Treatments for Colon Cancer







The options for treatments for colon cancer

A cancer diagnosis almost always makes people feel they must get treatment as soon as possible. But it's important to take time to consider all your treatment choices so you can make the one that is right for you. If time permits, you may want to get a second opinion from another doctor. This can help you feel more confident about the treatment plan you choose. It is also important to know that your chances for having the best possible outcome are highest in the hands of a medical team that has a lot of experience in treating colorectal cancer. You should ask questions that will help you feel comfortable with the experience of your doctor and medical team. You may want to read our document Choosing a Doctor and Hospital.

How is colorectal cancer treated? These views are based on studies published in medical journals, as well as their own professional experience. It is intended to help you and your family make informed decisions, together with your doctor.

Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options.

The following information is a summary of the types of treatments available to people with colon and rectal cancers. The usual treatments for colorectal cancers at each stage are then discussed.

The main types of treatment for colon cancer and rectal cancer are surgery, radiation therapy, chemotherapy and targeted therapies called monoclonal antibodies. Depending on the stage of the cancer, 2 or more of these types of treatment may be combined at the same time or used after one another.

After the cancer is found it is important to take time and think about your possible choices. In choosing a treatment plan, one of the most important factors is the stage of the cancer. Other factors to consider include your overall health, the likely side effects of the treatment, and the probability of curing the disease, extending life, or relieving symptoms.



When considering your treatment options it is often a good idea to seek a second opinion, if possible. This may provide you with more information and help you feel more confident about the treatment plan you have chosen. It is also important to know that your chances for having the best possible outcome are highest in the hands of a medical team that is experienced in treating colorectal cancer.

What should I ask my doctor about my cancer?

As you cope with cancer and cancer treatment, you need to have honest, open discussions with your doctor. You should feel free to ask any question that's on your mind no matter how small it might seem. Here are some questions you might want to ask at points during your treatment. Nurses, social workers, and other members of the treatment team may also be able to answer many of your questions.

-Where is my cancer located?

-Has my cancer spread beyond where it started?

-What is the stage (extent) of my cancer and what does that mean in my case?

-Are there other tests that need to be done before we can decide on treatment?

-How much experience do you have treating this type of cancer?

-Should I get a second opinion?

-What treatment choices do I have?

-What do you recommend and why?

-What risks or side effects are there to the treatments you suggest? Are there things I can do to reduce these side effects?

-What should I do to be ready for treatment?

-How long will treatment last? What will it involve? Where will it be done?

-How will treatment affect my daily activities?

-What are the chances my cancer will recur (come back) with these treatment plans?

-What would we do if the treatment doesn't work or if the cancer recurs?

-What type of follow-up might I need after treatment?

Along with these sample questions, be sure to write down some of your own. For instance, you might want to know how long it might take to recover so you can plan your work schedule. Or you may want to ask about clinical trials for which you may qualify.

How is treatment planned?

Although planning cancer treatment may take some time, most people are anxious to start treatment. They worry that extra appointments for tests and consulting with other doctors will take up time that could be spent treating the cancer.

How long is too long? Different types of cancer grow at different rates. Most cancers, however, do not grow very quickly, so there is usually time to gather information about your cancer, talk with specialists, and decide which treatment is best for you. Keep in mind that the information gathered during this planning period is important in choosing the best treatment plan for you. However, if you are worried that treatment is not starting right away, discuss your concerns with your physician.

Gathering information about your cancer is the first step your cancer care team will take. A biopsy (removal of a small tissue sample so it can be looked at under a microscope) and other lab tests, physical exams, your signs and symptoms, and imaging tests also are used to determine the best treatment for you. Your doctor will use all of this information to select treatment options and recommendations. He or she may talk with other specialists and with other health care professionals to help plan your treatment.



Surgery

The types of surgery used to treat colon and rectal cancers are slightly different and are described separately.

Surgery is often the main treatment for earlier stage colon cancers.

Open colectomy

A colectomy (sometimes called a hemicolectomy or segmental resection) involves removing part of the colon, as well as nearby lymph nodes.

Before surgery, you will most likely be instructed to completely empty your bowel.. This is done with a bowel preparation, which may consist of laxatives and enemas. Just before the surgery, you will be given general anesthesia, which puts you into a deep sleep.

During the surgery, your surgeon will make an incision in your abdomen. He or she will remove the part of the colon with the cancer and a small segment of normal colon on either side of your cancer. Usually, about one fourth to one third of your colon is removed, but more or less may be removed depending on the exact size and location of the cancer. The remaining sections of your colon are then reattached. Nearby lymph nodes are removed at this time as well. Most experts feel that taking out as many nearby lymph nodes as possible is important, but at least 12 should be removed.

When you wake up after surgery, you will have some pain and will probably need pain medicines for 2 or 3 days. For the first couple of days, you will be given intravenous (IV) fluids. During this time you may not be able to eat or you may be allowed limited liquids, as the colon needs some time to recover. But a colon resection rarely causes any major problems with digestive functions, and you should be able to eat solid food in a few days.

It's important that you are as healthy as possible for this type of major surgery, although in some cases an operation may need to be done right away. If the tumor is large and has blocked your colon, it may be possible for the doctor to use a colonoscope to put a stent (a hollow metal or plastic tube) inside the colon to keep it open and relieve the blockage for a short time to help prepare for surgery a few days later.

If a stent cannot be placed or if the tumor has caused a hole in the colon, surgery may be needed right away. This usually is the same type of operation as above to remove the cancer, but instead of reconnecting the segments of the colon, the top end of the colon is attached to an opening (stoma) in the skin of the abdomen to allow body wastes out. This is known as a colostomy and is usually temporary. A removable collecting bag is connected to the stoma to hold the waste. Once you are healthier, another operation (known as a colostomy reversal) can be done to attach the ends of the colon back together. Rarely, if a tumor can't be removed or a stent placed, the colostomy may need to be permanent. For more information on colostomies, refer to the separate American Cancer Society document, Colostomy: A Guide.

