10 Questions About Advanced Colon Cancer Treatment
You’ve gotten your initial diagnosis, which already was a shock. Now your doctor has more potentially bad news—your cancer has spread and you are among the 22% of patients who has stage 4, or advanced, colon cancer. Now what? You’ll probably have a lot of questions about your treatment plan and what you can expect. Here are some reassuring answers.
What does stage 4 cancer really mean?
“The way that I approach thinking about staging is if you see cancer outside of the colon, that's metastatic disease, and that’s stage four,” says Leah Biller, M.D., an oncologist at Dana-Farber’s Gastrointestinal Cancer Treatment Center in Boston. Doctors arrive at the number by doing imaging tests (CT scans or, sometimes, MRIs or PET scans) as well as surgically removing the tumor. If the scans show that there’s cancer in other parts of your body—your lungs, your liver—or in the lymph nodes outside the colon, that’s stage 4.
What is the goal of treatment?
Stage 4 colon cancer is sometimes curable, but, sadly, for most patients it’s not. The 5-year survival rate (the percentage of those who live five years past diagnosis) is a daunting 14%. But that doesn’t mean your cancer isn’t treatable, says Rishi Jain, M.D., an oncologist specializing in gastrointestinal tract cancers at the Fox Chase Cancer Center in Philadelphia. “The goal is to keep someone around longer and maintain a reasonable quality of life during that process.” Treatment will help reduce symptoms, too.
Will you have chemotherapy?
Yes, quite probably. Every patient’s case is different, but you most likely will be treated with a combination of medications and maybe surgery and radiation, says Dr. Jain. Chemo is sometimes used before surgery to shrink tumors to make them easier to remove. It’s also used after surgery, especially in combination with other types of therapies, to kill cancer cells that may have been left behind after surgery and relieve symptoms.
Will you get other types of medications?
Again, probably yes. But in order to know what type of drug will work for you, it’s important that a pathologist does genetic testing on the tumor to check for certain mutations, says Dr. Biller. This is something that should be done for all stage 4 patients, regardless of whether your tumor turns out to have the exact mutations for treatments already in use. “There may also be clinical trial options and drugs that are used for a different type of cancer with that mutation,” she says.
What is targeted treatment?
These are drugs that attack specific genes and proteins in cancer cells. They’re often used in combination with chemotherapy (which kills cancer cells but also, unfortunately, healthy ones). There are two types of targeted therapy, says Dr. Biller. One “works on targeting blood vessel growth. Those can be used in stage 4 patients generally. The majority of the other targeted therapies are directed to a specific mutation or something specific about the pathology of the tumor itself.” Meaning if testing shows your tumor has one of these markers, these drugs are another treatment option for you.
How do targeted therapies work?
You get both types via IV infusions. Let’s start with the anti-angiogenesis therapy—angiogenesis means the development of new blood vessels, and these drugs prevent that from happening. (In fact, if you’re going to have surgery or have just had it, you won’t get anti-angiogenesis therapy because your wound wouldn’t heal as quickly.) Stopping blood vessel growth is important for cancer treatment because tumors need more blood vessel growth than other parts of the body, says Dr. Biller.
And what about the other kind?
These are therapies that block various proteins that help cancer cells grow. Which one you get (if any) depends on the genetic mutations doctors find when they test your tumor—or whether they find any at all. If you’re a candidate, you might hear the names of such drugs as Erbitux (cetuximab), Braftovi (encorafenib), and Stivarga (regorafenib).
What about immunotherapy?
“Immunotherapy basically helps rev up your own immune system so that it can target the cancer,” says Dr. Biller. It can be effective, but there’s a catch: “Immunotherapy is only used in colon cancers that have a certain molecular feature that's called microsatellite instability.” So it only benefits about 5% of stage 4 colon cancer patients (usually the ones with Lynch syndrome, an inherited genetic mutation). Currently, there are clinical trials to see if different combinations of immunotherapy drugs will work for the other 95%, says Dr. Jain.
What happens if your treatment doesn’t work?
No matter what medications you’re taking, they sometimes just stop working. “Somehow the cancer becomes resistant to either the chemotherapy or the targeted therapy, but there's still a lot that we don't know about why,” says Dr. Biller. In that case, there are many other types of drugs or combinations of drugs that doctors will try, and if those are exhausted, that’s where clinical trials can come in: You can volunteer to receive newer, not-yet-approved treatments that may work better.
What can you do to improve your odds?
The biggest change in the last five years has been the number of drugs approved to treat colon cancer—and the wider use of targeted therapies, says Dr. Biller. Talk to your doctor about the entire range of treatment available to you (and make sure your tumor gets genetically tested). Dr. Biller also recommends that her patients get palliative care early to help manage the symptoms and side effects (both physical and emotional) of treatment. One study found that palliative care decreased such symptoms as fatigue and pain.
Survival Rate in Stage 4: National Cancer Institute/Surveillance, Epidemiology, and End Results Program (n.d.) “Colorectal Cancer—Cancer Stat Facts.” seer.cancer.gov/statfacts/html/colorect.html
EGRF Target Therapy Benefits: Annals of Oncology (2017). “Prognostic and predictive value of primary tumor side in patients with RAS wild-type metastatic colorectal cancer treated with chemotherapy and EGFR directed antibodies in six randomized trials.” pubmed.ncbi.nlm.nih.gov/28407110/
Palliative Care and Colon Cancer: Annals of Surgical Oncology (2019). “Palliative Care and Symptom Burden in the Last Year of Life: A Population Based Study of Patients With Gastrointestinal Cancers.” pubmed.ncbi.nlm.nih.gov/30969388/