The colon cancer treatment mainly depends on the stage, location of the tumor, performance status of the patient, presence of certain genetic abnormalities, along with other factors.
Following are the preferred treatment approaches for different stages of colon cancer, but the final decision is taken after clinical assessment of the patient by an oncologist.
Tis N0 M0 (Stage 0) – Local excision or simple polypectomy with clear margins is considered preferred treatment approach.
T1-2 N0 M0 (Stage I)– Wide surgical resection of the part of colon depending on the involvement and site of disease.
T3-T4b N0 M0 (Stage II) – Wide surgical resection of the part of colon depending on the involvement and site of disease. Chemotherapy may be employed after surgery depending upon the presence of high risk factors as assessed by oncologist.
T1-4b N1-2b M0 (Stage III – Node positive disease) – Wide surgical resection of the part of colon depending on the involvement and site of disease followed by chemotherapy is considered as the standard treatment approach.
Any T Any N M1 (Metastatic disease) – Resectable disease
Wide surgical resection of the part of rectum depending on the involvement and site of disease along with the surgical resection/ablation/embolization of the metastases in the liver and/or surgical resection of lung metastases, as per surgeon’s discretion. Chemotherapy may be added thereafter.
Any T Any N M1 (Metastatic disease) – Unresectable disease
Chemotherapy, targeted therapy, and/or immunotherapy is the mainstay of treatment in case the disease has spread to distant body parts/organs and considered unresectable. If the disease becomes resectable as per surgeon’s discretion, it may be managed as per resectable disease mentioned above.
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Treatment of Localised and Locally Advanced Colon Cancer
Watch this video to better understand how localised and locally advanced colon cancer is treated.
Broadly, colon cancer may be divided into localized or locally advanced disease, and metastatic disease.
First, we will discuss the localized or locally advanced colon cancer treatment.
In T1, the disease extends up to the submucosa. And in T2, it extends upto the muscular propria. Now, we will discuss the treatment of T1 or T2 disease, without any lymph node involvement.
Surgical resection of the colon is the treatment in these cases, which may be in the form of right or left hemicolectomy.
Now we come to the treatment of the T3 disease, that is, the disease involving the pericolorectal tissue, without the involvement or regional lymph nodes.
Surgery of the colon is the mainstay of the treatment in these cases, as we have discussed previously, and chemotherapy may be added in selected patients, with hight high-risk disease.
CancerBro, how is it decided which patients will receive chemotherapy for T3 disease?
It is decided by the oncologist, depending upon the clinical presentation of the patient, tumor marker levels, imaging findings, his pathological report, and performance status of the patient.
Next comes the T4a disease, which extends up to the serosa.
Surgery, followed by chemotherapy is the standard treatment for T4a disease.
Now we come to the treatment for T4b disease, that is, the disease which extends through the wall of the colon to involve the adjacent structures.
In this figure, the tumor extends to involve the small intestine.
Cancer in ascending colon may extend locally to involve right kidney.
And that in descending colon may extend to involve left kidney.
Transverse colon cancer may extend locally to involve pancreas or the stomach.
Surgery and chemotherapy is the standard treatment for most of the patients of T4b disease.
If cancer involves regional lymph nodes, then irrespective of the T status of the patient, chemotherapy should be added to surgery.
But again, the final decision is taken by the oncologist on an individual patient basis, after assessing the performance status and the disease of the patient.
With this, we come to the end of localized or locally advanced colon cancer treatment.
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Treatment of Metastatic Colon Cancer
Watch this video to better understand how metastatic colon cancer is treated.
Now, we come to metastatic colon cancer treatment.
It may present as metastasis to liver or lungs.
It may also present as metastasis to both, lungs and liver.
Or peritoneum in the form of peritoneal or omental deposits to one or both the ovaries.
Very rarely, it may also spread to brain or bones.
For most cases of metastatic disease, chemotherapy is the treatment of choice.
But CancerBro, surgery was done in my case for metastatic disease?
In some cases of metastasis to liver, when the disease involves only a certain part of liver, surgery maybe possible.
So, if initially the metastasis involves a large part of liver. But after giving chemotherapy it regresses to a small part, surgery maybe tried.
The final decision to do surgery or not is taken by the oncologist on an individual patient basis, after assessing the exact pattern of liver involvement by the tumor, performance status of the patient along with other factors.
Other modalities are also being used to address the liver metastasis.
One such modality is embolization, in which different kinds of substances are injected into the hepatic artery. It is called as chemoembolization if chemotherapy is injected. Radioembolization, if radioisotopes are injected. And arterial embolization, if small particles and beads are injected to block the artery.
