Colorectal Cancer Treatment Plans

Colon cancer sometimes is treated differently from rectal cancer. Treatment for colon and rectal cancer may involve one or a combination of the following:

• Surgery
• Chemotherapy
• Targeted Therapy
• Immunotherapy
• Radiation Therapy

Treating Colon Cancer

Patients diagnosed with early-stage colon cancer often undergo surgery to remove the tumor. However if found at a later stage, this may need to wait until the tumor is reduced through other treatments. 

When chemotherapy is necessary, the commonly used method is FOLFOX. In cases of advanced or recurrent colon cancer, targeted therapies designed to focus on specific genetic mutations found through biomarkers in the patient's blood work are used.

While not all colon cancer patients use radiation therapy, it can be helpful in reducing the size of the tumor before surgery, eliminating any cancer cells left behind post-surgery, or alleviating discomfort the tumor may be causing in the colon or other parts of the body.

Treating Rectal Cancer

Surgery remains the primary treatment approach for all stages of rectal cancer. Some patients may receive a combination of treatments that can include surgery, radiation therapy, and chemotherapy. Advanced cases of rectal cancer might also benefit from targeted therapy.

Approximately one in eight individuals with rectal cancer require a permanent colostomy. This requires the surgical creation of an opening in the body for waste to be removed. 

Radiation therapy can be administered both before and after surgery to help shrink a tumor before surgery or eliminate any remaining cancer cells after surgery.  Patients may receive radiation to alleviate pain and other complications caused by the cancer.

Surgery for Colon and Rectal Cancers

Surgery is often included in the treatment of colorectal cancer. If it’s only a small polyp that can be completely removed during the screening colonoscopy, there may not need to be any more surgery.

For later stage colorectal cancers another type of surgery may be needed. Your oncologist will meet with the surgeon to discuss the details of your case and what type of surgery would be best. You will have follow up appointments with your surgeon, separate from your oncology visits.

Colon Cancer Surgeries

• Polypectomy: A small malignant polyp may be removed from your colon or upper rectum during a colonoscopy. Some small tumors in the lower rectum can be removed through your anus without a colonoscope. A follow-up colonoscopy may be recommended to look for any other polyps once cancer is diagnosed. 
• Local excision: If small cancers are seen on the lining of the colon during a colonoscopy, a local excision can be done to remove the cancer and a small amount of the surrounding healthy tissue. 
• Colectomy: Surgery to remove all or part of the colon. A colectomy can be done in 2 ways:
  • Open colectomy: The tumor and part of the healthy colon or rectum is removed through a single long incision in the abdomen. Some nearby lymph nodes are also removed. The surgeon checks the rest of your intestine and your liver to see if the cancer has spread.
  • Laparoscopic-assisted colectomy: Early-stage colon cancer may be removed with the help of a laparoscope, a thin, lighted tube. The surgeon sees inside your abdomen with the laparoscope by making three or four tiny incisions into the abdomen. The tumor and part of the healthy colon are removed. Lymph nodes that are close by may also be removed, and your intestine and liver will be checked to see if the cancer has spread.

Rectal Cancer Surgeries

How close the tumor is to the anus impacts the type of surgery performed. Common procedures for rectal cancer treatment can include: 

• Polypectomy, local transanal resection, or excision: These surgical procedures are used to remove rectal cancers in the lower rectum that are at an early stage. The surgeon removes the cancer from the rectal wall and may remove some of the surrounding rectal tissue. This method allows the doctor to remove the polyps or cancer without cutting into the abdomen (belly). 
• Transanal endoscopic surgery (TEM): This type of surgery removes larger cancers that may be higher in the rectum and more challenging to remove through local transanal resection. A specially-designed magnifying scope is inserted through the anus and into the rectum.
• Proctectomy: For some stage I and many stage II and III cancers in the middle and lower rectum, this surgery removes the entire rectum so that a total mesorectal excision (TME) can be done to remove all of the lymph nodes near the rectum. Then, the colon is attached to the anus (called a colo-anal anastomosis) so that the patient will move their bowels normally.
• Low anterior resection (LAR): For some stage I, II, and III cancers in the upper rectum, this procedure removes the part of the rectum with the tumor and reattaches the colon to the remaining portion of the rectum. This surgery requires incisions to be made through the abdomen, and a permanent colostomy is not needed.
• Abdominoperineal resection (APR): Usually performed for stage II and stage III cancers in the lower to middle rectum, this procedure removes the rectum through abdominal incisions as well as the anus and sphincter muscles through incisions around the anus. This surgery type is often needed if the cancer grows into the sphincter muscle (the muscle that keeps the anus closed and prevents stool leakage) or the nearby levator muscles that help control urine flow.
• Pelvic exenteration: This procedure is a major operation that may be recommended if the rectal cancer is growing into nearby organs. The surgeon removes the rectum and any nearby organs that cancer has reached, such as the bladder, prostate (in men), or uterus (in women).

