colon and rectal cancer - dr. francesco g. biondo del colon... · 2012-09-11 · colon and rectal...

Colon and Rectal Cancer

Treatment Guidelinesfor PatientsVERSION I MARCH 2000

National ComprehensiveCancer Network

NCCN®

Colon and Rectal Cancer

Treatment Guidelinesfor PatientsVERSION I MARCH 2000

The mutual goal of the National Comprehensive Cancer Network® (NCCN®) and theAmerican Cancer Society (ACS) partnership is to provide patients and the general public withstate-of-the-art cancer treatment information in understandable language. This information,based on the NCCN’s Clinical Practice Guidelines, is intended to assist you in the dialogue withyour physician. These guidelines do not replace the expertise and clinical judgment of your physician.Each patient’s situation must be evaluated individually. It is important to discuss the guidelinesand all information regarding treatment options with your physician. To ensure that you have themost up-to-date version of the guidelines, 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.

NCCN Clinical Practice Guidelines were developed by a diverse panel of experts. The guidelines are astatement of consensus of its authors regarding the scientific evidence and their views of currently acceptedapproaches to treatment. The NCCN guidelines are updated as new significant data becomes available.The Patient Information version will be updated accordingly and will be available on-line through the NCCNand the ACS web sites. To ensure you have the most recent version, you may contact the ACS or the NCCN.

©2000, by the National Comprehensive Cancer Network (NCCN) and the American Cancer Society(ACS). All rights reserved. The information herein may not be reprinted in any form for commercial purposes without the expressed written permission of the NCCN and the ACS. Single copies of each pagemay be reproduced for personal and non-commercial uses by the reader.

CONTENTS

Introduction ....................................................................................5

Making Decisions about Colon and Rectal Cancer Treatment ......6

About the Colon and Rectum..........................................................6

Known Risk Factors for Colon and Rectal Cancers........................8

Prevention and Early Detection of Colon and Rectal Cancer ........10

Colon and Rectal Cancer Work-up (Evaluation) ............................12

Colon and Rectal Cancer Stages ......................................................15

Types of Treatment for Colon and Rectal Cancers ........................17

Side Effects of Colon and Rectal Cancer Treatments......................20

Other Things to Consider During and after Treatment....................21

About Clinical Trials ........................................................................23

Decision TreesColon Cancer–Primary Therapy ..............................................26

Colon Cancer–Adjuvant Therapy ............................................30

Colon Cancer with Metastases ................................................34

Recurrent Colon Cancer ..........................................................38

T1, T2, and T3 Rectal Cancer without Distant Metastases ....42

T4 and/or M1 Rectal Cancer....................................................46

Follow-up of Rectal Cancer Recurrence..................................50

Rectal Cancer Salvage Therapy ................................................52

Glossary ............................................................................................56

NATIONAL COMPREHENSIVE CANCER NETWORKMEMBER INSTITUTIONS

CITY OF HOPE NATIONAL MEDICAL CENTER

DANA-FARBER CANCER INSTITUTE

FOX CHASE CANCER CENTER

FRED HUTCHINSON CANCER RESEARCH CENTER

H. LEE MOFFITT CANCER CENTER & RESEARCH INSTITUTEAT THE UNIVERSITY OF SOUTH FLORIDA

HUNTSMAN CANCER INSTITUTE AT THE UNIVERSITY OF UTAH

JAMES CANCER HOSPITAL AND SOLOVE RESEARCH INSTITUTEAT THE OHIO STATE UNIVERSITY

JOHNS HOPKINS ONCOLOGY CENTER

MEMORIAL SLOAN-KETTERING CANCER CENTER

ROBERT H. LURIE COMPREHENSIVE CANCER CENTEROF NORTHWESTERN UNIVERSITY

ROSWELL PARK CANCER INSTITUTE

ST. JUDE CHILDREN’S RESEARCH HOSPITAL

UCSF STANFORD HEALTH CARE

UNIVERSITY OF TEXAS M.D. ANDERSON CANCER CENTER

UNIVERSITY OF ALABAMA AT BIRMINGHAMCOMPREHENSIVE CANCER CENTER

UNIVERSITY OF MICHIGAN COMPREHENSIVE CANCER CENTER

UNMC/EPPLEY CANCER CENTER AT THEUNIVERSITY OF NEBRASKA MEDICAL CENTER

NCCN®

With this report, patients have theirfirst access to information on theway colon and rectal cancer is

treated at the nation’s leading cancer centers.Originally devised for cancer specialists by theNational Comprehensive Cancer Network(NCCN®), these treatment guidelines havenow been translated for the lay public by theAmerican Cancer Society (ACS). To obtainanother copy of these guidelines as well as moreinformation, call the ACS at 1-800-ACS-2345,or the NCCN at 1-888-909-NCCN, or visitthese organizations’ websites at www.cancer.org(ACS) and www.nccn.org (NCCN).

Since 1995, doctors have looked to theNCCN for advice on treating cancer. NCCNClinical Practice Guidelines were developedby a diverse panel of experts from 17 of thenation’s leading cancer centers. The guidelinesare a statement of consensus of its authorsregarding the scientific evidence and theirviews of currently accepted approaches totreatment. The NCCN guidelines are updatedas new significant data become available. ThePatient Information version will be updatedaccordingly and will be available on-linethrough the NCCN and the ACS web sites.To ensure you have the most recent version,you may contact the ACS or the NCCN.

For more than 85 years, the public hasrelied on the American Cancer Society forinformation about cancer. The Society’s booksand brochures provide comprehensive, current, and understandable information tohundreds of thousands of patients, their families and friends. This collaboration

between the NCCN and ACS provides anauthoritative and understandable source ofcancer treatment information for the layperson.

These patient guidelines will help you betterunderstand your cancer treatment options. Weurge you to discuss them with your physicianand ask the following questions:

• Where is my cancer located?

• How far has my cancer spread? What are its T, N, M, and grouped stages?How do these stages influence my outlook for cure and survival and mytreatment options?

• What treatment options do I have?

• What are the risks or side effects associ-ated with each of my treatment optionsand how are they likely to affect myquality of life?

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

• What rehabilitation and support servicesare available to me and my family?

In addition to these questions, be sure towrite down some of your own. For instance,you might want more information aboutrecovery times so you can plan your workschedule. Or, you may want to ask about clinicaltrials for which you may qualify.

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MAKING DECISIONSABOUT COLON AND

RECTAL CANCERTREATMENT

Colon cancer and rectal cancer have manyfeatures in common. They are often consid-ered together as colorectal cancer. They arebeing discussed together in some sections ofthis document. But, in other sections, colonand rectal cancers are discussed separately toreflect ways in which treatments differ.

Colorectal cancer is the third most commoncancer (excluding skin cancer) of Americanmen and women. The ACS estimates thatabout 93,800 new cases of colon cancer and36,400 new cases of rectal cancer will be diag-nosed in 2000. Colon cancer is expected to beresponsible for about 47,700 deaths during2000. About 8,600 people will die from rectalcancer during 2000.

Over 95% of colorectal cancers are adeno-carcinomas (cancers of the glandular cells thatline the inside of the colon and rectum). Theinformation in this document refers to colorectal adenocarcinomas only. Gastro-intestinal carcinoid tumors (tumors of hormone-producing cells of the digestive system), gastrointestinal stromal tumors (tumors of the connective tissue in the stomach and intestinalwall), and gastrointestinal lymphomas (cancersof the immune system cells in the stomach andintestines) are found less often in the colonand rectum. The treatment and prognosis forthese rarer types of colorectal tumors differfrom that of adenocarcinomas and are not covered in this document.

Although colorectal cancer is a serious disease, it is one that a multidisciplinary teamof health care professionals can treat. Theteam of health care professionals may includea gastroenterologist, surgeon, radiation oncol-ogist, medical oncologist, pathologist, nurse,social worker, radiologist and enterostomaltherapist. This report is intended to help youunderstand the treatment options available topeople with colon and rectal cancers so thatyou and your doctor can work together toidentify which best meet your medical andpersonal needs.

On the following pages you’ll find flowcharts that doctors call “algorithms,” “decisiontrees,” or “clinical pathways.” The charts represent different stages of colon or rectalcancer and each one shows how you and yourdoctor can arrive at the choices you need tomake about your treatment.

To reach an informed decision you need tounderstand some of the medical terms yourdoctor uses. You may feel you’re on familiarground already, or perhaps you need to refer tothe various sections listed on the front-pageindex. Not only will you find backgroundinformation on colorectal cancer, but alsoexplanations of colorectal cancer stages, work-up (evaluation), and treatments—all categoriesused in the flow charts. We’ve also provided aglossary of medical terms.

ABOUT THE COLONAND RECTUM

Understanding a little about the normal function and anatomy of the colon and rectumcan help patients understand how colorectal

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cancers spread and what tissues are removedby the operations we will discuss later in thisdocument.

The colon and rectum are parts of the largeintestine which is, in turn, a part of the digestivesystem. The digestive system processes food forenergy and rids the body of solid waste matter.After food is chewed and swallowed, it travelsthrough the esophagus to the stomach. Thereit is partly broken down and then sent to thesmall intestine, also called the small bowel.The small intestine continues breaking downthe food and absorbs most of the nutrients.The small intestine joins the colon, a musculartube about five feet long. The large intestinecontinues to absorb water and mineral nutrientsfrom the food matter and stores waste matter,called feces or stool. The waste matter left afterthis process passes out of the body through theanus. The first 41⁄2 feet or so of the large intestineis called the colon, and the remainder is therectum. The colon has four sections. The smallintestine is connected to the first of these,called the ascending colon because it extendsupward on the right side of the abdomen. Thepart of the ascending colon that is connectedto the small intestine is called the cecum. Thesecond section is called the transverse colonsince it goes across the body from the right tothe left side. There it joins the third section,the descending colon, which continues downwardon the left side. The fourth section is known asthe sigmoid colon because of its S-shape. Thesigmoid colon joins the rectum, which in turnjoins the anus.

Each of these sections of the colon and rectum has several layers of tissue. Colorectalcancers start in the innermost layer and cangrow through some or all of the other layers.

Knowing a little about these layers is important,because the stage (extent of spread) of a colo-rectal cancer depends to a great degree onwhich of these layers it affects. This is discussedin the section of this document on staging.

Lymph is a clear fluid that contains tissuewaste products and immune system cells.Lymphatic vessels carry this fluid to lymph nodes(small, bean-shaped collections of immunesystem cells important in fighting infections).Most lymphatic vessels of the colon or rectumlead to regional (nearby) lymph nodes. Cancercells may enter lymph vessels and spread outalong these vessels to reach lymph nodes,where they can continue to grow. If cancercells have multiplied in these lymph nodes,they are more likely to have spread to otherorgans of the body as well.

Blood from arteries enters and nourishesthe tissues of the wall of the colon and rectum(but normally does not enter the hollow partof the colon and rectum to mix with feces).

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Organs of the Digestive System

Esophagus

Stomach

TransverseColon

DescendingColon

SigmoidColon

Anus

Liver

Gallbladder

AscendingColon

SmallIntestine

Cecum

Rectum

After flowing through these tissues, the bloodflows into veins. Veins from the colon and rectum lead to the liver and eventually flowback to the heart. This pattern of blood flow isimportant, because cells may break off of a colorectal cancer, enter veins leaving theseorgans, and travel to the liver. This is why theliver is a common site for colorectal cancer tometastasize (spread) to.

KNOWN RISK FACTORSFOR COLON AND RECTAL CANCERS

A risk factor is anything that increases a person’schance of getting a disease such as cancer.Different cancers have different risk factors.For example, unprotected exposure to strongsunlight is a risk factor for skin cancer andsmoking is a risk factor for cancers of the lungs,larynx, mouth, throat, esophagus, kidneys,bladder and several other organs. Researchershave identified several factors that increase aperson’s chance of developing colorectal cancer:People have control over some of these riskfactors (unhealthy diet, alcohol abuse, not getting enough physical activity), and canlower their colorectal cancer risk by avoidingthem. Other risk factors, such as havingintestinal polyps, chronic inflammatory boweldisease, or a family history of colorectal cancercannot be avoided. But, people with theseunavoidable factors can lower their cancer risk.

