colon and rectal cancer - colorectal cancer association of canada

Colon andRectal CancerTreatment Guidelines for Patients

Version IV/ February 2005

The mutual goal of the National Comprehensive Cancer Network (NCCN) andthe American Cancer Society (ACS) partnership is to provide patients and thegeneral public with state-of-the-art cancer treatment information in an easy-to-understand language. This information is to assist you in a discussion about yourtreatment options with your doctor.

To ensure that you have the most up-to-date version of the treatment guidelines,consult the Web sites of the ACS (www.cancer.org) or NCCN (www.nccn.org).You may also call the ACS at 1-800-ACS-2345 or the NCCN at 1-888-909-NCCNfor the most recent information.

Colon andRectal CancerTreatment Guidelines for Patients

Version IV/ February 2005

http://www.nccn.org

http://www.cancer.org

Since 1995, doctors have looked to the NCCN for advice on treating cancer. TheNCCN Clinical Practice Guidelines were developed by a diverse panel of expertsfrom 19 of the nation’s leading cancer centers. The guidelines are a statement ofconsensus of its authors regarding the scientific evidence and their views ofcurrently accepted approaches to treatment.

For more than 85 years, the public has relied on the American Cancer Society forinformation about cancer. The Society’s books and patient education materialsprovide reliable and understandable information to hundreds of thousands ofpatients, their families, and caregivers.

©2005 by the National Comprehensive Cancer Network (NCCN) and the AmericanCancer Society (ACS). All rights reserved. The information herein may not bereprinted in any form for commercial purposes without written permission ofthe ACS. Single copies of each page may be reproduced for personal and non-commercial uses by the reader.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Making Decisions About Colon and Rectal Cancer Treatment . . . . . . . . . . . . . . . . .5About the Colon and Rectum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Colon and Rectal Cancer Work-Up (Evaluation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Colon and Rectal Cancer Stages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Types of Treatment for Colon and Rectal Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . .12Adjuvant Treatment and Neoadjuvant Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . .15Side Effects of Colon and Rectal Cancer Treatments . . . . . . . . . . . . . . . . . . . . . . . . .17Other Things to Consider During and After Treatment . . . . . . . . . . . . . . . . . . . . . .18About Clinical Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Colon and Rectal Cancer Treatment Guidelines . . . . . . . . . . . . . . . . . . .21Colon Cancer Decision Trees

Treatment for Cancerous Polyps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Treatment for Colon Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24Adjuvant Treatment for Colon Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26Colon Cancer With Metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30Colon Cancer and Liver Metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32Colon Cancer and Spread to Sites Other Than the Liver . . . . . . . . . . . . . . . . . .34Recurrent Colon Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36Chemotherapy for Advanced or Metastatic Colon Cancer . . . . . . . . . . . . . . . . .38

Rectal Cancer Decision TreesTreatment of Rectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42Treatment of Early Stage Rectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44Treatment of Large Rectal Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48Rectal Cancer With Spread to Distant Sites (metastases) . . . . . . . . . . . . . . . . .52Rectal Cancer With Spread to Distant Sites That Cannot Be Removed . . . .56Treatment of Recurrent Rectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58Chemotherapy for Advanced Disease or Distant Spread That Cannot Be Removed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

Arthur G. James Cancer Hospital and Richard J. Solove Research Institute at The Ohio State UniversityCity of Hope Cancer Center

Dana-Farber/Partners CancerCare

Duke Comprehensive Cancer Center

Fox Chase Cancer Center

Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance

H. Lee Moffitt Cancer Center & Research Institute at the University of South Florida

Huntsman Cancer Institute at the University of Utah

The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

Memorial Sloan-Kettering Cancer Center

Robert H. Lurie Comprehensive Cancer Center of Northwestern University

Roswell Park Cancer Institute

St. Jude Children’s Research Hospital/University of Tennessee Cancer Institute

Stanford Hospital and Clinics

UCSF Comprehensive Cancer Center

University of Alabama at Birmingham Comprehensive Cancer Center

University of Michigan Comprehensive Cancer Center

The University of Texas M. D. Anderson Cancer Center

UNMC/Eppley Cancer Center at the Nebraska Medical Center

Member Institutions

Introduction

With this report, patients have informationon the way colon and rectal cancer is treatedat the nation’s leading cancer centers.Originally developed for cancer specialists bythe National Comprehensive Cancer Network(NCCN), these treatment guidelines havenow been written for the general public bythe American Cancer Society (ACS). Toobtain another copy of these guidelines, callthe ACS at 1-800-ACS-2345, or the NCCN at1-888-909-NCCN, or visit these organizations’Web sites at www.cancer.org (ACS) andwww.nccn.org (NCCN).

These patient guidelines will help youbetter understand your cancer treatmentoptions. We urge you to discuss them withyour doctor and ask the following questions:

• Where is my cancer located?• How far has my cancer spread? What is

the stage of my cancer? How does thisstage influence my outlook for cure andsurvival and my treatment options?

• What treatment options do I have?• What are the risks or side effects

associated with each of my treatmentoptions and how are they likely to affectmy quality of life?

• What should I do to be ready for treat-ment, reduce side effects of treatment,and hasten my recovery?

• What support services are available tome and my family?

In addition to these questions, be sure towrite down some of your own. For instance,you might want more information about howlong it will take you to recover from surgery

so you can plan your work schedule. Or youmay want to ask about clinical trials.

Making Decisions AboutColon and Rectal CancerTreatment

Colon cancer and rectal cancer have many fea-tures in common. They are often referred totogether as “colorectal cancer,” and in somesections of this document, they are discussedtogether. In other sections, however, colon andrectal cancers are discussed separately toreflect ways in which treatments differ.

Colorectal cancer is the third most com-mon cancer (excluding skin cancer) of bothmen and women in the United States. TheACS estimates that about 106,000 new casesof colon cancer and 41,000 new cases of rectalcancer are diagnosed each year. About 57,100people die of colorectal cancer each year.

Most colorectal cancers are adenocarcino-mas (cancers of the glandular cells that line theinside of the colon and rectum). The informa-tion here refers to colorectal adenocarcinomasonly. Other tumors that can involve the colonor rectum, such as carcinoid tumors, stromaltumors, and lymphomas, are much less com-mon. The treatment and prognosis for theserarer types of colorectal tumors differ fromthat of adenocarcinomas and are not coveredin this document.

Although colorectal cancer is a seriousdisease, it can be treated by a team of healthcare professionals. The team may include agastroenterologist, surgeon, radiation oncol-ogist, medical oncologist, pathologist, oncol-ogy nurse, social worker, radiologist, and

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http://www.nccn.org


enterostomal therapist. This information isintended to help you understand the treat-ment options available to people with colonand rectal cancers so that you and your doc-tor can work together to decide which onesbest meet your medical and personal needs.

On the following pages you’ll find flowcharts that doctors call decision trees. Thecharts represent different stages of colon orrectal cancer, and each one shows how youand your doctor can arrive at the choices youneed to make about your treatment. You willalso find information on colorectal cancer, anexplanation of colorectal cancer stages, whattests are needed to diagnose and stage yourcancer, and treatment options with possibleside effects for each option. A glossary of med-ical terms is also included; words in italicsare found in the glossary.

About the Colon and Rectum

Understanding a little about the normal func-tion and anatomy of the colon and rectum canhelp you understand how colorectal cancersspread and what is removed by the operationswe will discuss later in this booklet.

The colon and rectum are parts of the largeintestine, or bowel, which is part of the digestivesystem. The digestive system processes food forenergy and rids the body of solid waste matter.

After food is chewed and swallowed, ittravels through the esophagus to the stom-ach. There it is partly broken down and thensent to the small intestine, also called thesmall bowel. The small intestine continues

breaking down the food and absorbs most ofthe nutrients. The small intestine joins thecolon, a muscular tube about 5 feet long. Thelarge intestine continues to absorb water andmineral nutrients from the food and storeswaste matter, called feces or stool. The wastematter left after this process passes out of thebody through the anus. The first 41⁄2 feet or soof the large intestine is called the colon, andthe remainder is the rectum. The colon has 4sections. The small intestine is connected tothe first of these, called the ascending colonbecause it extends upward on the right sideof the abdomen. The part where the ascend-ing colon joins the small intestine is calledthe cecum. The second section is called thetransverse colon because it goes across thebody from the right to the left side. There itjoins the third section, the descending colon,

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Organs of the Digestive System

Liver Esophagus

Rectum

Anus

Cecum

StomachGallbladder

Ascendingcolon

Transversecolon

Descendingcolon

Sigmoidcolon

Small intestine

which continues downward on the left side.The fourth section is known as the sigmoidcolon because of its S-shape. The sigmoid colonjoins the rectum, which in turn joins the anus.

Each of these sections of the colon and rec-tum has several layers. (See diagram on page11.) Colorectal cancers start in the innermostlayer and can grow through some or all of theother layers. Knowing a little about these layersis important because the stage (extent ofspread) of a colorectal cancer depends to agreat degree on which of these layers it affects.This is discussed further in the section onColon and Rectal Cancer Stages.

The lymphatic system carries fluidthroughout the body. Lymph is a clear fluidthat contains waste products and immunesystem cells. Lymphatic vessels carry this fluidto lymph nodes (small, bean-shaped collectionsof immune system cells important in fightinginfections). Most lymphatic vessels of the colonor rectum lead to nearby (regional) lymphnodes. Cancer cells may enter lymph vesselsand travel to lymph nodes, where they cancontinue to grow. If cancer cells grow in theselymph nodes, they are more likely to havespread to other organs of the body as well.

The walls of the colon and rectum arenourished by blood from arteries. After flow-ing through these body parts, the blood flowsinto veins. Veins from the colon and rectumlead to the liver and then back to the heart.This pattern of blood flow is important,because cells may break off from a colorectalcancer, enter veins leaving these organs, andtravel to the liver. This is why the liver is themost common site for colorectal cancer tospread (metastasize).

Colon and Rectal CancerWork-Up (Evaluation)

If there is reason to suspect that you havecolon or rectal cancer, the doctor will take acomplete medical history and do a physicalexam. Also, one or more of the following testswill be done to find out if the disease is reallypresent and to determine its stage (how farthe cancer has spread).

Medical history and physical exam:When your doctor “takes a history,” he or shewill ask you a series of questions about yoursymptoms and risk factors. Some colorectalcancers may be found because of symptomssuch as a change in bowel habits, blood in thestool, weakness or fatigue, abdominal pain,loss of appetite, nausea, weight loss, andstraining during a bowel movement. Ofcourse, many noncancerous conditions andsome other cancers can cause one or more ofthese symptoms. But if these symptoms arepresent, a medical evaluation is the only wayto determine their cause so that the mostappropriate treatment can be chosen. Aphysical exam for patients thought to havecolorectal cancer will include a digital rectalexamination (DRE), careful examination ofthe abdomen to feel for masses or enlargedorgans, and a general survey of the rest of thebody.

Colonoscopy: A colonoscope is a long,flexible, lighted tube about the thickness of afinger. It is inserted through the rectum upinto the colon. A colonoscope is longer thana sigmoidoscope and allows the doctor, inmost cases, to see the entire colon lining. Thecolonoscope is connected to a video camera

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and video display monitor so that the doctorcan look closely at the inside of your colon.Before this test, you will take strong laxativesto cleanse your bowel and on the morning ofthe test you will also take an enema.Colonoscopy lasts about 15 to 30 minutesand is generally not painful because a mildsedative is given.

Biopsy: If a mass or any other abnormalareas are seen through the flexible sigmoido-scope or through the colonoscope, a samplewill be taken. A pathologist will examine thesample under a microscope to determinewhether it is a cancer or some benign condi-tion. Some abnormalities, such as smallpolyps, may be entirely removed through acolonoscope. If the abnormal area is large, abiopsy (small tissue sample) is taken. Thebiopsy sample is usually about 1⁄8-inch acrossand is removed with instruments that areused through the scope.

If you have questions about pathologyresults or any other aspect of the diagnosticprocess, do not hesitate to ask your doctor.You can obtain a pathology review by havingmicroscope slides containing thin slices ofyour specimen sent to a consulting pathologistat an NCCN cancer center or other laboratoryrecommended by your doctor.

Blood counts and blood chemistry:Your doctor will order a blood test that willdetermine if you are anemic. Many people withcolorectal cancer become anemic because ofbleeding from the tumor. A blood test willalso show how your liver is functioning.Colorectal cancer can spread to the liver andcause changes in blood proteins and enzymes.

Tumor markers: Colon and rectal cancersproduce substances such as carcinoembryonic

antigen (CEA) and CA 19-9 that are releasedinto the bloodstream. Blood tests for these“tumor markers” are used most often withother tests to watch patients who alreadyhave been treated for colorectal cancer. Theymay provide an early warning that a cancerhas returned.