Laparoscopic-assisted colectomy

This newer approach to removing part of the colon and nearby lymph nodes may be an option for some earlier stage cancers. Instead of making one long incision in the abdomen, the surgeon makes several smaller incisions. Special long instruments are inserted through these incisions to remove part of the colon and lymph nodes. One of the instruments has a small video camera on the end, which allows the surgeon to see inside the abdomen. Once the diseased part of the colon has been freed, one of the incisions is made larger to allow for its removal.

Because the incisions are smaller than with a standard colectomy, patients may recover slightly faster and have less pain than they do after standard colon surgery.

Laparoscopic-assisted surgery is as likely to be curative as the standard approach for colon cancers. But the surgery requires special expertise. If you are considering this approach, be sure to look for a skilled surgeon who has done a lot of these operations.

Polypectomy and local excision

Some early colon cancers (stage 0 and some early stage I tumors) or polyps can be removed by surgery through a colonoscope. When this is done, the surgeon does not have to cut into the abdomen. For a polypectomy, the cancer is removed as part of the polyp, which is cut at its stalk (the area that resembles the stem of a mushroom). Local excision removes superficial cancers and a small amount of nearby tissue.

Rectal surgery

Surgery is usually the main treatment for rectal cancer, although radiation and chemotherapy will often be given before or after surgery. Several surgical methods are used for removing or destroying rectal cancers.

Polypectomy and local excision

These procedures, described in the colon surgery section, can be used to remove superficial cancers or polyps. They are done with instruments inserted through the anus, without making a surgical opening in the skin of the abdomen.

Local transanal resection (full thickness resection)

As with polypectomy and local excision, local transanal resection is done with instruments inserted through the anus, without making an opening in the skin of the abdomen. This operation involves cutting through all layers of the rectum to remove cancer as well as some surrounding normal rectal tissue. This procedure can be used to remove some stage I rectal cancers that are relatively small and not too far from the anus.

Transanal endoscopic microsurgery (TEM)

This operation can sometimes be used for early stage cancers that are higher in the rectum than could be reached using the standard transanal resection (see above). A specially designed microscope is placed through the anus, allowing the surgeon to do a transanal resection with great precision and accuracy. This operation is only done at certain centers, as it requires special equipment and surgeons with special training and experience.

Low anterior resection

Some stage I rectal cancers and most stage II or III cancers in the upper third of the rectum (close to where it connects with the colon) can be removed by low anterior resection. In this operation the tumor is removed without affecting the anus. After low anterior resection, your colon will be attached to the remaining part of the rectum and you will move your bowels in the usual way.

A low anterior resection is like most abdominal operations. You will most likely be instructed to take laxatives and enemas before surgery to completely clean out the intestines. Just before surgery, you will be given general anesthesia, which puts you into a deep sleep. The surgeon makes an incision in the abdomen. Then the surgeon removes the cancer and a margin of normal tissue on either side of the cancer, along with nearby lymph nodes and a large amount of fatty and fibrous tissue around the rectum. The colon is then reattached to the rectum that is remaining so that a permanent colostomy is not necessary. If radiation and chemotherapy have been given before surgery, it is common for a temporary ileostomy to be made (where the last part of the small intestine -- the ileum -- is brought out through a hole in the abdominal wall). Usually this can be closed about 8 weeks later.

The usual hospital stay for a low anterior resection is 4 to 7 days, depending on your overall health. Recovery time at home may be 3 to 6 weeks.

Proctectomy with colo-anal anastomosis

Some stage I and most stage II and III rectal cancers in the middle and lower third of the rectum will require removal of the entire rectum (proctectomy) and the colon attached to the anus. This is called a colo-anal anastomosis (anastomosis means connection). Removal of the rectum is necessary in order to do a total mesorectal excision (TME), which is required to remove all of the lymph nodes near the rectum. This is a harder procedure to do, but modern techniques have made it possible. Sometimes when a colo-anal anastomosis is done, a small pouch is made by doubling back a short segment of colon (colonic J-pouch) or by enlarging a segment (coloplasty). This small reservoir of colon then functions as a storage space for fecal matter like the rectum did before surgery. When special techniques are needed to avoid a permanent colostomy, you may need to have a temporary ileostomy opening for about 8 weeks while the bowel heals. A second operation is then done to close the ileostomy opening.

The usual hospital stay for a colo-anal anastomosis, like a low anterior resection, is 4 to 7 days, depending on your overall health. Recovery time at home may be 3 to 6 weeks.

Abdominoperineal (AP) resection

This operation is more involved than a low anterior resection. It can be used to treat some stage I cancers and many stage II or III rectal cancers in the lower third of the rectum (the part nearest to the anus), especially if the cancer is growing into the sphincter muscle (the muscle that keeps the anus closed and prevents stool leakage). Here, the surgeon makes one incision in the abdomen, and another in the perineal area around the anus. This incision allows the surgeon to remove the anus and the tissues surrounding it, including the sphincter muscle. Because the anus is removed, you will need a permanent colostomy to allow stool a path out of the body.

As with a low anterior resection or a colo-anal anastomosis, the usual hospital stay for a low anterior resection or an AP resection is 4 to 7 days, depending on your overall health. Recovery time at home may be 3 to 6 weeks.

Pelvic exenteration

If the rectal cancer is growing into nearby organs, a pelvic exenteration may be recommended. This is an extensive operation. Not only will the surgeon remove the rectum, but also nearby organs such as the bladder, prostate (in men), or uterus (in women) if the cancer has spread to these organs. You will need a colostomy after pelvic exenteration. If the bladder is removed, you will also need a urostomy (opening where urine exits the front of the abdomen and is held in a portable pouch).