Aging: About 90% of people found to havecolorectal cancer are older than 50.

A diet mostly from animal sources: A dietthat consists mostly of foods that are high infat, especially from animal sources, can increase

the risk of colorectal cancer. Instead, the ACSrecommends choosing most of your foods fromplant sources and limiting intake of high-fatfoods such as those from animal sources. TheACS also recommends eating at least fiveservings of fruits and vegetables every day andsix servings of other foods from plant sourcessuch as breads, cereals, grain products, rice,pasta, or beans.

Physical inactivity: A sedentary lifestylewithout at least moderate physical activity isassociated with an increased risk of colon cancer.

A personal history of intestinal polyps:Polyps are small outgrowths from the innerlining of the colon. Under the microscope,there are several types. Polyps themselves arebenign. Some types of polyps, such as inflam-matory polyps and hyperplastic polyps, do notincrease the risk of colorectal cancer. Othertypes such as adenomatous polyps do increasethe risk of colorectal cancer, especially if theyare large or there are many of them.

Ulcerative colitis and Crohn’s disease:These are the two main types of chronicinflammatory bowel disease. Ulcerative colitisis characterized by inflammation of the colonover a long period of time. Crohn’s disease typically affects the small bowel, although thecolon may also be affected. Ulcerative colitisand cases of Crohn’s disease that affect thecolon increase a person’s risk of developingcolon cancer, so starting colorectal cancerscreening earlier and doing these tests moreoften is recommended.

Individuals with 8 or more years of pancolitis(inflammatory bowel disease affecting theentire colon) or 15 or more years of left-sidedcolitis are at an increased risk for colorectalcancer. Therefore, the NCCN recommends:

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• Colonoscopy (see Early Detection sectionon page 10) every 1-2 years with biopsyto look for cancer or dysplasia (abnormalfeatures in cells lining the colon andrectum that may develop into cancer).

• If a high-grade dysplasia or multiple areasof low-grade dysplasia are present, or iflow-grade dysplasia is found in biopsiesdone over a period of time, total abdominalcolectomy (removal of the entire colon)or proctocolectomy (removal of the entirecolon and the rectum) are recommended.

Because recognizing dysplasia and classifying itas low- or high-grade is sometimes difficult,examination of biopsy samples from peoplewith inflammatory bowel disease should bedone by an experienced pathologist.

A family history of colorectal cancer:Relatives of colorectal cancer patients are alsoat increased risk for developing this disease.An individual with one immediate familymember with colorectal cancer has a risk thatis 1.5–2 times the normal risk. Some individualshave family histories that include many members with colorectal cancer. Some ofthese families may have a colorectal cancersyndrome such as familial adenomatous polyposis (FAP) or hereditary nonpolyposiscolorectal cancer (HNPCC). Accurate identi-fication of people with these syndromes isimportant because their doctors will recommendspecific measures to prevent cancer or find itas early as possible, when treatment is mostsuccessful. The NCCN recommends that allpeople with colorectal cancer have evaluationof their family history of the disease. Peoplewith a family history suggesting a colorectal

cancer syndrome should be referred for geneticcounseling and consideration of genetic testing.

Familial adenomatous polyposis (FAP):FAP is a hereditary condition that greatlyincreases a person’s risk of developing colorectalcancer. People with this syndrome typicallydevelop hundreds of polyps in the colon andrectum. Usually one or more of these polypsbecomes cancerous if preventive surgery is notdone.

For patients diagnosed with FAP, colectomyis recommended, usually by age 25, in order toprevent a colon cancer from developing. Forsurveillance following colectomy, the NCCNrecommends:

• Sigmoidoscopy every 6 months for 3years in patients whose rectum has notbeen removed,

• An upper endoscopy every 4 years, anda physical exam annually.

It is important to note the distinction betweenpeople who are actually diagnosed with FAPand young people who have a family history ofFAP but have no intestinal symptoms andhave not had any polyps diagnosed. The lattergroup can discuss genetic counseling andgenetic testing with their physicians. If a persondoes not want to have genetic testing, NCCNrecommends starting flexible sigmoidoscopy atpuberty, and repeating this test:

• Every 12 months until the age of 24,

• Every 2 years until the age of 34,

• Every 3 years until the age of 44,

• Then every 3-5 years thereafter.

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Hereditary nonpolyposis colon cancer(HNPCC) develops in people at a relativelyyoung age without first having many polyps.Experts in colorectal cancer genetics havedeveloped lists of criteria for determiningwhether a person with a family history of colorectal cancer has HNPCC. The mostcommonly used among these, called theAmsterdam criteria, requires the following: Atleast 3 relatives should have medically provencolorectal cancer, one of these should be afirst-degree relative (parent, sibling, or child)to the other two, and FAP should be excluded.At least two successive generations should beaffected. In one of the relatives, colorectalcancer should be diagnosed before age 50 years.Genetic testing is often useful in confirmingthat someone has HNPCC.

The NCCN recommends that people withHNPCC consider colonoscopy starting at age25 or 5 years younger than the youngest age atdiagnosis in the family, which ever comes first,and have colonoscopy every 1-2 years there-after. In addition, women with HNPCC arealso at increased risk of developing cancer ofthe uterus and should consider having trans-vaginal ultrasound (ultrasound exam in whichthe ultrasound probe is placed into the vagina)or endometrial aspirate (test to remove a smallsample of tissue from inside the uterus) annuallybeginning at age 25-35 years.

LIFESTYLE CHOICES TO LOWERCOLORECTAL CANCER RISK

People may be able to lower their risk of devel-oping colorectal cancer by managing the riskfactors that they can control, such as diet andphysical activity. Limiting intake of high fat

foods, eating at least 5 servings of fruits andvegetables each day as well as plenty of wholegrain foods, can lower risk.

Contact the ACS or NCCN for moreinformation on colorectal cancer preventionand early detection.

PREVENTION ANDEARLY DETECTION

OF COLON AND RECTAL CANCER

Colon and rectal cancers develop slowly overa period of many years. Before a true cancerdevelops, there usually are precancerouschanges in the lining of the colon or rectum.A colorectal adenoma, one form of colon polypalso known as an adenomatous polyp, is a benigntumor of glandular tissue that grows inward,into the hollow inner part of the colon or rec-tum. Although adenomas are noncancerous,they may eventually change into a cancer.

Unlike adenomatous polyps, colorectalcancers can grow inward toward the hollowpart of the colon or rectum, and outwardthrough the wall of these organs. If not treated,cells from the tumor may break away andspread through the bloodstream or lymph system to other parts of the body. There, theycan form “colony” tumors. This process iscalled metastasis.

By finding and removing adenomas beforethey have a chance to develop into cancers,and by finding and removing early cancersbefore they have spread through the lymphaticvessels or bloodstream, many colorectal cancerscan be either prevented or found early and cured.

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Both the ACS and NCCN recommendroutine colorectal cancer screening, beginningat age 50. Several tests are available to detectadenomas and early colorectal cancers in peoplewithout any colorectal symptoms. Theseinclude the fecal occult blood test, digital rectalexamination, flexible sigmoidoscopy, colon-oscopy, and double contrast barium enema.

SCREENING TESTS

Fecal occult blood test: The fecal occultblood test (FOBT) is used to find occult (hidden)blood in feces. Blood vessels at the surface ofcolorectal adenomas or cancers are often fragileand easily damaged by the passage of feces.The damaged vessels may release enoughblood to change the color of the stool. Moreoften, the damaged blood vessels release only asmall amount of blood into the feces. Thisblood does not change the appearance of thestool, but may be detected by the FOBT. If thistest is positive, additional testing is neededbecause colorectal cancer is not the only condition that can cause blood in the stool. Apositive test does not necessarily indicate thata polyp or cancer is present. Other sources ofbleeding such as hemorrhoids may be present.Blood from meat an individual ate can alsocause a false-positive test. More importantly,the FOBT can miss some adenomas and cancers.That is why the ACS and NCCN do not recommend using the FOBT alone for colo-rectal cancer screening. The FOBT is oftenused in combination with the digital rectalexamination (DRE) and flexible sigmoidoscopy.

Digital Rectal Examination (DRE): Thedoctor inserts a gloved finger into the rectumto feel for anything that is abnormal. This simple

test, which is not painful, can detect many rectalcancers. But, even the longest of fingers are fartoo short to examine the full length of thelarge intestine. For this reason, the ACS andNCCN recommend using this exam togetherwith other tests and examinations, such as theFOBT and flexible sigmoidoscopy.

Flexible sigmoidoscopy: In this examina-tion, a slender, flexible, hollow, lighted tube isplaced into the rectum and advanced upwards.This allows the doctor to look at the inside ofthe rectum and the lower part of the colon, thesigmoid, for cancer or for polyps. The patientis given an enema (fluid inserted through theanus) before the procedure to remove fecesfrom the rectum and lower colon so that anygrowths can be seen more clearly. This testmay be somewhat uncomfortable, but it shouldnot be painful. This test examines only thelower part of the colon. Within the UnitedStates, two-thirds of colorectal cancers occurwithin the reach of sigmoidoscope.

Colonoscopy: A colonoscope is a long, flex-ible, lighted tube about the thickness of a finger.It is inserted through the rectum up into thecolon. A colonoscope is longer than a sigmoido-scope, and allows the doctor, in most cases, tosee the entire colon lining. The colonoscope isconnected to a video camera and video displaymonitor so the doctor can look closely at theinside of your colon. Before this test, you willbe told how to cleanse your bowel the nightbefore and the morning of the exam, usingstrong laxatives. This test lasts approximately15–30 minutes and is generally not painful dueto the administration of a mild sedative.

Barium enema with air contrast: For thistest, also called a double contrast barium enemathe patient is given barium sulfate, a chalky

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substance used to partially fill and open up thecolon. The barium sulfate is given through theanus. When the colon is about half-full of barium, the patient will be turned on the x-raytable so the barium spreads throughout thecolon. Then air is inserted to cause the colonto expand. This allows good x-ray films to betaken. Before this test, you will be told how tocleanse your bowel the night before and themorning of the exam, using strong laxatives.

COLON AND RECTALCANCER WORK-UP

(EVALUATION)

INITIAL EVALUATION

If there is reason to suspect that you havecolon or rectal cancer, the doctor will take acomplete medical history and perform 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 far thecancer has spread).

History and Physical Exam: When yourdoctor “takes a history,” he or she will ask youa series of questions about your symptoms andrisk factors. Some colorectal cancers may befound because of symptoms such as a change inbowel habits, blood in the stool, weakness orfatigue, abdominal pain, loss of appetite, nausea,weight loss, and straining during a bowelmovement. Of course, many noncancerousconditions and some other cancers can causeone or more of these symptoms. But if thesesymptoms are present, medical evaluation isthe only way to determine their cause so that

the most appropriate treatment can be chosen.A physical exam for patients suspected of havingcolorectal cancer will include a DRE, carefulexamination of the abdomen to feel for massesor enlarged organs, and a general survey of therest of the body.

Colonoscopy: Although this test hasalready been discussed in the earlier section onearly detection of colon and rectal cancer,colonoscopy is also an important part of themedical evaluation of people with symptomsof colorectal cancer.

Biopsy: If a mass or any other types ofabnormal areas are seen through the flexiblesigmoidoscope or through the colonoscope, asample will be taken for examination under amicroscope, to determine whether the abnor-mality is a cancer or some benign condition.Some abnormalities, such as small polyps, maybe entirely removed through a scope. If theabnormal area is larger, a biopsy (small tissuesample) is taken. The biopsy sample is usuallyabout 1⁄8 inch across, and is removed withinstruments that are operated through thescope. If you have questions about pathologyresults or any other aspect of the diagnosticprocess, do not hesitate to ask your doctor. Youcan obtain a pathology review by havingmicroscope slides containing thin slices ofyour tissue specimen sent to a consultingpathologist at an NCCN center or other laboratory recommended by your doctor.

