A cancer diagnosis almost always makes people feel they must get treatment as soon as possible. However, you need time to consider all your treatment choices so you will know as much as possible. You may want to ask for a second opinion from another doctor. This can provide more information and 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. So your questions should include those 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?

This information represents the views of the doctors and nurses serving on the American Cancer Society's Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.

The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. 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 and staged, your cancer care team will discuss your treatment options with you. 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.

In 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. 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 the primary site (the place where it started)? 
• What is the stage of my cancer, and what does that mean in my case? 
• What treatment choices do I have? 
• What do you recommend and why? 
• What risks or side effects are there to the treatments you suggest? 
• What are the chances my cancer will come back with these treatment plans? What would we do if that happens?Will I need a colostomy? Will it be permanent? 
• What should I do to be ready for treatment? 
• What can I do to reduce the side effects of treatment? 
• Should I follow a special diet? 
• What type of follow-up will 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 will take to recover so you can plan your work schedule. Or you may want to ask about second opinions or about clinical trials for which you may qualify. Clinical trials are discussed in detail later in this document.

How is treatment planned?

Planning cancer treatment involves time, and 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 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 cancer care team.

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.

Colon surgery

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

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

Prior to surgery, you will need to make sure your bowels are completely empty. 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 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 tissue may be removed depending on the exact size and location of your 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 need to be given pain medicines for 2 or 3 days. For the first couple of days, you will be given intravenous (IV) fluids and will not be able to eat, 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 in a few days (starting with clear liquids).

If the tumor is large and has blocked your colon, it may be possible to use a colonoscope to put a stent (a hollow metal or plastic tube) inside the colon to relieve the blockage and 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, a temporary colostomy may be needed. This involves the same type of surgery as above, but instead of reconnecting the segments of the colon, the end of the colon is attached to an opening (stoma) in the abdomen for the purpose of getting rid of body wastes. A removable collecting bag is then 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, a permanent colostomy may be needed. For more information on colostomies, refer to the separate American Cancer Society document, Colostomy: A Guide.

Laparoscopic-assisted colectomy: This is a newer approach to removing part of the colon and nearby lymph nodes that 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, they usually heal faster. Patients may recover slightly faster and have less pain than they do after standard colon surgery.

Laparoscopic-assisted surgery appears to be about as likely to be curative as the standard approach for earlier stage 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 cut out across the base of the polyp's 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 invasive 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.

Low anterior resection: Some stage I rectal cancers and most stage II or III cancers in the upper two thirds of the rectum (close to where it connects with the colon) can be removed by low anterior resection. In this procedure the tumor is removed without affecting the anus. After low anterior resection, your colon will be attached to the anus and your waste will leave the body in the usual way.

A low anterior resection is like most abdominal operations. You will need 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 the incision only 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 colostomy is not necessary.

Sometimes, the entire rectum may be removed and the colon attached to the anus. This is called a colo-anal anastomosis (anastomosis means connection). 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 like the rectum did before surgery. When special techniques are needed to prevent a permanent colostomy, you may need to have a temporary colostomy opening for about 8 weeks while the bowel heals. A second operation is then done to close the colostomy opening.

Abdominoperineal (AP) resection: This operation is more involved than a low anterior resection. It can be used to treat some stage I cancers and most 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.

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. If you have had a colostomy, 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 mark a site for the colostomy opening, and later can come to your house or an outpatient setting to provide you with more training. For more information on colostomies, please see the separate American Cancer Society document,Colostomy: A Guide.

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 may 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 adhesions can sometimes cause pain. In rare cases they may cause the bowel to become blocked, requiring further surgery.

Some people may require a temporary or permanent colostomy after surgery. This may take some time to get used to and may require some lifestyle adjustments. Your surgical team can help you learn what to expect.

Sexual impact of 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. This difference is important if you want to father a child. Retrograde ejaculation is less serious because infertility specialists can 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. Of course, 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 and Cancer: For the Man Who Has Cancer and His Partner and Sexuality and Cancer: For the Woman Who Has Cancer and Her Partner.

Surgical treatment of 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 (RFA) uses high-energy radio waves for treatment. A thin, needle-like probe placed through the skin and into the tumor releases these radio waves. Placement of the probe is guided by ultrasound or CT scans. The probe releases a high-frequency current that heats the tumor and destroys the cancer cells.