Side effects of colorectal surgery

Potential side effects of surgery depend on several factors, including the extent of the operation and a person's general health before surgery. Most people will have at least some pain after the operation, although this can usually be controlled with medicines if needed. Eating problems usually resolve within a few days of surgery.

Other problems may include bleeding from the surgery, blood clots in the legs, and damage to nearby organs during the operation. Rarely, the connections between the ends of the intestine may not hold together completely and may leak, which can lead to infection. It is also possible that the incision might open up, causing an open wound. After the surgery, you might develop scar tissue that causes tissues in the abdomen to stick together. These are called adhesions. In some cases, adhesions may cause the bowel to become blocked, requiring further surgery.

(b>Colostomy or ileostomy

Some people may require a temporary or permanent colostomy (or ileostomy) after surgery. This may take some time to get used to and may require some lifestyle adjustments. If you have had a colostomy or ileostomy, you will need help in learning how to manage it. Specially trained ostomy nurses or enterostomal therapists can do this. They will usually see you in the hospital before your operation to discuss the ostomy and to mark a site for the opening. After the operation they may come to your house or an outpatient setting to provide you with more training. For more information, please see the separate American Cancer Society documents, Colostomy: A Guide and Ileostomy: A Guide.

Sexual function and fertility after colorectal surgery

If you are a man, an AP resection may stop your erections or ability to reach orgasm. In other cases, your pleasure at orgasm may become less intense. Normal aging may cause some of these changes, but they may be made worse by the surgery.

An AP resection can also cause you to have "dry" orgasms (without semen) by damaging the nerves that control ejaculation. Sometimes the surgery only causes retrograde ejaculation, which means the semen goes backward into the bladder during an orgasm. This difference is important if you want to father a child. Retrograde ejaculation is less serious because infertility specialists can often recover sperm cells from the urine, which can be used to fertilize an egg. If sperm cells cannot be recovered from your semen or urine, specialists may be able to retrieve them directly from the testicles by minor surgery, and then use them for in vitro fertilization.

If you are a woman, most colorectal surgeries should not cause any loss of sexual function. Abdominal adhesions (scar tissue) may sometimes cause pain or discomfort during intercourse. If the uterus is removed, pregnancy will not be possible.

No matter what your gender, a colostomy can have an impact on your body image and your sexual comfort level. While it may require some adjustments, it should not prevent you from having an enjoyable sex life.

More information on dealing with the sexual impact of cancer and its treatment is available in the American Cancer Society documents, Sexuality for the Man With Cancer and Sexuality for the Woman With Cancer.

Surgery and other local treatments for colorectal cancer metastases

Sometimes, surgery for cancer that has spread (metastasized) to other organs can help you to live longer or, depending on the extent of the disease, may even cure you. If only a small number of metastases are present in the liver or lungs (and nowhere else), they can sometimes be removed by surgery. This will depend on their size, number, and location.

In some cases where surgically removing the tumors is not possible, non-surgical treatments may be used to destroy (ablate) tumors in the liver, although these methods are less likely to be curative. Several different techniques may be used.

Radiofrequency ablation

Radiofrequency ablation (RFA) uses high-energy radio waves for treatment. A thin, needle-like probe is placed through the skin and into the tumor. Placement of the probe is guided by ultrasound or CT scans. The tip of the probe releases high-frequency radio waves that heat the tumor and destroy the cancer cells.

Ethanol (alcohol) ablation

Also known as percutaneous ethanol injection (PEI), this procedure involves injecting concentrated alcohol directly into the tumor to kill cancer cells. This is usually done though the skin using a needle, which is guided by ultrasound or CT scans.

Cryosurgery (cryotherapy)

Cryosurgery destroys a tumor by freezing it with a metal probe. The probe is guided through the skin and into the tumor using ultrasound. Then very cold gasses are passed through the probe to freeze the tumor, killing the cancer cells. This method can treat larger tumors than either of the other ablation techniques, but it sometimes requires general anesthesia (where you are asleep).

Since these 3 treatments usually do not require surgery to remove any of the patient's liver, they are often good options for patients whose disease cannot be cured with surgery.

Hepatic artery embolization

This is sometimes another option for tumors that cannot be removed. This technique is used to reduce the blood flow in the hepatic artery, the artery that feeds most cancer cells in the liver. This is done by injecting materials that plug up the artery. Most of the healthy liver cells will not be affected because they get their blood supply from the portal vein.

For this procedure, the doctor puts a catheter into an artery in the inner thigh and threads it up into the liver. A dye is usually injected into the bloodstream at this time to allow the doctor to monitor the path of the catheter via angiography, a special type of x-ray. Once the catheter is in place, small particles are injected into the artery to plug it up.

Embolization also reduces some of the blood supply to the normal liver tissue. This may be dangerous for patients with diseases such as hepatitis and cirrhosis, who already have reduced liver function.



Radiation therapy

Radiation therapy uses high-energy rays (such as x-rays) or particles to destroy cancer cells. It may be part of treatment for either colon or rectal cancer. Chemotherapy can make radiation therapy more effective against some colon and rectal cancers, and these 2 treatments are often used together.

Radiation therapy is mainly used in people with colon cancer is when the cancer is found to have attached to an internal organ or the lining of the abdomen. When this occurs, the surgeon cannot be certain that all the cancer has been removed, and radiation therapy may be used to try to kill any cancer cells that may remain after surgery. Radiation therapy is seldom used to treat metastatic colon cancer because of side effects, which limit the dose that can be used.

