin®)

Chemotherapy for metastatic disease Commonly used first line chemotherapy regimens involve the combination of infusional 5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX) with bevacizumab OR infusional 5-fluorouracil, leucovorin, and irinotecan (FOLFIRI) with bevacizumab

• 5-fluorouracil (5-FU) or Capecitabine
• Leucovorin (LV, Folinic Acid)
• Irinotecan (Camptosar®)
• Oxaliplatin (Eloxatin®)
• Bevacizumab (Avastin®)
• Cetuximab (Erbitux®)
• Panitumumab (Vectibix)

In clinical trials for treated/untreated metastatic disease [2]

• Bortezomib (Velcade®)
• Oblimersen (Genasense®, G3139)
• Gefitinib and Erlotinib (Tarceva®)
• Topotecan (Hycamtin®)

Radiation therapy

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.

Indications include:

• Colon cancer

• Pain relief and palliation
• Targeted at metastatic tumor deposits if they compress vital structures and/or cause pain

• Rectal cancer

• Neoadjuvant - given before surgery in patients with tumors that extend outside the rectum or have spread to 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 - to decrease the tumor burden in order to relieve or prevent symptoms

Sometimes chemotherapy agents are used to increase the effectiveness of radiation by sensitizing tumor cells if present.

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.

References

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