Ethanol (alcohol) ablation, also known as percutaneous ethanol injection (PEI), 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 destroys a tumor by freezing it with a very cold metal probe. The probe is guided into the tumor using ultrasound. This method can treat larger tumors than either of the other ablation techniques but 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 is not curable with surgery.

Hepatic artery embolization 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.

This procedure involves putting a catheter into an artery in the inner thigh and threading 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 that are affecting the part of the liver not affected by cancer.

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.

The main use for radiation therapy in people with colon cancer is when the cancer has 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 kill any cancer cells remaining 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 to help prevent the cancer from coming back in the pelvis where the tumor started. It may be given either before or after surgery, but recently doctors have begun to favor preoperative treatment, along with chemotherapy. If a rectal cancer's size and/or position make surgery difficult, radiation may be used before surgery to shrink the tumor. Radiation therapy can also be given to help control rectal cancers in people who are not healthy enough for surgery.

Radiation also may be used 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 focuses radiation on the cancer from a machine outside the body called a linear accelerator. This is the type of radiation therapy most often recommended for people with colon 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.

Endocavitary radiation therapy, as with external-beam radiation therapy, is delivered from a radiation source outside the body. It is a hand-held device that is placed into the anus. 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 radical surgery and colostomy. It is used only for small tumors. Sometimes external-beam therapy is also given.

Brachytherapy (internal radiation therapy) 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:

• mild 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 persist. 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. 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. 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 situations 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.

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 increases its effectiveness.

There are several different schedules for using this drug. It may be given as an infusion 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 a syndrome of hand and foot redness that is sometimes accompanied by 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.

While this drug may be taken at home as a pill, it is still a strong chemotherapy medicine. The possible side effects that 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 are unable to break down the drug so it stays in the body and causes severe side effects. This is due to an inherited genetic 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 genetic variation that makes people sensitive to irinotecan. So far, most doctors aren't routinely testing for the genetic 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 advise 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 in the extremities, especially the hands and feet. This goes away after treatment has stopped in most patients, but in some cases it can cause long-lasting nerve damage. If you are going to be getting oxaliplatin, talk with your doctor about side effects beforehand, and let him or her know as soon as 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 develop newer drugs that specifically target these changes. These targeted drugs work differently than 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 manmade version of an 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 metastatic 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. It can be used either with irinotecan or by itself in those who can't take irinotecan or whose cancer is no longer responding to it.

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. Other, less serious side effects may include an acne-like rash, 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 by itself to treat metastatic colorectal cancer after other treatments have been tried.

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 primary or first 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 many cases by polypectomy or local excision through a colonoscope. Colon resection may 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) is usually the only treatment needed. If your doctor thinks your cancer is likely to come back because of how it looks under the microscope or other factors, adjuvant chemotherapy may be recommended. Chemotherapy is not standard treatment for this stage of colon cancer, but many doctors recommend it if the risk of recurrence seems high, such as in stage IIB disease. There are clinical trials studying this issue, and you might consider enrolling in one. Doctors aren't sure which chemotherapy regimen might be best in this situation. Some of the more commonly used treatments include FOLFOX (5-FU, leucovorin, and oxaliplatin), 5-FU and leucovorin alone, or capecitabine. Your doctor may recommend 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. The FOLFOX regimen is the most common chemotherapy combination, although some doctors may prefer 5-FU and leucovorin, capecitabine and oxaliplatin (CapeOX), or capecitabine alone if they are better suited to your health needs.

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

Stage IV

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

Surgery in stage IV disease is usually not done with the expectation of curing the colon cancer. However, if only a few small metastases (usually 5 or fewer) are present in the liver or lung and can be completely removed along with the colon cancer, surgery can help you live longer and may even cure you. This is usually followed by chemotherapy. In some cases, hepatic artery infusion may be used if the tumors were 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 be treated 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.

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), with or without bevacizumab 

• FOLFIRI (leucovorin, 5-FU, and irinotecan), with or without bevacizumab 

• CapeOX (capecitabine and oxaliplatin), with or without bevacizumab 

• 5-FU and leucovorin, with or without bevacizumab 

• capecitabine, with or without bevacizumab 

• 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. If one of these regimens is no longer effective, another may be tried.

