2018
Colon Cancer
Available online at NCCN.org/patients
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GUIDELINES
FOR PATIENTS®
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1
NCCN Guidelines for Patients®:
Colon Cancer, 2018
Colon Cancer
LEARNING that you have cancer
can be overwhelming.
The goal of this book is to help you get the best care. It explains which cancer
tests and treatments are recommended by experts in colon cancer.
The National Comprehensive Cancer Network® (NCCN®) is a not-for-profit
alliance of 28 leading cancer centers. Experts from NCCN have written treatment
guidelines for doctors who treat colon cancer. These treatment guidelines suggest
what the best practice is for cancer care. The information in this patient book is
based on the guidelines written for doctors.
This book focuses on the treatment of colon cancer in adults. Key points of the
book are summarized in the related NCCN Quick Guide™. NCCN also offers
patient resources on lung, melanoma, and many other cancer types. Visit NCCN.
org/patients for the full library of patient books, summaries, and other patient and
caregiver resources.
2
NCCN Guidelines for Patients®:
Colon Cancer, 2018
About
These patient guidelines for cancer care are produced by the National
Comprehensive Cancer Network® (NCCN®).
The mission of NCCN is to improve cancer care so people can live better lives. At
the core of NCCN are the NCCN Clinical Practice Guidelines in Oncology (NCCN
Guidelines®). NCCN Guidelines® contain information to help health care workers
plan the best cancer care. They list options for cancer care that are most likely to
have the best results. The NCCN Guidelines for Patients® present the information
from the NCCN Guidelines in an easy-to-learn format.