Because the CEA level in the blood can behigh for reasons other than cancer or may benormal in a person who has cancer, it is notused to find cancer in people who have neverhad cancer and appear to be healthy.

Chest x-ray: This familiar imaging testcan often detect the spread of colorectalcancer to the lungs.

Ultrasound: This imaging test uses adevice called a transducer that producessound waves, which are reflected by nearbybody tissues and organs. The pattern of soundwave echoes is detected by the transducerand analyzed by a computer to create animage of the area being studied. Since normalbody tissues and tumors reflect sound wavesdifferently, ultrasound is sometimes used tofind masses that indicate local or distant spreadof cancer. Two special types of ultrasoundexaminations are used to evaluate peoplewith colon and rectal cancer. Endorectalultrasound uses a special transducer that canbe inserted into the rectum. This test is usedto see how far a rectal cancer may havegrown and whether it has spread to nearbyorgans or tissues. Intraoperative ultrasoundis done after the surgeon has opened theabdominal cavity. The transducer can beplaced against the surface of the liver, makingthis test very useful in detecting metastasesof colorectal cancer to the liver.

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Computed tomography: Commonlyreferred to as CT or a CAT scan, this test usesa rotating x-ray beam to create a series ofpictures of the body from many angles. Acomputer combines the information fromthese pictures, producing a detailed cross-sectional image. Contrast material is usuallyinjected into a vein before CT scanning tohelp produce clearer pictures. A CT scan canoften detect the spread of colorectal cancerto internal organs such as the liver, lungs, orelsewhere in the abdomen. Spiral CT uses aspecial scanner that can provide greater detailand is sometimes useful in finding metastasesfrom colorectal cancer. For a spiral CT withportography, contrast material is injectedinto veins that lead to the liver, to help findmetastases from colorectal cancer to thatorgan.

CT-guided needle biopsy: If a metastasisis discovered, this test is often done. For thistest, the patient remains on the CT scanningtable while a radiologist places a biopsy nee-dle in the mass. CT scans are repeated untilthe doctors are confident that the needle iswithin the mass. A fine needle biopsy sample(tiny fragment of tissue) or a core needlebiopsy sample (a thin cylinder of tissue about1⁄2-inch long and less than 1⁄8-inch in diameter)is removed and examined under a microscope.

Magnetic resonance imaging: Likecomputed tomography, magnetic resonanceimaging (MRI or an MRI scan) displays across-section of the body. However, MRI usespowerful magnetic fields instead of radia-tion. The procedure can show cross-sectionalviews from several angles and is useful inlocating metastases from colorectal cancer

that are sometimes hard to see on standardx-rays and CT scans. A special MRI can showthe doctor more about rectal tumors.

Positron emission tomography: Positronemission tomography (PET or a PET scan)uses glucose (a form of sugar) that contains aradioactive atom. The cancer cells will absorbthe glucose and can be detected by a scanner.PET is often useful in identifying cancers thathave spread and is used in patients with a ris-ing CEA or suggested metastatic disease byother tests.

Angiography: For this test, a catheter(thin tube) is placed in a blood vessel andmoved until it reaches the area to be studied.Contrast dye is injected rapidly, and a series ofx-ray images is then taken. When the picturesare complete, the catheter is removed.Angiography is sometimes used to show sur-geons the location of blood vessels next to aliver metastasis from colorectal cancer so thatan operation can be planned.

Colon and Rectal Cancer Stages

Staging is a process that tells the doctor howwidespread the cancer may be — that is,whether the cancer has spread and how far.The stage of a cancer is one of the mostimportant factors in selecting treatmentoptions and predicting outcome. If you haveany questions about your stage, please dis-cuss them with your doctor.

A staging system is a standardized way inwhich the cancer care team describes theextent to which a cancer has spread. Staging

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systems for colorectal cancer include the olderDukes and Astler-Coller systems as well as themore modern AJCC/TNM system. This docu-ment uses the American Joint Committee onCancer (AJCC) system, also called the TNMSystem. All 3 systems describe the spread ofthe cancer in relation to the layers of the wallof the colon or rectum, nearby lymph nodes,other organs next to the colon and rectum,and organs farther away.

In addition, there are 2 types of AJCCstages. The clinical stage is based on physicalexamination and some imaging studies donebefore surgery. The clinical stage is used todecide which, if any, operations should bedone for people with colorectal cancer. Aftercolorectal surgery, the pathologic stage isdetermined by examining the body tissuethat has been removed. The pathologic stageis used to decide which patients with colonand rectal cancer should receive adjuvanttreatment and, if so, exactly which treatment.

The TNM System describes the extent ofthe primary tumor (T), the absence or presenceof metastasis (spread) to nearby lymph nodes(N), and the absence or presence of distantmetastasis (M).

T Categories for Colorectal CancerT stages of colorectal cancer describe how farthe cancer has spread through the layers thatform the wall of the colon and rectum. Theselayers, from the inner to the outer, includethe mucosa (the lining) which includes themuscularis mucosae (a thin layer of muscletissue beneath the mucosa), the submucosa(connective tissue beneath this thin musclelayer), the muscularis propria (a thick layer ofmuscle that contracts to force the contents of

the intestines along), the subserosa (a thinlayer of connective tissue), and the serosa (athin layer that covers the outer surface ofsome parts of the large intestine).

Tis: The cancer is in the earliest stage. Ithas not grown beyond the mucosa (inner layer)of the colon or rectum. This stage is alsoknown as carcinoma in situ or intramucosalcarcinoma.

T1: The cancer has grown through themucosa and extends into the submucosa.

T2: The cancer has grown through themucosa and the submucosa and extends intothe thick muscle layer.

T3: The cancer has grown through themucosa, the submucosa, and completelythrough the thick muscle layer. It has spreadto the subserosa but not to any nearby organsor tissues.

T4: The cancer has spread completelythrough the wall of the colon or rectum intonearby tissues or organs.

N Categories for Colorectal CancerN0: No lymph node involvement.N1: Cancer cells found in 1 to 3 regional

lymph nodes.N2: Cancer cells found in 4 or more

regional lymph nodes.

M Categories for Colorectal CancerM0: No distant spread.M1: Distant spread is present.

Stage groupingOnce a patient’s T, N, and M categories areknown, this information is combined todetermine the stage, expressed in Romannumerals from stage I (the least advanced

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stage) to stage IV (the most advanced stage).The following table illustrates how TNM cat-egories are grouped together into stages.

STAGE TNM CATEGORY

Stage 0: Tis, N0, M0

Stage I: T1, N0, M0T2, N0, M0

Stage IIA: T3, N0, M0Stage IIB: T4, N0, M0

Stage IIIA: T1-T2, N1, M0Stage IIIB: T3-T4, N1, M0Stage IIIC: Any T, N2, M0

Stage IV: Any T, Any N, M1

Stage 0: Tis, N0, M0: The cancer is in theearliest stage. It has not grown beyond theinner layer (mucosa) of the colon or rectum.This stage is also known as carcinoma in situor intramucosal carcinoma.

Stage I: T1, N0, M0, or T2, N0, M0: Thecancer has grown through the mucosa into thesubmucosa (T1) or it may also have growninto the muscularis propria (T2), but it hasnot spread into nearby lymph nodes (N0) ordistant sites.

Stage IIA: T3, N0, M0: The cancer hasgrown through the wall of the colon or rectum,into the outermost layers (T3). It has not yetspread to the nearby lymph nodes (N0) ordistant sites.

Stage IIB: T4, N0, M0: The cancer hasgrown through the walls of the colon or rectuminto other nearby tissues or organs (T4). Ithas not yet spread to the nearby lymph nodes(N0) or distant sites.

Stage IIIA: T1-2, N1, M0: The cancer hasgrown through the mucosa into the submucosa(T1) or it may also have grown into the mus-cularis propria (T2), and it has spread to 1 to 3nearby lymph nodes (N1) but not distant sites.

The layers of the colon wall

Normal Intestinal Tissue(Cross section of digestive tract)

Muscularis propriaThick muscle layer

Submucosa

EpitheliumConnective tissueThin muscle layer

Mucosa

SerosaSubserosa

Stage IIIB: T3-4, N1, M0: The cancer hasgrown through the wall of the colon or rectum(T3) or into other nearby tissues or organs(T4) and has spread to 1 to 3 nearby lymphnodes (N1) but not distant sites.

Stage IIIC: Any T, N2, M0: The cancer canbe any T but has spread to 4 or more nearbylymph nodes but not distant sites.

Stage IV: Any T, Any N, M1: The cancercan be any T, any N, but has spread to distantsites such as the liver, lung, peritoneum (themembrane lining the abdominal cavity), orovary (M1).

The Dukes system uses letters A throughC, and the Astler-Coller system uses Athrough D. If your stage is reported in eitherof these systems, this table can be used tofind the matching AJCC/TNM stage:

AJCC/TNM DUKES ASTLER-COLLER

0 – –

I A A, B1

II B B2, B3

III C C1, C2, C3

IV – D

Types of Treatment forColon and Rectal Cancers

The 4 main types of treatment for colon andrectal cancer are surgery, radiation therapy,chemotherapy, and immunotherapy. Dep-ending on the stage of the cancer, 2 or even 3of these types of treatment may be combinedat the same time or after one another.

After your cancer has been found andstaged, your doctor will recommend one ormore treatment options. It is important totake time and think about all of the choices.You may want to ask for a second opinion.This can provide more information and helpyou feel more confident about the treatmentplan you choose.

SurgeryColon surgery: Surgery is the main treatmentfor colon cancer. The usual operation is calleda segmental resection or partial colectomy. Toprepare for this surgery you will be givenlaxatives and enemas. Just before the surgeryyou will be given general anesthesia, whichputs you into a deep sleep. During this sur-gery, the cancer and a length of normal tissueon either side of the cancer as well as the nearbylymph nodes are removed. The remainingsections of the colon are then attached backtogether. When you wake up you will havesome pain and will need to be given painmedicines, usually morphine for the first dayor two. This operation rarely causes anymajor permanent problems with digestivefunctions. Sometimes, a temporary colostomymay be needed. In a colostomy, the colon isattached to the abdominal wall and fecalmaterial drains through an opening in thewall into a bag. Even more rarely, a permanentcolostomy may be needed. Patients can usu-ally leave the hospital about 5 to 7 days aftersurgery and resume usual activities in 6 weeks.Of course, hospitalization and recovery timesdepend on each patient’s specific medicalcondition.

It is sometimes possible to remove somevery early colon cancers by surgery through a

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colonoscope. When this is done, the surgeondoes not have to cut into the abdomen.

Some very advanced colon cancers canblock the flow of feces. When it is not possibleto remove the cancer, the flow of feces can bediverted to a colostomy. This operation is calleda diverting colostomy. If there is blockage,surgery is more likely to lead to complica-tions because the bowel cannot be cleansedwith enemas, which help prevent infection.Also, a complete colonoscopy cannot be done.

It is sometimes possible to remove seg-ments of the colon and nearby lymph nodesthrough a laparoscope. This instrument is along, lighted viewing tube through which thedoctor can operate with special surgicalinstruments. The viewing tube and instru-ments are placed into the abdomen throughseveral small surgical incisions. The NCCNguidelines recommend laparoscopic colec-tomy as an option because clinical trials haveshown that laparoscopic colectomy is as gooda procedure as abdominal colectomy

Rectal surgery: Several methods are usedfor removing or destroying rectal cancers.Local resection is an option for some peoplewith stage I rectal cancer. It involves cuttingthrough all layers of the rectum to removeinvasive cancers as well as some surroundingnormal rectal tissue. This procedure can bedone through the anus without cuttingthrough the abdomen and it leaves the rectumintact. This procedure is called “transanalresection.” Because complete removal of thecancer is so important, local resection is notan option for people whose cancers cannotbe completely removed by that procedure.Doctors consider the cancer’s size, its exactlocation within the rectum, and how far

around the circumference of the rectum itextends in order to select which patientsshould have a local resection.

Many stage I and most stage II and stageIII rectal cancers are removed by either lowanterior (LA) resection or abdominoperineal(AP) resection. LA resection is used forcancers near the upper part of the rectum,close to where it connects with the sigmoidcolon. After LA resection, the colon is attachedto the lower rectum and waste is eliminatedin the usual way.

AP resection is used for cancer in thelower part of the rectum, close to its outerconnection to the anus. Because the cancer isclose to the anus, the anus is also removed.After AP resection, a permanent colostomy isneeded. Some patients with stage IV rectalcancers will need a diverting colostomy. Inthis operation the surgeon does not remove arectal cancer that is blocking fecal flow, butinstead bypasses the blockage and divertsfecal flow to a colostomy. Some patients maynow have a stent (a plastic or metal tube)placed to keep the colon or rectum frombecoming blocked if the tumor cannot beremoved. Heating the rectal tumor with alaser beam aimed through the anus, calledphotocoagulation, is another option forrelieving or preventing rectal blockage inpatients with stage IV cancer.

