Treatment Options for Colorectal Cancer
Treatment options for colorectal cancer depend on the stage of the cancer, how well it responds to a chosen therapy, and your overall health. New therapies may be able to offer better outcomes than ever.
Colorectal cancer is the fourth most common cancer in the United States. Colorectal cancer outlook and treatment options depend on how advanced the cancer is at diagnosis, a person’s overall health, and their response to treatment.
Early stage colorectal cancer may only require surgery, while more advanced stages may use a variety of treatment methods. Each stage of cancer has various treatment options and outcomes.
In general, colorectal treatment options include:
In this article, we take a closer look at each of these treatment options — how they’re typically used and potential side effects.
Surgery is the most common initial treatment used in all stages of colorectal cancer. The goal is to remove the tumor through one of three methods of surgery:
- Local excision: This procedure is most successful as a singular treatment in the early stage of colorectal cancer. Doctors insert a small cutting tool through the rectum and into the colon to cut out (excise) the tumor. In stages 0 and 1, this may be the only treatment needed.
- Colon resection with anastomosis: This surgery addresses larger tumors. It removes the cancerous part of the colon and some nearby healthy tissue and then connects the cut ends of the colon. Lymph nodes may also be removed and examined for cancerous tissue.
- Colon resection with colostomy:This procedure is used in more advanced cancers or if the colon is too damaged to be sewn back together. Here, the colon is essentially rerouted to a stoma (an opening) outside the abdominal wall where waste can pass through. A bag is put in place to collect the waste. This procedure is called a colostomy, and it can be either temporary or permanent, depending on how much of the colon needs to be removed.
Chemotherapy or radiation treatments are commonly used after surgery to kill off any remaining cancer cells. This post-surgical treatment — called adjuvant therapy — reduces the risk of cancer returning.
Surgery plus chemotherapy as adjuvant therapy is the treatment standard for colorectal cancers in stage 3 and beyond.
Stages of colorectal cancer
Colorectal cancer treatments are different depending on how far the cancer has progressed. Here is an overview of colorectal cancer stages:
- Stage 0 (carcinoma in situ): Abnormal cells are found in the innermost layer of the colon wall.
- Stage 1: Cancer has formed in the inner layer of the colon but hasn’t spread beyond the colon or to nearby lymph nodes.
- Stage 2: Cancer has grown through the colon wall and maybe into nearby tissue but hasn’t spread to the lymph nodes.
- Stage 3: Cancer has spread to nearby lymph nodes but not to other parts of the body.
- Stage 4: Cancer has spread from the colon to distant organs and tissues.
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Chemotherapy uses specific drugs to stop the growth of cancer cells. Depending on the cancer’s stage, chemotherapy is often recommended before or after surgery to eliminate or reduce cancer cells.
While it’s possible that cancers in stage 0 or 1 may not need chemotherapy, cancers in stage 2 and higher often require it to help prevent the cancer from returning.
The specific type of chemotherapy used is determined by the cancer’s stage and location. Chemotherapy treatment often involves side effects, which vary depending on the type of medications used.
Common side effects of chemotherapy include:
- nausea and vomiting
- mouth sores
- weight loss or loss of appetite
- diarrhea
- skin and nail changes
- hair thinning
Additional chemotherapy side effects may differ based on the method and specific medications used.
Radiation therapy uses high energy X-rays or other types of radiation to kill or contain cancer cells. The type of radiation given depends on the cancer’s stage, but there are two general types of radiation therapy:
- External radiation: External radiation uses an outside machine to send radiation into the body aimed at the cancer areas. This kind of radiation is more often used to relieve symptoms and improve quality of life for people with advanced cancer.
- Internal radiation: This radiation strategy places a radioactive substance directly in contact with the cancer cells. It’s delivered into the body using catheters, seeds, wires or needles.
Radiation therapy is often used combined with chemotherapy in more advanced stages of colorectal cancers.
Ablation therapy is a minimally invasive procedure that uses heat or extreme cold to destroy abnormal or cancerous tissues. Doctors typically use the following types of ablation therapies for colorectal cancer:
- Radiofrequency ablation: This procedure uses a special probe with small electrodes to destroy localized cancer cells. The probe can either be inserted directly through the skin or through an abdominal incision. Radio waves are sent through the probe to create a current that heats and destroys the desired area.