Panels of experts create the NCCN Guidelines. Most of the experts are from
NCCN Member Institutions. Their areas of expertise are diverse. Many panels
also include a patient advocate. Recommendations in the NCCN Guidelines are
based on clinical trials and the experience of the panelists. The NCCN Guidelines
are updated at least once a year. When funded, the patient books are updated to
reflect the most recent version of the NCCN Guidelines for doctors.
For more information about the NCCN Guidelines, visit NCCN.org/clinical.asp.
Dorothy A. Shead, MS
Director, Patient
Information Operations
Laura J. Hanisch, PsyD
Medical Writer/Patient
Information Specialist
Alycia Corrigan
Medical Writer
Erin Vidic, MA
Medical Writer
Rachael Clarke
Guidelines Data and
Layout Coordinator
NCCN Foundation was founded by NCCN to raise funds for patient education
based on the NCCN Guidelines. NCCN Foundation offers guidance to people
with cancer and their caregivers at every step of their cancer journey. This is done
by sharing key information from leading cancer experts. This information can be
found in a library of NCCN Guidelines for Patients® and other patient education
resources. NCCN Foundation is also committed to advancing cancer treatment
by funding the nation’s promising doctors at the center of cancer research,
education, and progress of cancer therapies.
For more information about NCCN Foundation, visit NCCNFoundation.org.
© 2018 National Comprehensive Cancer Network, Inc. Based on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®)
Colon Cancer (Version 4.2018, October 19, 2018).
All rights reserved. NCCN Guidelines for Patients® and illustrations herein may not be reproduced in any form for any purpose without the
express written permission of NCCN. No one, including doctors or patients, may use the NCCN Guidelines for Patients® for any commercial
purpose and may not claim, represent, or imply that the NCCN Guidelines for Patients® that has been modified in any manner is derived
from, based on, related to or arises out of the NCCN Guidelines for Patients®. The NCCN Guidelines are a work in progress that may be
redefined as often as new significant data become available. NCCN makes no warranties of any kind whatsoever regarding its content, use,
or application and disclaims any responsibility for its application or use in any way.
National Comprehensive Cancer Network (NCCN) • 3025 Chemical Road, Suite 100 • Plymouth Meeting, PA 19462 • 215.690.0300
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NCCN Guidelines for Patients®:
Colon Cancer, 2018
Supporters
Endorsed and sponsored in part by
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impacted by colorectal cancer find trusted resources and information
they need to make informed decisions about their health, we are proud to
support this comprehensive resource. FightColorectalCancer.org
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NCCN Guidelines for Patients®:
Colon Cancer, 2018
5
NCCN Guidelines for Patients®:
Colon Cancer, 2018
Colon Cancer
Contents
6
How to use this book
7
Part 1
Colon cancer basics
Explains what cancer is and how it affects the
colon.
13 Part 2
Treatment planning
Describes the health care needed before
treatment.
23 Part 3
Overview of cancer treatments
Briefly describes the treatments used to cure
and control colon cancer.
34 Part 4
Treatment guide: Nonmetastatic
cancer
Presents treatment options for colon cancer
that hasn’t spread to distant sites.
43 Part 5
Treatment guide: Metastatic
cancer
Presents treatment options for colon cancer
that has spread to the liver, lungs, or other
areas.
52 Part 6
Follow-up care
Presents the recommended care after colon
cancer treatment.
57 Part 7
Treatment guide: Systemic therapy
Presents the order of drug options for
advanced colon cancer.
68 Part 8
Making treatment decisions
Offers tips for choosing the best treatment.
77 Dictionary
81 Acronyms
82 NCCN Panel Members for
Colon Cancer
83 NCCN Member Institutions
84
Index
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NCCN Guidelines for Patients®:
Colon Cancer, 2018
How to use this book
Who should read this book?
This book is about treatment for colon cancer. It does
not discuss rectal cancer. Patients and those who
support them—caregivers, family, and friends—may
find this book helpful. It is a good starting point to
learn what your options may be.
Are the book chapters in a
certain order?
Early chapters explain concepts that are repeated
in later chapters. Starting with Part 1 may help.
It explains what colon cancer is. It also explains
how colon cancer is found and given a stage. Your
treatment plan will be partly based on the cancer
stage. Tests that help doctors plan treatment are
described in Part 2.
An overview of treatments for colon cancer is
presented in Part 3. Knowing what a treatment is will
help you understand the treatment options presented
in Parts 4 and 5. Recommendations for follow-up
care are provided in Part 6, and Part 7 lists the
systemic therapy treatment options for advanced
colon cancer. Tips for talking and deciding your
options with your doctor are presented in Part 8.
Does this book include all
options?
This book includes information for many people.
You treatment team can point out what applies to
you. They can also give you more information. While
reading, make a list of questions to ask your doctors.
The treatment options are based on science and
the experience of NCCN experts. However, their
recommendations may not be right for you. Your
doctors may suggest other options based on your
health and other factors. If other options are given,
ask your treatment team questions.
Help! What do the words
mean?
In this book, many medical words are included.
These are words you will likely hear from your
treatment team. Most of these words may be new to
you, and it may be a lot to learn.
Don’t be discouraged as you read. Keep reading
and review the information. Feel free to ask your
treatment team to explain a word or phrase that you
don’t understand. Words that you may not know are
defined in the text or in the Dictionary. Acronyms are
also defined when first used and in the Glossary.
One example is DNA for deoxyribonucleic acid.
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NCCN Guidelines for Patients®:
Colon Cancer, 2018
1
Colon cancer basics
8
The colon
10 How cancer works
11 Polyps
12 Cancer staging
12 Review
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NCCN Guidelines for Patients®:
Colon Cancer, 2018
1 Colon cancer basics
The colon
You’ve learned that you have colon
cancer. It’s normal to feel shocked and
confused. This chapter will give you some
basic information about cancer and how it
affects the colon.
The colon
The colon is part of the digestive system. This
system breaks down food for the body to use. After
being swallowed, food moves through four organs
known as the digestive tract. See Figure 1. First,
food passes through the esophagus and into the
stomach, where it is turned into a liquid. From the
stomach, food enters the small intestine. Here,
food is broken down into very small parts to allow
nutrients to be absorbed into the bloodstream.
Food then moves into the large intestine, which turns
unused food from a liquid into a solid by absorbing
water. This solid, unused food is called feces or
stool. The large intestine has four parts, including the
colon. See Figure 2.
† Cecum. This pouch is the first part of the large
intestine. Food comes here first after leaving
the small intestine. It is around the size of a
small orange. Sticking out from the cecum is a
skinny tube called the appendix. It is closed at
one end, and is about the size of a finger.
† Colon. The colon is the longest part of the large
intestine. It is almost 5 feet long and has four
parts: the ascending, transverse, descending,
and sigmoid colon.
† Rectum. This is the last part of the large
intestine, and is about 5 inches long.
† Anus. The anus is the opening at the bottom of
the rectum. This is where stool leaves the body.
The wall of the colon has four main layers. The
names of the layers (from inner to outer) are the
mucosa, submucosa, muscularis propria, and
serosa or adventitia. Cancer starts in the inner layer
and grows towards the outer layer. You don’t need
to remember the names of each layer, but having
a general idea of the structure will be helpful to
understand how colon cancer is staged.
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NCCN Guidelines for Patients®:
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1 Colon cancer basics
The colon
Figure 1
The digestive tract
The digestive tract consists of four
main parts. The esophagus moves
food from your throat to your
stomach. In the stomach, food is
turned into a liquid. Nutrients from
the liquid are absorbed into your
body in the small intestine. The large
intestine absorbs liquid from and
pushes unused food out of the body.
Figure 2
The colon
The colon is part of the large
intestine. It is almost 5 feet long and
has four sections: the ascending,
transverse, descending, and sigmoid
colon.
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NCCN Guidelines for Patients®:
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1 Colon cancer basics
How cancer works
How cancer works
Your body is made of over 30 trillion cells. All
cells have built-in rules that tell them how to act.
These rules, or instructions, are called genes.
Genes are a part of your DNA (deoxyribonucleic
acid). Changes (called mutations) in genes cause
normal cells to become cancer cells.
Cancer cells don’t act like normal cells. See
Figure 3. The three most important differences
between cancer cells and normal cells are:
† Normal cells grow and then divide to make
new cells when needed. They also die when
old or damaged. Cancer cells make new
cells that aren’t needed and don’t die quickly
when old or damaged. Over time, cancer
cells form a lump called a tumor.
† Normal cells listen to signals from nearby
cells telling them to “stop” when they get too
close. Cancer cells ignore the “stop” signals
from nearby cells and invade nearby tissues.
† Normal cells stay in the area of the body
where they belong. For example, stomach
cells stay in the stomach. Cancer cells
can travel to other parts of your body
(metastasize). They can then grow and
make more tumors in the new area of your
body.
Figure 3
Key differences between normal
cells and cancer cells
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NCCN Guidelines for Patients®:
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1 Colon cancer basics
Polyps
Polyps
A polyp is an overgrowth of cells that line the inner
colon wall. While most colon polyps do not become
cancer, almost all colon cancers start in a polyp. The
two main shapes of polyps are called sessile and
pedunculated. Pedunculated polyps are shaped like
mushrooms and stick out from the colon wall. They
have a stalk and round top. See Figure 4. Sessile
polyps are flatter, don’t stick out much from the
colon wall, and don’t have a stalk. See Figure 5.
Just like there are different shapes of polyps, there
are also different types. This means that they look
different under a microscope. Some types are
more likely to turn into cancer than others. Polyps
that are highly unlikely to turn into cancer include
hyperplastic and inflammatory polyps.
The most common type of polyp is called an
adenoma. Adenomas are considered “pre-cancer”
because, while it may take many years, they can
turn into cancer. This is the type to be concerned
about. Serrated is a term for any polyp that has a
saw-tooth pattern. Sessile serrated adenomas are
rare but have been linked to cancer.
Polyps need to be removed and tested for cancer.
Most polyps can be removed during a colonoscopy,
using a minor surgical procedure called a
polypectomy.
Figure 4
Pedunculated polyp
Pedunculated polyps (shown here)
have a stalk and are mushroom-like in
appearance.
Figure 5
Sessile polyp
Sessile polyps (shown here) don’t have
a stalk and can be harder to spot than
pedunculated polyps.