For rectal cancer, radiation therapy is usually given along with chemotherapy to help prevent the cancer from coming back in the pelvis where the tumor started. It may be given either before or after surgery. Many doctors now favor giving it before surgery, as it may make it easier to remove the cancer. Giving radiation before surgery may also result in fewer complications such as scar formation that can interfere with bowel movements. It may also lower the risk that the tumor will come back (recur) in the pelvis. If a rectal cancer's size and/or position make surgery difficult, radiation may be used to try to shrink the tumor first to make surgery easier. Radiation therapy can also be given to help control rectal cancers in people who are not healthy enough for surgery or to ease (palliate) symptoms in people with advanced cancer causing intestinal blockage, bleeding, or pain.

Types of radiation therapy

Different types of radiation therapy can be used to treat colon and rectal cancers.

External-beam radiation therapy

The radiation is focused on the cancer from a machine outside the body called a linear accelerator. This is the type of radiation therapy most often used for people with colorectal cancer.

Before treatments start, the radiation team takes careful measurements to determine the correct angles for aiming the radiation beams and the proper dose of radiation. External radiation therapy is much like getting an x-ray, but the radiation is more intense. The procedure itself is painless. Each treatment lasts only a few minutes, although the setup time -- getting you into place for treatment -- usually takes longer. Most often, radiation treatments are given 5 days a week for several weeks, although the length of time may be shorter if it is given before surgery.

Endocavitary radiation therapy

A small device placed into the anus delivers the radiation. The device delivers high-intensity radiation over a few minutes. This is repeated about 3 more times at about 2-week intervals for the full dose. The advantage of this approach is that the radiation reaches the rectum without passing through the skin and other tissues of the abdomen, which means it is less likely to cause side effects. This can allow some patients, particularly elderly persons, to avoid major surgery and a colostomy. It is used only for small tumors. Sometimes external-beam radiation therapy is also given.

Brachytherapy (internal radiation therapy)

Brachytherapy uses small pellets of radioactive material placed next to or directly into the cancer. The radiation travels only a short distance, limiting the effects on surrounding healthy tissues. Internal radiation is sometimes used in treating people with rectal cancer, particularly people who are not healthy enough to tolerate curative surgery. This is generally a one-time only procedure and doesn't require daily visits for several weeks.

Side effects of radiation therapy

If you are going to get radiation therapy, it's important to speak with your doctor beforehand about the possible side effects so that you know what to expect. Potential side effects of radiation therapy for colon and rectal cancer can include:

-skin irritation at the site where radiation beams were aimed nausea

-rectal irritation, which can cause diarrhea, painful bowel movements, or blood in the stool

-bowel incontinence

-bladder irritation, which can cause frequent urination, burning sensations while urinating, or blood in the urine

-fatigue

-sexual problems (impotence in men and vaginal irritation in women)

Most side effects should lessen after treatments are completed, but problems such as rectal and bladder irritation may remain. Some degree of rectal and/or bladder irritation may be a permanent side effect. If you begin to develop these or other side effects, talk to your doctor right away so steps can be taken to reduce or relieve them.



Chemotherapy

Chemotherapy (also known as "chemo") is treatment with anti-cancer drugs. Chemotherapy can be given in different ways.

Systemic chemotherapy

Systemic chemotherapy uses drugs that are injected into a vein or given by mouth. These drugs enter the bloodstream and reach all areas of the body. This treatment is useful for cancers that have metastasized (spread) beyond the organ they started in.

Regional chemotherapy

In regional chemotherapy, drugs are injected directly into an artery leading to a part of the body containing a tumor. This approach concentrates the dose of chemotherapy reaching the cancer cells. It reduces side effects by limiting the amount reaching the rest of the body.

Hepatic artery infusion: where chemotherapy is given directly into the hepatic artery, is an example of regional chemotherapy sometimes used for colon cancer that has spread to the liver.

There are several ways in which chemotherapy may be used to treat colon or rectal cancers.

Adjuvant chemotherapy

The use of chemotherapy after surgery, known as adjuvant chemotherapy, can increase the survival rate for patients with some stages of colon cancer and rectal cancer. It is given when there is no evidence of cancer remaining but there is a chance that it might come back. The theory behind adjuvant therapy is that a small number of cancer cells may not have been removed by surgery or may have escaped from the primary tumor and settled in other parts of the body. The hope is that the chemotherapy can kill these cells, wherever they may be.

Neoadjuvant chemotherapy

For some rectal cancers, chemotherapy is given (along with radiation) before surgery to try to shrink the cancer and make surgery easier. This is known as neoadjuvant treatment.

Chemotherapy for advanced cancers

Chemotherapy can also be used to help shrink tumors and relieve symptoms for more advanced cancers. While it is very unlikely to be curative in such situations, it may significantly extend survival time in some people.

Drugs used to treat colorectal cancer

Several drugs can be used to treat colorectal cancer. Often, 2 or more of these drugs are combined to try to make them more effective.

5-Fluorouracil (5-FU): This drug had been around for several decades, and it is part of most chemotherapy regimens for colorectal cancer. It is often given together with another drug called leucovorin (folinic acid), which makes it work better.

This drug may be given as an infusion into a vein over 2 hours, or (more commonly) as a quick injection followed by continuous infusion over 1 or 2 days. For continuous infusions, the patient wears a small battery-operated pump that infuses 5-FU into an intravenous (IV) catheter.

For most chemotherapy regimens, treatment with 5-FU is repeated every 2 weeks over a period of 6 months to a year.

The possible side effects of this drug include nausea, loss of appetite, mouth sores, diarrhea, low blood cell counts, sensitivity to sunlight, and hand-foot syndrome (pain, sensitivity, and redness in the hands and feet, sometimes along with blistering or skin peeling).

Capecitabine (Xeloda): This is a chemotherapy drug in pill form. It is usually taken twice a day for 2 weeks, followed by a week off. Once in the body, it is changed to 5-FU when it gets to the tumor site. This drug seems to be about as effective as giving continuous intravenous 5-FU.

Capecitabine is usually taken twice a day for 2 weeks, followed by a week off.