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.

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

For rectal cancers that have not spread to distant sites, surgery is usually the primary or first treatment. Adjuvant (additional) treatment with radiation and chemotherapy may also be used. Most adjuvant treatment is given for about 6 months.

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 be treated with a polypectomy, local excision, or transanal resection. You will need no further treatment.

If you are too sick to withstand surgery, you may be treated only with radiation therapy such as endocavitary radiation therapy (aiming radiation through the anus) or brachytherapy (placing radioactive pellets directly into the cancer), although it's not clear if this is as effective as surgery.

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 rectal wall itself.

Surgery is the main treatment for this stage. Either a low anterior resection 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). In most cases, adjuvant therapy with radiation and chemotherapy (usually 5-FU) is advised for patients having such surgery.

If you are too sick to withstand surgery, you may be treated only 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 into nearby tissues. They have not yet spread to the lymph nodes.

Stage II rectal cancers are usually treated by low anterior resection 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. Chemotherapy may be the FOLFOX regimen (oxaliplatin, 5-FU, and leucovorin), 5-FU and leucovorin, capecitabine and oxaliplatin (CapeOX), 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 this is 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 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. For larger tumors, it may also make the surgery more effective.

After surgery, chemotherapy is given. The most common regimens include FOLFOX (oxaliplatin, 5-FU, and leucovorin), 5-FU and leucovorin, capecitabine and oxaliplatin (CapeOX), 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 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 shrinks 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), with or without bevacizumab 

• FOLFIRI (leucovorin, 5-FU, and irinotecan), with or without bevacizumab 

• CapeOX (capecitabine and oxaliplatin), with or without bevacizumab 

• 5-FU and leucovorin, with or without bevacizumab 

• capecitabine, with or without bevacizumab 

• 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 the tumor 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 and radiation therapy aimed at the tumor may be given if radiation therapy was not used before. Surgery to remove the cancer is used if possible. In some cases this may be followed by radiation therapy.

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

If the cancer can be removed, surgery is done to remove the tumor. This is followed by chemotherapy (see treatment of stage IV cancer for a list of possible regimens). If the patient hasn't received chemotherapy within the last year (or never received it), neoadjuvant chemotherapy may be given before 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. If the cancer shrinks enough, surgery may be an option in some cases. This would be followed by more chemotherapy.

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 deciding 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 one way to get state-of-the art cancer care. Still, they are not right for everyone.

Here we will give you a brief review of clinical trials. Talking to your health care team, your family, and your friends can help you make the best treatment choice for you.

What are clinical trials?

Clinical trials are carefully controlled research studies that are done with patients. These studies test whether a new treatment is safe and how well it works in patients, or they may test new ways to diagnose or prevent a disease. Clinical trials have led to many advances in cancer prevention, diagnosis, and treatment.

The purpose of clinical trials

Clinical trials are done to get a closer look at promising new treatments or procedures in patients. A clinical trial is only done when there is good reason to believe that the treatment, test, or procedure being studied may be better than the one used now. Treatments used in clinical trials are often found to have real benefits and may go on to become tomorrow's standard treatment.

Clinical trials can focus on many things, such as:

• new uses of drugs that are already approved by the US Food and Drug Administration (FDA) 

• new drugs that have not yet been approved by the FDA 

• non-drug treatments (such as radiation therapy) 

• medical procedures (such as types of surgery) 

• herbs and vitamins 

• tools to improve the ways medicines or diagnostic tests are used 

• medicines or procedures to relieve symptoms or improve comfort 

• combinations of treatments and procedures

Researchers conduct studies of new treatments to try to answer the following questions:

• Is the treatment helpful? 

• What's the best way to give it? 

• Does it work better than other treatments already available? 

• What side effects does the treatment cause? 

• Are there more or fewer side effects than the standard treatment used now? 

• Do the benefits outweigh the side effects? 

• In which patients is the treatment most likely to be helpful?

Phases of clinical trials

There are 4 phases of clinical trials, which are numbered I, II, III, and IV. We will use the example of testing a new cancer treatment drug to look at what each phase is like.