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NCCN Guidelines for Patients®:
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1 Colon cancer basics
Cancer staging | Review
Cancer staging
A cancer stage is a rating by your doctors of the
extent of the cancer. It is used to plan which tests
may be needed and which treatments are best
for you. The AJCC (American Joint Committee on
Cancer) TNM (tumor, node, metastasis) system is
used to stage colon cancer.
In the AJCC system, the following key pieces of
information about your cancer are used to give it a
stage:
† T: How far the cancer has grown through the
colon wall
† N: Whether any lymph nodes have cancer
† M: Whether the cancer has spread to areas far
from the colon (metastasized)
The T, N, and M scores are combined to assign
the cancer a stage. There are five stages of colon
cancer. They are numbered 0, I (1), II (2), III (3), or IV
(4). The stages are explained below.
Stage 0
These cancers are also called carcinoma in situ of
the colon. The cancer is noninvasive. This means it
has not grown beyond the first layer of the colon wall.
You may not need more treatment if a polypectomy
removed all of the cancer.
Stage I
The cancer has grown into either the second or third
layer of the colon wall. There is no cancer in nearby
lymph nodes or in areas far from the colon.
Stage II
The cancer has grown into, or beyond, the fourth
layer of the colon wall. There is no cancer in nearby
lymph nodes or in areas far from the colon.
Stage III
The cancer has spread from the colon to nearby
lymph nodes or there are tumor deposits. Tumor
deposits are small tumors in the fat around the colon.
Stage IV
The cancer has spread to areas far from the colon.
Colon cancer often spreads to the liver and the lungs
first.
Review
† The colon is the longest part of the large
intestine and has four parts: the ascending,
transverse, descending, and sigmoid colon.
† Cancer starts on the inside of the colon wall
and grows toward the outside.
† Cancer cells form a tumor since they don’t grow
and die as normal cells do.
† Cancer cells can spread to other body
parts through lymph or blood. This is called
metastasis.
† Most colon cancers start in polyps called
adenomas.
† The cancer stage is a rating of how much
cancer there is in your body.
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NCCN Guidelines for Patients®:
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2
Treatment planning
14 Health history
16 Physical exam
16 Biopsy
17 Colonoscopy
18 Blood tests
18
Imaging tests
21 Tumor marker testing
22 Review
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NCCN Guidelines for Patients®:
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2 Treatment planning
Health history
Your doctors will make a treatment plan
just for you. First, they need to gather
information about your unique cancer and
your general health. This chapter goes
over the tests you may need to have done
and other steps needed to create your
treatment plan.
There are a number of tests that can provide
your doctors with helpful information about which
treatments might help you the most, and which
treatments might be too harsh for you. The health
tests you may have before treatment are described
next. Some tests are for anyone with colon cancer,
while others are for a select group.
Health history
Your medical history includes any health events and
medicines you’ve taken in your life. It helps your
doctors decide if you can have surgery. It also helps
doctors decide if chemotherapy is a good treatment
option for you.
Colon cancer and other diseases can run in families.
For this reason, your doctor will ask about the
medical history of your blood relatives. It’s important
to know who in your family has had what diseases
and at what ages. You doctor may ask about the
health of your siblings, your parents and their
siblings, and your grandparents and their siblings.
Inherited cancer syndromes
Colon cancer often occurs for unknown reasons.
Some people, however, are more likely to get
colon cancer than the average person. This is
because a gene mutation in their DNA was passed
down to them from their parents. Because of this
mutation, they have a disorder that increases
their risk of getting colon cancer. This is called an
inherited cancer syndrome. There are two main
inherited cancer syndromes for colon cancer—
Lynch syndrome and FAP (familial adenomatous
polyposis).
Lynch syndrome is also called HNPCC (hereditary
non-polyposis colon cancer). It’s the most common
type of inherited syndrome to cause colon cancer.
It also increases the risk for other types of cancer.
Only 3 to 5 out of every 100 people with colon cancer
have Lynch syndrome.
FAP is a rare inherited syndrome that often leads to
colon cancer. However, only 1 out of 100 people with
colon cancer have FAP. FAP causes hundreds of
polyps to form in the colon and rectum. You are likely
to have cancer by age 50 if you have classic FAP. In
a milder version called attenuated FAP, the disease
causes fewer polyps and usually starts later in life.
If your doctor thinks you might have an inherited
syndrome, you will likely be referred to a genetic
counselor. A genetic counselor can talk with you
about getting tested for syndromes related to colon
cancer. To be tested, you must provide a sample
of blood. Using the sample, a pathologist can test
your genes for abnormal changes that cause these
syndromes.
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NCCN Guidelines for Patients®:
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2 Treatment planning
Physical exam | Biopsy
Physical exam
Doctors often perform a physical exam along with
taking a medical history. A physical exam is a study
of your body for signs of disease. To start, your basic
body functions will be measured. These functions
include your temperature, blood pressure, and pulse
and breathing (respiration) rate. Your weight will also
be checked.
During the exam, your doctor will listen to your lungs,
heart, and gut. Your doctor will also look at and feel
parts of your body. This is done to see if organs are
of normal size, are soft or hard, or cause pain when
touched. Cancer and other diseases can cause
organs to become enlarged and hard.
Biopsy
A biopsy involves removing small pieces of tissue,
which are sent to a pathologist for testing. A biopsy
can be done during a colonoscopy. Sometimes a
needle is used to do the biopsy. In this case, a CT
scan or ultrasound may be used to help guide the
needle into the tumor in order to remove the tissue
sample.
Pathology report
A report will be written each time tissue is removed
from your body and tested for cancer. The report is
called a pathology report. Pathology reports are very
important for planning the best treatment for you.
One important test result is the cancer grade. The
cancer grade is a score assigned by the pathologist.
He or she will rate the cancer based on how the
cancer cells look. The score is a sign of how fast the
cancer will likely grow and spread. Higher scores
mean that the cancer will likely grow and spread fast.
Review your pathology report(s) with your doctor. Ask
questions if you don’t understand. This information
can be complex. It’s also a good idea to get a copy of
your pathology report(s) and take notes.
SNAPSHOT
Lynch syndrome
ü
Also called HNPCC (hereditary
nonpolyposis colorectal cancer)
ü
About 5 out of 100 people with colon
cancer will also have Lynch syndrome
ü
People born with this syndrome are at
high risk of getting colon cancer and
some other cancers
ü
Caused by inherited mutations of the
genes that fix damaged DNA, called
MMR (mismatch repair) genes
ü
NCCN experts recommend testing all
people with colon cancer for problems
with the MMR genes. This helps
determine who should be tested for
Lynch syndrome.
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NCCN Guidelines for Patients®:
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2 Treatment planning
Colonoscopy | Blood tests
Colonoscopy
A colonoscopy is a procedure that allows your doctor
to examine your colon for polyps and other diseases.
A colonoscope is the device used for the test. Part
of it looks like a thin tube. It has a light and camera.
This part will be inserted into your anus and gently
guided through your large intestine.
You may be put on a liquid diet for 1 to 3 days before
the test. You may also take a laxative or an enema
the night before. This will clean out your intestine.
Right before the test, you may be given a sedative
to lessen any pain. As shown in Figure 6, you
will likely wear a hospital gown. The test will be
performed while you lie on your side.
To see better, gas may be pumped into your intestine
to make it bigger. You may be asked to shift a little to
help your doctor guide the device. A picture of your
colon will be viewed by your doctor on a screen. If a
polyp is found, a cutting tool will be inserted through
the tube to remove it.
A colonoscopy takes about 30 to 60 minutes.
Afterward, you may stay for another hour for any
drugs that were used to wear off. However, you’ll still
need someone to drive you home. The next day, you
will likely feel normal. If you have severe pain, bloody
stool, or weakness, contact your doctor.
Blood tests
Blood tests are used to look for signs of disease. A
needle will be inserted into your vein to remove a
sample of blood. The needle may bruise your skin
and you may feel dizzy from the blood draw. Your
blood sample will then be sent to a lab where a
pathologist will test it. A pathologist is a doctor who’s
an expert in testing cells to find disease.
SNAPSHOT
FAP
(familial adenomatous
polyposis)
üA rare, inherited condition that can
cause hundreds to thousands of
polyps to form in the colon
üThe polyps start as non-cancerous
(benign) growths, but over time they
can turn into colon cancer
üThere is a milder form called
attenuated FAP, which doesn’t cause
as many polyps. People with this type
usually get colon cancer a little later
than people with classic FAP.
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NCCN Guidelines for Patients®:
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2 Treatment planning
Imaging tests
Complete blood count
A CBC (complete blood count) measures the number
of blood cells in a blood sample. It includes numbers
of white blood cells, red blood cells, and platelets.
Cancer and other health problems can cause low or
high counts.
Chemistry profile
A blood test called a chemistry profile measures the
amount of certain substances in the blood, such as
metabolites, electrolytes, fats, and proteins. This
test gives important information about how well your
kidneys, liver, and other organs are working.
CEA blood test
When colon cancer spreads, it can cause high or
low levels of chemicals in the blood. One example is
a high CEA (carcinoembryonic antigen) level. CEA
is normally low in healthy adults unless a woman is
pregnant. High CEA levels suggest the cancer has
spread far.
Imaging tests
Imaging tests make pictures (images) of the insides
of your body. They can show areas of the body that
have cancer. This information helps your doctors
stage the cancer and plan treatment. Certain imaging
tests also reveal some features of a tumor and its
cells.
A radiologist is a doctor who’s an expert in reading
images. Your radiologist will convey the imaging
results to your cancer doctor. This information helps
your doctor decide what the next steps of care
should be.
Figure 6
Colonoscopy
A total colonoscopy is a procedure
that allows your doctor to look for
and remove any abnormal tissue
from the colon. It involves inserting
a thin device through the anus, up
the rectum, and into the colon. The
device has a light, a camera, and a
cutting tool.
Illustration Copyright © 2018 Nucleus Medical Media, All rights reserved. www.nucleusinc.com
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NCCN Guidelines for Patients®:
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2 Treatment planning
Imaging tests
Your treatment team will tell you how to prepare
for these tests. You may need to stop taking some
