Treatment for Stage IV, Metastatic Cancer or Recurrent CRC

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Even though you may be terrified when you’re first told that your cancer has spread beyond your colon or rectum and is metastatic, you can take time to get the very best information and advice possible from a multidisciplinary team. This process is vitally important.

With your healthcare team, consider whether:

  • Your metastatic tumors are limited enough to be removed surgically (resectable) and might be curable
  • Your tumors are not resectable now, but with adjuvant treatment might become resectable and converted to a curable situation
  • Your cancer is widespread and unlikely to become resectable and should be treated palliatively with the goal of extending your quality of life for as long as possible

Make sure to get a second opinion, even if it takes extra time. Work with your doctor to determine how to best integrate your treatment needs with your desire to get a second opinion.


Questions to ask if you have Stage IV or Recurrent CRC

Treatment for stage IV or recurrent colorectal cancer is complex, and generally requires consultation with medical, surgical and radiological doctors.

  • What is the standard treatment for someone in my situation? What do you recommend?
  • What will my treatment schedule look like?
  • Am I eligible for a clinical trial? If yes, do you feel that would be a good choice for me?
  • What can be done to remove or treat my metastatic tumors?
  • Is there a way to determine whether specific drugs will be effective in treating my cancer? Should my tumor be genetically tested
  • How long will I receive this treatment?
  • What are the short- and long-term side effects of the treatment you are recommending? What can we do to minimize my side effects?
  • When I am in treatment and experiencing side effects, what side effects should trigger a call to your office (for example, a fever > 101, diarrhea > 4 times/day) and which can wait for my next visit?
  • How will my health be monitored during treatment? When will we know if the treatment is working?
  • If this treatment stops working for me, what’s the next option?
  • Do you have any recommendations for support groups?

For more info, visit NCCN’s Guidelines for Patients


Examples of treatment options combined to treat metastatic disease over time

  • Surgery to remove primary colon or rectal tumors
  • Drug therapy using a variety of chemotherapy and targeted treatments
  • Radiation therapy to shrink or destroy both primary and metastatic tumors
  • Radiofrequency ablation to shrink or kill tumors with heat from radio waves
  • Surgery to remove metastatic tumors in other areas of the body
  • Chemotherapy directly applied to liver metastases (Hepatic Arterial Infusion or HAI)
  • Treatment with radioactive beads called Selective Internal Radiation
  • One or more clinical trials

Surgery

If the liver, lungs, or the lining of the abdomen (peritoneum) are affected, you may undergo multiple surgeries to remove metastatic disease. Often, chemotherapy and radiation are combined with surgery to shrink tumors. Surgical treatments for metastases are highly specialized procedures which require an expert team. These are frequently done after the initial surgery is performed on your primary tumor.

Partial hepatectomy

The part of the liver with metastases is surgically removed

Pulmonary metastasectomy

lung metastases are removed by surgery or laser

Chemoembolization surgery

surgery to block the flow of blood to the liver so anti-cancer drugs can flow directly through the liver’s arteries to the cancer site

Hyperthermic Intraperitoneal Chemotherapy

peritoneal metastases are removed then chemotherapy is directed to the abdominal cavity


Chemotherapy Combinations

Chemotherapy is used to slow or stop the growth of cancer. If colon cancer continues to grow after initial chemotherapy treatment, there are many varieties and combinations of anti-cancer drugs that doctors may explore with you.

CAPOX or XELOX

    • Capecitabine (Xeloda®) plus oxaliplatin (Eloxatin®)
    • Capecitabine is an oral drug that works the same way as 5-FU inside the cancer cell.

FOLFOX

    • 5-FU, Oxaliplatin (Eloxatin®), and Leucovorin

FOLFIRI

    • 5-FU, Irinotecan (Camptosar®), and Leucovorin

These regimens may be combined with targeted therapies such as bevacizumab (Avastin®), cetuximab (Erbitux®), or panitumumab (Vectibix®). Patients who are not able to tolerate intensive therapy have other options. Doctors may recommend:

  • 5-FU plus leucovorin with or without bevacizumab (Avastin®).
  • Capecitabine (Xeloda®) with or without bevacizumab (Avastin®). Treatment with capectiabine (Xeloda®) alone should only be considered a reasonable option for selected patients who are not candidates for more aggressive combination regimens with oxaliplatin (Eloxatin®) or irinotecan (Camptosar®).

For more information on the wide variety of drug combinations for patients who have a cancer recurrence or when the first line of chemotherapy treatment doesn’t stop the growth of cancer, learn more here.

 

Content medically-reviewed by members of the Fight Colorectal Cancer Medical Advisory Board, February 2014

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