- Cryosurgery:Cryosurgery uses extremely cold gas to destroy cancer cells. The process is similar to radiofrequency ablation, where an inserted probe delivers a freezing gas that kills cancer cells.
Radiofrequency ablation and cryosurgery are primarily used to treat unresectable advanced colorectal cancer that has spread to the liver. These procedures are typically used with other treatments, not as a standalone treatment.
Side effects of ablation procedures include:
- liver infection
- abdominal pain
- fever
- bleeding into the chest or abdominal cavities
- abnormal liver tests
Targeted therapy uses drugs or other substances to locate and attack specific cancer cells. This kind of treatment is currently limited to people with stage 4 metastatic colorectal cancer. These therapies sometimes work when chemo drugs don’t and may have different side effects.
The types of targeted therapy most used in colorectal cancer treatment include:
- Monoclonal antibodies: These lab-made immune system proteins are engineered to destroy cancer cells. The antibodies attach to a specific target on cancer cells and can then either kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion, either alone or in combination with other treatments. There are different types of monoclonal therapies:
- Vascular endothelial growth factor (VEGF) inhibitor therapy: This therapy stops new blood vessels from forming, depriving and killing cancer cells that rely on new blood vessels. VEGF inhibitor therapy does this by blocking VEGF. VEGF is a substance made by cancer cells that causes new blood vessels to form. Common VEGF inhibitor drugs include bevacizumab (Avastin) and ramucirumab (Cyramza).
- Epidermal growth factor receptor (EGFR) inhibitor therapy: EGFR inhibitor therapy stops the cancer cells from growing and dividing. It does this by preventing a protein called epidermal growth factor from finding its attachment to the cancer cell. If the protein cannot attach, then the cancer cell cannot grow. Common EGFR inhibitor drugs include cetuximab (Erbitux) and panitumumab (Vectibix).
Immunotherapy is a type of biologic therapy that uses your immune system to fight cancer. It uses proteins called “checkpoints” on immune system cells that need to be activated or turned “off” to start an immune response. Colorectal cancer cells may use these checkpoints to avoid an attack by the immune system.
Immunotherapy drugs that target these checkpoints are called “checkpoint inhibitors.” They help restore an immune system response against cancerous cells. They may be used in people whose colorectal cancer cells are positive for specific gene changes, and whose cancer cannot be surgically removed, has come back, or has spread to other parts of the body.
There are two types of checkpoint inhibitors used in advanced stage colorectal cancer:
- PD-1 Inhibitor: These are drugs that target checkpoint proteins called PD-L1 on cancer cells and PD-1 found on immune system T cells. In colorectal cancer, if PD-L1 is able to bind with PD-1, they can stop the T cell from killing tumor cells. PD-1 inhibitors stop these proteins from binding, so the T cells are able to destroy tumor cells. Two PD-1 inhibitor drugs are:
- Pembrolizumab (Keytruda):This drug can be used to treat advanced or metastatic colorectal cancer. It’s given as an intravenous infusion every 3 or 6 weeks.
- Nivolumab (Opdivo):This drug can be used alone or with other medications for people whose metastatic colorectal cancer has continued to grow after chemotherapy treatment. As a standalone medication, it’s usually given as an intravenous infusion every 2 or 4 weeks.
It’s possible to have an infusion reaction while receiving these drugs. The response may be similar to an allergic reaction. Additionally, standard side effects of immunotherapy include:
- nausea
- cough
- joint pain
- itching and skin rash
- fatigue
- loss of appetite
- constipation
- diarrhea
Immunotherapy drugs work by improving the immune system’s ability to see and attack cancer cells. However, it’s possible that the immune system may attack other body areas causing serious issues in certain organs or other body systems. For this reason, it’s important to be monitored closely while undergoing immunotherapy in the event of any adverse reactions.
Questions for your doctor
Facing colorectal cancer treatment can be overwhelming. Take notes and keep a list of questions to ask your doctor about your treatment options. Here are a few suggestions:
- What is the cancer stage and what does that mean?
- What are my treatment options?
- Will I need an ostomy?
- What’s your experience with colorectal cancer?
- What is the goal of treatment?
- How long will my treatment last?
- What kind of side effects should I expect?
- What is my outlook with this treatment?
- How will I know if the treatment is working?
- How can I prepare for treatment?