medicines and stop eating and drinking for a few
hours before the scan. Tell your team if you get
nervous when in small spaces. You may be given a
sedative to help you relax.
Some imaging tests use contrast. Contrast is a dye
that will be injected into your bloodstream. It makes
the pictures clearer. Some people have an allergic
reaction to the dye. Tell your doctor if you’ve had
problems with contrast in the past.
CT with contrast
CT (computed tomography) takes many pictures
of a body part using x-rays. A computer combines
the x-rays to make one detailed picture. The picture
is saved for later viewing by the radiologist. See
Figure 7.
If the cancer has spread beyond the second layer
of the colon wall, CT scans of your chest, abdomen,
and pelvis are recommended. Contrast should be
used. The radiologist will look for cancer in nearby
and distant sites.
PET/CT
Sometimes CT is combined with PET (positron
emission tomography). When used together, it is
called a PET/CT scan. PET/CT scan is not often
used to plan treatment for colon cancer. There are
three reasons why you may have a PET/CT scan:
† To show how big a tumor is if you have
metastases
† To find metastases other than in the liver that
would exclude surgery
† PET/CT may be an option if you can’t receive
contrast dye for CT or MRI
What to expect: CT
scan
ü
You will lie face-up on a table
that moves through a tunnel-like
machine. See Figure 7.
ü
Contrast dye ("contrast" for short)
will be used to see everything
better.
ü
The dye will be injected into your
vein and mixed with a liquid you
drink.
ü
The contrast may cause you to feel
flushed or get hives.
ü
You will be alone during the scan,
but a technician will be nearby. You
will be able to hear and talk to the
technician.
ü
You may hear buzzing or clicking
during the scan.
ü
Tell your doctor if you get nervous in
tight spaces.
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NCCN Guidelines for Patients®:
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2 Treatment planning
Imaging tests
PET/CT may be done with one or two machines
depending on the cancer center. For PET, a sugar
radiotracer will first be injected into your body. The
radiotracer is detected with a special camera during
the scan. Cancer cells appear brighter than normal
cells because they use sugar more quickly. PET can
show even small amounts of cancer.
MRI
MRI (magnetic resonance imaging) uses a magnetic
field and radio waves to make pictures. It is not
often used to plan treatment for colon cancer.
Your doctor may order an MRI if the CT scan was
unclear. Contrast should be used. For stages II or
III, CT without contrast may also be done if you can’t
receive CT contrast.
Getting an MRI is much like getting a CT. Except, you
will need to wear a coil device. The device covers
your body from below your chest to the top of your
legs. It sends and receives radio waves. Straps may
be used to help you stay in place. An MRI may cause
your body to feel a bit warm. See Figure 8.
Figure 7
CT scan
CT takes many pictures of a body
part using x-rays. A computer
combines the x-rays to make
one detailed picture. The picture
is saved for later viewing by the
radiologist.
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NCCN Guidelines for Patients®:
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2 Treatment planning
Tumor marker testing
Tumor marker testing
Just like each person’s DNA is unique, each person’s
cancer is unique. This means that a treatment that
helps one person might not help you. To find out if
certain treatments might help you, your doctor may
offer you tumor marker testing. This is also called
biomarker (short for biological marker) testing.
Tumor markers can be substances, like molecules or
proteins, that are made by your body because you
have cancer. Tumor markers can also be processes,
such as the way your DNA “acts” that makes it
unique. To find out if your cancer has any markers,
the primary tumor removed during surgery is tested
in a laboratory.
MMR deficiency
Some people have tumors that have developed
a problem making them unable to fix damaged
DNA. In normal cells, a process called MMR fixes
errors that happen when the DNA divides and
makes a copy of itself. If a cell’s MMR system isn’t
working right, errors build up and cause the DNA to
become unstable. This is called MSI (microsatellite
instability).
There are two kinds of laboratory tests for this tumor
marker. Depending on which method is used, if
you have this genetic defect the result will either
be MSI-H (microsatellite instability high) or dMMR
(mismatch repair deficient). Both results mean the
same thing.
NCCN experts recommend testing for this tumor
marker in all people with colon cancer for two
Figure 8
MRI
MRI makes pictures of areas inside
the body without using radiation.
Not everyone with colon cancer will
need an MRI. Your doctor may order
it to help determine if you have
colon or rectal cancer, or if results
of other imaging tests were unclear.
21
NCCN Guidelines for Patients®:
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2 Treatment planning
Tumor marker testing
important reasons. One reason is to determine if
you should also be tested for Lynch syndrome.
The other is to determine if treatment with certain
immunotherapy drugs may help you.
KRAS and NRAS mutations
RAS is a family of genes that includes the HRAS,
KRAS, and NRAS genes. Two of these genes—
KRAS and NRAS—can play a role in colon cancer.
Genes work as instruction manuals for making
important proteins. Some people with colon cancer
have abnormal KRAS or NRAS genes. As a result,
the proteins these genes make are overactive and
can help the cancer grow.
Some treatments for metastatic colon cancer do not
work if the RAS genes are abnormal. For this reason,
NCCN experts only recommend testing for KRAS
and NRAS mutations if your colon cancer has spread
to other parts of your body (metastasized).
BRAF mutation
About 5 to 9 out of every 100 people with colon
cancer have a mutation called BRAF V600E. Having
this mutation may cause cancer cells to grow and
spread more quickly than they normally would.
NCCN experts recommend testing for this mutation
in all patients with stage IV colon cancer. If cancer
has spread to other parts of your body and you have
this mutation, a type of targeted therapy called a
BRAF inhibitor may help you when combined with
chemotherapy and another targeted therapy.
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NCCN Guidelines for Patients®:
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2 Treatment planning
Review
Review
† A medical history is a report of all health events
in your lifetime. It will include questions about
your family’s health to help assess if you have
a syndrome related to colon cancer. Such
syndromes include Lynch syndrome and FAP.
† Your doctor will examine your body for signs of
disease. He or she will touch parts of your body
to see if anything feels abnormal.
† Blood tests you may have include a CBC,
chemistry profile, and CEA blood test.
† Imaging tests are a noninvasive way for your
doctor to see how far the cancer has spread.
† A needle biopsy may be done to test for cancer
in distant sites.
† Testing for defects with the MMR system
is advised for all colon cancers. Testing for
mutated KRAS, NRAS, and BRAF genes is
recommended for colon cancer that has spread
to other parts of the body.
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3
Overview of cancer treatments
24 Surgery
26 Chemotherapy
28 Targeted therapy
29
Immunotherapy
30 Radiation therapy
31 Ablation
32 Embolization
32 Clinical trials
33 Review
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NCCN Guidelines for Patients®:
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3 Overview of cancer treatments
Surgery
This chapter describes the ways colon
cancer is usually treated. Knowing what
a treatment is will help you understand
your treatment options listed in Parts 4
and 5. Not every person will receive every
treatment described in this chapter.
Surgery
Some colon cancers grow beyond the polyp and into
the colon wall. In many of these cases, surgery is
a key part of treatment. This section describes the
types of surgery used for colon cancer. You may
have more than one type of surgery.
Your treatment team will tell you how to prepare for
and what to expect during surgery. You may need
to stop taking some medicines to reduce the risk of
severe bleeding. Eating less, changing to a liquid
diet, or using enemas or laxatives will empty your
colon for surgery. Right before surgery, you will be
given general anesthesia.
Colectomy
A colectomy is a surgery that removes the part of
the colon with cancer. See Figure 9. After the
cancerous part is removed, the two ends of the
remaining colon are often joined back together. They
are either sewn or stapled together.
Before surgery, the cancer site may be marked
with a tattoo. The tattoo allows your surgeon to find
the cancer site after the polyp has been removed.
Figure 9
Colectomy
Colon cancer is often removed with
a surgery called colectomy. The
surgery removes the part of the colon
that has cancer. The two ends of the
remaining colon are then attached to
each other.
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NCCN Guidelines for Patients®:
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3 Overview of cancer treatments
Surgery
Marking isn’t always needed. For example, marking
isn’t done if the cancer site can be easily found.
A colectomy can be done in two ways. The open
method removes cancer tissue through a large cut
in your abdomen. The minimally invasive method
involves making a few small cuts. Tools are inserted
through the cuts to see and remove part of your
colon.
A colectomy can take 1 to 4 hours to complete. You
may stay in the hospital for several days to recover.
After surgery, you will be told what you can and can’t
eat to prevent discomfort and help healing.
After a colectomy, some people may have a
procedure called a colostomy. A colostomy connects
a part of the colon to the outside of the abdomen.
This creates an opening in your abdomen that
allows stool to pass through. If a colostomy is done,
it is usually for a short period of time. It is rare for a
colostomy not to be removed.
Lymphadenectomy
A lymphadenectomy is a surgery that removes lymph
nodes. It is done at the same time as the colectomy.
At least 12 lymph nodes near to the cancer site
should be removed for cancer testing. All nodes that
look abnormal should be removed, too.
Metastasectomy
Surgery to remove a metastasis is called a
metastasectomy. Not all metastatic disease can be
treated with surgery. The methods of surgery for
metastasectomy vary based on where the cancer
has spread.
Side effects of surgery
Surgery causes pain, swelling, and scars. Pain and
swelling often fade away in the weeks following
surgery. Scars from surgery don’t fully fade away.
As with any surgery, there is a chance of
complications. These include major blood loss,
infection, heart attack, and blood clots. There can
also be injury to nearby organs. Your surgical team
will design care to prevent these risks.
Colectomy may cause certain side effects. Organs
may push through weakened tissue (hernia). Scar
tissue may block the colon. Food may leak out where
the colon was reconnected.
Not all side effects of surgery are listed here. Please
ask your treatment team for a complete list of
common and rare side effects.
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NCCN Guidelines for Patients®:
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3 Overview of cancer treatments
Chemotherapy
Chemotherapy
Chemotherapy (“chemo” for short) is treatment
with drugs to kill cancer cells. Most chemotherapy
drugs are liquids that are slowly injected into a
vein. The drugs travel in your bloodstream to treat
cancer throughout your body. Treatments that
affect the whole body are called systemic. If you
need chemotherapy, you are most likely to have a
combination of two or three chemotherapy drugs.
Combinations of chemotherapy drugs are called
regimens. Regimens commonly used to treat colon