Blood counts and blood chemistry: Acomplete blood count (CBC) determineswhether the patient’s blood has the correctnumber of various cell types. A test for hemo-globin, the oxygen-carrying pigment of redblood cells, is also part of the CBC. A lowhemoglobin level may suggest ongoing loss of

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blood cells, possibly due to bleeding from thesurface of a cancer. Doctors repeat this test regularly in patients treated with chemotherapy,because these drugs temporarily affect blood-forming cells of the bone marrow. Spread ofcancer to the liver and bones may causecertain chemical abnormalities in the blood. Todetect these changes, physicians perform bloodchemistry tests.

Carcinoembryonic antigen blood test:Carcinoembryonic antigen (CEA) is a substanceproduced by cells of most colon and rectal cancers and released into the bloodstream.The CEA blood test is most often used withother tests for follow-up of patients whoalready have had colorectal cancer and havebeen treated. CEA may be useful to provide anearly warning of a cancer that has returned.CEA may be present in the blood of some people without colon or rectal cancer. Oftenthese people have ulcerative colitis, non-cancerous tumors of the intestines, or sometypes of liver disease or chronic lung disease.Smoking can also cause an increase in CEAlevels. Because the CEA level in the blood canbe high for reasons other than cancer, or itmay be normal in a person who has cancer, itis not used as a method for finding cancer inpeople who have never had a cancer andappear to be healthy. However, this test is usefulfor follow-up after treatment. After successfultreatment, blood CEA levels should return tonormal. If follow-up tests detect a steadyincrease in levels, additional testing is recom-mended to find out if the cancer has recurred(come back).

Ultrasound: This imaging test uses adevice called a transducer that produces sound

waves, which are reflected by tissues of nearbyorgans. The pattern of sound wave echoes isdetected by the transducer and analyzed by acomputer to create an image of these tissuesand organs. Since normal tissues and tumorsreflect sound waves differently, ultrasound issometimes used to find masses that indicatelocal or distant spread of cancer. Two specialtypes of ultrasound examinations are used inevaluation of people with colon and rectalcancer. Endorectal ultrasound uses a specialtransducer that can be inserted directly intothe rectum. This test is used to see how far arectal cancer may have penetrated andwhether it has spread to nearby organs or tissues.Intraoperative ultrasound is done after the surgeonhas opened the abdominal cavity. The trans-ducer can be placed against the surface of theliver, making this test very useful in detectingmetastases of colorectal cancer to the liver.

Computed tomography: Commonly referredto as a CT or CAT scan, this test uses a rotatingx-ray beam to create a series of pictures of thebody from many angles. A computer combinesthe information from these pictures, producinga detailed cross-sectional image. Contrastmaterial is usually injected into a vein beforeCT scanning to help produce clearer pictures.Spread of colorectal cancer to internal organssuch as the liver, lungs, or elsewhere in theabdomen can often be detected by a CT scan.Spiral CT uses a special scanner that can provide greater detail and is sometimes usefulin finding metastases from colorectal cancer.For spiral CT with portography, contrast materialis injected into veins that lead to the liver, tohelp find metastases from colorectal cancer tothat organ.

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Chest x-ray: This familiar imaging test canoften detect the spread of colorectal cancer to the lungs.

EVALUATION FOR METASTASIS

In addition to the tests listed above, if yourphysician suspects that your cancer has spread beyond the colon, the following testsmay be ordered:

CT-guided needle biopsy: For this test, thepatient remains on the CT scanning table,while a radiologist advances a biopsy needletoward the location of the mass. CT scans arerepeated until the doctors are confident thatthe needle is within the mass. A fine needlebiopsy sample (tiny fragment of tissue) or acore needle biopsy sample (a thin cylinder oftissue about 1⁄2 inch long and less than 1⁄8 inchin diameter) is removed and examined under a microscope.

Magnetic resonance imaging: Like com-puted tomography, magnetic resonance imaging(MRI) displays a cross-section of the body.However, MRI uses powerful magnetic fieldsinstead of radiation. The procedure can presentcross-sectional views from several angles and isuseful in locating metastases from colorectalcancer that are sometimes hard to see on standard x-rays and CT scans.

Positron emission tomography: Positronemission tomography (PET) uses glucose (aform of sugar) that contains a radioactiveatom. The substance emits tiny subatomic particles called positrons. A special camerarecords the precise location of the positrons asthey leave the body. Cells of the body absorbvarying amounts of the radioactive sugar,depending on their rate of metabolism. Unlike

most other imaging tests, which provide viewsof the shape and size of internal structuresonly, PET scanning also provides informationabout their metabolic activity. Since themetabolism of cancers differs from that of normal tissues, PET is sometimes useful inidentifying cancers and determining how farthey may have spread. But, PET scans are notroutinely ordered, and their role in colorectalcancer is still under investigation.

Angiography: For this test, a cannula(tube) is inserted into a blood vessel andmaneuvered until it reaches the area to bestudied. Contrast dye is injected rapidly and aseries of x-ray images is then taken. When thepictures are complete, the cannula is removed.Angiography is occasionally used to show surgeons the location of blood vessels next toa liver metastasis from colorectal cancer, sothat an operation can be planned to minimizeblood loss.

Consultation with an enterostomal therapist: NCCN guidelines recommend thatpeople with rectal cancer be referred to anenterostomal therapist (a health care professional,often a nurse, trained to help people with theircolostomies) as part of their initial work-up.The enterostomal therapist can address concerns about how a colostomy might affecttheir daily activities. A colostomy is an openingin the abdomen for getting rid of body wastes.Discussing these issues shortly after diagnosiscan help patients make informed decisionsabout treatment options, some of which mayinvolve a colostomy. Consultation with anenterostomal therapist is also recommendedfor the relatively small number of people with colon cancer that require a temporary orpermanent colostomy. If a colorectal cancer

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patient’s surgical treatment requires a colostomy,the enterostomal therapist will provide infor-mation and training on care of the colostomy.

COLON AND RECTALCANCER STAGES

Staging is a process that tells the doctor howwidespread the cancer may be, that is whetherthe cancer has spread and how far. The stage ofa cancer is one of the most important factorsin selecting treatment options. If you have anyquestions about your stage, ask your doctor toexplain the extent of your disease.

A staging system is a standardized way inwhich the cancer care team describes theextent to which a cancer has spread. Stagingsystems for colorectal cancer include theDukes, Astler-Coller and AJCC/TNM systems.This section concentrates on American JointCommittee on Cancer (AJCC) system, also

called the TNM system. All three systemsdescribe the spread of the cancer in relation tothe layers of the wall of the colon or rectum,nearby lymph nodes, other organs next to thecolon and rectum, and organs farther away.

In addition, there are two types of AJCCstages. The clinical stage is based on physicalexamination and some imaging studies donebefore surgery. The clinical stage is used todetermine which, if any, operations should bedone for people with colorectal cancer. Aftercolorectal surgery, the pathologic stage is determined by examination of the tissue thathas been removed. The pathologic stage isused to determine which patients with colonand rectal cancer should be treated with adjuvant therapy and, if so, exactly what treat-ment is recommended.

The TNM System describes the extent of theprimary Tumor (T), the absence or presence ofmetastasis to nearby lymph Nodes (N), and theabsence or presence of distant Metastasis (M).

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The layers of the colon wall

Normal Intestinal Tissue(Cross section of digestive tract)

EpitheliumConnective tissue MucosaThin muscle layerSubmucosa

Thick muscle layers

SubserosaSerosa

T CATEGORIES FORCOLORECTAL CANCER

T stages of colorectal cancer describe theextent of spread through the layers that formthe wall of the colon and rectum. These layers,from the inner to the outer, include the mucosa(the lining), the muscularis mucosae (a thinlayer of muscle tissue beneath the mucosa),the submucosa (connective tissue beneath thisthin muscle layer), the muscularis propria (athick layer of muscle that contracts to forcethe contents of the intestines along), the subserosa (a thin layer of connective tissue),and the serosa (a thin layer that covers theouter surface of some parts of the large intestine.

Tx: No description of the tumor’s extent ispossible because of incomplete information.

Tis: The cancer is in the earliest stage. Ithas not grown beyond the mucosa (innerlayer) of the colon or rectum. This stage isalso known as carcinoma in situ or intra-mucosal carcinoma.

T1: The cancer has grown through themucosa and the next layer, the muscularismucosae, and extends into the submucosa.

T2: The cancer has grown through themucosa, the muscularis mucosae, the sub-mucosa, and extends into the muscularispropria

T3: The cancer has grown throughmucosa, the muscularis mucosae, the submucosa, and completely through themuscularis propria. It has spread to the

subserosa but not to any neighboringorgans or tissues.

T4: The cancer has spread completelythrough the wall of the colon or rectuminto nearby tissues or organs.

N CATEGORIES FORCOLORECTAL CANCER

Nx: No description of lymph nodeinvolvement is possible because of incomplete information

N0: No lymph node involvement

N1: Cancer cells found in 1 to 3 regionallymph nodes

N2: Cancer cells found in 4 or moreregional lymph nodes

M CATEGORIES FORCOLORECTAL CANCER

Mx: No description of distant spread ispossible because of incomplete information

M0: No distant spread

M1: Distant spread is present

Stage grouping: Once a patient’s T, N, and Mcategories have been determined, this infor-mation is combined in a process called stagegrouping to determine the stage, expressed inRoman numerals from stage I (the least

16

advanced stage) to stage IV (the mostadvanced stage). The following table illus-trates how TNM categories are groupedtogether into stages.

Stage 0: Tis, N0, M0

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

Stage II: T3, N0, M0T4, N0, M0

Stage III: Any T, N1, M0Any T, N2, M0

Stage IV: Any T, Any N, M1

The Dukes system uses letters A through C,and the Astler-Coller system uses A throughD. If your stage is reported in either of thesesystems, this table can be used to find thematching AJCC/TNM stage:

AJCC/TNM Dukes Astler-Coller

O – –I A A, B1II B B2, B3III C C1, C2, C3IV – D

TYPES OF TREATMENTFOR COLON AND RECTAL CANCERS

The three main types of treatment for colonand rectal cancer are surgery, radiation therapy,

and chemotherapy. Depending on the stage ofthe cancer, two or even three of these types oftreatment may be combined at the same timeor after one another.

After your cancer has been found and staged,your doctor will recommend one or more treat-ment options. It is important to take time andthink about all of the choices. You may wantto ask for a second opinion. This can providemore information and help you feel more con-fident about the treatment plan you choose.

SURGERY

Colon surgery: Surgery is the main treatmentfor colon cancer. The usual operation is calleda segmental resection or partial colectomy. Duringthis surgery, the cancer and a length of normaltissue on either side of the cancer as well as thenearby lymph nodes are removed. The remainingsections of the colon are then attached backtogether. This operation rarely causes any majorpermanent problems with digestive functions.Occasionally, a temporary colostomy may beneeded. Even more rarely, a permanent colo-stomy may be needed. Patients can usuallyleave the hospital about 5–7 days after surgeryand resume usual activities in 6 weeks. Of course,hospitalization and recovery times will dependon each patient’s specific medical condition.

It is sometimes possible to remove somevery early colon cancers by surgery through acolonoscope. When this is done, the surgeondoes not have to cut into the abdomen.

Some very advanced colon cancers canblock flow of feces. When it is not possible toremove the cancer, the flow of feces can bediverted to a colostomy. This operation iscalled a diverting colostomy.

17

It is sometimes possible to remove segmentsof the colon and nearby lymph nodes througha laparoscope. This instrument is a long, lightedviewing tube through which the doctor canoperate with special surgical instruments. Theviewing tube and instruments are placed intothe abdomen through several small surgicalincisions. These incisions are usually shorterthan one inch long and heal quickly.Although laparoscopic surgery has become anaccepted option in gallbladder surgery andsome gynecological operations, its use inremoving a colon cancer is still consideredexperimental. The NCCN guidelines recom-mend laparoscopic colectomy only in the contextof a clinical trial to learn more about its role inthe treatment of colon cancer.

Rectal surgery: Several methods are usedfor removing or destroying rectal cancers.Local or transanal resection is an option forsome people with stage I rectal cancer. Itinvolves cutting through all layers of the rectumto remove invasive cancers as well as some surrounding normal rectal tissue. This procedurecan be done through the anus without cuttingthrough the abdomen. Because it removes arelatively small amount of tissue, patients canusually continue to eliminate waste as usual,without the need for a colostomy. Becausecomplete removal of the cancer is so important,local resection is not an option for peoplewhose cancers cannot be completely removedby that procedure. Doctors consider the cancer’ssize, its exact location within the rectum, andhow far around the circumference of the rectumit extends in order to select which patientsshould have a local resection.