Surgical treatment of colorectal cancermetastases: For patients whose colorectalcancer has spread to a few areas in the liver,lungs, or elsewhere in the abdomen, removingthese metastases can cure the cancer in someinstances. Other times, destroying metastaseswithout surgery, although not curative, canhelp the patient live longer. Liver metastases

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may also be destroyed by freezing the tumor(cryosurgery) or by heating them withmicrowaves (radio frequency ablation). Thefreezing probe or microwave probe is placedthrough the skin and guided to the tumor byCT scans or ultrasound images.

Radiation TherapyRadiation has a major role in the treatmentof rectal cancers. Radiation therapy useshigh-energy x-rays or particles to kill cancercells. In treating rectal cancer, radiationtreatment is usually given by external beamradiation. External beam radiation is usuallygiven with a linear accelerator, 5 days a weekfor several weeks. This must be planned,using diagnostic x-ray machines, such as asimulator or a CT scanner. Radiation can begiven either before surgery — to cause thetumor to shrink to allow easier removal or todecrease the risk of complications — or aftersurgery if there is a risk of the cancer comingback in the tumor area. Chemotherapy withthe drug fluorouracil (5-FU) is given by con-tinuous infusion through an intravenous (IV)line (placed in a vein) at the same time asradiation to make the radiation more effective.Studies have shown that for cases of rectalcancer, radiation along with surgery willoften decrease the risk of the cancer comingback (recurrence).

ChemotherapyChemotherapy is the use of cancer-fightingdrugs injected into a vein or taken by mouth.Chemotherapy is a systemic treatment. Thedrugs enter the bloodstream and reach all areasof the body, making this treatment useful for

cancers that have spread beyond the organthey started in.

Fluorouracil (5-FU) is the chemotherapydrug most often used to treat colorectalcancer. It is usually given together with otherdrugs, such as leucovorin, that increase itseffectiveness. As stated above, 5-FU is alsogiven by continuous infusion along with radi-ation therapy to increase the effectiveness ofthe radiation.

In the past, 5-FU was usually given slowlyinto a vein over about 5 minutes. If theseinjections were given for 5 days, which was atypical treatment, no other chemotherapywould be given for about 3 weeks while thepatient recovers from the drug’s side effects.Some doctors would use a schedule of onceweekly injections. This cycle was repeated for6 to 8 months.

Recently it has been found that a differentway of giving these drugs may be better. Withthis treatment, called the de Gramont regimen,the 5-FU is given continuously over 2 days aswell as by rapid injection on each day. Theleucovorin is given on each day over 2 hours.The de Gramont regimen is given every otherweek.

In some cases, particularly along withradiation therapy, 5-FU is given as a continuousinfusion into a vein. The patient wears a smallbattery-operated pump that continuouslyreleases 5-FU into an IV line. For patients withspread of colon or rectal cancer to their liver,5-FU or a related drug, floxuridine (FUDR), maybe given directly into the artery that suppliesblood to the liver. This approach to treatmentof liver metastases is called hepatic arteryinfusion.

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Irinotecan is another chemotherapydrug that is used with 5-FU. This treatment iscalled FOLFIRI. It adds irinotecan to the deGramont 5-FU/leucovorin regimen. Recentstudies have shown a chance of excessive sideeffects when 5-FU, leucovorin, and irinote-can are combined. If this combination ofdrugs is used, the starting doses may bereduced and your doctor will carefully watchyou so that your doses can be adjusted if nec-essary. If excessive side effects occur, dosagesmay be adjusted.

Oxaliplatin is another drug that is effectivewhen combined with 5-FU and leucovorinand may be used instead of irinotecan. Likeirinotecan, it is often used with the deGramont 5-FU/leucovorin regimen. Thistreatment is called FOLFOX.

Capecitabine, a chemotherapy drug givenby mouth, is changed to 5-FU once it gets insidethe body to the tumor site. This drug can beused instead of intravenous 5-FU and acts asif the 5-FU was being given continuously.

ImmunotherapyImmunotherapies use natural substancesproduced by the immune system. These sub-stances may kill cancer cells, slow their growth,or activate the patient’s immune system tofight cancer more effectively.

Antibodies are produced by the immunesystem to help fight infections. Similar anti-bodies called monoclonal antibodies can bemade in the laboratory. Instead of attackinggerms as usual antibodies do, some mono-clonal antibodies can be designed to attackcancer cells. Two new monoclonal antibodieshave been approved by the US Food and Drug

Administration (FDA) to attack colon cancercells.

The first new agent, bevacizumab, worksby preventing the growth of new blood vesselsthat supply tumor cells with the blood, oxygenand other nutrients they need to grow.Bevacizumab is used with chemotherapy asfirst line treatment for patients withadvanced or metastatic colon or rectal cancer.

The second new agent, cetuximab, worksby binding to a special site on the cell surfacewhich stops the cell’s growth and promotescell death. It is used either alone or in combi-nation with a chemotherapy agent as a secondline treatment for patients with advancedcancer or metastatic colon or rectal cancerwhose disease is no longer responding tothe chemotherapy agent, irinotecan, or forpatients who cannot take irinotecan.

Adjuvant Treatment andNeoadjuvant Treatment

The terms adjuvant treatment and neoadju-vant treatment refer to radiation therapy and/or chemotherapy given before (neoadjuvant)or after (adjuvant) surgery. Adjuvant treatmentis given after surgery when there is a chancethat a small number of cancer cells havealready spread to distant sites. Neoadjuvanttherapy is given before surgery for large rectaltumors, particularly if the cancer appears tohave spread to lymph nodes.

Adjuvant treatment: After surgery, thetissue that has been removed is examinedunder a microscope to determine thecancer’s stage (how far it has spread). If the

15

cancer is large or has spread to lymph nodes,even though no remaining cancer can be seen,doctors believe it is possible that a few scat-tered cancer cells may remain in the patient’sbody. In this situation more treatment in theform of chemotherapy or radiation therapymay be given.

Neoadjuvant treatment: If the tumorappears large or has spread to lymph nodes,radiation therapy along with chemotherapymay be recommended before surgery. Thepurpose of neoadjuvant treatment is toshrink tumors so that they can be more com-pletely removed by surgery and prevent thecancer from coming back in the pelvis.

Talking with an enterostomal therapist:NCCN guidelines recommend that people withrectal cancer be referred to an enterostomaltherapist (a health care professional, often anurse, trained to help people with theircolostomies) as part of their initial work-up.The enterostomal therapist can address con-cerns about how a colostomy might affect theirdaily activities. A colostomy is an opening inthe abdomen where a section of the colon isattached to allow for passage of body waste.A bag is attached to the skin with adhesivesto collect waste. Discussing these issuesshortly after diagnosis can help patients makeinformed decisions about treatment options,some of which may involve a colostomy.

A discussion with an enterostomal thera-pist is also recommended for the few peoplewith colon cancer who need a temporary orpermanent colostomy. If a patient’s surgicaltreatment requires a colostomy, the enterosto-

mal therapist will provide information andtraining on care of the colostomy. The ACSand many cancer centers can refer patientswith colostomies to support groups andother programs that provide additional infor-mation and support.

Treatment of Pain and Other SymptomsMost of this document discusses ways toremove or destroy colorectal cancer cells orto slow their growth. But it is important torealize that maintaining the lifestyle you havealways enjoyed is an important goal. Don’thesitate to discuss your symptoms or anyother concerns with your cancer care team.There are effective and safe ways to treatpain, most other symptoms of colorectalcancer, and most of the side effects caused bycolorectal cancer treatment. (Refer to theACS/NCCN treatment guidelines for patientson the following topics: cancer pain, nauseaand vomiting, cancer-related fatigue, andfever and neutropenia.)

Alternative or ComplementaryTherapiesIf you are considering any alternative orcomplementary therapies, it is best to discussthis openly with your cancer care team andrequest information from the ACS or theNational Cancer Institute (NCI). Any treatmentthat has not be studied in clinical trials andproved to be safe and effective might interferewith standard medical treatments or causeserious side effects.

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Side Effects of Colon andRectal Cancer Treatments

Side Effects of SurgerySide effects that can occur as a result of colo-rectal surgery include bleeding from the sur-gery, blood clots in the legs, and damage tonearby organs during the operation. Rarely, theconnections between the ends of the intestinemay not hold together completely and leak. Ifan infection occurs, it is possible that the inci-sion might open up, causing a gaping wound.Later after the surgery, you might developwhat are called adhesions, which could causethe bowel to become blocked.

Side Effects of RadiationSide effects of radiation occur mainly in thearea where the radiation is given and mayinclude skin irritation, diarrhea, rectal irrita-tion, and bladder irritation. Nausea and fatiguemay also occur. These slowly build up duringtreatment and often disappear on comple-tion of treatment. Long-term effects such asscarring or bleeding are possible. Irritation ofthe rectum is called radiation proctitis, andirritation of the colon is called radiation colitis.Occasionally, chronic irritation of the rectumor bladder persists.

Side Effects of ChemotherapyChemotherapy drugs kill cancer cells butalso damage some normal cells. Therefore,careful attention must be given to avoiding orreducing side effects, which depend on thetype of drugs, the amount taken, and thelength of treatment. The most common sideeffects might include loss of appetite, mouthsores, diarrhea, which can sometimes be

quite severe and life threatening (particularlyif irinotecan is given), or a rash on thepatient’s hands and feet. Hair loss can alsooccur. Because chemotherapy can damagethe blood-producing cells of the bone mar-row, patients may have low blood cell counts.This can result in an increased chance ofinfection (due to a shortage of white bloodcells), bleeding or bruising after minor cutsor injuries (due to a shortage of bloodplatelets), and fatigue (sometimes due to lowred blood cell counts). Fatigue also occursoften even when blood counts are normal.

Most side effects disappear once treatmentis stopped. Hair will grow back after treatmentends. There are remedies for many of thetemporary side effects of chemotherapy. Forexample, antinausea drugs to prevent or reducenausea and vomiting can be given (see theACS/NCCN Nausea and Vomiting TreatmentGuidelines for Patients with Cancer).

Side Effects of ImmunotherapyAlthough monoclonal antibodies are similarto normal parts of the immune system, treat-ment with them can cause side effects.Common side effects of these agents are highblood pressure, blood clots, diarrhea, fatigue,decreased white blood cell counts, headache,and skin rashes like acne.

Body Image and Sexuality IssuesSurgery and radiation therapy may some-times affect how people feel about their bodyand may lead to specific physical problems thataffect sexuality. Men who have an AP resectioncan have “dry” orgasms following surgerybecause of damage to the nerves that controlejaculation. Sometimes the surgery only causes

17

retrograde ejaculation, which means the semengoes backward into the bladder. AP resectionshould not stop your erections or ability toreach orgasm. However, your pleasure atorgasm may be less intense. Radiation may alsocause sexual dysfunction in men. Women whohave an AP resection should not expect anyloss of normal sexual function.

Your cancer care team can discuss theseissues with you, so don’t hesitate to shareyour concerns and ask questions.

Other Things to ConsiderDuring and After Treatment

During and after treatment for your colon orrectal cancer, you may be able to hasten yourrecovery and improve your quality of life bytaking an active role. Learn about the benefitsand disadvantages of each of your treatmentoptions, and ask questions of your cancer careteam if there is anything you do not under-stand. Learn about and watch for side effectsof treatment, and report these promptly toyour cancer care team so that they can takesteps to reduce them.

Remember that your body is as unique asyour personality and your fingerprints.Although understanding your cancer’s stageand learning about your treatment options canhelp predict what health problems you mayface, no one can say how you will respond tocancer or its treatment.

You may have special strengths such as ahistory of excellent nutrition and physicalactivity, a strong family support system, or adeep faith, and these strengths may make a

difference in how you respond to cancer.There are also experienced professionals inmental health services, social work services,and pastoral services who may assist you incoping with your illness.

You can also help in your own recoveryfrom cancer by making healthy lifestylechoices. If you use tobacco, stop now.Quitting will improve your overall health,and the full return of the sense of smell mayhelp you enjoy a healthy diet during recovery.If you use alcohol, limit how much you drink.Have no more than 1 or 2 drinks per day.Good nutrition can help you get better aftertreatment. Eat a nutritious and balanceddiet, with plenty of fruits, vegetables, andwhole grain foods. Ask your cancer care teamif you might benefit from a special diet —they may have specific recommendations forpeople who have had radiation therapy, acolostomy, or other colorectal surgery.