cancer are shown in Guide 1. Keep the following
things in mind:
† The individual chemotherapy drugs and/
or regimens you are treated with depend (in
part) on the type of tumor you have and other
features of your cancer.
† There are other chemotherapy drugs and
regimens not shown in Guide 2 that may be
right for you.
Chemotherapy is given in cycles of treatment days
followed by days of rest. This allows your body to
recover before the next cycle. For example, you
might receive chemotherapy every day for 1 week
followed by 3 weeks with no chemotherapy. These
4 weeks make up one cycle. Cycles vary in length
depending on which drugs are used. Often, a cycle is
14, 21, or 28 days long.
While most chemo drugs for colon cancer travel in
the bloodstream through your whole body, chemo
can also be given using HAI (hepatic arterial
infusion). This method is sometimes used for colon
cancer that has spread to the liver. Using a port
or a pump, the drugs are funneled directly into the
artery leading to the liver. NCCN experts advise that
Guide 1. Commonly used chemotherapy regimens
Regimen name
Drugs included in regimen
5-FU/LV
Fluorouracil, leucovorin
Capecitabine
Capecitabine (Xeloda®)
CAPEOX
Capecitabine (Xeloda®), oxaliplatin (Eloxatin®)
FOLFIRI
Leucovorin, fluorouracil, irinotecan (Camptosar®)
FOLFOX
Leucovorin, fluorouracil, oxaliplatin (Eloxatin®)
FOLFOXIRI
Leucovorin, fluorouracil, oxaliplatin (Eloxatin®), irinotecan (Camptosar®)
Irinotecan
Irinotecan (Camptosar®)
Trifluridine + tipiracil
Trifluridine, tipiracil (Lonsurf®)
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NCCN Guidelines for Patients®:
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3 Overview of cancer treatments
Chemotherapy
HAI should only be done at treatment
centers with experience in this method.
Chemotherapy can be given in
different settings. Many people get
chemotherapy at cancer centers, in
areas called infusion rooms. See
Figure 10.
Figure 10
Chemotherapy infusion room
Chemotherapy is often given in
infusion rooms, which allow several
people to receive treatment at the
same time.
What to expect:
Chemotherapy
ü
Side effects of chemotherapy depend on many
things (drug type, dosage, length of treatment) and
are different for everyone.
ü
Common side effects include nausea, not feeling
hungry, diarrhea, hair loss, and mouth sores.
ü
Some chemotherapy drugs can damage your
sensory nerves. Symptoms of this include
numbness, tingling, and pain in fingers and toes.
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3 Overview of cancer treatments
Targeted therapy
Targeted therapy
Targeted therapy is a type of cancer treatment that
can target—and attack—specific kinds of cancer
cells. Different targeted therapies work in different
ways. One type stops the growth of new blood
vessels into colon tumors. Without the blood they
need to grow, cancer cells “starve” and die. A second
type of targeted therapy for colon cancer stops the
cancer cells from receiving signals to grow. Other
types work in more than one way.
Targeted therapy is less likely to harm normal cells
than chemotherapy. Targeted therapy drugs for colon
cancer are listed in Guide 2. Ask your treatment
team for a full list of common and rare side effects.
Not everyone with colon cancer will benefit from
treatment with a targeted therapy. In Parts 4, 5, and
7, information on who should receive these drugs is
provided.
SNAPSHOT
Targeted therapy
ü
Used to treat some colon cancers that
have spread to other parts of the body
and/or can’t be removed with surgery.
üNot everyone with colon cancer will
benefit from targeted therapy. For
example, some targeted therapies will
only work for people with (or without) a
specific gene mutation.
üMost (but not all) targeted therapies for
colon cancer are given by infusion. This
means they are put directly into your
bloodstream using an IV.
Guide 2. Targeted therapies
Generic name
Brand name
How it’s given
Bevacizumab
Avastin®
Infusion
Ramucirumab
Cyramza®
Infusion
Ziv-aflibercept
Zaltrap®
Infusion
Cetuximab
Erbitux®
Infusion
Panitumumab
Vectibix®
Infusion
Regorafenib
Stivarga®
Pill
Vemurafenib
Zelboraf®
Pill
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3 Overview of cancer treatments
Immunotherapy
Immunotherapy
The immune system is your body’s natural defense
against infection and disease. A newer type of
cancer treatment called immunotherapy increases
the activity of your immune system. By doing so,
it improves your body’s ability to find and destroy
cancer cells. Drugs called checkpoint inhibitors are a
type of immunotherapy used to treat colon cancer.
Your immune system has important white blood cells
called T cells. T cells’ main job is to attack harmful
things in your body, like bacteria, viruses, and cancer.
They do this with the help of certain proteins on their
surface. When T-cell proteins “meet” certain proteins
on cancer cells, it is called an immune checkpoint.
The T cell is “told” to leave the cancer cell alone
instead of attacking it. Checkpoint inhibitors can
stop the T-cell protein from meeting the cancer cell
protein. This means that the T cells will do their job
and attack the cancer cells.
Checkpoint inhibitors used for colon cancer are
shown in Guide 3. Not everyone with colon cancer
will benefit from treatment with immunotherapy. In
Parts 4, 5, and 7, information on who should receive
these drugs is provided.
Guide 3. Immunotherapy drugs
Generic name
Brand name
How it’s given
Ipilimumab
Yervoy®
Infusion
Nivolumab
Opdivo®
Infusion
Pembrolizumab
Keytruda®
Infusion
Chemobrain is real! My brain
does not work as quickly as it did
before. I have to employ strategies,
tactics and other people to help me
remember things. I am still good at
Jeopardy though!
– Evelyn
Survivor, Stage III colon cancer
“
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NCCN Guidelines for Patients®:
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3 Overview of cancer treatments
Radiation therapy
Radiation therapy
Radiation therapy uses high-energy, highly focused
rays to treat cancer. The rays damage DNA. This
either kills the cancer cells or stops new cancer cells
from being made.
Radiation therapy is not often used to treat colon
cancer. You may receive radiation therapy as part of
a clinical trial. Otherwise, Parts 4 and 5 explain when
radiation therapy is an option.
External beam radiation
Most often, EBRT (external beam radiation
therapy) is the method used to treat colon cancer.
This method delivers radiation from outside your
body using a large machine. See Figure 11. The
radiation passes through your skin and other tissue
to reach the tumor.
A planning session is needed to receive the best
treatment. This session is called simulation. First, you
will be guided and adjusted into the position needed
for treatment. After this, pictures of the cancer sites
will be made with an imaging test. Using the pictures,
your radiation team will plan treatment. They will
plan the best dose, number, and shape of radiation
beams, and number of treatments.
Conformal techniques are used for colon cancer.
These techniques shape the radiation dose to the
cancer site to spare healthy tissue. However, some
healthy tissue still gets radiated. The radiation dose
is shaped with computer software and hardware
added to the machine. The types of conformal
radiation include:
† 3D-CRT (three-dimensional conformal radiation
therapy) delivers, from different angles, a
photon beam that matches the shape of the
tumor. Treatment is completed in about 6
weeks.
† IMRT (intensity-modulated radiation therapy)
is a form of 3D-CRT that further modifies the
beam’s intensity during treatment. Treatment is
completed in about 6 weeks. IMRT should be
used only for a second treatment with radiation
or for cancer in an uncommon site.
† SBRT (stereotactic body radiation therapy)
treats cancer with very precise, high-dose
photon beams. Receiving SBRT is much like
What are some side effects of
radiation?
• Feeling tired and worn out
• Hair loss in the treated area
• Changes to urination and
bowel movements
• Diarrhea
• Nausea/vomiting
• Late side effects can include
infertility, sexual dysfunction,
bowel dysfunction, reduced
bone density, and second
cancers
• Not all side effects are listed
here. Ask your treatment team
for a full list.
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3 Overview of cancer treatments
Radiation therapy
other conformal techniques except treatment
is finished in about 5 visits. At this time, SBRT
should only be used to treat colon cancer in the
liver or lungs.
During treatment, you will lie on a table as you did for
simulation. Devices may be used to keep you from
moving. This helps to target the tumor. Radiation
beams are aimed with help from ink marks on your
skin or marker seeds in the tumor.
You will be alone in the treatment room. A technician
will operate the machine from a nearby room. He or
she will be able to see, hear, and speak with you at
all times. As treatment is given, you may hear noises.
You will not see, hear, or feel the radiation. One
session can take less than 10 minutes.
Intraoperative radiation
IORT (intraoperative radiation therapy) delivers
radiation inside your body at the time of an operation.
Different methods can be used. However, the usual
method involves a device that is placed where the
tumor was. The radiation kills remaining cancer cells
in the tissue that was near the tumor.
IORT can deliver a radiation dose similar to EBRT or
deliver extra radiation. This extra radiation is called
a boost. Some cancer centers do not have an IORT
machine. In this case, a boost of radiation can be
given with EBRT if technically feasible.
Figure 11
External beam radiation
therapy
A large machine aims radiation at
the tumor, passing through skin
and other tissue to reach it.
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3 Overview of cancer treatments
Ablation
Embolization | Clinical trials
Ablation
Surgery is the preferred way to remove colon cancer
that has spread to the liver or lungs. Sometimes,
however, a procedure called ablation may be used
to treat small tumors in these areas. Ablation may be
used by itself if surgery isn’t possible, or it may be
used in addition to surgery. Most available research
is on a type of ablation called radiofrequency
ablation. This method heats and kills cancer cells
using high-energy radio waves.
Embolization
Embolization treats liver tumors with chemotherapy
or radioactive beads. A catheter will be inserted into
an artery in your leg and guided to the tumor. Once
in place, the beads will be inserted into the blood
vessel.
The beads block blood flow to the tumor. Without
blood, the cancer cells “starve” and die. The
chemotherapy or radiation further damage the cancer
cells and cause the tumor to shrink.
This treatment is a type of arterially directed catheter
therapy. If radiation beads are used, it’s called
selective internal radiation therapy. Embolization is
an option for some people with liver metastases. It is
given when chemotherapy is not an option.
Clinical trials
New tests and treatments aren’t offered to the
public as soon as they’re made. They first need to
be studied. A clinical trial is a type of research that
studies how safe and helpful tests and treatments
are. When found to be safe and helpful, they may
become tomorrow’s standard of care. Because of
clinical trials, the tests and treatments in this book
are now widely used to help people with colon
cancer.
Joining a clinical trial can have both upsides and
downsides. See Figure 12 for some things to
consider when deciding to join a clinical trial. You will
need to weigh the pros and cons and decide what is
right for you.
To join a clinical trial, you must meet the conditions
of the study. Patients in a clinical trial are often alike
in terms of their cancer and general health. This is to
know that any progress is because of the treatment
and not because of differences between patients.
To join, you’ll need to review and sign a paper called
an informed consent form. This form describes the
study in detail. The study’s risks and benefits should