Many stage I and most stage II and stage IIIrectal cancers are removed by either low anterior (LA) resection or abdominoperineal(AP) resection. LA resection is used for cancersnear the upper part of the rectum, close towhere it connects with the sigmoid colon.After LA resection, the colon is attached tothe anus and waste is eliminated in the usualway. AP resection is used for cancer in thelower part of the rectum, close to its outer connection to the anus. After AP resection, apermanent colostomy is needed. Some patientswith stage IV rectal cancers will have to havea diverting colostomy. This operation does notremove a rectal cancer that is blocking fecalflow, but instead bypasses the blockage anddiverts fecal flow to a colostomy. Photo-coagulation (heating the rectal tumor with alaser beam aimed through the anus) is anotheroption for relieving or preventing rectal blockagein patients with stage IV cancer.

Surgical treatment of colorectal cancermetastases: For patients whose colorectal can-cer has metastasized (spread) to a few areas inthe liver, lungs, or elsewhere in the abdomen,removing or destroying these metastases canprevent some problems. Sometimes, treatmentof metastases can help the patient to livelonger. If only a small number of liver, lung, orabdominal metastases are present, they may beremoved by surgery. Liver metastases may alsobe destroyed by cryosurgery (freezing thetumor), or by radio frequency ablation (heatingthem with microwaves). These methods donot require a surgical operation. The freezingprobe or microwave probe is inserted throughthe skin and guided to the tumor by CT scansor ultrasound images.

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RADIATION THERAPY

Radiation has a major role in the treatment ofsome rectal cancers. Radiation therapy useshigh-energy x-rays or particles (such as protonsor electrons) to kill cancer cells. In treatingrectal cancer, radiation treatment can bedelivered externally (external beam radiation),or through a tube directly into the rectum(endocavitary radiation). External radiation isgenerally delivered with a linear accelerator,daily Monday through Friday, for severalweeks. This must be planned, using diagnosticx-ray machines, such as a simulator or a CTscanner. Endocavitary radiation is useful inearly stage rectal cancer and uses low energy x-rays focussed directly on the cancer throughthe anus. Radiation can be delivered eitherpreoperatively to cause tumor shrinkage toallow easier resection or to decrease the risk ofcomplications, or postoperatively if there is arisk of recurrence in the tumor area. Fluor-ouracil (5-FU) is often delivered at the sametime as radiation to make the radiation moreeffective. Studies have shown that for cases ofrectal cancer, radiation in conjunction withsurgery will often decrease the risk of recurrence.

CHEMOTHERAPY

Systemic chemotherapy uses anticancer drugsthat are injected into a vein or taken bymouth. These drugs enter the bloodstream andreach all areas of the body, making this treat-ment potentially useful for cancers that havemetastasized (spread) beyond the organ theystarted in.

Fluorouracil (5-FU) is the chemotherapy drugmost often used to treat colorectal cancer. It is

usually given together with other drugs, suchas leucovorin that increase its effectiveness. 5-FUis also given with radiation therapy in order toincrease the effectiveness of the radiation. 5-FUis usually slowly injected into a vein overabout 5 minutes. If these injections are givenfor 5 days, no additional chemo-therapy is givenfor about 3 weeks while the patient recoversfrom the drug’s side effects. Some physiciansuse a schedule of once weekly injections. Thiscycle is repeated for 6 to 8 months.

In some cases, 5-FU is given as a continuousinfusion into a vein. The patient wears a smallbattery-operated pump that continuouslyreleases 5-FU into an intravenous line. Forpatients with spread of colon or rectal cancerto their liver, 5-FU may be given directly intothe artery that supplies blood to the liver. Thisapproach to treatment of liver metastases iscalled hepatic artery infusion.

Irinotecan is another chemotherapy drug,which is often used for patients who are nolonger responding to 5-FU therapy. It may beused alone, or combined with 5-FU.

ADJUVANT THERAPY ANDNEOADJUVANT THERAPY

The terms adjuvant therapy and neoadjuvanttherapy do not refer to a specific treatment.Rather they indicate how, when, and why certain treatments (radiation therapy and/orchemotherapy) are given. Not all patientswith colorectal cancer receive neoadjuvant oradjuvant therapy.

Adjuvant therapy: After the initialsurgery, the tissue that has been removed willbe examined under a microscope to determinethe cancer’s pathologic stage (how far it has

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spread). Imaging tests such as x-rays and CTscans will also help identify spread that hasoccurred beyond the tissues removed bysurgery. If cancer is known to have spreadbeyond the tissues removed by surgery, adjuvant(additional) therapy, such as chemotherapyand/or radiation therapy, will be given to treatthe remaining cancer. In other cases, noremaining cancer is apparent, but doctorsbelieve it is possible that a few scattered cancercells may remain in the patient’s body. Evenwhen too few cells are present to detect by currently available tests, and the doctors cannotbe certain whether any cancer cells are reallythere, it is sometimes prudent to use adjuvanttherapy anyway. If initial evaluation indicatesthat remaining cancer is unlikely and the riskof cancer returning is low, adjuvant therapywill not be given.

Neoadjuvant therapy: When chemotherapyand/or radiation therapy are given beforesurgery, they are called neoadjuvant therapy.Some patients who receive neoadjuvant therapywill also have adjuvant therapy after surgery.The purpose of neoadjuvant therapy is to shrinktumors so that they can be more completelyremoved by surgery.

TREATMENT OF PAINAND OTHER SYMPTOMS

Most of this document discusses ways toremove or destroy colorectal cancer cells or toslow their growth. But it is important to realizethat maintaining your quality of life is animportant goal. Don’t hesitate to discuss yoursymptoms or any other quality of life concernswith your cancer care team. There are effectiveand safe ways to treat pain, most other symp-

toms of colorectal cancer, and most of the sideeffects caused by colorectal cancer treatment.

ALTERNATIVE ORCOMPLEMENTARY THERAPIES

If you are considering any unproven alternativeor complementary treatments, it is best to discuss this openly with your cancer care teamand request information from the ACS or theNational Cancer Institute. Some unproventreatments can interfere with standard medicaltreatments or may cause serious side effects.

SIDE EFFECTS OFCOLON AND RECTAL

CANCER TREATMENTS

SURGERY

Colostomy: A colostomy is an opening in thefront of the abdomen for elimination of feces.It is rarely used in surgical treatment of coloncancer. When it is required, the colostomy isusually temporary. After recovery from theoperation to remove the colon cancer, thecolon can be reconnected to route fecal flowto the anus and the colostomy is closed.Colostomy is used more often for rectal cancerthan for colon cancer, although advances inchemotherapy and radiation therapy havereduced the need for this procedure. NCCNguidelines recommend that people who mightneed a colostomy be referred to an entero-stomal therapist (a health care professional,often a nurse, trained to help people with their

20

colostomies). The enterostomal therapist willteach patients how to care for the colostomy,and can also help address any concerns abouthow the colostomy might affect their dailyactivities. The ACS and many cancer centerscan refer patients with colostomies to supportgroups and other programs that provide addi-tional information and support.

RADIATION

Side effects of radiation occur in the radiationfield and may include skin irritation, nausea,diarrhea, rectal irritation, bladder irritation,and fatigue. These slowly build up duringtreatment and often disappear on completionof treatment. Long term effects such as scarringor bleeding are possible. This is called radiationproctitis or radiation colitis. Occasionally,chronic irritation of the rectum or bladder persist. Radiation treatment will sometimesincrease the likelihood of surgical compli-cations. These can be treated medically or surgically. The radiation oncologist plans theradiation with these complications in mind,working to avoid treatment of unnecessary tissues. If you have these or other side effects,talk to your doctor.

CHEMOTHERAPY

Chemotherapy drugs kill cancer cells but alsodamage some normal cells. Therefore, carefulattention must be given to avoiding or mini-mizing side effects, which depend on the typeof drugs, the amount taken, and the length oftreatment. The major temporary side effectsmight include, loss of appetite, mouth soresand diarrhea or a rash on the patient’s hands

and feet. Nausea and vomiting and hair lossoccur infrequently. Because chemotherapy candamage the blood-producing cells of the bonemarrow, patients may have low blood cellcounts. This can result in an increased chanceof infection (due to a shortage of white bloodcells), bleeding or bruising after minor cuts orinjuries (due to a shortage of blood platelets),and fatigue (due to low red blood cell counts).

Most side effects disappear once treatmentis stopped. Hair will grow back after treatmentends, though it may look different. There areremedies for many of the temporary side effectsof chemotherapy. For example, antiemeticdrugs to prevent or reduce nausea and vomitingcan be given.

BODY IMAGE ANDSEXUALITY ISSUES

Surgery and radiation therapy may sometimesaffect a person’s feelings about their body, andmay lead to specific physical problems thataffect sexuality. Your cancer care team canhelp with these issues, so don’t hesitate toshare your concerns.

OTHER THINGS TOCONSIDER DURING 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 care

21

team if there is anything you do not understand.Learn about and look out for side effects oftreatment, and report these promptly to yourcancer care team so that they can take steps tominimize them and shorten their duration.

Remember that your body is as unique asyour personality and your fingerprints. Althoughunderstanding your cancer’s stage and learningabout the effectiveness of your treatmentoptions can help predict what health problemsyou may face, no one can say precisely howyou will respond to cancer 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 servicesand pastoral services who may assist you incoping with your illness.

You can also help in your own recoveryfrom cancer by making healthy lifestyle choices.If you use tobacco, stop now. Quitting willimprove your overall health and the full returnof the sense of smell may help you enjoy ahealthy diet during recovery. If you use alcohol,

limit how much you drink. Have no more thanone or two drinks per day. Good nutrition canhelp you get better after treatment. Eat a nutri-tious and balanced diet, with plenty of fruits,vegetables, and whole grain foods. Ask yourcancer care team if you may benefit from a special diet – they may have specific recom-mendations for people who have had radiationtherapy, a colostomy, or other colorectal surgery.

If you are in treatment for cancer, be awareof the battle that is going on in your body.Radiation therapy and chemotherapy add tothe fatigue caused by the disease itself. Giveyour body all the rest it needs so that you willfeel better as time goes on. Exercise once youfeel rested enough. Ask your cancer care teamwhether your cancer or its treatments mightlimit your exercise program or other activities.

A cancer diagnosis and its treatment is amajor life challenge, with an impact on youand everyone who cares for you. Before you getto the point where you feel overwhelmed, consider attending a meeting of a local supportgroup. If you need individual assistance inother ways, contact your hospital’s social service department or the ACS for help incontacting counselors or other services.

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When studying promising new or experimental treatments,researchers want to know:

• Does this new type of treatmentwork better than other treatmentsalready available?

• What side effects does the treatmentcause?

• Do the benefits outweigh the risks,including side effects?

• Which patients will the treatmentmost likely help?

During your treatment for colorectal cancer,your doctor may suggest that you take partin a clinical trial of a new treatment. Youshould know that scientists only conductclinical trials when they have reason tobelieve that the treatment under studymay indeed be superior to other treatments.No one will receive a placebo (sugar pill)if a treatment is already available. Duringtesting of a new drug that the Food andDrug Administration has not yet approved,some people will receive the standardtreatment while others will get the experi-mental drug. A computer randomly assignsparticipants to each group. Whether theexperimental treatment will work betterthan the standard treatment must beproved. The new therapy may have some

side effects, which your doctor will discusswith you before you enter the trial.

There are three phases of clinical trialsin which treatments are studied beforethey are eligible for approval by the Foodand Drug Administration. The purpose ofa Phase I study is to find the best way togive a new treatment, and how much of itcan be given safely. Physicians watchpatients carefully for any side effects.While treatments tested in a Phase I studyhave been well tested in laboratory andanimal studies, the side effects in patientsare not completely predictable.