If you are being treated for cancer, be awareof the battle going on in your body. Radiationtherapy and chemotherapy add to the fatiguecaused by the disease itself. Give your body therest it needs so that you will feel better as timegoes on. Ask your cancer care team aboutincluding a regular program of exercise in yourdaily routine to help in your recovery.

A cancer diagnosis and its treatment aremajor life challenges, with an impact on youand everyone who cares for you. Before youreach the point of feeling overwhelmed, con-sider attending a meeting of a local supportgroup. If you need individual assistance inother ways, contact your hospital’s socialservice department or the ACS for help incontacting counseling or other services.

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About Clinical Trials

Studies of promising new or experimentaltreatments in patients are known as clinicaltrials. A clinical trial is only done when thereis some reason to believe that the treatmentbeing studied may be valuable to the patient.Treatments used in clinical trials are oftenfound to have real benefits. Researchers con-duct studies of new treatments to answer thefollowing questions:

• Is the treatment helpful? • How does this new type of treatment

work?• Does it work better than other treat-

ments already available?• What side effects does the treatment

cause?• Are the side effects greater or less than

the standard treatment?• Do the benefits outweigh the side effects?• In which patients is the treatment

most likely to be helpful?

Types of clinical trials: A treatment isstudied in 3 phases before it is eligible forapproval by the US FDA.

Phase I clinical trials: The purpose of aphase I study is to find the best way to give anew treatment and how much of it can begiven safely. The treatment has been welltested in laboratory and animal studies, butthe side effects in patients are not completelyknown. Doctors conducting the clinical trialstart by giving very low doses of the drug tothe first patients and increasing the dose forlater groups of patients until side effectsappear. Although doctors are hoping to helppatients, the main purpose of a phase I studyis to test the safety of the drug.

Phase II clinical trials: These studies aredesigned to see if the drug works. Patientsare given the highest dose that doesn’t causesevere side effects (determined from thephase I study) and closely observed for aneffect on the cancer. The doctors also look forside effects.

Phase III clinical trials: Phase III studiesinvolve large numbers of patients. Some clin-ical trials may enroll thousands of patients.One group (the control group) receives thestandard (most accepted) treatment. Theother groups receive the new treatment. Allpatients in phase III studies are closelywatched. The study will be stopped if the sideeffects of the new treatment are too severe orif one group has had much better result thanthe others.

If you are participating in a clinical trial,you will have a team of experts taking care ofyou and monitoring your progress very care-fully. The study is especially designed to payclose attention to you. However, there aresome risks. No one involved in the studyknows in advance whether the treatment willwork or exactly what side effects will occur.That is what the study is designed to discover.Although most side effects disappear in time,some can be permanent or even life threaten-ing. Keep in mind, though, that even standardtreatments have side effects. Depending onmany factors, you may decide to enroll in aclinical trial.

Deciding to enter a clinical trial:Enrollment in any clinical trial is completelyup to you. Your doctors and nurses willexplain the study in detail to you and will giveyou a form to read and sign indicating yourdesire to take part. This process is known as

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giving your informed consent. Even aftersigning the form and after the clinical trialbegins, you are free to leave the study at anytime, for any reason. Taking part in the studywill not prevent you from getting other med-ical care you may need.

To find out more about clinical trials, talkto your cancer care team. Among the ques-tions you should ask are:

• Is there a clinical trial for which Iwould be eligible?

• What is the purpose of the study?• What kinds of tests and treatments

does the study involve?• What does this treatment do?• What is likely to happen in my case with,

or without, this new research treatment? • What are my other choices and their

advantages and disadvantages?• Will I know which treatment I receive?• 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 be hospitalized? 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 theresearch, what treatment would I beentitled to?

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

• Has the treatment been used to treatother types of cancers?

The American Cancer Society offers aclinical trials matching service for patients,their family, and friends. You can find thisservice on our Web site (www.cancer.org) orthrough our national call center at 1-800-ACS-2345. Based on the information you provideabout your cancer type, stage, and previoustreatments, this service will compile a list ofclinical trials that match your medical needs.

You can also get a list of current clinicaltrials by calling the National CancerInstitute’s Cancer Information Service tollfree at 1-800-4-CANCER or by visiting the NCIclinical trials Web site at www.cancer.gov/clinical_trials/.

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http://www.cancer.gov/clinical_trials/

http://www.cancer.gov/clinical_trials/


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Colon and Rectal CancerTreatment Guidelines

The decision trees on the following pages represent different stages of colorectalcancer. Each one shows you step-by-step how you and your doctor can arrive atthe choices you need to make about your treatment.

Keep in mind that this information is not meant to be used without the expert-ise of your own doctor, who is familiar with your situation, medical history, andpersonal preferences. You may even want to review this booklet together withyour doctor, who can show you which of the decision trees apply to you. We’veleft some blank spaces in the decision trees for you or your doctor to add notesabout the treatments. You also might use this space to write down some ques-tions to ask your doctors about the treatments.

Participating in a clinical trial is an option for people with any stage of colorectalcancer. Taking part in the study does not prevent you from getting other medicalcare you may need.

The NCCN guidelines are updated as new significant data become available. Toensure you have the most recent version, consult the Web sites of the ACS(www.cancer.org) or NCCN (www.nccn.org). You may also call the NCCN at 1-888-909-NCCN or the ACS at 1-800-ACS-2345 for the most recent information onthese guidelines or on cancer in general.

http://www.nccn.org


Treatment for Cancerous PolypsSelecting treatment for patients with coloncancer involves considering many factors.These factors are considered in a stepwisemanner, starting with the the doctor’s initialimpression of the patient’s medical situation(called the clinical situation).

Sometimes a patient is thought to have anon-cancerous, or benign, polyp of the colonthat is a mushroom-shaped growth of glan-dular tissue (called an adenomatous polyp).Only after the growth is removed and studiedunder a microscope can the doctors see thatpart of what was thought to be a benigngrowth has started to turn cancerous. If that

is the case, then colonoscopy should be doneand the site marked with metal clips for fur-ther study by x-ray.

If the cancerous part of the growth hasbeen completely removed and is limited tothe head of the polyp (the part that resemblesthe cap of a mushroom), no more treatmentis needed. If it appears that the cancer cells arespreading along the stalk of the polyp or tolymphatic channels, or if the cancer cells arehighly abnormal in appearance, suggestingspread is likely (high grade), or if there arecancer cells in the edges of the removed tissuemargin, or if the margins cannot be completelyevaluated, then surgery to remove the cancer

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Treatment Guidelines for Patients

Work-Up (Evaluation)Clinical Presentation

Villous adenoma or villousadenoma with cancer

Pathology review

Colonoscopy

Marking of polyp site

Pathology review

Colonoscopy

Marking of polyp site

Cancer in an adenomatous polyp thathas been removed by polypectomy

along with removal of nearby lymph nodes isrecommended.

If the adenomatous growth is a villousadenoma, it does not have a distinct stalk butinstead has a broad base. If doctors are certainthat all of the adenoma and cancer has beenremoved, and the cancer is not growing intothe bowel lining, no more treatment is needed.

But, if the cancer is growing into the bowelwall if it is removed in pieces or fragments,if there are cancer cells in the edges of thespecimen, or if the margins cannot be seenvery well, or if there is growth into lymphaticchannels, or if the cancer is high grade, thencolon resection along with removal of lymphnodes is recommended.

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©2005 by the National Comprehensive Cancer Network (NCCN) and theAmerican Cancer Society (ACS). All rights reserved. The information hereinmay not be reproduced in any form for commercial purposes without theexpressed written permission of the ACS. Single copies of each page may bereproduced for personal and non-commercial uses by the reader.

Treatment for Cancerous Polyps

One or more of the following:

• Spread into polyp’s stalk

• Spread to lymphatic channels

• High grade (very abnormal-looking cells)

• Surgical margins (edge of tissue)contain cancer cells or cannotbe evaluated

Cancer limited to tip of polyp thathas been completely removed

One or more of the following:

• Stage T1 or higher

• Cancer removed in fragments

• Surgical margins (edge of tissue)contain cancer cells or cannotbe evaluated

• Spread to lymphatic channels

• High grade (very abnormal-looking cells)

Cancer is superficial, completelyremoved as a single tumor, andthere are no cancer cells in edgeof tissue

Findings After Polyp Removal Surgery

No additionalsurgery needed

No additionalsurgery needed

Surgery with removalof cancer along withpart of colon andnearby lymph nodes


See AdjuvantTreatment forColon Cancer(pages 26–29)

Treatment for Colon Cancer If a cancer invades the wall of the colon, thenthere should be a complete evaluation with apathology review, colonoscopy, if not alreadydone, blood tests, chest x-ray, and CT scans ofthe abdomen and pelvis. If the cancer appearsto be completely removable, then surgeryshould be done to remove the part of thecolon containing the cancer and nearbylymph nodes.

If a large cancer is blocking the flow offeces and the bowel couldn’t be cleansed withenemas before surgery (this is always neces-sary before any colorectal surgery) there are 3options.

The first is for the surgeon to remove thecancer and nearby lymph nodes.

In the second option the surgeon can do asmaller operation to remove just the cancerand create a temporary colostomy. The bowel

24


Findings of Work-upWork-Up (Evaluation)Clinical Presentation

Colon cancer thatappears to havespread to distant sites

• Pathology review

• Colonoscopy

• Blood counts

• Blood chemistry tests

• CEA blood test

• CT scan of abdomenand pelvis

• Chest x-ray

See Colon Cancerwith Metastases(pages 30–31)

Colon cancer thatlooks like it can beremoved and has notspread to distant sites

Surgeon can removeall visible cancer

The cancer cannotbe removed

Surgeon can remove allvisible cancer, but canceris blocking the bowel(obstruction) and it couldnot be cleansed with enemas before surgery

can then be cleansed and the full operationdone with more of the colon removed andnearby lymph nodes removed. The colostomyis repaired so the colon is intact again.

The third option is to relieve the obstruc-tion with a plastic tube or stent, cleanse thecolon, and then do a colon resection andremoval of nearby lymph nodes.

If it turns out the cancer cannot be com-pletely removed, then either a colostomy canbe done or a stent placed. Later, the tumor maybe removed to prevent future complications.

If the cancer appears to have spread todistant sites, then a completely differenttreatment is used (see page 30).

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Treatment for Colon Cancer

Surgery

Surgery with removal of canceralong with part of colon andnearby lymph nodes


Consider removingtumor to preventfuture complications

Surgery with removal of canceralong with part of colon andnearby lymph nodes

OR

Relieve blockage by removingcancer and diverting flow offeces to a colostomy

OR

Insert stent (a tube) throughobstruction to relieve blockage

Divert flow of feces to a colostomy

OR

Insert stent (a tube) throughobstruction to relieve any blockage

See AdjuvantTreatment(pages 26–29)

See Chemotherapyfor Advanced orMetastatic Disease(pages 32–35)

Adjuvant Treatment for Colon CancerStages 0 or I: Tis; T1–2, N0, M0: The tumor issmall and doesn’t invade past the musclelayer. It has not spread to nearby nodes ordistant sites. Because the risk of cancerreturning after surgery is low, adjuvant, oradditional, treatment is not given.

Stage IIA: T3, N0, M0: The tumor is largerand invades through the bowel wall. It hasnot spread to nearby nodes or distant sites.There is no evidence that adjuvant treatmentis helpful, but this is not certain. Either notreatment or participation in a clinical trial isappropriate.

26


Adjuvant (Additional) Treatment

Pathological Stage

No treatment, or

Consider 5-FU and leucovorin, or

Capecitabine or FOLFOX, or

Clinical trial

No treatment, or

Clinical trial

No treatment, or

Consider 5-FU and leucovorin orcapecitabine or FOLFOX, possiblywith radiation to the site of thecancer if there is a perforation(hole) in the bowel wall, or

Clinical trial

5-FU and leucovorin or capecitabine orFOLFOX regimen (5-FU, leucovorin andoxaliplatin). Radiation may be addedto 5-FU/leucovorin for T4 tumors

Stages 0 or I: Tumor is small, doesn’tinvade past muscular layer, and hasnot spread to lymph nodes or distantsites (Tis, T1–2, N0, M0)

Stage IIA: Tumor is larger and invadesthrough bowel wall, but has notspread to lymph nodes or distant sites (T3, N0, M0)

Stage IIB: There is a hole in the bowelwall, or there is cancer at the edge ofthe surgical specimen (T3, N0, M0)

Stage IIB: The cancer has grown into surrounding tissues but has notspread to lymph nodes or distant sites(T4, N0, M0)

Stage IIIA, B, C: The tumor is of anysize and has spread to lymph nodesbut not distant sites (T1–4, N1–2, M0)

Stage IIB: Same as above but the canceris high grade (very abnormal-lookingcells), has grown into blood or lymphaticvessels, or has obstructed the colon (T3, N0, M0)

No treatment

Stage IIB: T3, N0, M0: If the cancer is highgrade, invades blood or lymphatic vessels, orhas blocked the bowel, the cancer might havea higher chance of coming back. Becausethere is still no evidence proving that adju-vant treatment is helpful, no treatment isappropriate. Chemotherapy with 5-FU andleucovorin or participation in a clinical trial

would also be appropriate. If there is a holeor perforation in the bowel, radiation mightbe added to the chemotherapy.