be described and may include others than those
described above.
Ask your treatment team if there is an open clinical
trial that you can join. There may be clinical trials
where you’re getting treatment or at other treatment
centers nearby. You can also find clinical trials
through the websites listed in Part 8, Making
treatment decisions.
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3 Overview of cancer treatments
Review
Review
† A colectomy is surgery that removes the part
of the colon with cancer. A lymphadenectomy
is the removal of lymph nodes, and a
metastasectomy is the removal of metastases.
† Chemotherapy stops cancer cells from
completing their life cycle so they can’t increase
in number.
† One type of targeted therapy stops the growth
of new blood vessels into colon tumors. Without
blood, cancer cells starve and die. A second
type stops the cancer cells from receiving
certain growth signals.
† Radiation kills cancer cells or stops new cancer
cells from being made. It isn’t often used to
treat colon cancer.
† Ablation destroys small tumors by freezing
or burning them. It isn’t often used for colon
cancer.
† Embolization treats cancer by blocking blood
flow to the tumor and damaging cancer cells
with chemotherapy or radiation. It is used for a
very select group of people.
† Clinical trials give people access to new tests
and treatments that otherwise can’t usually be
received. These new tests and treatments may,
in time, be approved by the FDA (U.S. Food
and Drug Administration).
Figure 12
Possible pros and cons of joining a
clinical trial
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NCCN Guidelines for Patients®:
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4
Treatment guide:
Nonmetastatic cancer
35 Stage I
38 Stages II and III
42 Review
35
NCCN Guidelines for Patients®:
Colon Cancer, 2018
4 Nonmetastatic cancer
Stage I
This chapter is a treatment guide for colon
cancer that hasn’t spread to areas far from
the colon. The cancer may be only in the
colon, or also in nearby organs or lymph
nodes. The treatment options presented
are partly based on the cancer stage.
Stage I
Stage I colon cancer means that the tumor has
grown into either the second layer of the colon wall
(a T1 tumor), or into the third layer of the colon wall
(a T2 tumor). Some T1 tumors need to be treated.
Treatment is based on the shape of the polyp and
whether your doctor thinks cancer will return after it’s
been removed. The cancer is more likely to return if:
† The tumor was removed in more than one
piece. This is called a fragmented specimen.
† There is cancer around the edge of the tissue
that was removed. This means there might still
be cancer leftover in the colon. This is called a
positive surgical margin.
† The tumor cells look very different from normal
cells under a microscope. This means that the
cancer is likely to grow and spread more quickly
than it normally would. These cells are called
high grade.
† Cancer cells can be seen under a microscope
in the tiny blood or lymph vessels of the tumor.
This is called angiolymphatic invasion.
† There are small groups of cancer cells in the
part of the tumor that was connected to the
colon. This is called tumor budding.
After two years of being
misdiagnosed and hopping from
doctor to doctor, I was finally heard
and seen by a doctor who ignored
my age. Had it not been for this
doctor I wouldn’t be here. My tumor
was the size of a grapefruit and
just 2cm away from blocking my
colon completely.
– April, 33
Survivor, Stage II colon cancer
“
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NCCN Guidelines for Patients®:
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4 Nonmetastatic cancer
Stage I
Guide 4. Treatment for T1 tumors
Type of polyp
What are the options?
Low-risk pedunculated polyp
Watch-and-wait (no treatment)
Low-risk sessile polyp
• Watch-and-wait (no treatment)
• Colectomy and lymphadenectomy
Any high-risk polyp
Colectomy and lymphadenectomy
Guide 5. Treatment for T2 tumors
Test results
What are the options?
The tumor can be treated with surgery
and ISN’T blocking the gut
• Colectomy + lymphadenectomy
The tumor can be treated with surgery
and IS blocking the gut
• Colectomy + lymphadenectomy
• Colectomy + lymphadenectomy + diversion
• Diversion followed by colectomy + lymphadenectomy
• In some cases, stent followed by colectomy + lymphadenectomy
Guide 6. Follow-up care for stage I colon cancer
Type of care
When?
Advanced
adenoma?
What’s next?
Colonoscopy One year after
treatment
No
Repeat colonoscopy in 3 years. If normal,
repeat every 5 years after that
Yes
Repeat colonoscopy in 1 year
Imaging tests
If you don’t have any symptoms, imaging tests aren’t needed on a regular basis. Your doctor
may order imaging tests if he or she thinks the cancer may have come back or spread.
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4 Nonmetastatic cancer
Stage I
T1 tumors
Guide 4 lists the treatment options for T1 tumors.
T1 tumors haven’t grown beyond the second layer
of the colon wall. If you had a low-risk pedunculated
polyp, a polypectomy likely removed all the cancer.
You don’t need more treatment, and you can start
follow-up testing. For a low-risk sessile polyp, there
are two options if the polyp was fully removed:
† Watch-and-wait (no treatment)
† Surgery
Either type of polyp may have high-risk features. In
this case, surgery is recommended. The part of the
colon with cancer and some lymph nodes should be
removed.
T2 tumors
Guide 5 lists the treatment options for tumors rated
as T2. These tumors haven’t grown beyond the third
layer of the colon wall. These tumors should be
treated. If you are able to have surgery, a colectomy
and lymphadenectomy are advised. It is very rare
that surgery can’t be done. If you can’t have surgery,
you may have chemotherapy if you’re healthy
enough. Radiation therapy may be added.
In very rare cases, a T2 tumor has grown so large
that it blocks the flow of stool. There are four options
when there is a blockage:
† A colectomy that unblocks your gut
† Removal of the cancer and a diversion within
one operation. A diversion is a surgery that
attaches the colon to the surface of the
abdomen, and an ostomy pouch is needed.
† A diversion followed by a second operation to
remove the cancer
† A stent followed by a second operation to
remove the cancer
The tissue that is removed from your body will be
sent to a pathologist. The pathologist will assess how
far the cancer has grown within the colon wall. He or
she will also test for cancer in your lymph nodes. If
the cancer stage doesn’t change, you will not need
more treatment. If the cancer stage changes to stage
II or III, see Guide 9.
Follow-up care
Guide 6 lists follow-up testing for stage I colon
cancer. Follow-up testing is started when there are
no signs of cancer after treatment. It can be helpful
for finding new cancer growth early.
A colonoscopy is recommended 1 year after
treatment has ended. If results are normal, the next
colonoscopy should be received in 3 years and then
every 5 years. If an advanced adenoma is found,
your next colonoscopy will be needed within 1 year.
Advanced adenomas include polyps with a ruffled
structure (villous), a polyp larger than the width of a
AAA battery (>1 cm), or a polyp with pre-cancerous
cells (high-grade dysplasia).
If you don’t have any symptoms, imaging tests aren’t
needed on a regular basis. Your doctor may order
imaging tests if he or she thinks the cancer may have
come back or spread.
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NCCN Guidelines for Patients®:
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4 Nonmetastatic cancer
Stages II and III
Stages II and III
Treatment before surgery
Guide 7 lists the options for treating stage II
and III cancers before surgery. Some stage II and
III cancers will need treatment before surgery.
The medical term for treatment before surgery is
neoadjuvant therapy. The aim of this treatment is
to shrink a tumor so it can be fully removed during
surgery.
Treatment before surgery is based on how far
through the colon wall the cancer has grown. Tumors
that are rated as T1, T2, T3, and T4a haven’t grown
through the colon wall to nearby organs. For these
tumors, treatment before surgery isn’t advised.
Tumors rated as T4b have grown through the colon
wall to nearby structures. In this case, your doctor
may want to use chemotherapy before surgery.
FOLFOX or CAPEOX are recommended.
Primary treatment
Guide 8 presents the primary treatment options
for stage II and III cancers. After any treatment you
received before surgery, the next step is primary
treatment. Primary treatment is the main treatment
used to rid your body of cancer (usually surgery).
Treatment options are based on whether the tumor
can be removed with surgery.
Surgery is an option
If you are able to have surgery, a colectomy and
lymphadenectomy are advised. In rare cases, a
tumor has grown so large that it blocks the flow
of stool. There are four options when there is a
blockage.
One option is a colectomy that unblocks your
gut. Another option is removal of the cancer and
a diversion within one operation. A diversion is a
surgery that attaches the colon to the surface of
the abdomen, and a “bag” is needed. A third option
is a diversion followed by a second operation to
remove the cancer. Last, some people can get a
stent followed by a second operation to remove the
cancer.
Pathology
The tissue that will be removed from your body will
be sent to a pathologist. The pathologist will assess
how far the cancer has grown within the colon wall.
He or she will also test for cancer in your lymph
nodes. Based on test results, a pathologic stage will
be assigned.
Surgery isn’t an option
It is very rare but you may be unable to have surgery.
Surgery may not be possible because of where the
cancer is. Some health issues also exclude surgery.
In this case, sometimes chemotherapy is given if you
are healthy enough. The chemotherapy listed in Part
7 may be used. Other preferred options are radiation
therapy with either infusional 5-FU or capecitabine.
If neither is an option, a third option is bolus 5-FU/LV
with radiation therapy.
For very invasive tumors, chemotherapy may shrink
the tumor enough for surgery. IORT may be added.
If you’re still unable to have surgery, you may be
treated with more cycles of chemotherapy.
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NCCN Guidelines for Patients®:
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4 Nonmetastatic cancer
Stages II and III
Guide 7. Treatment before surgery
T stage
What are the options?
Colon tumors haven’t grown to nearby sites
(T1–T4a)
No treatment needed before surgery
Colon tumors have grown to nearby sites
(T4b)
• Chemotherapy with FOLFOX or CAPEOX before surgery
• You can go straight to surgery
Guide 8. Primary treatment - stage II and III colon cancer
The tumor CAN be removed with surgery
Is gut blocked?
Primary treatment options
What’s next?
Tumor isn’t blocking gut
Colectomy + lymphadenectomy
Treatment after surgery
(see Guide 9)
Tumor is blocking gut
• Colectomy + lymphadenectomy
• Colectomy + lymphadenectomy + diversion
• Diversion followed by colectomy + lymphadenectomy
• Stent followed by colectomy + lymphadenectomy
Treatment after surgery
(see Guide 9)
The tumor CAN’T be removed with surgery
Treatment options
Result
What’s next?
What’s next?
• Treatment listed in Part 7
• Infusional 5-FU + radiation
• Capecitabine + radiation
• Bolus 5-FU/LV + radiation
Tumor can
now be
removed with
surgery
Colectomy +
lymphadenectomy, with
or without IORT
Treatment after surgery
(see Guide 9)
Tumor still
can’t be
removed with
surgery
Start (or continue)
treatment listed in Part 7
---
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NCCN Guidelines for Patients®:
Colon Cancer, 2018
4 Nonmetastatic cancer
Stages II and III
Guide 9. Stages II and III: treatment after surgery
Stage
MMR status
Risk level
Treatment options
Stage IIA
MSI-H or dMMR
Any level
Watch-and-wait (no treatment)
MSI-L or normal MMR
Low risk
• Watch-and-wait (no treatment)
• Chemotherapy with:

◦ Capecitabine

◦ 5-FU/LV
MSI-L or normal MMR
High risk
• Watch-and-wait (no treatment)
• Chemotherapy with:

◦ Capecitabine

◦ 5-FU/LV

◦ FOLFOX regimen

◦ CAPEOX regimen
Stage IIB
Stage IIC
Any status
Any level
• Watch-and-wait (no treatment)
• Chemotherapy with:

◦ Capecitabine

◦ 5-FU/LV

◦ FOLFOX regimen

◦ CAPEOX regimen
Stage III
Any status
Low risk
Chemotherapy with:

◦ CAPEOX regimen (3 months) (preferred)

◦ FOLFOX regimen (3–6 months) (preferred)

◦ Capecitabine (6 mo)

◦ 5-FU (6 mo)
High risk
Chemotherapy with:

◦ CAPEOX regimen (3–6 months) (preferred)

◦ FOLFOX regimen (6 months) (preferred)

◦ Capecitabine (6 months)

◦ 5-FU (6 months)
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NCCN Guidelines for Patients®:
Colon Cancer, 2018
4 Nonmetastatic cancer
Stages II and III
Treatment after surgery
The options for treatment after surgery for stage II
and III cancers are shown in Guide 9. Treatment
after surgery is given when all visible cancer has
been removed. The aim of this treatment is to kill any
unseen cancer cells. Some people won’t need any
further treatment after surgery. If you do, it’s best to
have it as soon as possible for the best results.
Options for treatment after surgery (adjuvant
treatment) depend on:
† The stage of your cancer
† If your tumor is dMMR/MSI-H (explained in Part
2, Treatment planning)
† If your cancer is at high risk of coming back
(explained next)
The risk level is high if these conditions are met:
† Positive surgical margin is cancer within the
normal-looking tissue around the tumor.
† Close surgical margin is cancer near the
normal-looking tissue around the tumor.
† Unknown surgical margin is an unclear
assessment of the normal-looking tissue around
the tumor.
† Cancer grade 3 or 4 means the cancer cells
are likely to grow and spread more quickly than
they normally would.
† Angiolymphatic invasion is cancer spread into
the tumor’s lymph and blood vessels.
† Perineural invasion is cancer spread around or
into the nerves.
† Limited lymphadenectomy means fewer than
12 lymph nodes were examined.
† Bowel obstruction means the tumor has grown
large enough to block the gut.
† Localized perforation is the presence of holes in
the colon caused by the tumor.