Phase II trials determine the effectivenessof a research treatment after safety has beenevaluated in a Phase I trial. Doctors closelyobserve patients for an anti-cancer effectby carefully measuring cancer sites presentat the beginning of the trial. In addition tomonitoring patients for response, any sideeffects are carefully recorded and assessed.

Phase III trials require a large number ofpatients, sometimes thousands. A “controlgroup” of patients may receive standard(the most accepted) treatment whileanother group, randomly assigned, mayreceive the treatment or drug under study.In this way researchers can compare thetwo to find out whether the new treatmentis more beneficial to survival and quality oflife. Doctors carefully monitor all patientsin Phase III trials for side effects. The trial isdiscontinued if the side effects are too severe.

ABOUT CLINICAL TRIALS

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Taking part in any clinical trial is completely voluntary. Your doctors andnurses will explain the study to you indetail and will give you a form to read andsign. This informed consent documentstates that you understand the potentialrisks and want to participate. Even afteryou sign the form and the trial begins, youmay leave the study at any time, for anyreason. Participating in a clinical trial is anappropriate option patients at any stage ofcolorectal cancer. Taking part in the study

does not prevent you from getting othermedical care you may need. But you shouldcheck with your health insurance companyto find out whether it will cover the costsof your taking part in a clinical trial.

Participating in a clinical trial may helpyou directly, and it may help other peoplewith colorectal cancer in the future. Forthese reasons, the NCCN and the ACSare committed to conducting clinical trialsand helping people with cancer learn moreabout these studies.

Work-Up (Evaluation) and Treatment Guidelines

‘Decision Trees’

The ‘decision trees,’ or algorithms, on the following pages represent different stages ofcolorectal cancer. Each one shows you step-by-step how you and your doctor can arriveat the choices you need to make about your treatment.

Keep in mind, this information is not meant to be used without the expertise of your ownphysician who is familiar with your situation, medical history, and personal preferences.

Participating in a clinical trial is an appropriate option for people with any stage of colo-rectal cancer. 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 becomes available. To ensureyou have the most recent version, consult the web sites of the ACS (www.cancer.org) orNCCN (www.nccn.org). You may also call the NCCN at 1-888-909-NCCN or the ACSat 1-800-ACS-2345 for the most recent information on these guidelines or on cancer in general.

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NCCN®

Treatment Guidelines for Patients

Early cancer in an adenomawith a stalk and head(“mushroom-shaped”)

CLINICAL PRESENTATION WORK-UP (EVALUATION)

Early cancer in a sessileadenoma (without a stalkand head)

Cancer growing outwardthrough the colon wall thathas not blocked the flow offeces through the colon

Cancer growing into thecenter of the colon that isblocking the flow of feces(obstruction)

Keep in mind this information is not meant to be used without the expertise of your own physician who is familiar with your situation, medical history, and personal preferences.

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

PRIMARY THERAPY FOR COLON CANCER

Selecting treatment for patients with coloncancer involves considering many factors.These factors are considered in a stepwise manner, starting with the clinical presentation

(the doctor’s initial impression of the patient’smedical situation).

For early cancers, the work-up consists of apathology review and colonoscopy. For a patient

Pathology reviewColonoscopy

Pathology reviewColonoscopy

Pathology reviewColonoscopyBlood countsBlood chemistry testsCEA blood testCT scan of abdomen and pelvisChest x-ray

Pathology reviewColonoscopy, if possibleBlood countsBlood chemistry testsCEA blood testCT scan of abdomen and pelvisChest x-ray

27

Decision Tree for Colon Cancer–Primary Therapy

One of the following:

T1N0M0T2N0M0T3N0M0T4N0M0T1-3N0M0T4N1-2M0

©2000 by the National Comprehensive Cancer Network (NCCN®)and the American Cancer Society (ACS). All rights reserved. Theinformation herein may not be reproduced in any form for commercialpurposes without the expressed written permission of the NCCNand the ACS. Single copies of each page may be reproduced for personal and non-commercial uses by the reader.

whose clinical presentation suggests a moreadvanced cancer, in addition to the pathologyreview and colonoscopy, more tests will bedone to determine the extent the cancer has

spread. These include blood tests, CT scans ofthe abdomen and pelvis, and a chest x-ray.

Sometimes a patient is thought to have anadenomatous polyp of the colon (a benign

No additional surgery needed TisCancer limited to head (tip)of polyp that has been completely removed

Stage T0, Tis, or T1 cancerremoved completely in onepiece of tissue

CLINICAL STAGE PRIMARY (MAIN OR FIRST) THERAPY

STAGE

Resectable (surgeon canremove all visible cancer)

Unresectable (surgeonunable to remove allvisible cancer)

1 or more of the following:Spread into polyp’s stalkSpread to lymphatic channelsHigh grade (very abnormal-appearing cells)

1 or more of the following:Stage T2 or higherCancer not completely removedor unable to evaluate completeness of removal

Colon & lymph node resection

or

Laparoscopic surgery

No additional surgery needed

Colon & lymph node resection,

or

Laparoscopic surgery

Colon & lymph node resection,followed by colonoscopy (if notdone during work-up) to checkfor additional tumors

Relieve blockage by removingcancer if possible, or by divertingflow of feces to a colostomy

28


mushroom-shaped growth of glandular tissue).Only after the growth is removed and analyzedunder a microscope can the doctors see thatpart of what was thought to be a benigngrowth has started to turn cancerous. If thecancerous part of the growth has been com-pletely removed and was limited to the head ofthe polyp (the part that resembles the cap of amushroom) no additional treatment is needed.If it appears that the cancer cells are spreadingalong the stalk of the polyp, to lymphaticchannels, or if the cancer cells are high grade(highly abnormal in appearance, suggesting

spread is likely to have occurred but mighthave been missed when the specimen wasexamined), then removal of additional colontissue and lymph nodes is recommended.

If the adenomatous growth does not have adistinct stalk, but rather a broad base, it iscalled a sessile adenoma. If doctors are confi-dent that the part of the sessile adenoma thathas become cancerous was completelyremoved, no additional treatment is needed.But, if there is a chance that some cancer wasleft behind, removal of additional colon tissueand lymph nodes is recommended.

NCCN®

NOTES

29

Decision Tree for Colon Cancer–Primary Therapy (continued)

If a cancer invades the wall of the colon,removal of a segment of colon containing thecancer and some nearby lymph nodes is therecommended treatment. Laparoscopic surgeryis an option for removing a segment of thecolon and nearby lymph nodes but it is stillconsidered an investigational procedure.Therefore it should only be done in the con-text of a clinical trial that will help doctorslearn more about the value of this procedure.

If a large cancer growing inward to the center of the colon is blocking the flow offeces, and has spread too extensively to be

completely removed, the main goal of surgerywill be to relieve the blockage of fecal flow.This may involve removing a short segment ofcolon including the cancer and reattachingthe ends. Rarely the surgeon will leave thecancer intact and divert the flow of feces to acolostomy. If colonoscopy could not be done(because the tumor blocked passage of thecolonoscope) during the patient’s initial work-up, it will need to be done after the colon andlymph node resection. The colonoscopy isnecessary to make sure the patient doesn’t haveanother cancer elsewhere in the colon or rectum.

NOTES

30

NCCN®


Tis, T1N0M0, T2N0M0: Because the ini-tial evaluation indicates that the risk of cancerremaining or returning after surgery is low, adju-vant therapy (additional treatment) is not given.

T3N0M0: People with T3N0M0 coloncancer have tumors that have spread throughthe muscle of the wall, but not to the sur-rounding lymph nodes. For most cases,


Participating in a clinical trial is an appropriate option for people at any stage of colorectal cancer.Taking part in the study does not prevent you from getting other medical care you may need.

PATHOLOGIC STAGE ADJUVANT(ADDITIONAL) THERAPY

None

T4N1-2M0

T3N0M0

T3 with one or more of the following:Bowel perforation (hole in colon wall),

Cancer not completelyremoved from colon, or

Uncertain about completenessof cancer removal

T4N0M0

Tis

T1N0M0

T2N0M0

ADJUVANT TREATMENT OF COLON CANCER

T1-3N1-2M0

Observation (thorough follow-up exams)

or

Clinical trial of adjuvant therapy

5-FU and leucovorin, or5-FU and leucovorin and radiation if perforation is present

5-FU and leucovorin, or5-FU and leucovorin and radiation

Consider 5-FU and leucovorin, or5-FU and leucovorin and radiation, orClinical trial of other adjuvant therapy

31

Decision Tree for Colon Cancer–Adjuvant Therapy


FOLLOW-UP TESTS AND EXAMINATIONS

adjuvant therapy is not indicated. In someinstances, however, the tumor has other features(bowel perforation, positive margins, or uncer-tainty regarding completeness of cancer

removal) which make the likeliness of recurrencegreater, therefore adjuvant chemotherapy withor without radiation may be given.

Physical exam (including DRE) every 3 months for 2 years, then every 6 months for 5 years

If blood CEA level was high at diagnosisor within 1 week of colon resection,repeat CEA blood test every 3 months for2 years, then every 6 months for 5 years(only for T2, T3 and T4 cancers).

Colonoscopy 1 year after surgery.Remove any polyps that are found, thenrepeat colonoscopy again in 1 year. If nopolyps are found, repeat every 3 years.

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NCCN®


T4N0M0 cancers: For patients with stageT4N0M0 cancers, adjuvant therapy consistingof fluorouracil (5-FU) and leucovorin, or acombination of 5-FU and leucovorin plus radiation therapy, or clinical trials can be considered options for treatment.

T1-3N1-2M0, T4N1-2M0: Patients whosetumors have spread to surrounding lymphnodes have a greater chance of having theirtumors recur. Studies have shown that admin-istering adjuvant chemotherapy can lower therisk by half. The options for patients who need

adjuvant therapy are 5-FU and leucovorin or a combination of 5-FU and leucovorin plusradiation therapy.

Follow-up tests and examinations forcolon cancer: After initial surgical and, insome cases, adjuvant treatments are finished,follow-up tests are routinely done. The purposeof these tests is to find colorectal cancer thathas recurred (come back) as soon as possible,when further treatments are most likely to behelpful. Since people cured of one colorectalcancer are at increased risk for developing a

NOTES

33

Decision Tree for Colon Cancer–Adjuvant Therapy (continued)

second one, early detection of second cancersis another goal of follow-up testing. Unlikerecurrence, in which cancer cells remainingafter treatment form additional tumors, secondcancers develop from previously benign areasof the colon or rectum. Selection of follow-uptests is based on the stage of the cancer, whichreflects its likelihood of recurring and spreadingfurther. The side effects of the initial treatmentare also monitored.

The digital rectal examination and colon-oscopy are used to detect local recurrences or

new cancers. The carcinoembryonic antigen(CEA) blood test, described in the section onevaluation, is often useful in detecting recurrentcancer. However, some rare colorectal cancersdo not produce enough CEA to cause elevationsin blood levels. The use of routine CT scanshas not been shown to be useful in findingrecurrent disease at a stage that is more treatablethan disease found by physical exam and CEA monitoring. Therefore, the use of this imagingtest generally occurs if an abnormality is foundon exam or blood testing.

NOTES

34

NCCN®


COLON CANCER WITH PROVEN OR

SUSPECTED DISTANT METASTASESAny T, any N, M1: Selecting treatment for

patients with proven or suspected distantspread of colon cancer involves consideringmany factors. These factors are considered in astepwise manner, starting with the clinicalpresentation (the doctor’s initial impression ofthe patient’s medical situation).

For patients whose clinical presentationsuggests that their colon cancer has spread to

distant organs, work-up will include pathologyreview and colonoscopy, as well as additionaltests. These tests include blood work, CTscans of the abdomen and pelvis, a chest x-ray,and a needle biopsy of suspected metastasis. Ifthe liver is the only area of suspected distantspread, more imaging tests may need to bedone such as spiral CT and portography, MRI,laparoscopy, an angiogram and a PET scan.