Phase I clinical trials: The purpose of a phase I study is to find the best way to give a new treatment safely to patients. The cancer care team closely watches patients for any harmful side effects.

For phase I studies, the drug has already been tested in lab and animal studies, but the side effects in patients are not fully known. Doctors start by giving very low doses of the drug to the first patients and increase the doses for later groups of patients until side effects appear or the desired effect is seen. Doctors are hoping to help patients, but the main purpose of a phase I trial is to test the safety of the drug.

Phase I clinical trials are often done in small groups of people with different cancers that have not responded to standard treatment, or that keep coming back (recurring) after treatment. If a drug is found to be reasonably safe in phase I studies, it can be tested in a phase II clinical trial.

Phase II clinical trials: These studies are designed to see if the drug works. Patients are given the best dose as determined from phase I studies. They are closely watched for an effect on the cancer. The cancer care team also looks for side effects.

Phase II trials are often done in larger groups of patients with a specific cancer type that has not responded to standard treatment. If a drug is found to be effective in phase II studies, it can be tested in a phase III clinical trial.

Phase III clinical trials: Phase III studies involve large numbers of patients -- most often those who have just been diagnosed with a specific type of cancer. Phase III clinical trials may enroll thousands of patients.

Often, these studies are randomized. This means that patients are randomly put in one of two (or more) groups. One group (called the control group) gets the standard, most accepted treatment. The other group(s) gets the new one(s) being studied. All patients in phase III studies are closely watched. The study will be stopped early if the side effects of the new treatment are too severe or if one group has much better results than the others.

Phase III clinical trials are usually needed before the FDA will approve a treatment for use by the general public.

Phase IV clinical trials: Once a drug has been approved by the FDA and is available for all patients, it is still studied in other clinical trials (sometimes referred to as phase IV studies). This way more can be learned about short-term and long-term side effects and safety as the drug is used in larger numbers of patients with many types of diseases. Doctors can also learn more about how well the drug works, and if it might be helpful when used in other ways (such as in combination with other treatments).

What it will be like to be in a clinical trial

If you are in a clinical trial, you will have a team of experts taking care of you and watching your progress very carefully. Depending on the phase of the clinical trial, you may receive more attention (such as having more doctor visits and lab tests) than you would if you were treated outside of a clinical trial. Clinical trials are specially designed to pay close attention to you.

However, there are some risks. No one involved in the study knows in advance whether the treatment will work or exactly what side effects will occur. That is what the study is designed to find out. While most side effects go away in time, some may be long-lasting or even life threatening. Keep in mind, though, that even standard treatments have side effects. Depending on many factors, you may decide to enter (enroll in) a clinical trial.

Deciding to enter a clinical trial

If you would like to take part in a clinical trial, you should begin by asking your doctor if your clinic or hospital conducts clinical trials. There are requirements you must meet to take part in any clinical trial. But whether or not you enter (enroll in) a clinical trial is completely up to you.

Your doctors and nurses will explain the study to you in detail. They will go over the possible risks and benefits and give you a form to read and sign. The form says that you understand the clinical trial and want to take part in it. This process is known as giving your informed consent. Even after reading and signing the form and after the clinical trial begins, you are free to leave the study at any time, for any reason. Taking part in a clinical trial does not keep you from getting any other medical care you may need.

To find out more about clinical trials, talk to your cancer care team. Here are some questions you might ask:

• Is there a clinical trial that I could take part in? 

• What is the purpose of the study? 

• What kinds of tests and treatments does the study involve? 

• What does this treatment do? Has it been used before? 

• Will I know which treatment I receive? 

• What is likely to happen in my case with, or without, this new treatment? 

• What are my other choices and their pros and cons? 

• How could the study affect my daily life? 

• What side effects can I expect from the study? Can the side effects be controlled? 

• Will I have to stay in the hospital? If so, how often and for how long? 

• Will the study cost me anything? Will any of the treatment be free? 

• If I am harmed as a result of the research, what treatment would I be entitled to? 

• What type of long-term follow-up care is part of the study? 

• Has the treatment been used to treat other types of cancers?

How can I find out more about clinical trials that might be right for me?

The American Cancer Society offers a clinical trials matching service for patients, their family, and friends. You can reach this service at 1-800-303-5691 or on our Web site at http://clinicaltrials.cancer.org.