Stage IIB: T4, N0, M0: The cancer hasgrown through the bowel wall and invadedsurrounding tissues. Because there is still noevidence proving that adjuvant treatment ishelpful at this stage, no treatment would be

27


Adjuvant Treatment for Colon Cancer

Follow-Up Tests and Examinations

History and physical exam every 3 months for 2 years, thenevery 6 months for a total of 5 years.

Repeat CEA blood test every 3 months for 2 years, thenevery 6 months for 5 years (only for T2, T3, and T4 cancers).

Consider CT if there is a high risk of recurrence.

Colonoscopy 1 year after surgery. Remove any polyps thatare found, and then repeat colonoscopy again in 1 year. Ifno polyps are found, repeat every 2–3 years.

If cancer has blocked the flow of feces (obstruction) andcolonoscopy is not done before surgery, then colonoscopyafter 3–6 months.

appropriate. But, chemotherapy with 5-FU andleucovorin, or capecitabine, or FOLFOX, orparticipation in a clinical trial would also beappropriate. Radiation might be added to thechemotherapy.

Stages III A, B, C: T1–3, N1–2, M0 and T4,N1–2, M0: The cancer has spread to nearbylymph nodes but not distant sites. Patientswhose tumors have spread to surroundinglymph nodes have a greater chance of having

their tumors recur. Studies have shown thatgiving adjuvant chemotherapy can lower therisk of recurrence. The recommended chemo-therapy is 5-FU and leucovorin or 5-FU leu-covorin and oxaliplatin (FOLFOX) orcapecitabine. Radiation therapy may beadded for T4 tumors.

Follow-up tests and examinations forcolon cancer: After treatments are finished,follow-up tests are routinely done. The purpose

28


NOTES

29

of these tests is to find colorectal cancer thathas recurred (come back) as soon as possible,when further treatments are most likely to behelpful.

You should see your doctor for a checkupregularly — first every 3 months and then,after 2 years, every 6 months for at least 5years. If you are healthy enough to have sur-gery to remove cancer that comes back in theliver or lungs, a CEA blood test should be

done at the same time as your checkup.Colonoscopy to detect new polyps should bedone in a year or in 3 to 6 months if yourcancer was blocking the bowel and it couldn’tbe done just before surgery. If polyps arefound, the colonoscopy should be repeated ina year. If none are found, then it can be doneevery 3 years. A CT scan may be performedfor patients that are considered high risk.

Adjuvant Treatment for Colon Cancer (continued)

NOTES

Colon Cancer With MetastasesAny T, any N, M1: The cancer has spread todistant sites. Work-up may include colonos-copy, blood work, CT scans of the abdomenand pelvis, a chest x-ray, and a needle biopsyof suspected metastasis. If the liver is the onlyarea of suspected distant spread, more testsmay need to be done, such as spiral CT, MRI,laparoscopy, PET scan, angiogram, and/orportography, especially if considering chemo-

therapy directly into the blood supply to theliver. This is called hepatic artery infusion, orHAI.

When spread to distant organs is suspectedor proven when a colon cancer is diagnosed,but before the colon and lymph node surgeryis done, the next step is to determine whetherthe metastases can be completely removed bysurgery. This decision is based on the numberof metastatic tumors present and their exact

30


Work-Up (Evaluation)Clinical Presentation

• Colonoscopy

• Chest x-ray

• CT scan of abdomen and pelvis

• Blood counts

• Blood chemistry tests

• CEA blood test

• Needle biopsy of suspected metastasis

If the spread is small enough to beremoved by surgery, more tests may bedone. These are:

• Spiral CT

• MRI

• Laparoscopy

• PET scan

• Special x-ray of blood vessels leadingto the liver

Colon cancer with proven or suspected distant spread(Any T, Any N, M1)

location. One tumor or a few tumors ofmetastatic colorectal cancer can often beremoved from the liver, lungs, or abdomen.Although not curative, destroying the tumorbut not removing it by surgery is anotheroption, and it can be accomplished by heatingthe tumors with radiofrequency waves or byfreezing them with cryosurgery (a very low-

temperature needle precisely aimed into thetumor). More tumors or tumors in certaincritical parts of these organs may be impossi-ble to remove without severely damaging theorgans in which they are found. Wheneverpossible, the surgeon will try to remove allvisible cancer, since this offers the bestchance for cure or long-term survival.

31


Findings

Spread (metastasis) to liverSee Surgery andAdjuvant Treatment(pages 32–33)

See Surgery andAdjuvant Treatment(pages 34–35)

Metastasis to lungs

Metastasis to other areasthat can’t be surgicallyremoved (abdomen, peritoneal area)

Impending blockage(obstruction)

Colon Cancer With Metastases

Colon Cancer and Liver Metastases If the cancer has already spread, but only

to the liver, doctors will decide if it is possibleto safely remove it. If only a few metastasesare present and they can be removed withsurgery, the NCCN recommends surgery toremove the colon cancer and nearby lymphnodes along with the liver metastases.

Another option is to remove the liver metas-tases 6 weeks after the colon surgery or togive chemotherapy after the colon surgeryand then operate on the liver metastases.

After surgery, adjuvant chemotherapymight be given with a number of differentchemotherapy combinations, includingchemotherapy given directly into the liver.

32


Surgical removal of colon cancerand nearby lymph nodes andremoval of the liver metastases atthe same time or later

OR

Surgical removal of colon cancerand nearby lymph nodes, chemo-therapy after surgery followed bysurgical removal of the liver metastases at a later time

OR

Surgical removal of the colon withchemotherapy (FOLFIRI or FOLFOX)

SurgeryFindings

If the risk of obstruction is highor there are not too many livermetastases, surgical removal ofthe colon cancer may be done.

Treating the liver metastaseswith cryosurgery or alcohol injections is an additional option.

Small number ofmetastases thatcan be removedby surgery

Colon cancerwith spread onlyto the liver

Too manymetastases tobe removed

For patients who received chemotherapybefore liver resection, not giving chemotherapyis also an option. In addition to the standardfollow-up outlined on page 27, the NCCNsuggests CT scans of the chest, abdomen, andpelvis every 3 to 6 months.

If there are too many liver metastases toremove safely and successfully, the tumor in

the colon may need to be removed to keep itfrom blocking the bowel later on. The livermetastases can be destroyed with cryo-surgery ( freezing), radiofrequency ablation,or alcohol injections. This may help somepatients feel better, but it is not curative.Chemotherapy may also be given.


33

If all cancer appears removed:

• CEA every 3 months if it had beenelevated, then every 6 months for3–5 years

• Chest x-ray, CT of chest, abdomenand pelvis every 3–6 months for 2years, then every 6–12 months for atotal of 5 years

• Colonoscopy 1 year after surgery.Remove any polyps that are found,and then repeat colonoscopy againin 1 year. If no polyps are found,repeat every 2–3 years

• If cancer has blocked the flow offeces (obstruction) and colonoscopywas not done before surgery, thencolonoscopy after 3–6 months

Adjuvant Therapy Follow-Up Tests

• 5-FU/leucovorin, or

• 5-FU/leucovorin/oxaliplatin (FOLFOX), or

• 5-FU/leucovorin/irinotecan (FOLFIRI), or

• Continuous 5-FU infusion, or

• Capecitabine, or

• Chemotherapy into the liver along withintravenous chemotherapy with 5-FU/ leucovorin or continuous 5-FU infusion, or

• No treatment

See Chemotherapy forAdvanced or MetastaticDisease (pages 38–39)

FOLFOX = Continuous infusion 5-FU and leucovorin and oxaliplatin

FOLFIRI = Continuous infusion 5-FU and leucovorin and irinotecan

IFL = 5-FU given IV push and leucovorin and irinotecan

Colon Cancer and Liver Metastases

34

Colon Cancer and Spread to SitesOther Than the LiverIf the cancer has spread only to the lungs,doctors will decide if it is possible to removeit safely. If the cancer can be removed fromthe lungs, then surgery is recommended toremove the colon cancer and nearby lymphnodes. At that time or later, the lung metas-tases can be removed.

After surgery, adjuvant chemotherapymight be given with any of the combinationslisted. Not giving chemotherapy is also anoption for those who received chemotherapybefore lung resection. In addition to the stan-dard follow-up, the NCCN suggests CT scansof the chest, abdomen, and pelvis every 3 to 6months for 2 years then every 6 to 12 monthsfor at least 5 years.


Surgical removal of colon cancerand nearby lymph nodes andremoval of the lung metastases

Chemotherapy (FOLFOX with orwithout bevacizumab, or FOLFIRIwith or without bevacizumab)

Consider resection of the colon

Consider surgery

Treatment Findings

Surgery to remove only thecancer, or

A colostomy to divert feces, or

Surgery on the colon thatbypasses the obstruction butleaves the cancer in place

Small number of metastases (1 lesion) thatcan be removedsurgicallyColon cancer

with spread tothe lungs

Colon cancer withspread to other areasthat can’t be removedand cancer is notblocking the bowel

Colon cancer withspread throughout theabdomen that can’t beremoved and cancer isblocking the bowel

Too manymetastases tobe removed

If there are too many lung metastases toremove safely, the tumor in the colon mayneed to be removed to keep it from blockingthe bowel later on. The metastases should betreated with chemotherapy.

The cancer may have already spread to thelungs, liver, or other areas and can’t be removed.To prevent colon blockage, the primary (original)colon tumor may need to be removed by surgery.This may be followed with chemotherapy.

Finally, if the cancer looks like it mayblock the bowel eventually even though itmay have also spread elsewhere, it still needstreatment. This can be with surgery thatremoves the cancer, or leaves the cancer inplace but creates a colostomy to empty fecesinto a bag, or that leaves the cancer in placebut bypasses the obstruction. Chemotherapyafter surgery is an option.


35

If all cancer appears gone:

• CEA every 3 months for 2 yearsif it has been elevated, thenevery 6 months for 3–5 years.

• Chest x-ray or CT of chest,abdomen and pelvis every 3 to 6 months.

• Colonoscopy 1 year after surgery. Remove any polypsthat are found, and thenrepeat colonoscopy again in 1 year. If no polyps are found,repeat every 2–3 years.

• If cancer has blocked the flowof feces (obstruction) andcolonoscopy was not donebefore surgery, then colonos-copy after 3–6 months.

Adjuvant Treatment Follow-up Testing


If surgery isnot possible

• 5-FU/leucovorin, or

• 5-FU/leucovorin/irinotecan(FOLFIRI), or

• 5-FU/leucovorin/oxaliplatin(FOLFOX), or

• Continuous 5-FU infusion, or

• Capecitabine, or

• No treatment

Colon Cancer and Spread to Sites Other Than the Liver

Recurrent Colon CancerCEA levels that rise steadily after initial treat-ment strongly suggest that a colorectalcancer is recurring and indicate the need fora thorough search for the recurrent cancer.There may be other reasons to suspect arecurrence, such as symptoms or somethingnot normal on examination. The search

includes colonoscopy, x-rays, CT and PETscans. If no cancer is found, these tests arerepeated at regular intervals. Some patientsmay have an elevated CEA level for monthsor years before recurrent disease is found.Patients are not given chemotherapy basedon a rising CEA level alone. If recurrentcancer is found by imaging tests, a biopsy

36


ClinicalPresentation

Rising bloodCEA levels

OR

Other findingsthat suggestrecurrence

All testsnegative(no cancerfound)

One ormore testsfind cancer

Evaluation

• Colonoscopy

• CT scans ofchest, abdomen,and pelvis

• Physical examination

• PET scan

Repeat CT scans of chest, abdomen, andpelvis every 3 months

Consider PET

may be done to be certain that this is cancerand not some other disease. In most cases,this involves a needle biopsy procedure thatuses a CT scan for guidance.

Recurrent cancer may be treated in 2ways. In the first, the recurrent tumor may becompletely removed with surgery, and cure is

possible. Before this is done, a PET scan mightbe done to make sure there isn’t any cancerelsewhere. After surgery, adjuvant chemo-therapy is recommended if it hasn’t beengiven before. If the tumor cannot be totallyremoved, the second way uses chemotherapyto control the recurrent disease.