When spread to distant organs is suspectedor proven when a colon cancer is detected, but



WORK-UP (EVALUATION)

CLINICAL PRESENTATION

ColonoscopyBlood countsBlood chemical testsCEA blood testCT scan of abdomen and pelvisChest x-rayNeedle biopsy of suspectedmetastasis

If liver is the only area of suspected spread, consider extraimaging tests of liver (spiral CT &portography, MRI, laparoscopy,angiogram, PET scan, ultrasounddone during surgery)

Colon cancer withproven or suspecteddistant spread (any T, any N, M1)

35

Decision Tree for Colon Cancer with Metastases


Impending obstruction(complete blockage of colonexpected to occur soon)

FINDINGS

Resectable

Unresectable

1-3 liver metastases that areresectable (removable by surgery)or can be completely ablated(destroyed) by cryosurgery

Unresectable liver metastases,cancer of right side of colonnot causing symptoms

Unresectable liver metastases,cancer of left side of colon orblocking bowel

Unresectable lung metastases

1-3 resectable lung metastases

Metastasis(spread) to liver

Metastasisto lungs

Metastasis toother areas ofabdomen

Continued onnext pages

before the colon and lymph node resection isdone, the next step in evaluation is to determinewhether the metastases can be resected (com-pletely removed by surgery). This determinationis based on the number of metastatic tumornodules and their exact location. Intraoperativeultrasonography (ultrasound imaging doneduring surgery) can be used to detect livermetastases at the time of colon resection. Onenodule or a few nodules of metastatic colorectal

cancer can often be removed from the liver,lungs, or abdomen. Ablation of metastases(destroying the tumor but not removing it) isanother option, and can be accomplished byheating the tumors with focused radiofrequencywaves or by freezing them with cryosurgery (avery low temperature needle precisely aimedinto the tumor). More numerous metastases,or metastases involving certain critical parts ofthese organs may be impossible to remove

36

NCCN®


without severely damaging the organs they are found in. Whenever possible, removal ofall visible cancer is the goal of surgery, sincethis offers the best chance for cure or long-term survival.

In order to prevent colon obstruction(blockage of fecal flow) the primary (original)colon tumor is usually removed, or fecal flow isdiverted around it to a colostomy.

If cancer is known to have spread beyondthe tissues removed by surgery, chemotherapyand/or radiation therapy will be given to treatthe remaining cancer. Even when it appearsthat all of a patient’s metastases have beenremoved or destroyed by ablation, doctorsknow from experience that other metastasesare probably present, even if they are too smallto be seen by imaging tests or during surgery.

PRIMARY THERAPY

Impending obstruction(complete blockage of colonexpected to occur soon)

Resectable (other areas)

Unresectable (other areas)

1-3 liver metastases that areresectable (removable by surgery)or can be completely ablated(destroyed) by cryosurgery

Unresectable liver metastases,cancer of right side of colonnot causing symptoms

Unresectable liver metastases,cancer of left side of colon orblocking bowel

Unresectable lung metastases

1-3 resectable lung metastases



Colon & lymph node resectionRemove liver metastases or destroy by cryosurgery (freezing)

None

Limited colon resection to relieve blockage

Consider limited colon resection

Colon & lymph node resection.Remove lung metastases

Colon resection. Remove metastases from abdomen

Relieve blockage by removingcancer or by diverting flow offeces to a colostomy

37

POST OPERATIVE/ADJUVANT THERAPY

5-FU/leucovorin with additional chemotherapy directly into artery leading to liver, or

5-FU/leucovorin, or 5-FU given continuously into a vein, or

5-FU/leucovorin/irinotecan


Physical exam (including DRE) every 3 months for 2 years, thenevery 6 months for 5 years

If blood CEA level was high at diagnosis or within 1 week ofcolon resection, repeat CEA bloodtest every 3 months for 2 years,then every 6 months for 5 years(only for T2, T3 and T4 cancers)

Colonoscopy 1 year after surgery.Remove any polyps that are found,then repeat colonoscopy again in 1 year. If no polyps are found,repeat every 3 years


Decision Tree for Colon Cancer with Metastases (continued)

Therefore, these patients should also receiveadjuvant chemotherapy. For patients whosemetastases are unresectable, salvage therapy isgiven after colon surgery.

The digital rectal examination and colon-oscopy are used to detect local recurrences ornew cancers. The carcinoembryonic antigen(CEA) blood test, described in the section onevaluation, is often useful in detecting recurrent

cancer. However, some rare colorectal cancersdo not produce enough CEA to cause elevationsin blood levels. The use of routine CT scanshas not been shown to be useful in findingrecurrent disease at a stage that is more treat-able than disease found by physical exam andCEA monitoring. Therefore, the use of thisimaging test generally occurs if an abnormalityis found on exam or blood testing.

Salvage therapyFollow pathway for salvage therapy(see Recurrence Work-up, page 39)

5-FU/leucovorin, or 5-FU given continuously into a vein, or 5-FU/leucovorin/irinotecan

Observation (thorough follow-up exams), or

5-FU/leucovorin, or 5-FU given continuously into a vein, or

5-FU/leucovorin/irinotecan

Salvage therapyfollow pathway for salvage therapy(see Recurrence Work-up, page 39)

38

NCCN®


RECURRENT COLON CANCER

CEA levels that rise steadily after initialtreatment strongly suggest that a colorectalcancer is recurring, and indicates the need fora thorough search for the recurrent cancer.This search includes colonoscopy, x-rays, andCT scans. If no cancer is found, these tests arerepeated at regular intervals. In some patients,a rising CEA may be present for months toyears before clinical evidence (imaging test orphysical exam results) of recurrent disease is

found. Patients are not given chemotherapybased on a rising CEA alone.

If masses likely to be recurrent cancer aredetected by imaging tests, a biopsy may bedone to be certain that the mass is due to cancerand not some other disease. In most cases thisinvolves a needle biopsy procedure done usinga CT scan for guidance. If recurrent cancer isproven by biopsy or if metastatic cancer isdetected at the time of initial diagnosis, thetreatment plan is referred to as “salvage therapy.”Recurrent cancer may be treated in two ways.

RECURRENCE WORK-UP (Evaluation if cancer issuspected to have come back after treatment)

One or moretests positive(cancer found)

All testsnegative(no cancer)




Positivefollow-upexamination

Distantmetastasesproven bybiopsy

Rising bloodCEA levels

ColonoscopyChest x-ray and chest CT scan

CT scan of abdomen and pelvis

39

Decision Tree for Recurrent Colon Cancer


RECURRENCE WORK-UP(continued)

THERAPY

Repeat CT scans ofabdomen, pelvis andchest every 3 monthsif symptoms suggestmetastasis

Metastases too largeor numerous toremove completely



In the first, the recurrent tumor can be com-pletely removed surgically and long termremission is possible. In the second group, thetumor can not be totally removed and non-curative chemotherapy is used to control therecurrent disease. Complete removal of therecurrent or metastatic cancer may be consid-ered when there are fewer than four metastasesto the liver, and no metastases in other organs.

Even when it appears that all of a patient’srecurrences have been removed or destroyed

by ablation, doctors know from experience thatmore recurrent tumors are probably present,even if they are too small to be seen by imagingtests or during surgery. Therefore, these patientsshould also receive adjuvant chemotherapy.

For patients whose recurrences or metastasesare too large or numerous to remove com-pletely, treatment options depend on whetherthey previously had any adjuvant therapy and,if so, how soon after completion of adjuvanttherapy the recurrence was detected.

Salvage therapy

Completely removerecurrent or metastaticcancer when possible

40

NCCN®


THERAPY (continued)

For patients whose cancer progresses duringadjuvant therapy or within 6 months of com-pleting adjuvant therapy, and who are in goodgeneral health; second line salvage therapiessuch as irinotecan or 5-FU given by continuousinfusion into a vein or given directly into thehepatic artery (the artery that supplies bloodto the liver) are options.

For patients whose cancer progresses morethan 6 months after completing adjuvant ther-apy and who are in good general health, firstline therapies are given. These include 5-FUchemotherapy, or combination chemotherapywith 5-FU and irinotecan, or chemotherapygiven directly into the hepatic vein, if the liveris the only organ with resectable metastases.



Cancer starts growing and/or spreading again more than 6 months after completing adjuvant therapy

Patient’s general health is relatively good

No previous chemotherapyPatient’s general health is relatively good

No previous chemotherapyPatient’s general health too poor to tolerate additional treatment


Completely removerecurrent or metastaticcancer when possible

Cancer continues to grow and/or spread during adjuvant therapy or first line salvagetherapy, or within 6 months of completing adjuvant therapy


41

Decision Tree for Recurrent Colon Cancer (continued)


SALVAGE THERAPY OF RECURRENT OR METASTATIC CANCER

Adjuvant therapy (if not already given) with 5-FU/leucovorin, or 5-FU given continuously into a vein, or 5-FU/leucovorin/irinotecan

If cancer continues to growand/or spread during thistherapy, consider tryingsecond line therapies

For patients who have never had chemo-therapy and are in good general health, first-line therapies, supportive care, or observationare all options. New forms of chemotherapygiven into the artery leading to the liver, newtechniques for ablation of liver metastases,new immunotherapy approaches, or other new

ways to treat colon cancer may be availablethrough clinical trials, and may be an especiallyworthwhile option for these patients.

For patients who have never had chemo-therapy and are in poor health, supportive carethat focuses on relieving symptoms but is notexpected to destroy the cancer is recommended.

Second line therapies:Irinotecan alone, or 5-FU given continuously into a vein, orChemotherapy directly into artery leading to liver, if liver is only organ with metastasis

First line therapies:Combination chemotherapy including 5-FUCombination chemotherapy including 5-FU and irinotecanChemotherapy directly into artery leading to liver, if liver is the only organ with metastasis

First line therapies, orClinical trial of treatment to destroy liver metastases, if liver is the only organ with metastasis, or

Clinical trial of other treatment, orObservation, orSupportive care

Supportive care

42

NCCN®

Selecting treatment for patients with rectalcancer involves considering many factors.These factors are considered in a stepwisemanner, starting with the clinical presentation(the doctor’s initial impression of the patient’s

medical situation) and clinical stage (estimateof how far the cancer has spread based onphysical examination and imaging test results).

The work-up (evaluation) for patients with T1, T2, or T3 rectal cancer consists of a



CLINICAL PRESENTATION WORK-UP (EVALUATION)

Rectal cancers that can be removedby local excision (need all of the following features):Involve less than 40% of rectal circumference

Smaller than 4 cm (about 11⁄2 inch)Moveable (not stuck to deep rectal tissues)

Less than 10 cm (about 4 inches) from anal opening

Stage T1 or T2

T1 or T2 or T3 Rectal cancers thatcannot be removed by local excision

CLINICAL STAGE

T1N0M0

T2N0M0

T1N0M0, orT2N0M0

T1-2N1M0, orT1-2N2M0, orT3N0-2M0


T1, T2, AND T3 RECTAL CANCER WITHOUT DISTANT METASTASIS

Pathology reviewBlood countsBlood chemistry testsCEA blood testEndorectal ultrasoundCT scan of abdomen and pelvisChest x-rayConsultation with enterostomaltherapist


43

pathology review, blood counts, blood chemistrytests, carcinoembryonic antigen (CEA) bloodlevels, CT scans of the abdomen and pelvis, achest x-ray, and an endorectal ultrasoundexamination. NCCN guidelines also recom-

mend that people with rectal cancer bereferred to an enterostomal therapist (a healthcare professional, often a nurse, trained to helppeople with their colostomies) as part of theirinitial work-up.