Based on the information you give about your cancer type, stage, and previous treatments, this service can put together a list of clinical trials that match your medical needs. The service will also ask where you live and whether you are willing to travel so that it can look for a treatment center that you can get to.

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.

For even more information on clinical trials, see Clinical Trials: What You Need to Know.

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 are different from mainstream (standard) medical treatment. These methods can include vitamins, herbs, and special diets, or methods such as acupuncture or massage -- among many others. You may have a lot of questions about these treatments. Here are some you may have thought of already:

• How do I know if a non-standard treatment is safe? 

• How do I know if it works? 

• Should I try one or more of these treatments? 

• What does my doctor know/think about these methods? Should I tell the doctor that I'm thinking about trying them? 

• Will these treatments cause a problem with my standard medical treatment? 

• What is the difference between "complementary" and "alternative" methods? 

• Where can I find out more about these treatments?

The terms can be confusing

Not everyone uses these terms the same way, so it can be confusing. The American Cancer Society uses complementary to refer to medicines or methods that are used along with your regular medical care. Alternative medicine is a treatment used instead of standard medical treatment.

Complementary methods: Complementary treatment methods, for the most part, are not presented as cures for cancer. Most often they are used to help you feel better. Some methods that can be used in a complementary way are meditation to reduce stress, acupuncture to relieve pain or peppermint tea to relieve nausea. There are many others. Some of these methods are known to help, while others have not been tested. Some have been proven not be helpful. A few have even been found harmful. However, some of these methods may add to your comfort and well-being.

There are many complementary methods that you can safely use right along with your medical treatment to help relieve symptoms or side effects, to ease pain, and to help you enjoy life more. For example, some people find methods such as aromatherapy, massage therapy, meditation, or yoga to be useful.

Alternative treatments: Alternative treatments are those that are used instead of standard medical care. These treatments have not been proven safe and effective in clinical trials. Some of these methods may even be dangerous and some have life-threatening side effects. The biggest danger in most cases is that you may lose the chance to benefit from standard treatment. Delays or interruptions in your standard medical treatment may give the cancer more time to grow.

Deciding what to do

It is easy to see why people with cancer may consider alternative methods. You want to do all you can to fight the cancer. Sometimes mainstream treatments such as chemotherapy can be hard to take, or they may no longer be working.

Sometimes people suggest that their method can cure your cancer without having serious side effects, and it's normal to want to believe them. But the truth is that most non-standard methods of treatment have not been tested and proven to be effective for treating cancer.

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

• Talk to your doctor or nurse about any method you are thinking about using. 

• Check the list of "red flags" below. 

• Contact the American Cancer Society at 1-800-ACS-2345 to learn more about complementary and alternative methods in general and to learn more about the specific methods you are thinking about.

Red flags

You can use the questions below to spot treatments or methods to avoid. A "yes" answer to any one of these questions should raise a "red flag."

• Does the treatment promise a cure for all or most cancers? 

• Are you told not to use standard medical treatment? 

• Is the treatment or drug a "secret" that only certain people can give? 

• Does the treatment require you to travel to another country? 

• Do the promoters attack the medical or scientific community?

The decision is yours

Decisions about how to treat or manage your cancer are always yours to make. If you are thinking about using a complementary or alternative method, be sure to learn about the method and talk to your doctor about it. With reliable 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.

More treatment information

For more details on treatment options -- including some that may not be addressed in this document -- the National Comprehensive Cancer Network (NCCN) and the National Cancer Institute (NCI) are good sources of information.

The NCCN, made up of experts from many of the nation's leading cancer centers, develops cancer treatment guidelines for doctors to use when treating patients. Those are available on the NCCN Web site.

The American Cancer Society collaborates with the NCCN to produce a version of these treatment guidelines for colorectal cancer, written specifically for patients and their families. This less-technical version is available on both the NCCN Web site and the American Cancer Society Web site. A print version can also be requested from the American Cancer Society at 1-800-ACS-2345.

The NCI provides treatment guidelines via its telephone information center (1-800-4-CANCER) and its Web site. Detailed guidelines intended for use by cancer care professionals are also available on www.cancer.gov.

Revised: 03/05/2008