While this drug may be taken at home as a pill, it is still a strong chemotherapy medicine. The possible side effects are similar to those listed for 5-FU. Although most of the side effects seem to be less common with this drug than with 5-FU, problems with the hands and feet are more common.

Irinotecan (Camptosar): This drug is often combined with 5-FU and leucovorin (known as the FOLFIRI regimen) as a first-line treatment for advanced colorectal cancer. In some cases it may be tried by itself as a second-line treatment if other chemotherapy drugs are no longer effective. It is given as an IV infusion over 30 minutes to 2 hours.

One problem with irinotecan is that some people's bodies aren't able to break down the drug, so it stays in the body and causes severe side effects. This is due to an inherited gene variation that can be tested for. The simplest test is to measure the blood level of bilirubin, a substance made in the liver. If it is slightly elevated, this can be a sign of the gene variation that makes people sensitive to irinotecan. So far, most doctors aren't routinely testing for the gene variant itself.

The major possible side effects of irinotecan are severe diarrhea and low blood counts, although other effects such as nausea are possible as well. Your doctor will likely give you medicine to take before treatment to help prevent diarrhea. You need to tell your doctor right away if you develop diarrhea or any other side effects. Your doctor may not use irinotecan if you are elderly or have serious health problems. In rare cases, severe side effects can even be fatal.

Oxaliplatin (Eloxatin): This drug is usually combined with 5-FU and leucovorin (known as the FOLFOX regimen) or with capecitabine (known as the CapeOX regimen) as a first- or second-line treatment for advanced colorectal cancer. It may also be used as adjuvant therapy after surgery for earlier stage cancers. Oxaliplatin is given as an IV infusion over 2 hours, usually once every 2 or 3 weeks.

Oxaliplatin can affect peripheral nerves, which can cause numbness, tingling, and intense sensitivity to temperature, especially the hands and feet. This goes away in most patients after treatment has stopped, but in some cases it can cause long-lasting nerve damage. If you will be getting oxaliplatin, talk with your doctor about side effects beforehand, and let him or her know right away if you develop numbness and tingling or other side effects.

Side effects of chemotherapy

Chemotherapy drugs work by attacking cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow, the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells are also likely to be affected by chemotherapy, which can lead to side effects.

The side effects of chemotherapy depend on the type and dose of drugs given and the length of time they are taken. General side effects of chemotherapy drugs can include:

hair loss mouth sores loss of appetite nausea and vomiting increased chance of infections (due to low white blood cell counts) easy bruising or bleeding (due to low blood platelet counts) fatigue (due to low red blood cell counts) Along with these, some side effects are specific to certain medicines. These are discussed above in the descriptions of the individual drugs.

Most side effects are short-term and tend to go away after treatment is finished. There are often ways to lessen these side effects. For example, drugs can be given to help prevent or reduce nausea and vomiting. Do not hesitate to discuss any questions about side effects with the cancer care team.

You should report any side effects or changes you notice while getting chemotherapy to your medical team so that they can be treated promptly. In some cases, the doses of the chemotherapy drugs may need to be reduced or treatment may need to be delayed or stopped to prevent the effects from getting worse.

Elderly people seem to be able to tolerate chemotherapy for colorectal cancer fairly well. There is no reason to withhold treatment in otherwise healthy people simply because of age.

For more general information about chemotherapy, please see the separate American Cancer Society document, Understanding Chemotherapy: A Guide for Patients and Families.

Targeted therapies

As researchers have learned more about the gene and protein changes in cells that cause cancer, they have been able to develop newer drugs that specifically target these changes. These targeted drugs work differently from standard chemotherapy drugs. They often have different (and less severe) side effects. At this time, they are most often used either along with chemotherapy or by themselves if chemotherapy is no longer working.

Bevacizumab (Avastin): Bevacizumab is a man-made version of a type of immune system protein called a monoclonal antibody. This antibody targets vascular endothelial growth factor (VEGF), a protein that helps tumors form new blood vessels to get nutrients (a process known as angiogenesis). Bevacizumab is most often used along with chemotherapy drugs as a first- or second-line treatment for advanced colorectal cancer.

Bevacizumab is given by intravenous (IV) infusion, usually once every 2 or 3 weeks. While it has been shown to help improve survival when added to chemotherapy, it can also add to the side effects. Rare but possibly serious side effects include blood clots, holes forming in the colon (requiring surgery to correct), heart problems, and slow wound healing. More common side effects include high blood pressure, tiredness, bleeding, low white blood cell counts, headaches, mouth sores, loss of appetite, and diarrhea.

Cetuximab (Erbitux): This is a monoclonal antibody that specifically attacks the epidermal growth factor receptor (EGFR), a molecule that often appears in high amounts on the surface of cancer cells and helps them grow.

Cetuximab is used in metastatic colorectal cancer, usually after other treatments have been tried. Most often it is used either with irinotecan or by itself in those who can't take irinotecan or whose cancer is no longer responding to it.

About 4 out of 10 people with colorectal cancers have mutations in the K-ras gene, which make this drug ineffective. Many doctors now test the tumor for this gene mutation and only use this drug in people who do not have the mutation.

Cetuximab is given by IV infusion, usually once a week. A rare but serious side effect of cetuximab is an allergic reaction during the first infusion, which could cause problems with breathing and low blood pressure. You may be given medicine before treatment to help prevent this. Many people develop skin problems such as an acne-like rash on the face and chest during treatment, which in some cases can lead to infections. Other side effects may include headache, tiredness, fever, and diarrhea.

Panitumumab (Vectibix): Panitumumab is another monoclonal antibody that attacks colorectal cancer cells. Like cetuximab, it targets the EGFR protein. It is used to treat metastatic colorectal cancer after other treatments have been tried.

As with cetuximab, this drug is not effective in the 4 out of 10 people with colorectal cancers who have mutations in the K-ras gene. Many doctors now test the tumor for the K-ras mutation and only use this drug in people who do not have the mutation.