37

Recurrent Colon Cancer

Cancer mightbe able to be removed surgically

PET scan findsno more cancer

PET scan findsmore cancer —surgery not anoption

See Chemotherapyfor Advanced orMetastatic Diseaseon next page

Cancer cannotbe removedsurgically

Treatment

PET scan mightbe consideredif not donepreviously

Surgical removal ofcancer followed byadjuvant treatmentfor 4–6 months ifnot given before

38

Chemotherapy for Advanced orMetastatic Colon CancerFor patients whose recurrences or metastasesare too large or numerous to remove com-pletely, treatment options depend on whetherthey are in good health apart from the cancerand are able to care for themselves. Many

studies have shown that patients who are tooill to care for themselves almost never bene-fit from chemotherapy.

For patients able to tolerate intensivechemotherapy, the options include intravenouschemotherapy with these combinations:


Metastases cannot becompletely removed

Patient is in goodhealth and is ableto care for self

Patient able totolerate intensivetherapy

Patient unable totolerate intensivetherapy

Patient’s generalfunctioning ispoor — unableto care for self

• 5-FU given as a continuous infusionwith leucovorin and oxaliplatin with orwithout bevacizumab

• 5-FU given as a continuous IV infusionwith leucovorin and irinotecan with orwithout bevacizumab

• 5-FU, leucovorin and irinotecan givenIV push

• bevacizumab with 5-FU and leucovorin,with or without oxaliplatin or irinotecan.


39

Chemotherapy for Advanced or Metastatic Colon Cancer

Additional Treatment for Recurrent or Metastatic Cancer

Chemotherapy with 1 of the following:

• 5-FU/leucovorin/oxaliplatin (FOLFOX)+/- bevacizumab

• 5-FU/leucovorin/irinotecan (FOLFIRI) +/- bevacizumab

• 5-FU/leucovorin/irinotecan given IVpush (IFL)

• Bevacizumab and 5-FU/leucovorin withor without oxaliplatin or irinotecan


• Capecitabine

• 5-FU/leucovorin (except if 5-FU/leucovorin was given as an adjuvantwithin the last 6 months)

• 5-FU given continuously into a vein or IV push along with leucovorin(bevacizumab may also be given)

Supportive care

If functioning improves,chemotherapy might bean option.

If cancer continues to growor treatment causes seriousside effects, try anotherchemotherapy if patientcontinues to function well.

Otherwise change to different treatment ofeither oxaliplatin-containingor irinotecan-containingchemotherapy regimens if not already given, oririnotecan alone if notgiven earlier, or cetuximabwith or without irinotecan.

Chemotherapy nolonger effective

40

If less intense treatment is more appropri-ate, the options are:

• continuous intravenous infusion of 5-FU with leucovorin, or

• capecitabine, or • 5-FU given IV push and not as an infu-

sion and leucovorin with or without

bevacizumab — if these latter had notbeen received as adjuvant treatmentwithin the last 6 months.

In either case, if the cancer continues togrow or begins to grow after shrinking withthe chemotherapy, a different chemotherapyfrom the one selected to try first may be given


NOTES

if the patient remains well. In addition, singleagent irinotecan or cetuximab with or with-out irinotecan may be appropriate. Ifchemotherapy is no longer effective, thensupportive care only should be given.

For patients who are in poor health andunable to care for themselves, supportivecare to relieve symptoms and maintain apatient’s well-being is recommended. Some-times, patients can improve so that they cantolerate chemotherapy.

41

Chemotherapy for Advanced or Metastatic Colon Cancer(continued)

NOTES

Treatment of Rectal Cancer The work-up (evaluation) for patients with arectal tumor begins with a medical history,physical examination, biopsy and a pathology

review of the specimen, colonoscopy, CEAblood levels, CT scans of the abdomen andpelvis, a chest x-ray, and an endorectal ultra-sound or endorectal MRI examination.

42


• Biopsy

• Pathology review

• Colonoscopy

• Chest x-ray

• CT scan of abdomenand pelvis

• CEA blood test

• Endorectal ultrasoundor endorectal MRI

• If colostomy isneeded, evaluation by therapist trained in colostomy care

Rectal tumor

ClinicalPresentation

Work-Up (Evaluation)

Consultation with a therapist or nursetrained in colostomy care is recommended ifit is likely that a colostomy will be needed.

Further treatment depends on the doctor’sestimate of the stage, depending on what thephysical examination and imaging tests show.

43

©2005 by the National Comprehensive Cancer Network (NCCN) and theAmerican Cancer Society (ACS). All rights reserved. The information herein maynot be reproduced in any form for commercial purposes without the expressedwritten permission of the ACS. Single copies of each page may be reproducedfor personal and non-commercial uses by the reader.

Tumor invades nodeeper than muscularlayer (T1, T2) with nolymph node spreada

Tumor invades pastthe muscular layer (T3)or has spread to lymphnodes (N1, N2)

Cancer has grownthrough rectal wall intoadjacent tissues (T4)

Cancer has spread to distant sites and they cannot be surgically removed(T1–4, N1–2, M1)

Cancer has spread to distant sites and they canbe surgically removed(T1–4, N1–2, M1)

See Treatment ofEarly Stage RectalCancer (pages 44–47)

See Treatment ofLarge Rectal Cancers(pages 48–51)

See Treatment ofLarge Rectal Cancers(pages 48–51)

See Rectal Cancer withSpread to Distant Sites(pages 52–55)

See Rectal Cancer withSpread to Distant SitesThat Cannot Be Removed(pages 56–57)

Clinical Stage Primary (Main)Treatment

a These stages should be determinedby endorectal ultrasound or MRI

Treatment of Rectal Cancer

Treatment of Early Stage Rectal Cancer If the cancer does not invade deeper than themuscular layer of the rectal wall (T1, T2) anddoesn’t appear to have spread to nearby lymphnodes, surgery is the first treatment recom-mended. An abdominal operation, either low

abdominal resection or AP resection isappropriate depending on where the cancerlies in the rectum.

But if the tumor is small enough — lessthan 3 cm in size (about an inch) and lessthan 8 cm from the anus (about 3 inches) andhas no bad features such as very abnormal

44


Primary TreatmentClinical Stage Pathologic Findings

Cancer removedthrough anus

Cancer removedthrough abdominaloperation

Small tumor notinvading pastmuscular layer(T1–2) and noenlarged lymphnodes on MRI orultrasound

Tumor invades no deeper thanmuscular layer (T1, T2, N0, M0)with no lymph node spread

Tumor found to invade pastthe muscular layer (T3) or hasspread to lymph nodes (N1, N2)

Tumor does not invade muscularlayer (T1) and edges of specimendo not contain cancer

Tumor does not invade muscularlayer (T1) but edges of specimencontain cancer, OR

The cancer invades vessels, OR

The cells look very different

Invades the muscular layer andnodes cannot be assessed (T2, NX)

cells or invasion of blood or lymphatic vessels— the cancer might be removed by operatingthrough the anus. This procedure is calledtransanal resection.

After surgery, the stage of the cancer isdetermined by the pathologist who examinesthe tumor and lymph nodes under the micro-scope.

45


Follow-up TestsAdjuvant Treatment

Tumor invadesno deeperthan muscularlayer with nolymph nodespread

Tumorfound toinvade pastthe muscularlayer or positivelymph nodes

5-FU with or without leucovorin for1–2 cycles; then continuous infusion5-FU with radiation, then 5-FU withor without leucovorin for 2 cycles

Remove cancerthroughabdominaloperation, orgive radiationtherapy alongwith 5-FU

Remove cancerthroughabdominaloperation

No Treatment

No Treatment

No Treatment

• Physical exam every3 months for 2years, then every 6months for 5 years

• Blood CEA testevery 3 months for2 years, then every6 months for 5 years

• Consider CT scan ifthere is a high riskfor recurrence.

• Colonoscopy in 1year; repeat in 1year if abnormal orat least every 2–3years if no polypsfound. If colonos-copy could not be done before surgery, then colonoscopy in 3–6 months.

5-FU +/- leucovorin,then 5-FU givencontinuously withRT, then 5-FU +/-leucovorin

Treatment of Early Stage Rectal Cancer

46


NOTES

If the cancer is removed by an abdominaloperation and does not grow past the musclelayer or spread to lymph nodes, then no furthertreatment is needed. If the cancer is found bythe pathologist to have spread into the musclelayer or to lymph nodes, further treatment isneeded. First, chemotherapy with 5-FU withor without leucovorin is given for 1 or 2cycles. Radiation therapy to the pelvis alongwith either a continuous infusion of 5-FU orcapecitabine pills follow this. When this is

complete, another 2 cycles of 5-FU with orwithout leucovorin are given.

If the cancer is removed through the anusand does not invade the muscle layer and theedges of the specimen are free of cancer, nofurther treatment is needed. But, if it is foundthat cancer is present at the edges of thespecimen or the cancer has invaded lym-phatic or blood vessels, then an abdominaloperation should be done. If the tumor hasinvaded the muscle layer and the doctors can

47

NOTES

not determine whether the cancer had spreadto lymph nodes, then either an abdominaloperation should be done or the patientshould receive radiation treatment to thepelvis along with a 5-FU infusion.

After treatment, patients should see theirdoctor for a checkup every 3 months for 2years, then every 6 months for at least 5 years.CEA blood tests should be done along with thecheckups for lesions that are T2 or greater with

positive lymph nodes. Colonoscopy shouldbe done 1 year after surgery. If polyps arefound, it should be repeated in a year. If thecolonoscopy is normal, it can be repeated in2 to 3 years. If colonoscopy could not be donebefore surgery, then it should be done within3 to 6 months after surgery. A CT scan may bedone for patients considered to be at highrisk for recurrence.

Treatment of Early Stage Rectal Cancer (continued)

48

Treatment of Large Rectal CancersIf the cancer has grown through the musclelayer (T3) or there are enlarged lymph nodeson MRI or ultrasound (N1–2) the first treat-ment would be either radiation along with acontinuous infusion of 5-FU or capecitabinepills, or an abdominal operation.

If the radiation is given first, then anabdominal operation to remove the cancershould be done. This is followed bychemotherapy with 5-FU with or without leu-covorin or the FOLFOX treatment (continu-ous infusion FU/leucovorin/oxaliplatin).


Primary TreatmentClinical Stage Pathologic Findings

OR

Large tumorinvading throughmuscular layer(T3) or enlargedlymph nodes onMRI or ultrasound(N1, N2)

Large tumorinvading throughrectal wall intosurrounding tissue

Cancer does not invadethrough muscular layer(T1, T2) or spread tolymph nodes (N0)

Tumor found to invadepast the muscular layer(T3) or has spread tolymph nodes (N1, N2)

Radiation therapy alongwith continuous 5-FUgiven before surgery,then remove cancerthrough abdominaloperation

Radiation therapyalong with continuousinfusion 5-FU orcapecitabine; then ifpossible, removecancer throughabdominal operation

Remove cancer throughabdominal operation(no RT before surgery)

If surgery is done first, further treatmentdepends on the pathologist’s findings. If itturns out that the tumor has not invadedthrough the muscle layer and spread to lymphnodes, no further treatment is recommended.

But if it has spread through the muscle layeror to lymph nodes, further treatment is rec-ommended. This would be chemotherapywith 5-FU with or without leucovorin for 1 or2 cycles followed by radiation therapy to the


49

Follow-up TestsAdjuvant Treatment

5-FU with or without leucovorin, or

5-FU/leucovorin/oxaliplatin (FOLFOX)

5-FU with or without leucovorin for3–4 cycles, or

5-FU/leucovorin/oxaliplatin (FOLFOX)

5-FU with or without leucovorin, or 5-FU/ leucovorin/oxaliplatin (FOLFOX);then radiation along with continuous infusion 5-FU;then 5-FU with or without leucovorin, or 5-FU/leucovorin/oxaliplatin (FOLFOX)

• Physical exam every 3 monthsfor 2 years, then every 6months for 5 years

• Blood CEA test every 3months for 2 years, thenevery 6 months for 5 years

• Colonoscopy in 1 year; repeatin 1 year if abnormal or atleast every 2–3 years if nopolyps found. If colonoscopycould not be done before surgery, then colonoscopy in3 to 6 months.

• Consider CT scan if there is ahigh risk for recurrence.

Treatment of Large Rectal Cancers

No Treatment

50

pelvis along with either a continuous infusionof 5-FU or capecitabine pills. When this iscomplete, another 2 cycles of 5-FU with orwithout leucovorin or FOLFOX (5-FU/leu-covorin/oxaliplatin) should be given.

If the cancer has invaded through the rectal wall into nearby tissues or organs, theNCCN recommends that treatment begin with

radiation therapy to the pelvis and continuous5-FU infusion or capecitabine pills. Afterwards,the tumor should be removed surgically by anabdominal operation if possible. Followingsurgery, 5-FU with or without leucovorinshould be given for 3 to 4 cycles. FOLFOX mayalso be considered.