Another such method to address the liver metastasis is called an ablation, in which a probe is inserted to destroy the metastatic site.
It is called as radiofrequency ablation if radio frequency waves are used to destroy the tumor. Microwave ablation, if microwaves are used.
Cryoablation, if cold gases are used to freeze the tumor. Percutaneous ethanol injection may also be used to destroy the tumor cells.
CancerBro, in my case, surgery was done even after the disease had spread to lungs.
Similar to the liver metastasis, if lung metastasis involves a very small part of the lung, which can be removed safely, surgery may be possible.
Even in limited metastasis in both liver and lungs, surgery may be tried.
But these are very selective situations, in which a number of factors have to be considered, before taking up for surgery.
The final decision is taken by the oncologist on an individual patient basis, after assessing the performance status and disease of the patient in detail.
Other modalities like radiotherapy, surgery or bone-directed therapy, may also be used, for palliation or relief of symptom.
Always remember that the treatment for metastatic colon cancer is not generally curative, so the main intent for the treatment is a prolongation of life, reduction of symptoms and improvement of the quality of life.
With this, we come to the end of metastatic colon cancer treatment.
Following is the brief description of various treatment types employed for COLON CANCER:
- Surgery: Surgery is the treatment of choice for early stage and some advanced stage colon cancers that have not spread to distant body parts and can be completely removed.
In certain cases of advanced stage disease with distant metastases to liver and/or lungs, surgical resection of primary and metastasis may be done upfront or after chemotherapy, if the disease can be removed completely without affecting organ function, and as per physician discretion and patient’s condition.
- Chemotherapy: Chemotherapy means treatment with anti-cancer drugs that kill or decrease the growth of rapidly growing cancer cells. It is considered to be the mainstay of treatment for advanced stage disease that has spread to distant body parts.
Depending on the physician’s preference and patient’s condition, it may also be combined with other treatment options to accelerate the benefit achievement. It may be associated with side effects due to its effect on normal body cells apart from cancerous cells.
- Ablation: Ablation is a technique in which tumor is destroyed without actual removal from the body. This technique is mainly used for destroying liver metastasis, if patient is a suitable candidate for the same.
High-energy radio waves are utilized in radiofrequency ablation (RFA), microwaves are used in microwave ablation (MWA) technique, while very cold gases are used in cryoablation to destroy tumors. Sometimes, an ethanol injection given directly into the tumor tissue can be used to kill tumor cells. Imaging techniques are utilized along with these ablation techniques to accurately locate the target tumors.
- Embolization: Embolization is a technique in which tumor is destroyed by blocking the blood supply to the tumor cells with tiny particles injected directly in the artery supplying blood to tumor cells.
In arterial embolization, inert particles are used, whereas, particles are loaded with drugs in chemoembolization, and with radioactive substances in radioembolization). This technique is mainly used for destroying liver metastasis, if patient is a suitable candidate for the same.
- Targeted Therapy: Targeted drugs are designed to target a specific gene or protein characteristic of colon cancer cells. With advancements in diagnostic techniques, a number of genetic abnormalities for colon cancer have been identified that can be targeted with the help of targeted drugs.
Molecular testing to confirm the genetic abnormality is the pre-requisite for starting a targeted therapy. They work differently than chemotherapy drugs that they target a specific gene or protein characteristic of the cancer cells. For example, Cetuximab targets epidermal growth factor receptor (EGFR) protein, Bevacizumab targets vascular endothelial growth factor (VEGF) receptor. They are generally used alone or in combination with chemotherapy for the treatment of higher stage disease.
- Immunotherapy: Cancer cells utilize certain mechanisms to escape from the immune system of the patient from attacking these cells. Immunotherapeutic agents activate the immune system to recognize and kill cancer cells.
Pembrolizumab targets PD-1, a protein on T-cells that normally helps keep these cells from attacking cancer cells. This activates the immune system to kill the PD-L1 expressing cancer cells.
- Palliative Treatment: These treatments help in improving the overall quality of life by providing relief from the symptoms and reducing the suffering caused by the disease.
It includes but not limited to placing stent in the colon for obstructive symptoms, using drugs to reduce pain, bleeding, and other symptoms such as diarrhea, external-beam radiation therapy or surgery to reduce tumor load.
It is very important to assess the benefits of each treatment option versus the possible risks and side effects before making a treatment decision. Sometimes patient’s choice and health condition are also important to make a treatment choice.
Following are ultimate goals of treating stomach cancer:
- Prolongation of life.
- Reduction of symptoms
- Improvement overall quality of life of the patient