Panitumumab is given by IV infusion, usually once every 2 weeks. Most people develop skin problems such as a rash during treatment, which in some cases can lead to infections. Other possible serious side effects are lung scarring and allergic reactions to the drug. Sensitivity to sunlight, fatigue, diarrhea, and changes in fingernails and toenails are also possible.

Treatment by stage of colon cancer

For colon cancers that have not spread to distant sites, surgery is usually the main treatment. Adjuvant (additional) chemotherapy may also be used. Most adjuvant treatment is given for about 6 months.

Stage 0

Since these cancers have not grown beyond the inner lining of the colon, surgery to take out the cancer is all that is needed. This may be done in most cases by polypectomy or local excision through a colonoscope. Colon resection (colectomy) may occasionally be needed if a tumor is too big to be removed by local excision.

Stage I

These cancers have grown through several layers of the colon, but they have not spread outside the colon wall itself. Colectomy -- surgery to remove the section of colon containing cancer and nearby lymph nodes -- is the standard treatment. You do not need any additional therapy.

Stage II

These cancers have grown through the wall of the colon and may extend into nearby tissue. They have not yet spread to the lymph nodes.

Surgery (colectomy) may be the only treatment needed. But your doctor may recommend adjuvant chemotherapy if he or she thinks your cancer has a higher risk of coming back because of certain factors, such as if:

the cancer looks very abnormal (is high grade) when viewed under a microscope the cancer has invaded into nearby organs the surgeon did not remove at least 12 lymph nodes cancer was found in or near the margin (edge) of the surgical specimen, meaning that some cancer may have been left behind the cancer had blocked off (obstructed) the colon the cancer caused a perforation (hole) in the wall of the colon Not all doctors agree on when chemotherapy should be used for stage II colon cancers. It is important to discuss the pros and cons of chemotherapy with your doctor, including how much it might reduce your risk of recurrence and what the likely side effects will be. Some of the more commonly used chemotherapy regimens include FOLFOX (5-FU, leucovorin, and oxaliplatin), 5-FU and leucovorin alone, or capecitabine. Your doctor may recommend a particular one of these if it is better suited to your health needs.

If your surgeon is not sure he or she was able to remove all of the cancer because it was growing into other tissues, radiation therapy may be advised to try to kill any remaining cancer cells. Radiation therapy can be given to the area of your abdomen where the cancer was growing.

Stage III

In this stage, the cancer has spread to nearby lymph nodes, but it has not yet spread to other parts of the body.

Surgery (colectomy) followed by adjuvant chemotherapy is the standard treatment for this stage. The FOLFOX regimen is the most common chemotherapy combination, although some doctors may prefer 5-FU and leucovorin, or capecitabine alone if they are better suited to your health needs. Doctors are now studying whether adding targeted drugs such as bevacizumab to chemotherapy might be more effective.

Your doctors may also advise radiation therapy if your surgeon feels some cancer may have been left behind after surgery.

In people who aren't healthy enough for surgery, radiation therapy and/or chemotherapy may be options.

Stage IV

The cancer has spread from the colon to distant organs and tissues such as the liver, lungs, peritoneum, or ovaries.

In most cases surgery is unlikely to cure these cancers. However, if only a few small metastases are present in the liver or lungs and they can be completely removed along with the colon cancer, surgery may help you live longer and may even cure you. Many doctors also recommend chemotherapy, which may be given before and/or after surgery. In some cases, hepatic artery infusion may be used if the tumors are in the liver.

If the metastases cannot be surgically removed because they are too large or there are too many of them, chemotherapy may be tried first to shrink the tumors to allow for surgery. Chemotherapy would then be given again after surgery. Another option may be to destroy tumors in the liver with cryosurgery, radiofrequency ablation, or other non-surgical methods.

If the cancer is too widespread to try to cure it with surgery, operations such as a segmental resection or diverting colostomy may still be used in some cases to relieve or prevent blockage of the colon and to prevent other local complications. In some patients with extensive spread of cancer, such a blockage can be prevented or managed by inserting a stent (a hollow metal or plastic tube) into the colon during colonoscopy to keep it open so that surgery can be avoided.

If you have stage IV cancer and your doctor recommends surgery, it is very important to understand what the goal of the surgery is -- whether it is to try to cure the cancer or to prevent or relieve symptoms of the disease.

Most patients with stage IV cancer will get chemotherapy and/or targeted therapies to control the cancer. The most commonly used regimens include:

FOLFOX (leucovorin [folinic acid], 5-FU, and oxaliplatin) FOLFIRI (leucovorin, 5-FU, and irinotecan) CapeOX (capecitabine and oxaliplatin) any of the above combinations plus either bevacizumab or cetuximab (but not both) 5-FU and leucovorin, with or without bevacizumab capecitabine, with or without bevacizumab FOLFOXIRI (leucovorin, 5-FU, oxaliplatin, and irinotecan) irinotecan, with or without cetuximab cetuximab alone panitumumab alone The choice of regimens may depend on several factors, including any previous treatments you've had and your overall health. If one of these regimens is no longer effective, another may be tried.

For advanced cancers, radiation therapy may also be used to help prevent or relieve symptoms such as pain. While it may shrink tumors for a time, it is very unlikely to result in a cure. If your doctor recommends radiation therapy, it is important that you understand the goal of treatment.

Recurrent colon cancer

Recurrent cancer means that the cancer has returned after treatment. The recurrence may be local (near the area of the initial tumor), or it may affect distant organs.

If the cancer comes back locally, surgery (followed by chemotherapy) can sometimes help you live longer and may even cure you. If the cancer can't be removed surgically, chemotherapy may be tried first. If it shrinks the tumor enough, surgery may be an option at this point. This would again be followed by more chemotherapy.