PRIMARY (MAIN) THERAPY

PATHOLOGIC STAGE

ADJUVANT (ADDITIONAL) THERAPY

None (observe routine follow-up)

5-FU given continuouslyor intermittently

None

Decision Tree for T1, T2, and T3 Rectal Cancer without Distant Metastases

Transanal resection (remove cancer through anus). If cancerremains after first excision, thenrepeat local excision

or

Endocavitary radiation therapy

LA or AP resection, orNeoadjuvant (before surgery) radiation therapy and 5-FU given continuously or intermittently, followed by resection

Low anterior (LA) resection orAbdominoperineal (AP) resection

Transanal resection

T1-2N1M0, orT1-2N2M0, orT3N0-2M0

T1N0M0T2N0M0

T2Nx

T1Nx

If patient had 5-FU and radiationtherapy before surgery, then 5-FUand leucovorin is given after surgery

If patient did not have neoadjuvanttherapy, 5-FU and leucovorin aregiven after surgery, followed by 5-FUand radiation, then more 5-FU andleucovorin

44

NCCN®

The cancer’s clinical stage, its size, its exactlocation within the rectum, and what percent-age of the circumference (perimeter) of therectum it involves will determine whetherlocal or transanal resection is an option forremoving the cancer. The main advantage ofthis procedure is that it avoids the need for acolostomy. After local or transanal resection,careful microscopic examination of the tissuethat has been removed is essential to deter-mine whether the cancer has been completelyremoved. If cancer cells are present at the edge

of the tissue or very near to the edge, doctorssay that there are positive margins or closemargins. In either case, the surgeon may needto remove additional tissue by another localresection or by a low anterior (LA) or abdominoperineal (AP) resection. Endocavitaryradiation therapy (given through the anus) isanother sphincter-sparing option (that is, itavoids a colostomy) for some patients with T1rectal cancer.

Depending on the exact location of theircancer within the rectum, patients with T3


NOTES

45

cancers, and those patients with T1 or T2 cancers who do not meet the requirements forlocal resection (described in the decision tree)will have LA resection or AP resections.Cancer in the upper part of the rectum canoften be treated by LA resection. After thissurgery, the patient can eliminate solid wastein the usual manner. For cancers of the lowerpart of the rectum near the sphincter (muscleresponsible for bowel control), an AP resectionmay be needed, and waste is eliminatedthrough a colostomy. Patients with tumors

extending through the rectal wall muscle (T3),or with spread to one or more lymph nodesreceive adjuvant therapy with radiation and 5-FU given at the same time. This treatmentmay be given before (neoadjuvant) or after(adjuvant) the surgery. If the cancer has spreadto lymph nodes, patients will also receive adju-vant therapy alone after the radiation.

As noted in the decision tree, decisionsregarding adjuvant (additional) chemotherapyand radiation therapy are based on the T category and the N category.

Decision Tree for T1, T2, and T3 Rectal Cancer without Distant Metastases (continued)

NOTES

46

NCCN®

The initial work-up (evaluation) for patientsin these categories is similar to that for patientswith T1, T2, or T3 rectal cancer, and consists

of a pathology review, blood counts, bloodchemistry tests, blood CEA levels, CT scans ofthe abdomen and pelvis, a chest x-ray, and an




WORK-UP (EVALUATION)

CLINICAL STAGE


T4 rectal cancer

Any rectal cancerthat has metasta-sized (spread todistant lymphnodes or distantinternal organs)

T4


T4 RECTAL CANCER AND T1-4 RECTAL CANCERWITH DISTANT METASTASIS

Pathology reviewBlood countsBlood chemistry testsCEA blood testCT scan of abdomen and pelvisChest x-rayConsultation with enterostomaltherapist

Any T, Any N, M1with unresectablemetastases

Any T, Any N, M1with resectable(removable bysurgery) metastases

47


PRIMARY (MAIN) THERAPY

PATHOLOGIC STAGE

ADJUVANT (ADDITIONAL) THERAPY

T4 Any NM0

T1N0M1, orT2N0M1

T3AnyNM1, orT4AnyNM1,orAnyTN1M1, orAny TN2M1

AnyTAnyNM1

endorectal ultrasound examination. NCCNguidelines also recommend that people withrectal cancer be referred to an enterostomal

therapist (a health care professional, often anurse, trained to help people with theircolostomies) as part of their initial work-up.

Decision Tree for T4 and/or M1 Rectal Cancer

5-FU (given continuously orintermittently) and radiationtherapy, followed by resectionif possible

Remove metastases andrectal cancer by surgery

Remove rectal cancer, orDestroy rectal cancer with photocoagulation (laser beam), or

Diverting colostomy (relieve/prevent blockage by diverting flow of feces to a colostomy), or

Radiation and 5-FU chemotherapy

5-FU and leucovorin

5-FU and leucovorin (givenfor longer time than above)

5-FU and leucovorin, then 5-FU(given continuously or intermittently)and radiation therapy, then more 5-FU and leucovorin

Follow decision tree for “Metastasestoo large or numerous to removecompletely” on page 52

48

NCCN®

The guidelines recommend that peoplewith T4 rectal cancers and no apparent distantmetastases have neoadjuvant (before surgery)5-FU chemotherapy and radiation therapy,followed by resection, if the cancer can beremoved completely by surgery. Adjuvantchemotherapy (after surgery) with 5-FU andleucovorin is also recommended.

Treatment options for people whose colo-rectal cancer has spread to distant organs suchas the lungs or liver (M1 cancers) depend onwhether imaging tests suggest that the meta-stases can be removed completely by surgery. Ifso, removal of metastases is followed by adju-vant therapy. If the rectal tumor has not invadedthe bowel wall very deeply (T1 or T2 tumors)


NOTES

49

adjuvant chemotherapy consists of 5-FU andleucovorin. If the cancer invades more deeply(T3 or T4 tumors) adjuvant therapy involves5-FU and leucovorin, then 5-FU and radiationtherapy, then more 5-FU and leucovorin.

Patients with metastases that are unresectable(cannot be completely removed by surgery)have several options for treatment of the rectal tumor. It may be surgically removed,

destroyed by photocoagulation (heating with alaser beam), bypassed by use of a divertingcolostomy, or treated by radiation therapytogether with 5-FU chemotherapy. After oneof these treatments is given, the patient mayalso receive additional chemotherapy, accord-ing to the decision tree for “Metastases too largeor too numerous to remove completely,” which iscontinued on pages 51 and 52.

Decision Tree for T1 and/or M1 Rectal Cancer (continued)

NOTES

50

NCCN®

RECURRENCE WORK-UP(Evaluation if cancer issuspected to have comeback after treatment)

FOLLOW-UP FORRECTAL CANCER RECURRENCE

After initial surgery or radiation therapyand, in some cases, adjuvant treatments arefinished, follow-up tests are routinely done.The purpose of these tests is to find rectal cancer that has recurred (come back) as soonas possible, when further treatments are mostlikely to be helpful. Since people cured of onerectal cancer are at increased risk for developinga second cancer of the rectum or colon, earlydetection of second cancers is another goal of

follow-up testing. Unlike recurrence, in whichcancer cells remaining after treatment formadditional tumors, second cancers developfrom previously benign areas of the colon orrectum. The side effects of the initial treatmentare also monitored.

The DRE and colonoscopy are used to detectlocal recurrences or new cancers, respectively.The CEA blood test, described in the sectionon evaluation, is often useful in detectingrecurrent cancer. However, some rare colorectalcancers do not produce enough CEA to causeelevations in blood levels.




RECURRENCE


Rising blood CEA levels

Distant metastases

Physical exam (includingdigital rectal exam) every 3months for 2 years, thenevery 6 months for 5 years

If blood CEA level was high at diagnosis or within1 week of resection, repeatCEA blood test every 3months for 2 years, thenevery 6 months for 5 years(only for T2, T3 and T4 cancers)

Colonoscopy 1 year afterdiagnosis. If normal, repeatevery 3 years. If polypsfound, repeat every year

ColonoscopyChest x-ray Chest CT scanCT scan of abdomen and pelvis

51

Finding a mass by DRE or detecting steadilyrising CEA levels strongly suggest that a rectalcancer is recurring, and indicate the need for athorough search for the recurrent cancer. Thissearch includes colonoscopy, chest x-rays, andCT scans of the chest, abdomen, and pelvis. Ifno cancer is found, these tests are repeated atregular intervals.

If a mass likely to be recurrent cancer isdetected by imaging tests, a biopsy may bedone to be certain that the mass is due to cancerand not some other type of disease. In most

cases this procedure is a needle biopsy donewith CT guidance. If recurrent cancer is foundby biopsy, or if metastatic cancer is detected atthe time of initial diagnosis, the treatmentoptions for patients in this situation arereferred to as salvage therapy. Choosing a specific salvage therapy starts with learningthe exact location, size, and number of metas-tases. The types of rectal cancer recurrencesand their recommended salvage therapies areoutlined in the “Decision Tree for Rectal CancerSalvage Therapy” on page 52.


RECURRENCE WORK-UP (continued)

Continuedon nextpages

Cancer returned at anastomoticsite of LA resection (where rectumand colon were reattached)

Resectable (can be removedby surgery) organ-confinedmetastases within one ormore organs

Isolated pelvic recurrence(cancer returned near therectum and is not confinedto any particular organ)

Metastases too large ornumerous to removecompletely

Decision Tree for Follow-up of Rectal Cancer Recurrence

All tests negative(no cancer)

One or more testspositive (cancerfound)

Salvage therapy

Repeat CT scansof abdomen,pelvis and chestevery 3 months ifsymptoms suggestmetastasis

52

NCCN®

If recurrent cancer is proven by biopsy or ifmetastatic cancer is detected at the time ofinitial diagnosis, the treatment plan is referredto as salvage therapy.

If cancer returns at the anastomotic site(where the rectum and colon were attachedfollowing LA resection) and no metastaseselsewhere are apparent, 5-FU and radiation



Cancer returned atanastomotic site ofLA resection (whererectum and colonwere reattached)

5-FU and radiationtherapy (if notgiven previously),then AP resection

Intermittent orcontinuous 5-FUwith radiationtherapy beforesurgery. Then,resect if possible

Completelyremove recurrentcancer by surgeryplus adjuvanttherapy if notpreviously given

No previous chemotherapyPatient’s general health is too poorto tolerate additional treatment

Resectable (can beremoved by surgery)organ-confinedmetastases withinone or more organs

Isolated pelvicrecurrence (cancerreturned near therectum and is notconfined to anyparticular organ)


THERAPY OF RECURRENT RECTAL CANCER


SALVAGE THERAPY OF RECURRENT OR METASTATIC RECTAL CANCER

Cancer continues to grow and/or spreadduring adjuvant therapy or first line salvage therapy, or within 6 months ofcompleting adjuvant therapy


Cancer starts growing and/or spreading again more than 6 months after completing adjuvant therapy.


No previous chemotherapy Patient’s general health is relatively good

53

therapy are given, followed by AP resection.Isolated pelvic recurrence means that cancerhas returned near the rectum, is not confinedto any particular organ, and has not spread to

distant organs in the abdomen (such as theliver) or chest (such as the lungs). Theserecurrences are treated by chemotherapy with5-FU, followed by surgical resection, if possible.


Decision Tree for Rectal Cancer Salvage Therapy

Second line therapies:Irinotecan alone, or5-FU given continuously into a vein, orChemotherapy directly into artery leading to liver, if liver is only organ with metastasis

First line therapies:Combination chemotherapy including 5-FUCombination chemotherapy including 5-FU and irinotecanChemotherapy directly into artery leading to liver, if liver is the only organ with metastasis

First line therapies, orClinical trial of treatment to destroy liver metastases, if liver is the only organ with metastasis, or

Clinical trial of other treatment, orSupportive care

Supportive care

If cancer continuesto grow and/orspread during thistherapy, considertrying second linetherapies

54

NCCN®

Likewise, recurrences or metastases confinedto one organ (such as the liver or lung) areremoved by surgery, if possible.

Salvage chemotherapy is divided into first-line therapies and second-line therapies. Thelatter may be used if a rectal cancer continuesto grow and spread during or shortly after adjuvant therapy, or if first-line therapies arenot helping. These therapies are listed in thedecision tree on pages 51–53.

For patients whose cancer continues togrow and spread during adjuvant therapy, orwithin 6 months of completing adjuvant therapy, and who are in good general health,second-line therapies are recommended.

For patients whose cancer continues togrow and spread more than 6 months aftercompleting adjuvant therapy, and who are in good general health, first-line therapies are given.


NOTES

If a patient has never had chemotherapyand is in good general health, first-line therapies, a clinical trial of an investigational(experimental) treatment to destroy livermetastases (if the liver is the only affectedorgan), or clinical trials of other investigationaltreatments, or supportive care are all options.Supportive care focuses on relieving symptoms

but is not expected to destroy the cancer. If thecancer continues to grow and spread duringthese treatments, second-line therapies may be considered.

For patients who have never had chemo-therapy and are in poor health, supportive careis recommended.