Is a Colostomy Bag Required After Colon or Rectal Surgery?

Sometimes, the surgeon isn’t able to reconnect the healthy parts during the procedure. When this happens, the surgeon creates a new path for waste to leave your body. The surgeon makes an opening (stoma) in the wall of the abdomen, connects the upper end of the intestine to the stoma, and closes the other end. The operation to create the stoma is called a colostomy. A flat bag fits over the stoma to collect waste, and a special adhesive holds it in place.

The stoma is temporary for most people and is needed only until the colon or rectum heals from surgery. After healing takes place, the surgeon reconnects the parts of the intestine and closes the stoma. Some people, especially those with a tumor in the lower rectum, need a permanent stoma.

Chemotherapy for Colorectal Cancer

Chemotherapy uses anticancer drugs to kill cancer cells. The drugs enter the bloodstream and can affect cancer cells all over the body. This systemic treatment approach is helpful in treating colorectal cancer that has spread to other areas of the body. Chemo may be used either before surgery to shrink tumors or after surgery to kill any remaining cancer cells. 

There are many drugs approved by the U.S. Food and Drug Administration (FDA) to treat colorectal cancer. The chemo regimen commonly recommended to kill colorectal cancer cells in the colon, rectum, and throughout the body is called Folfox. This particular chemotherapy is usually given over the course of 24 hours. It will be started in the cancer center with instructions on how to go home with the chemo drugs. 

Some patients may be given chemotherapy drugs in combination with targeted therapy. 

Targeted Therapy for Colorectal Cancer

Targeted therapy focuses on specific genetic mutations, proteins, or the tissue that contributes to the cancer growth. This type of treatment blocks the growth and spread of cancer cells and limits damage to healthy cells.

Because not all tumors have the same targets, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. One of the following types of targeted therapy may be included in your cancer treatment based on results from testing:

• Anti-angiogenesis therapy. These unique cancer-fighting agents, called angiogenesis inhibitors, block the growth of blood vessels that support tumor growth rather than the growth of tumor cells. Some are monoclonal antibodies that specifically recognize and bind to VEGF (vascular endothelial growth factor), a substance made by cells that stimulate new blood vessel formation. In some cancers, angiogenesis inhibitors appear to be most effective when combined with additional therapies. Because angiogenesis inhibitors work by slowing or stopping tumor growth without killing cancer cells, they are given over a long period.
• Epidermal growth factor reception (EGFR) inhibitors. EGFR is a protein that helps cancer cells grow. Cancerous cells tend to have a lot of this protein on them. By slowing the growth of the protein, the colorectal cancer cells are slower to reproduce.

Immunotherapy for Colorectal Cancer

Immunotherapy, or biological therapy, uses the immune system to fight cancer. This method of treatment uses materials made by the body or laboratory to simulate a natural substance.

Checkpoint inhibitors are an important type of immunotherapy used to treat colorectal cancer. These drugs block proteins called checkpoints that are made by some types of immune system cells, such as T cells and some cancer cells. Checkpoints keep the immune system from responding and can often keep T cells from killing cancer cells. Using the inhibitor blocks the proteins to reinforce the body’s ability to fight the cancer cells.

Radiation Therapy for Colorectal Cancer

Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. It affects cancer cells only in the treated area. Radiation therapy may be given before surgery, after surgery, or both, depending on your individual case. 

Different types of radiation therapy are used to treat colon and rectal cancer: 

• External radiation: The radiation comes from a machine. The most common type of machine used for radiation therapy is called a linear accelerator. Typically, patients go to the hospital or clinic for their treatment, generally 5 days a week for several weeks.
• Internal radiation (implant radiation or brachytherapy): The radiation comes from radioactive material placed in thin tubes put directly into or near the tumor. The patient stays in the hospital, and the implants generally remain in place for several days. With high doses, the seeds are only inserted for a few minutes at a time before being removed. Treatments are about every two weeks for a total of about four treatments. Brachytherapy is more commonly used for rectal cancer. 
• Intraoperative radiation therapy (IORT): In some cases, radiation is given during surgery.

The Latest Colorectal Cancer Treatments are Available in Winchester, Virginia 

If you have been newly diagnosed with colorectal cancer and are seeking treatment, the next step is to schedule a consultation with an oncologist. The colorectal cancer specialists at Shenandoah Oncology offer personalized treatment plans as well as a second opinion on a recommended treatment plan. Our cancer center in Winchester, Virginia, serves patients in and around the area, including the Shenandoah Valley, Northern Virginia, West Virginia, and Western Maryland.

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