If the cancer comes back in a distant site, it is most likely to appear first in the liver. Surgery may be an option in some cases. If not, chemotherapy may be tried first to shrink the tumor(s), which may then be followed by surgery. If the cancer is too widespread to be treated surgically, chemotherapy and/or targeted therapies may be used. Possible regimens are the same as for stage IV disease. The options depend on which, if any, drugs you received before the cancer came back and how long ago you received them, as well as on your health. Surgery may still be needed at some point to relieve or prevent blockage of the colon and to prevent other local complications. Radiation therapy may be an option to relieve symptoms in some cases as well.

As these cancers can often be difficult to treat, you may also want to speak with your doctor about clinical trials you might be eligible for.

Treatment by stage of rectal cancer

Surgery is usually the main treatment for rectal cancers that have not spread to distant sites. Additional treatment with radiation and chemotherapy may also be used before or after surgery.

Stage 0

At this stage the cancer has not grown beyond the inner lining of the rectum. Removing or destroying the cancer is all that is needed. You can usually be treated with a polypectomy, local excision, or transanal resection and should need no further treatment.

Stage I

In this stage, the cancer has grown through the first layer of the rectum into deeper layers but has not spread outside the wall of the rectum itself.

Surgery is usually the main treatment for this stage. Either a low anterior resection, colo-anal anastomosis, or an abdominoperineal resection may be done, depending on exactly where the cancer is found within the rectum. Adjuvant therapy is not needed after these operations, unless the surgeon finds the cancer is more advanced than was thought before surgery.

For some small stage I rectal cancers, another option may be removing them through the anus without an abdominal incision (transanal resection or transanal endoscopic microsurgery). In some cases, adjuvant therapy with radiation and chemotherapy (usually 5-FU) is advised for patients having such surgery. In other cases, if the tumor turns out to have high-risk features (such as a worrisome appearance under the microscope or if cancer is found at the edges of the removed specimen), a second, more extensive surgery may be advised.

If you are too sick to withstand surgery, you may be treated with radiation therapy such as endocavitary radiation therapy (aiming radiation through the anus) or brachytherapy (placing radioactive pellets directly into the cancer). However, this has not been proven to be as effective as surgery.

Stage II

These cancers have grown through the wall of the rectum and may extend into nearby tissues. They have not yet spread to the lymph nodes.

Stage II rectal cancers are usually treated by low anterior resection, colo-anal anastomosis, or abdominoperineal resection (depending on where the cancer is in the rectum), along with both chemotherapy and radiation therapy. Radiation can be given either before or after surgery. Many doctors now favor giving the radiation therapy along with chemotherapy before surgery (neoadjuvant treatment), as well as giving adjuvant chemotherapy after surgery, usually for about 6 months. Chemotherapy may be the FOLFOX regimen (oxaliplatin, 5-FU, and leucovorin), 5-FU and leucovorin, or capecitabine alone, based on what's best suited to your health needs.

If neoadjuvant therapy shrinks the tumor enough, in some cases a transanal full thickness rectal resection can be done instead of a more invasive low anterior resection or abdominoperineal resection. This may avert the need for a colostomy. A problem with using this procedure is that then there is no way of knowing whether the cancer has spread to your lymph nodes or being sure the cancer hasn't spread further in your pelvis. For this reason, the procedure isn't generally recommended.

Stage III

These cancers have spread to nearby lymph nodes but not to other parts of the body.

The rectal tumor is usually removed by low anterior resection, colo-anal anastomosis, or abdominoperineal resection. In rare cases where the cancer has reached nearby organs, a pelvic exenteration may be needed. Radiation therapy is given before or after surgery. As in stage II, many doctors now prefer to give the radiation therapy along with chemotherapy before surgery because it lowers the chance that the cancer will come back in the pelvis and has less complications than radiation given after surgery. This treatment may also make the surgery more effective for larger tumors.

After surgery, chemotherapy is given, usually for about 6 months. The most common regimens include FOLFOX (oxaliplatin, 5-FU, and leucovorin), 5-FU and leucovorin, or capecitabine alone. Your doctor may recommend one of these if it is better suited to your health needs.

Stage IV

The cancer has spread to distant organs and tissues such as the liver or lungs. Treatment options for stage IV disease depend to some extent on how widespread the cancer is.

If there's a chance that all of the cancer can be removed (for example, there are only a few tumors in the liver or lungs), treatment options include:

surgery to remove the rectal lesion and distant tumors, followed by chemotherapy (and radiation therapy in some cases) chemotherapy, followed by surgery to remove the rectal lesion and distant tumors, usually followed by more chemotherapy and radiation therapy chemotherapy and radiation therapy, followed by surgery to remove the rectal lesion and distant tumors, followed by more chemotherapy These approaches may help you live longer and in some cases may even cure you. Surgery to remove the rectal tumor would usually be a low anterior resection or abdominoperineal (AP) resection, depending on where it's located. If you have only liver metastases, you may be treated with chemotherapy given directly into the artery leading to the liver. This may shrink the cancers in the liver more effectively than if the chemotherapy is given intravenously.

If the cancer is more widespread and can't be completely removed by surgery, treatment options may depend on whether the cancer is causing any symptoms. Widespread cancers that are not causing symptoms are usually treated with chemotherapy. The most commonly used regimens include:

FOLFOX (leucovorin [folinic acid], 5-FU, and oxaliplatin) FOLFIRI (leucovorin, 5-FU, and irinotecan) CapeOX (capecitabine and oxaliplatin) any of the above combinations, plus bevacizumab or cetuximab (but not both) 5-FU and leucovorin, with or without bevacizumab capecitabine, with or without bevacizumab FOLFOXIRI (leucovorin, 5-FU, oxaliplatin, and irinotecan) irinotecan, with or without cetuximab cetuximab alone panitumumab alone The choice of regimens may depend on several factors, including any previous treatments and your overall health and ability to tolerate treatment.