55

Decision Tree for Rectal Cancer Salvage Therapy (continued)

NOTES

56

GLOSSARY

ABDOMENThe part of the body between the chestand the pelvis; it contains the stomach(with the lower part of the esophagus),small and large intestines, liver, gall-bladder, spleen, pancreas, and bladder.

ADENOCARCINOMACancer of the glandular cells, for exam-ple, those that line the inside of thecolon and rectum.

ADENOMATOUS POLYPSOR ADENOMAA benign growth of glandular cells, forexample, those that line the inside ofthe colon or rectum. There are threetypes of colorectal adenomas: tubular,villous, and tuberovillous.

ADJUVANT THERAPYTreatment used in addition to the maintreatment. It usually refers to chemo-therapy, radiation therapy, immuno-therapy, or hormonal therapy addedafter surgery to increase the chances ofcuring the disease or keeping it in check.

ANASTOMOSIS ORANASTOMOTIC LINEThe site where two structures are surgi-cally joined together. For example, afterremoval of a segment of colon contain-ing a cancer, the ends of the colon arereconnected.

ANTIEMETICA drug that prevents or relieves nauseaand vomiting, common side effects ofchemotherapy.

ANUSThe outlet of the digestive tract throughwhich stool passes out of the body.

ASCENDING COLONThe first of the four sections of thecolon. It extends upward on the rightside of the abdomen and leads to thetransverse colon.

BENIGNNot cancer; not malignant.

BIOPSYThe removal of a sample of tissue to seewhether cancer cells are present. Thereare several kinds of biopsies. In an endo-scopic biopsy, a small sample of tissue isremoved using instruments operatedthrough a colonoscope.

BOWELThe intestine.

CARCINOEMBRYONICANTIGEN (CEA)A substance normally found in fetal tissue. If found in an adult, it may suggestthat a cancer, especially one starting inthe digestive system, may be present.Tests for this substance may help infinding out if a colorectal cancer hasrecurred after treatment.

COLECTOMYSurgical removal of all (total) or part(partial colectomy or hemicolectomy,for example) of the colon.

COLONPart of the large intestine, the colon isa muscular tube about five feet long. Itis further divided into four sections: theascending, transverse, descending, andsigmoid colon. It continues the processof absorbing water and mineral nutrientsfrom food.

COLONOSCOPYA slender, flexible, hollow lighted tubeabout the thickness of a finger. It is

57

inserted through the rectum up into thecolon. A colonoscope is much longer than asigmoidoscope, and usually allows the doctorto see all of the colon’s lining. The colono-scope is connected to a video camera andvideo display monitor so the doctor can lookclosely at the inside of the colon. If abnormal-ities are found, the doctor can take a biopsy(tissue sample) or remove polyps, using instru-ments operated through the colonoscope.

COLOSTOMYAn opening from the colon onto the skin ofthe abdomen for getting rid of body waste(stool). A colostomy is sometimes neededafter surgery for cancer of the rectum. Peoplewith colon cancer sometimes have a tempo-rary colostomy but they rarely need a perma-nent one.

COMPLEMENTARY THERAPYTherapies used in addition to standard therapy.Some complementary therapies may helprelieve certain symptoms of cancer, relieveside effects of standard cancer therapy, orimprove a patient’s sense of well-being.Patients considering use of any alternative orcomplementary therapy discuss this with theirhealth care team. See also, alternative therapy.

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 SYSTEMThe digestive system, also called the gastro-intestinal tract, or GI tract, processes food forenergy and rids the body of solid waste matter.

ENDOCAVITARY RADIATION THERAPYA type of radiation therapy for treating rectalcancer. The radiation beam is aimed throughthe anus, into the rectum.

ENTEROSTOMAL THERAPISTA health professional, often a nurse, whoteaches people how to care for ostomies (surgi-cally created openings such as a colostomy)and other wounds.

EXTERNAL BEAM RADIATIONRadiation is focused from a source outside thebody on the area affected by the cancer. It ismuch like getting a diagnostic x-ray, but for alonger time.

FAMILIAL ADENOMATOUSPOLYPOSIS (FAP)A hereditary condition that is a risk factor forcolorectal cancer. People with this syndrometypically develop hundreds of polyps in thecolon and rectum. Usually one or more ofthese polyps becomes cancerous if preventivesurgery is not done.

FECAL OCCULT BLOOD TEST (FOBT)A test for “hidden” blood in the stool. Thepresence of such blood could be a sign of cancer.

FECESSolid waste matter; bowel movement or stool.

FINE NEEDLE ASPIRATIONIn this procedure, a thin needle is used todraw up (aspirate) samples for examinationunder a microscope. Also called FNA. FNA isnot generally used for biopsies of a colorectaltumor, but is often used to take samples ofmasses in the liver or other organs that mightbe colorectal cancer metastases.

GASTROENTEROLOGISTA doctor who specializes in diseases of thedigestive (gastrointestinal or GI) tract.

HEREDITARY NONPOLYPOSISCOLON CANCER (HNPCC)People with this condition are at increasedrisk of developing colorectal cancer withoutfirst having many polyps.

58

IMMUNOTHERAPYTreatments to help the immune system recog-nize and destroy cancer cells more effectively.These may include cancer vaccines and mon-oclonal antibody therapy.

INTESTINESThe digestive tract from the pylorus (lower endof the stomach) to the anus. It includes thesmall intestine and the large intestine, alsocalled the small and large bowel, respectively.

INVESTIGATIONALUnder study; often used to describe drugs usedin clinical trials.

LAPAROSCOPEA long, slender tube inserted into the abdomenthrough a very small incision. Surgeons withexperience in laparoscopy can do some typesof surgery for colorectal cancer using specialsurgical instruments operated through thelaparoscope.

LAPAROSCOPYExamination of the abdominal cavity with aninstrument called a laparoscope.

LOWER GI SERIESSeries of x-rays taken after a barium enema isgiven.

LYMPHADENECTOMYSurgical removal of lymph nodes. Afterremoval, the lymph nodes are examined bymicroscope to see if cancer has spread.

LYMPH NODESSmall bean-sized collections of immune systemcells that help fight infections and also have arole 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 that

no cancer was left behind near the area it wasremoved from. A negative surgical margindoes not guarantee a cure because cancer cellsmay have spread to other areas of the bodybefore surgery. A positive surgical margin indi-cates that cancer cells are found at the outeredge of the tissue removed and is usually asign that some cancer remains in the body.

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

NEOADJUVANT THERAPYTreatment given before radiation or surgery.

ONCOLOGYThe branch of medicine concerned with thediagnosis and treatment of cancer.

PALLIATIVE TREATMENTTherapy that relieves symptoms, such as painor blockage of fecal flow, but is not expectedto cure the cancer. Its main purpose is toimprove the patient’s quality of life.

PATHOLOGISTA physician who specializes in diagnosis andclassification of diseases by laboratory testssuch as examination of tissue and cells under a 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 the rectum or the colon. Adenomatous polypssometimes turn into cancer. Many other typesof polyps (inflammatory polyps, hyperplasticpolyps) do not.

POLYPECTOMYSurgery to remove a polyp. This can often be done using instruments operated through a colonoscope.

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PRIMARY SITEThe place where cancer begins. Primary canceris usually named after the organ in which itstarts. For example, cancer that starts in thecolon is always colon cancer even if it metas-tasizes (spreads) to other organs such as liveror lungs.

PRIMARY TREATMENTThe main, and usually the first, treatment.

PROTOCOLA formal outline or plan, such as a descriptionof what treatments a patient will receive andexactly when each should be given. See alsoregimen.

RADIATION PROCTITISA possible side effect of radiation therapy.Problems can include pain, bowel frequency,bowel urgency, bleeding, chronic burning, orrectal leakage.

RADIOLOGISTA doctor with special training in diagnosis ofdiseases by interpreting x-rays and other typesof diagnostic imaging studies, for example, CTscans and magnetic resonance imaging.

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

RECURRENCECancer that has come back after treatment.Local recurrence means that the cancer hascome back at the same place as the originalcancer. Regional recurrence means that thecancer has come back after treatment in thelymph nodes near the primary site. Distantrecurrence is when cancer metastasizes aftertreatment to organs or tissues (such as thelungs, liver, bone marrow, or brain) fartherfrom the original site than the regional lymph nodes.

REGIMENA strict, regulated plan (such as diet, exercise,or other activity) designed to reach certaingoals. In cancer treatment, a plan to treat cancer. See also protocol.

RELAPSEReappearance of cancer after a disease-freeperiod. See also recurrence.

RISK FACTORAnything that increases a person’s chance ofgetting a disease such as cancer. Different cancers have different risk factors. For exam-ple, unprotected exposure to strong sunlight is a risk factor for skin cancer, smoking is a riskfactor for cancers of the lung, mouth, larynx,and many other organs. Some risk factors, suchas smoking or unhealthy diet, can be controlled.Others, like a person’s age or family history,can’t be changed.

SCREENINGThe search for disease, such as cancer, in peoplewithout symptoms. For example, screeningtests for early detection of colorectal cancerinclude digital rectal examination, fecal occultblood test, flexible sigmoidoscopy, colonoscopy,and double contrast barium enema.

SEGMENTAL RESECTIONIn this surgery, the cancer and a length of normal 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.

SIDE EFFECTSUnwanted effects of treatment, such as hairloss caused by chemotherapy and fatiguecaused by radiation therapy.

SIGMOID COLONThe fourth section of the colon is known asthe sigmoid colon because of its S-shape. Thesigmoid colon joins the rectum, which in turn

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joins the anus, or the opening where wastematter passes out of the body.

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. Thistest may be somewhat uncomfortable, but itshould not be painful.

SIMULATIONA process involving special x-ray pictures thatare used to plan radiation treatment so thatthe area to be treated is precisely located andmarked for treatment.

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.

STOOLSolid waste matter; feces.

TRANSVERSE COLONThe second section of the colon, following theascending colon and leading to the descendingcolon. It is called the transverse colon since itgoes 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 over a longperiod of time. This increases a person’s risk ofdeveloping colon cancer, so starting colorectalcancer screening earlier and doing these testsmore often is recommended.

X-RAYOne form of radiation that can be used at lowlevels to produce an image of the body on filmor at high levels to destroy cancer cells.

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

Paul F. Engstrom, MD, FACPFox Chase Cancer Center

Ted Gansler, MD, MBAAmerican Cancer Society

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

Pamela McAllister, PhDColon Cancer Survivor

LaMar McGinnis, MDAmerican Cancer Society

John M. Skibber, MDUniversity of Texas M.D. Anderson Cancer Center

Dia TaylorNational Comprehensive Cancer Network

Rodger J. Winn, MDNational Comprehensive Cancer Network

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

The NCCN Colon and Rectal Cancer Clinical Practice Guidelines were developed by the following NCCN Panel Members:

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

Michael A. Choti, MDJohns Hopkins Oncology Center

Alfred M. Cohen, MD, FACSMemorial Sloan-Kettering Cancer Center

James H. Doroshow, MDCity of Hope National Medical Center

Paul F. Engstrom, MD, FACPFox Chase Cancer Center

Charles Fuchs, MDDana-Farber Cancer Institute

Phillip Gold, MDUniversity of Washington Medical Center

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

Edward W. Martin Jr., MDJames Cancer Hospital & SoloveResearch Institute at the Ohio State University

Cornelius McGinn, MDUniversity of MichiganComprehensive Cancer Center

Nicholas J. Petrelli, MDRoswell Park Cancer Institute

James A. Posey, MDUniversity of Alabama at Birmingham Comprehensive Cancer Center

John M. Skibber, MDUniversity of Texas M.D. Anderson Cancer Center

Margaret Tempero, MDUCSF Medical Center

Alan Venook, MDUCSF Medical Center

Timothy J. Yeatman, MD, FACSH. Lee Moffitt Cancer Center

00-80M-No.9409-HCP

National ComprehensiveCancer Network

NCCN®

1-800-ACS-2345www.cancer.org

©2000, American Cancer Society, Inc.

1-888-909-NCCNwww.nccn.org

colon and rectal cancer - dr. francesco g. biondo del colon... · 2012-09-11 · colon and rectal...

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