NOTES

After treatment, patients should see theirdoctor for a checkup every 3 months for 2years, then every 6 months for 5 years. If iso-lated metastases can be removed, then a CEAblood test should be done along with thecheckups. Colonoscopy should be done 1 year

after surgery. If polyps are found, it shouldbe repeated in a year. If the colonoscopy isnormal, it can be repeated in 2 to 3 years. Ifcolonoscopy could not be performed beforesurgery, then it should be done within 3 to 6months after surgery.

51

NOTES

Treatment of Large Rectal Cancers (continued)

Rectal Cancer With Spread toDistant Sites (metastases)Treatment for people whose rectal cancerhas spread to distant organs such as thelungs or liver (M1 cancers) depends onwhether the metastases can be removed

completely by surgery. If the metastases canbe completely removed by surgery, there areseveral options.

Radiation to the pelvis along with contin-uous infusion of 5-FU can be given beforesurgery. Then surgery can be done to remove

52


Clinical Stage Primary Treatment PathologicFindings

Any size rectaltumor with orwithout lymphnode spread,but with distantspread that canbe surgicallyremoved

OR

OR

Pathologist findscancer does notinvade throughmuscular layer(T1, T2) orspread to lymphnodes (N0)

Tumor found toinvade past themuscular layer(T3, T4) or hasspread to lymphnodes (N1, N2)

Radiation therapyto tumor alongwith continuousinfusion of 5-FU

5-FU/leucovorin/oxaliplatin (FOLFOX)with or withoutbevacizumab,or

5-FU/leucovorin/irinotecan (FOLFIRI)with or withoutbevacizumab for 2–3months

Surgery toremove rectaltumor andmetastases



the metastases and the rectal tumor. Thisshould be followed by chemotherapy witheither 5-FU with or without leucovorin orFOLFOX (5-FU/leucovorin/oxaliplatin) orFOLFIRI (5-FU/leucovorin/irinotecan).

The third option is to do the surgery firstand remove the rectal tumor and the metas-tases. If the tumor is early stage and has notgrown past the muscle layer or into lymphnodes then the only treatment after surgery

53


Adjuvant Treatment Follow-up Tests

5-FU with or without leucovorin, or

5-FU/leucovorin/oxaliplatin (FOLFOX),or

5-FU/leucovorin/irinotecan (FOLFIRI)

5-FU with or without leucovorin for6 months, OR

5-FU/leucovorin/oxaliplatin (FOLFOX)for 4–6 months, OR

5-FU/leucovorin/irinotecan (FOLFIRI)for 4–6 months

5-FU with or without leucovorin for1–2 cycles, or FOLFOX;

then radiation along with continuousinfusion 5-FU;

then 5-FU with leucovorin for 3–4cycles or 5-FU/leucovorin/oxaliplatin(FOLFOX)

Radiation therapy to pelvis alongwith continuous infusion 5-FU

• Physical examination every 3months for 2 years, then every6 months for 5 years

• Blood CEA test every 3 monthsfor 2 years, then every 6 monthsfor 5 years

• Consider CT scan if there is ahigh risk for recurrence.

• Colonoscopy in 1 year; repeat in1 year if abnormal or at leastevery 2–3 years if no polypsfound. If colonoscopy could notbe done before surgery, thencolonoscopy in 3–6 months.

Rectal Cancer With Spread to Distant Sites (metastases)

would be chemotherapy. This could be either5-FU with or without leucovorin or FOLFOX(5-FU/leucovorin/oxaliplatin) or FOLFIRI(5FU/leucovorin/irinotecan) given for 4 to 6months. If it grew through the muscular layeror spread to lymph nodes, then the NCCN

recommends 5-FU with or without leucovorinfor 1 to 2 cycles or FOLFOX, then continuousinfusion of 5-FU along with radiation therapy,then 5-FU and leucovorin for 3 to 4 cycles orFOLFOX (5-FU/leucovorin/oxaliplatin).

54


NOTES

All these patients should see their doctorfor a checkup every 3 months for 2 years, thenevery 6 months for at least 5 years A CEAblood test should be done with the checkups.Colonoscopy should be done 1 year after sur-gery. If polyps are found, it should be repeated

in a year. If the colonoscopy is normal, it can berepeated in 2 to 3 years. If colonoscopy couldnot be done before surgery, then it should bedone within 3 to 6 months after surgery. A CTscan may be considered for patients who areconsidered at high risk for recurrence.

55

Rectal Cancer With Spread to Distant Sites (metastases)(continued)

NOTES

Rectal Cancer With Spread to DistantSites That Cannot Be RemovedPatients with metastases that cannot becompletely removed by surgery have several

options for treatment of the rectal tumor. Anoperation may be done to remove it, or it maybe treated with radiation therapy togetherwith 5-FU infusion or capecitabine pills.

56


Clinical Stage

Any size rectal tumor with orwithout lymph node spread,but with distant spread thatcannot be surgically removed

Other options are to destroy it by laser photo-coagulation or simply bypass the tumor witha diverting colostomy. Another possibletreatment is to keep the rectum open with a

stent. Chemotherapy can be given with any ofthese options or just by itself. Chemotherapytreatment is described in the decision tree onpages 62–63.

57

Primary Treatment

Surgery to remove rectal tumor

OR

Destroy tumor with laser photocoagulation

OR

Perform colostomy to bypass rectal tumor

OR

Radiation therapy along with continuousinfusion 5-FU or capecitabine

OR

Chemotherapy alone

OR

Place a tube (stent) through the rectaltumor to prevent blockage

See Chemotherapyfor advanced ormetastatic disease(see pages 62–63)


Rectal Cancer With Spread to Distant Sites That Cannot Be Removed

Treatment of Recurrent Rectal CancerAfter surgery or radiation therapy and anyadjuvant treatments are finished, checkupsand follow-up tests are routinely done. Thepurpose of these tests is to find rectal cancerthat has recurred (come back) as soon aspossible, when further treatments are mostlikely to be helpful.

CEA levels that rise steadily after the firsttreatment strongly suggest that a colorectalcancer is coming back or regrowing. There alsomay be other reasons to suspect a recurrence,such as symptoms or something abnormalfound when the doctor examines the patient.The search for recurrence should includecolonoscopy, x-rays, and CT scans. A PET

58


Clinical Presentation

Evaluation

Rising bloodCEA levels

OR

Other findingsthat suggestrecurrence

All testsnegative(no cancer)

One ormore testsfind cancer

• Colonoscopy

• Chest x-ray

• CT scans of chest,abdomen, and pelvis

• PET scan for pelvicrecurrence if surgeryis planned

Repeat CTand PET scansin 3 months

scan is useful if a recurrence in the pelvis issuspected. If no cancer is found, these testsare repeated at 3 month intervals. Somepatients may have an elevated CEA level formonths or years before clinical evidence(imaging test or physical exam results) of

recurrent disease is found. Patients are notgiven chemotherapy based on a rising CEAlevel alone.

If recurrent cancer is found by imagingtests, a biopsy may be done to confirmcancer, not some other disease. In most

59


Treatment of Recurrent Rectal Cancer

Treatment

Cancer in oneorgan and mightbe surgicallyremovable

ConsiderPET

No metastaticdisease foundthat can besurgicallyremoved

Surgery notpossible

Cancer in pelvisor in rectum atsurgical site

Cancer cannotbe surgicallyremoved


Surgeryto removecancer

Radiation therapy andcontinuous infusion of 5-FU given before surgeryif not given previously

Adjuvanttreatmentfor 6 monthsif not givenpreviously

Surgery toremove cancerif possible

Radiationtherapy duringsurgery mightbe added.

cases, this involves a needle biopsy proce-dure that uses a CT scan for guidance.Recurrent cancer may be treated in 2 ways.

• In the first, the recurrent tumor can becompletely removed with surgery.

Before this is done, a PET scan mightbe done to make sure there isn’t anycancer elsewhere. After surgery, adju-vant chemotherapy is recommended ifit hasn’t been given before.

60


NOTES

• If the recurrence appears to be only inthe pelvis or at the site of surgery, thenit can be treated with radiation andcontinuous 5-FU or capecitabine if thishasn’t been done before. After this, if it ispossible, it may be removed with surgery.

Sometimes further radiation to thetumor can be given during the operation.

If the tumor cannot be totally removed,chemotherapy is used to control the recurrentdisease.

61

Treatment of Recurrent Rectal Cancer (continued)

NOTES

Chemotherapy for AdvancedDisease or Distant Spread ThatCannot Be RemovedFor patients whose cancer is too large ornumerous to remove completely, treatmentoptions depend on whether they are in goodhealth apart from the cancer and are able to

care for themselves. Many studies haveshown that patients who are too ill to care forthemselves are not likely to benefit fromchemotherapy.

If the cancer continues to grow or begins togrow after shrinking with the chemotherapy,a different chemotherapy from the one

62


Metastasescannot becompletelyremoved

Patient is in goodhealth and is ableto care for self

Patient’s generalfunctioning ispoor — unableto care for self

Patient unable totolerate intensivetherapy

Patient able totolerate intensivetherapy

Clinical Presentation

selected to try first may be given if the patientremains well. In addition, giving just irinotecanor cetuximab with or without irinotecan maybe appropriate.

For patients who are in poor health andunable to care for themselves, supportive careto relieve symptoms and maintain a patient’swell-being is recommended.

63


Chemotherapy for Advanced Disease or Distant Spread That Cannot Be Removed

If chemotherapy isno longer effective


• 5-FU/leucovorin/oxaliplatin (FOLFOX)with or without bevacizumab

• 5-FU/leucovorin/irinotecan (FOLFIRI) withor without bevacizumab

• 5-FU/leucovorin/oxaliplatin given IV push

• 5-FU/leucovorin/bevacizumab

• 5-FU/leucovorin (except if already givenas adjuvant within last 6 months) withor without bevacizumab

• 5-FU given continuously into a veinalong with leucovorin

• Capecitabine

Supportive care

If functioning improves, chemotherapymight be an option if not given previously

If cancer continues to growor treatment is too toxic, try another chemotherapy if patient continues to function well.

Otherwise change to different treatment ofeither oxaliplatin-containingor irinotecan-containingchemotherapy regimens if not already given or,irinotecan alone if notgiven earlier, or cetuximabwith or without irinotecan.

Treatment

For patients with widespread disease whoare able to tolerate intensive chemotherapy,the options include intravenous chemotherapywith:

• irinotecan combined with 5-FU continuous infusion and leucovorin,

• oxaliplatin combined with 5-FU continuous infusion and leucovorin

• 5-FU, leucovorin, and oxaliplatin given IV push

• bevacizumab in combination with 5-FU and leucovorin.

64


NOTES

If less intense therapy is more appropriate,the options are:

• continuous intravenous infusion of 5-FU, • capecitabine • 5-FU, given as an IV push and not an

infusion, and leucovorin — if these latterhad not been received as adjuvanttherapy within the last 6 months.

If one chemotherapy is not successful inshrinking the cancer or it continues to grow,then other different treatments may be triedas long as the patient remains reasonably well.If the patient becomes too ill or frail to carefor himself or herself, then chemotherapy isbest stopped and only supportive care shouldbe given.

65

Chemotherapy for Advanced Disease or Distant Spread That Cannot Be Removed (continued)

NOTES

66

NOTES

67

Abdominoperineal (AP) resectionSurgery that removes cancer located in thelower part of the rectum, close to its outerconnection to the anus.

AblationDestroying a tumor by heating it withmicrowaves or freezing. This does not usuallyinvolve surgery, but may sometimes be doneduring surgery.

AdenocarcinomaCancer of the glandular cells, for example, thosethat line the inside of the colon and rectum.

Adenomatous polyp or adenomaA benign growth of glandular cells, for example,those that line the inside of the colon or rectum.There are 3 types of colorectal adenomas:tubular, villous, and tuberovillous.

Adjuvant treatmentTreatment used in addition to the maintreatment. It usually refers to chemotherapy,radiation therapy, immunotherapy, or hor-monal therapy added after surgery to increasethe chances of curing the disease or keepingit in check. Adjuvant therapy is given to treattumor cells in small numbers that mayremain after surgery but cannot be detected.

Alternative therapyUse of an unproven treatment instead ofstandard (proven) treatment. Some alternative

therapies have dangerous or even life-threatening side effects. With others, themain danger is that the patient may lose theopportunity to benefit from standard therapy.

Anastomosis or anastomotic lineThe site where 2 structures are surgicallyjoined together. For example, after removal ofa segment of colon containing a cancer, theends of the colon are reconnected.

AnusThe outlet of the digestive tract through whichstool passes out of the body.

Ascending colonThe first of the 4 sections of the colon. Itextends upward on the right side of theabdomen and leads to the transverse colon.