If the chemotherapy shrinks the tumors, in some cases it may be possible to consider surgery to try to remove all of the cancer at this point.

Cancers that don't shrink with chemotherapy and widespread cancers that are causing symptoms are unlikely to be cured, and treatment is aimed at relieving symptoms and avoiding long-term complications such as bleeding or blockage of the intestines. Treatments may include one or more of the following:

surgical resection of the rectal tumor surgery to create a colostomy and bypass the rectal tumor using a special laser to destroy the tumor within the rectum placing a stent (hollow plastic or metal tube) within the rectum to keep it open; this does not require surgery radiation therapy and chemotherapy chemotherapy alone If tumors in the liver cannot be removed by surgery because they are too large or there are too many of them, it may be possible to destroy them by freezing (cryosurgery), heating (radiofrequency ablation), vaporizing them with a laser (photocoagulation), or other non-surgical methods.

Recurrent rectal cancer

Recurrent cancer means that the cancer has returned after treatment. It may come back locally (near the area of the initial rectal tumor) or in distant organs. Most recurrences develop in the first 2 to 3 years after surgery.

If the cancer comes back locally, chemotherapy may be given (as well as radiation therapy aimed at the tumor if it was not used before). Surgery to remove the cancer is used if possible, and is typically more extensive than the initial surgery. In some cases radiation therapy may be given during the surgery (intraoperative radiotherapy) or afterwards.

If the cancer comes back in a distant site, treatment depends on whether it can be removed (resected) by surgery.

If the cancer can be removed, surgery is done to remove the tumor. Neoadjuvant chemotherapy may be given before surgery (see treatment of stage IV cancer for a list of possible regimens). Chemotherapy is then given after surgery as well. When the cancer is in the liver, chemotherapy may be given into the hepatic artery leading to the liver.

If the cancer can't be removed by surgery, chemotherapy is usually the first option. The regimen used will depend on what a person has received previously and on their overall health. Surgery may be an option if the cancer shrinks enough. This would be followed by more chemotherapy. If the cancer doesn't shrink with chemotherapy, a different drug combination may be tried.

As with stage IV cancer, surgery or other approaches may be used at some point to relieve symptoms and avoid long-term complications such as bleeding or blockage of the intestines.

As these cancers can often be difficult to treat, you may also want to speak with your doctor about clinical trials you might be eligible for.

Should I consider a clinical trial?

You may have had to make a lot of decisions since you've been told you have cancer. One of the most important decisions you will make is choosing which treatment is best for you. You may have heard about clinical trials being done for your type of cancer. Or maybe someone on your health care team has mentioned a clinical trial to you.

Clinical trials are carefully controlled research studies that are done with patients who volunteer for them. They are done to get a closer look at promising new treatments or procedures.

If you would like to take part in a clinical trial, you should start by asking your doctor if your clinic or hospital conducts clinical trials. You can also call our clinical trials matching service for a list of clinical trials that meet your medical needs. You can reach this service at 1-800-303-5691 or on our Web site at http://clinicaltrials.cancer.org. You can also get a list of current clinical trials by calling the National Cancer Institute's Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) or by visiting the NCI clinical trials Web site at www.cancer.gov/clinicaltrials.

There are requirements you must meet to take part in any clinical trial. If you do qualify for a clinical trial, it is up to you whether or not to enter (enroll in) it.

Clinical trials are one way to get state-of-the art cancer treatment. They are the only way for doctors to learn better methods to treat cancer. Still, they are not right for everyone.

You can get a lot more information on clinical trials in our document called Clinical Trials: What You Need to Know. You can read it on our Web site or call our toll-free number (1-800-ACS-2345) and have it sent to you.

What about complementary and alternative methods?

When you have cancer you are likely to hear about ways to treat your cancer or relieve symptoms that your doctor hasn't mentioned. Everyone from friends and family to Internet groups and Web sites offer ideas for what might help you. These methods can include vitamins, herbs, and special diets, or other methods such as acupuncture or massage, to name a few.

What exactly are complementary and alternative therapies?

Not everyone uses these terms the same way, and they are used to refer to many different methods, so it can be confusing. We use complementary to refer to treatments that are used along with your regular medical care. Alternative treatments are used instead of a doctor's medical treatment.

Complementary methods: Most complementary treatment methods are not offered as cures for cancer. Mainly, they are used to help you feel better. Some methods that are used along with regular treatment are meditation to reduce stress, acupuncture to help relieve pain, or peppermint tea to relieve nausea. Some complementary methods are known to help, while others have not been tested. Some have been proven not be helpful, and a few have even been found harmful.

Alternative treatments: Alternative treatments may be offered as cancer cures. These treatments have not been proven safe and effective in clinical trials. Some of these methods may pose danger, or have life-threatening side effects. But the biggest danger in most cases is that you may lose the chance to be helped by standard medical treatment. Delays or interruptions in your medical treatments may give the cancer more time to grow and make it less likely that treatment will help.

Finding out more

It is easy to see why people with cancer think about alternative methods. You want to do all you can to fight the cancer, and the idea of a treatment with no side effects sounds great. Sometimes medical treatments like chemotherapy can be hard to take, or they may no longer be working. But the truth is that most of these alternative methods have not been tested and proven to work in treating cancer.

As you consider your options, here are 3 important steps you can take:

Look for "red flags" that suggest fraud. Does the method promise to cure all or most cancers? Are you told not to have regular medical treatments? Is the treatment a "secret" that requires you to visit certain providers or travel to another country? Talk to your doctor or nurse about any method you are thinking about using.

Decisions about how to treat or manage your cancer are always yours to make. If you want to use a non-standard treatment, learn all you can about the method and talk to your doctor about it. With good information and the support of your health care team, you may be able to safely use the methods that can help you while avoiding those that could be harmful.