BenignNot cancer; not malignant.

BiopsyThe removal of a sample of tissue to seewhether cancer cells are present. There areseveral kinds of biopsies. In an endoscopicbiopsy, a small sample of tissue is removedusing instruments operated through acolonoscope.

BowelThe intestine.

Glossary

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ColectomySurgical removal of all (total) or part (partialcolectomy or hemicolectomy, for example) ofthe colon.

ColonPart of the large intestine. The colon is a mus-cular tube about 5 feet long. It is further dividedinto 4 sections: the ascending, transverse,descending, and sigmoid colon. It continuesthe process of absorbing water and mineralnutrients from food.

ColonoscopeA slender, flexible, hollow lighted tube aboutthe thickness of a finger. It is inserted throughthe rectum up into the colon. A colonoscopeis much longer than a sigmoidoscope andusually allows the doctor to see the entirelining of the colon. The colonoscope is con-nected to a video camera and video displaymonitor so that the doctor can look closely atthe inside of the colon. If abnormalities arefound, the doctor can take a biopsy (tissuesample) or remove polyps, using instrumentsoperated through the colonoscope.

ColostomyAn opening from the colon onto the skin ofthe abdomen (stomach) for getting rid ofbody waste (stool). A colostomy is sometimesneeded after surgery for cancer of the rectum.People with colon cancer sometimes have atemporary colostomy, but they rarely need apermanent one.

Complementary therapyTherapies used in addition to standard treat-ments. Some complementary therapies may

help relieve certain symptoms of cancer,relieve side effects of standard cancer therapy,or improve a patient’s sense of well-being.

Computed tomography (CT or CAT scan)A test that uses a rotating x-ray beam to cre-ate a series of pictures of the body from manyangles. A spiral CT uses a special scannerthat can provide greater detail and is some-times useful in finding metastases from colo-rectal cancer.

CryosurgeryUse of extreme cold to freeze and destroycancer cells.

Descending colonThe third section of the colon. It comes afterthe transverse colon, continues downward onthe left side of the abdomen, and leads to thesigmoid colon.

Digestive systemAlso called the gastrointestinal tract, or GItract. It processes food to obtain energy andrids the body of solid waste matter.

Double constrast barium enemaA method used to help diagnose colorectalcancer. Barium sulfate, a chalky substance, isused to partially fill and open up the colon.When the colon is about half-full of barium,air is inserted to cause the colon to expand.This allows x-rays films to show abnormalitiesof the colon.

Endocavitary radiation therapyA type of radiation therapy used for treatingrectal cancer. The radiation beam is aimedthrough the anus, into the rectum.

Enterostomal therapistA health professional, often a nurse, whoteaches people how to care for ostomies (sur-gically created openings such as a colostomy)and other wounds.

External beam radiationThe most common way to deliver radiationto a cancer. Radiation is focused from a sourceoutside the body on the area affected by thecancer. It is much like getting a diagnostic x-ray, but for a longer time.

Familial adenomatous polyposis (FAP)A hereditary condition that is a risk factor forcolorectal cancer. People with this syndrometypically develop hundreds of polyps in thecolon and rectum at an early age. Usually 1 ormore of these polyps becomes cancerous ifpreventive surgery is not done.

Fecal occult blood test (FOBT)A test for occult (hidden) blood in the stool.The presence of such blood could be a sign ofcancer.

FecesSolid waste matter; bowel movement or stool.

Hereditary nonpolyposis colorectalcancer (HNPCC)People with this condition are at increasedrisk of developing colorectal cancer withoutfirst having many polyps.

ImmunotherapyTreatments to help the immune system rec-ognize and destroy cancer cells more effec-tively. These may include cancer vaccines andmonoclonal antibody therapy.

LaparoscopeA long, slender tube inserted into theabdomen through a very small incision.Surgeons with experience in laparoscopy cando some types of surgery for colorectalcancer using special surgical instrumentsoperated through the laparoscope.

Low anterior (LA) resection Surgery that removes a cancer and the nor-mal tissue around it near the upper part ofthe rectum, close to where it connects withthe sigmoid colon.

Lymph nodesSmall bean-shaped collections of immunesystem cells that help fight infections and alsohave a role in fighting cancer. Also called lymphglands. Cancers of the colon and rectum mayspread to regional (nearby) lymph nodes.

MarginEdge of the tissue removed during surgery. Anegative surgical margin is usually a sign thatno cancer was left behind near the area it wasremoved from. A negative surgical margin doesnot guarantee a cure because cancer cells mayhave spread to other areas of the body beforesurgery. A positive surgical margin indicatesthat cancer cells are found at the outer edgeof the tissue removed and is usually a signthat some cancer remains in the body.

MetastasisThe spread of cancer cells to distant areas ofthe body by way of the lymph system orbloodstream.

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Monoclonal antibodyImmune substance made in the laboratorythat attacks cancer cells

Neoadjuvant therapyTreatment given before the primary treatmentof radiation or surgery. However, radiationcan also be a part of neoadjuvant treatment.

PathologistA doctor who specializes in diagnosis andclassification of diseases by laboratory testssuch as examination of tissue and cells undera microscope. The pathologist determineswhether a tumor is benign or cancerous, and,if cancerous, the exact cell type and grade.

PolypA benign growth commonly found in therectum or the colon. Adenomatous polypssometimes turn into cancer. Many other typesof polyps (inflammatory polyps, hyperplasticpolyps) do not.

Radiation colitisIrritation of the colon caused by radiationtherapy. Problems can include pain, cramping,and diarrhea.

Radiation proctitisIrritation of the rectum caused by radiationtherapy. Problems can include pain, bowelfrequency, bowel urgency, bleeding, chronicburning, or rectal leakage.

RectumThe lower part of the large intestine, justabove the anus.

RecurrenceCancer that has come back after treatment.Local recurrence means that the cancer has

come back at the same place as the originalcancer. Regional recurrence means that thecancer has come back after treatment in thelymph nodes or tissues near the primary site.Distant recurrence is when cancer metasta-sizes after treatment to organs or tissues(such as the lungs, liver, bone marrow, orbrain) farther from the original site than theregional lymph nodes.

Risk factorAnything that increases a person’s chance ofgetting a disease such as cancer. Differentcancers have different risk factors. For example,unprotected exposure to strong sunlight is arisk factor for skin cancer. Some risk factors,such as smoking or an unhealthy diet, can becontrolled. Others, like a person’s age or familyhistory, can’t be changed.

ScreeningThe search for disease, such as cancer, inpeople without symptoms. For example,screening tests for early detection of colo-rectal cancer include fecal occult blood test,flexible sigmoidoscopy, colonoscopy, anddouble contrast barium enema.

Segmental resectionIn this surgery, the cancer and a length ofnormal tissue on either side of the cancer aswell as the nearby lymph nodes are removed.The remaining sections of the colon are thenattached back together.

Sigmoid colonThe fourth section of the colon is known asthe sigmoid colon because of its S-shape. Thesigmoid colon joins the rectum, which inturn joins the anus, or the opening wherewaste matter passes out of the body.

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SigmoidoscopeA slender, flexible, hollow, lighted tube aboutthe thickness of a finger. It is inserted throughthe rectum up into the colon. This allows thedoctor to look at the inside of the rectum andpart of the colon for cancer or for polyps.

Small intestineThe small intestine is the longest section ofthe GI tract. It breaks down food and absorbsmost of the nutrients. The small intestinejoins the colon.

StageExtent of disease. Clinical stage refers to theextent of disease determined by the physicalexamination and imaging tests. The pathologicstage is determined by examination of thetissue after surgery.

StoolSolid waste matter; feces.

Supportive careTreatment directed at keeping a patient feel-ing as well as possible without specificallytreating the underlying disease (in this case,cancer).

Transanal ResectionA procedure in which the doctor cuts throughall layers of the rectum, through the anus,without cutting through the abdomen inorder to remove cancerous tissue.

Transverse colonThe second section of the colon, following theascending colon and leading to the descendingcolon. It is called the transverse colon becauseit goes across the body to the left side.

TumorAn abnormal lump or mass of tissue. Tumorscan be benign (not cancerous) or malignant(cancerous).

Ulcerative colitisA type of inflammatory bowel disease. In thiscondition, the colon is inflamed for a longtime. This increases a person’s risk of devel-oping colon cancer, so starting colorectalcancer screening earlier and doing thesetests more often is recommended.

UltrasoundHigh frequency sound waves used to produceimages of body tissue. Two special types ofultrasound examinations are used to evaluatepeople with colon and rectal cancer. Theendorectal ultrasound uses a special trans-ducer that can be inserted directly into therectum. This test is used to see how far a rectalcancer may have penetrated and whether ithas spread to nearby organs or tissues. Theintraoperative ultrasound is done after thesurgeon has opened the abdominal cavity. Itis used for detecting colorectal cancer thatmay have spread to the liver.

Upper endoscopyInspection of the upper part of the digestivesystem using a flexible, lighted tube knownas an endoscope.

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Current NCCN Treatment Guidelines for Patients

Advanced Cancer and Palliative Care Treatment Guidelines (English and Spanish)

Bladder Cancer Treatment Guidelines for Patients (English and Spanish)

Breast Cancer Treatment Guidelines for Patients (English and Spanish)

Cancer Pain Treatment Guidelines for Patients (English and Spanish)

Cancer-Related Fatigue and Anemia Treatment Guidelines for Patients(English and Spanish)

Colon and Rectal Cancer Treatment Guidelines for Patients(English and Spanish)

Distress Treatment Guidelines for Patients (English and Spanish)

Fever and Neutropenia Treatment Guidelines for Cancer Patients(English and Spanish)

Lung Cancer Treatment Guidelines for Patients (English and Spanish)

Melanoma Cancer Treatment Guidelines for Patients (English and Spanish)

Nausea and Vomiting Treatment Guidelines for Patients With Cancer(English and Spanish)

Non-Hodgkin’s Lymphoma Treatment Guidelines for Patients(English and Spanish)

Ovarian Cancer Treatment Guidelines for Patients (English and Spanish)

Prostate Cancer Treatment Guidelines for Patients (English and Spanish)

Terri Ades, MS, APRN-BC, AOCNAmerican Cancer Society

Al B. Benson III, MDRobert H. Lurie Comprehensive Cancer Center of Northwestern University

Paul F. Engstrom, MD, FACPFox Chase Cancer Center

Herman Kattlove, MD, American Cancer Society

Pamela McAllister, PhDColon Cancer Survivor

Joan McClure, MSNational Comprehensive Cancer Network

Shannan RafineNational Comprehensive Cancer Network

The Colon and Rectal Cancer Treatment Guidelines for Patients were developed by a diverse groupof experts and were based on the NCCN clinical practice guidelines. These patient guidelineswere translated, reviewed, and published with help from the following individuals:

The NCCN Colon and Rectal Cancer Clinical Practice Guidelines were developed by the followingNCCN Panel Members.

Al B. Benson III, MDRobert H. Lurie Comprehensive Cancer Center of Northwestern University

Yi-Jen Chen, MD, PhDCity of Hope Cancer Center

Michael A. Choti, MDThe Sidney Kimmel ComprehensiveCancer Center at Johns Hopkins

Raza A. Dilawari, MDSt. Jude Children’s ResearchHospital/University of TennesseeCancer Institute

Paul F. Engstrom, MD/ChairFox Chase Cancer Center

Charles Enke, MDUNMC Eppley Cancer Center at theNebraska Medical Center

Marwan Fakih, MDRoswell Park Cancer Institute

Charles Fuchs, MDDana-Farber/Partners CancerCare

Krystyna Kiel, MDRobert H. Lurie Comprehensive Cancer Center of Northwestern University

James A. Knol, MDUniversity of MichiganComprehensive Cancer Center

Lucille Leong, MDCity of Hope Cancer Center

Kirk Ludwig, MDDuke Comprehensive Cancer Center

Edward W. Martin Jr., MDArthur G. James Cancer Hospital & Richard J. Solove Research Institute at The Ohio State University

Sujata Rao, MDFred Hutchinson Cancer ResearchCenter/Seattle Cancer Care Alliance

M. Wasif Saif, MDUniversity of Alabama atBirmingham ComprehensiveCancer Center

Leonard Saltz, MDMemorial Sloan-Kettering Cancer Center

John M. Skibber, MDThe University of Texas M. D. Anderson Cancer Center

Alan Venook, MDUCSF Comprehensive Cancer Center

Timothy J. Yeatman, MDH. Lee Moffitt Cancer Center & Research Institute at the University of South Florida

©2005, American Cancer Society, Inc.No.9409.01

1.800.ACS.2345www.cancer.org

1.888.909.NCCNwww.nccn.org

http://www.nccn.org


colon and rectal cancer - colorectal cancer association of canada

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