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NCCN Guidelines for Patients®:
Colon Cancer, 2018
4 Nonmetastatic cancer
Review
Review
† Stage I colon cancer has grown into the second
layer of the colon wall (T1 tumors) or into
the third layer (T2 tumors). Some T1 tumors
may not need treatment after a polypectomy.
Otherwise, T1 and T2 tumors may be treated
with colectomy and lymphadenectomy.
† Surgery is advised for stages II and III colon
cancer if you are able and willing to have it.
You may receive chemotherapy before surgery
if you have a T4b tumor. Chemotherapy after
surgery may not be helpful for stage II cancers
but is helpful for stage III.
† If you can’t have surgery, chemotherapy is an
option.
† Follow-up care is started when there are no
signs of cancer. It includes tests to look for
any new cancer and help for side effects. It
also includes help to prevent or detect other
diseases.
43
NCCN Guidelines for Patients®:
Colon Cancer, 2018
5
Treatment guide:
Metastatic cancer
44 Metastases at diagnosis
47 Metastases at recurrence
51 Review
44
NCCN Guidelines for Patients®:
Colon Cancer, 2018
5 Metastatic cancer
Metastases at diagnosis
Colon cancer spreads most often to the
liver, sometimes to the lungs, and less
often to the abdomen or other areas.
Cancer may have already spread to these
areas by the time it is first diagnosed.
This is stage IV colon cancer. Or, after
successful treatment and a cancer-free
period, cancer may return and spread
to areas far from the colon. This chapter
discusses both of these scenarios.
Metastases at diagnosis
If cancer was found in areas far from the colon at the
time you were first diagnosed with colon cancer, your
cancer is stage IV. Because the cancer has spread
(metastasized) to areas far from the colon, this stage
is also called advanced cancer or metastatic cancer.
Cancer is in the liver or lungs
Treatment of metastatic colon cancer depends on
whether surgery is possible. If it is, that is the best
way to treat cancer that has spread to the liver or
lungs. However, surgery will not be an option for
most people. Your treatment team will determine if
surgery is an option for you. Because surgery is not
often possible, nonsurgical treatment is described
first.
Nonsurgical treatment
The main treatment for stage IV colon cancer that
cannot be removed with surgery is chemotherapy.
The chemotherapy regimens that may be used are
listed below. A targeted therapy drug may be given
with the chemotherapy. The targeted therapy drugs
panitumumab and cetuximab should only be used for
left-sided tumors that have normal KRAS and NRAS
genes.
† FOLFIRI with or without bevacizumab,
panitumumab, or cetuximab
† FOLFOX with or without bevacizumab,
panitumumab, or cetuximab
† CAPEOX with or without bevacizumab
† FOLFOXIRI with or without bevacizumab
For some people, chemotherapy may greatly shrink
the tumors. If they shrink enough, surgery may
be an option. If your doctors think that surgery
might be possible for you, the size of the tumor
should be checked about every two months during
chemotherapy.
If chemotherapy didn’t shrink the tumors enough
to be removed with surgery, you can continue
systemic therapy. Systemic therapy may include a
combination of chemotherapy, targeted therapy, and
immunotherapy. The systemic therapy regimens that
may be used are found in Part 7, Treatment guide:
Systemic therapy.
If chemotherapy worked well enough and the cancer
can now be removed with surgery, you will have
surgery to remove the colon tumor and the tumors in
the liver and/or lungs. You may have the surgeries
at the same time or separately. If you were being
treated with bevacizumab, it should be stopped
6 weeks before surgery. It increases your risk for
stroke and bleeding, especially if you’re older than
65. Bevacizumab can be re-started 6 to 8 weeks
after surgery. Otherwise, it can slow healing.
After surgery, most people will need more
chemotherapy. A targeted therapy may be given with
chemotherapy. Chemotherapy received before and
after surgery should not exceed 6 months.
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NCCN Guidelines for Patients®:
Colon Cancer, 2018
5 Metastatic cancer
Metastases at diagnosis
Surgical treatment options
There are three options that include surgery to treat
colon cancer that had spread to the liver or lungs
at diagnosis (stage IV). Surgery is only an option
if all the tumors can be totally removed. If your
doctor thinks your liver will be too small after the
part with cancer is removed, you may need to have
it enlarged. This is done using a procedure called
portal vein embolization. This blocks the blood vessel
to the liver tumor, which causes the healthy part of
the liver to grow larger.
The three treatment pathways also include
chemotherapy, either before or after surgery.
Instead of chemotherapy given by infusion (the most
common way), putting the chemotherapy medicine
directly into your liver using HAI may be an option.
NCCN experts advise that HAI should only be
received at treatment centers with experience in this
method.
The three treatment options are described next and
shown in Guide 10.
Option 1
This option starts with surgery to remove the part of
the colon with cancer (colectomy). NCCN experts
recommend surgically removing the liver and/or lung
metastases at the same time, or later in a second
surgery. Instead of removing the metastases with
surgery, another option is to treat them using local
therapy (image-guided ablation or SBRT). While
surgery is preferred by NCCN experts to remove the
metastases, local therapy may be appropriate for
patients with many small metastases. After surgery,
you will likely have a CT scan (with contrast) of your
chest, abdomen, and pelvis.
The next phase of this treatment option is
chemotherapy. FOLFOX and CAPEOX are preferred
regimens, but capecitabine and 5-FU/LV are options
as well. Six months of chemotherapy is preferred.
Option 2
This option starts with chemotherapy. FOLFOX or
CAPEOX are preferred regimens, but FOLFIRI is an
option as well. There are pros and cons to starting
with chemotherapy.
Some of the advantages include:
† You may receive early treatment of possible
cancer not yet found.
† Knowing your response to chemotherapy early
can help with treatment planning.
† If the cancer grows while taking chemotherapy,
you can avoid local treatment.
Some of the disadvantages include:
† Fat may build up in your liver and your liver
may swell.
† You may become unable to have surgery if the
cancer grows or shrinks too much.
† Injury to small blood vessels may occur in your
liver.
After 2 to 3 months of chemotherapy, the next step
is surgery to remove the part of the colon with
cancer (colectomy) and to remove the metastases.
These can be done together during one operation or
separately in two operations. After surgery, you will
likely have a CT scan (with contrast) of your chest,
abdomen, and pelvis.
Sometimes, more chemotherapy will be given after
surgery. FOLFOX and CAPEOX are preferred
regimens, but capecitabine and 5-FU/LV are options
as well. Together, chemotherapy given before and
after surgery should not exceed 6 months.
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NCCN Guidelines for Patients®:
Colon Cancer, 2018
5 Metastatic cancer
Metastases at diagnosis
Option 3
Option 3 starts with surgery (colectomy), followed
by 2 to 3 months of chemotherapy. FOLFOX and
CAPEOX are preferred regimens, but FOLFIRI is
an option as well. After chemotherapy, surgery to
remove the metastases will be done. After surgery,
you will likely have a CT scan (with contrast) of your
chest, abdomen, and pelvis.
Sometimes, more chemotherapy will be given after
surgery. FOLFOX and CAPEOX are preferred
regimens, but capecitabine and 5-FU/LV are options
as well. Together, chemotherapy given before and
after surgery should not exceed 6 months.
Cancer is in the abdomen
About 17 out of 100 people with metastatic rectal
cancer will also form tumors in the peritoneum. The
peritoneum is the thin layer of tissue that lines the
abdomen and covers most of the abdominal organs.
The goal of treatment for most abdominal/peritoneal
metastases is to relieve or prevent symptoms. The
main treatment is systemic therapy.
Tumors growing in or around the intestines can
cause what’s called a bowel obstruction. A bowel
obstruction is a blockage of the small or large
intestine by something other than stool (feces).
If the intestines are blocked, stool is prevented
from moving and leaving the body. If the cancer
isn’t causing a bowel blockage, you would begin
treatment with systemic therapy. See Part 7,
Treatment guide: Systemic therapy. If the cancer is
(or is expected to) block the bowel, you will first need
care to unblock the bowel before beginning systemic
therapy. This can be done using one of several
surgical techniques, or with a mesh metal tube called
a stent.
The visiting Oncologist, told me
I was terminal. No chance of
survival. Liver involvement was too
large. Because of our rural area,
my treatment team was my family
and research was the internet. We
were fortunate to find a cancer
center and surgeon who saved my
life.
– Elaine
Survivor, Stage IV colon cancer
“
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NCCN Guidelines for Patients®:
Colon Cancer, 2018
5 Metastatic cancer
Metastases at recurrence
Metastases at recurrence
Sometimes, during the course of follow-up care,
testing shows that cancer has come back. One sign
that cancer may have returned is if your CEA blood
test levels are getting higher each time your blood
is tested. In this case, your doctor will likely do a
physical exam, a colonoscopy, and a CT scan with
contrast of your chest, abdomen, and pelvis. Or, your
doctor may find cancer far from the colon during a
follow-up imaging test.
If cancer returns, it is called a recurrence or recurrent
cancer. There are different types of recurrent colon
cancer, described below.
† Local recurrence means that the cancer has
returned to the colon.
† Regional recurrence means that the cancer
has returned to the lymph nodes or other
tissues near the colon.
† Distant recurrence means that the cancer
has returned and has spread to areas far from
the colon, such as the liver or lungs. Because
the cancer has spread to areas far from where
Guide 10. Surgical options for stage IV colon cancer
Option 1
Surgery options
Chemotherapy options
• Colectomy and metastasectomy, with or without local treatment
• Colectomy and local treatment
• FOLFOX (preferred)
• CAPEOX (preferred)
• Capecitabine
• 5-FU/LV
Option 2
Chemotherapy options
Surgery
Chemotherapy options
• FOLFOX (preferred)
• CAPEOX (preferred)
• FOLFIRI
Colectomy + metastasectomy
• FOLFOX (preferred)
• CAPEOX (preferred)
• Capecitabine
• 5-FU/LV
Option 3
Surgery
Chemotherapy options
Next surgery
Chemotherapy options
Colectomy
• FOLFOX (preferred)
• CAPEOX (preferred)
• FOLFIRI
Metastasectomy
• FOLFOX (preferred)
• CAPEOX (preferred)
• Capecitabine
• 5-FU/LV
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NCCN Guidelines for Patients®:
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5 Metastatic cancer
Metastases at recurrence
it started (metastasized), this is also called
metastatic cancer.
This section is about the last type of recurrence
described above—distant recurrence. Distant
recurrence of colon cancer is not the same as
metastatic disease discovered at diagnosis, although
both are considered metastatic cancer. There are
differences in how these types of cancer are treated.
Treatment of a distant recurrence of colon cancer
depends on whether surgery is possible. If it is, that
is the best treatment option. However, surgery will
not be an option for most people. Your treatment
team will determine if surgery is an option for you.
Because surgery is not often possible, nonsurgical
treatment is described first.
Nonsurgical treatment
Colon cancer that returned and spread to the liver
or lungs, and that cannot be removed with surgery,
is treated with systemic therapy. Systemic therapy
may include chemotherapy, targeted therapy, or
immunotherapy (or a combination of these). If you’ve
had chemotherapy with FOLFOX or CAPEOX within
the past 12 months, there are four possible systemic
therapy options. These are described next and
shown in Guide 11. Systemic therapy options for
everyone else are discussed in Part 7, Treatment
guide: Systemic therapy.
FOLFOX or CAPEOX within last 12 months
Chemotherapy with FOLFIRI or irinotecan are
options. A targeted therapy drug may be added.
Bevacizumab is the preferred targeted therapy, but
ziv-aflibercept and ramucirumab are also options. If
the tumor has normal KRAS/NRAS genes, adding
panitumumab or cetuximab to chemotherapy
FOLFIRI or irinotecan is another option.
If the tumor has a BRAF V600E mutation, treatment
with irinotecan, vemurafenib, and either cetuximab or
panitumumab is an option. For tumors that are dMMR/
MSI-H, you will likely be treated with pembrolizumab
alone, or with nivolumab (with or without ipilimumab).
For some people, chemotherapy may greatly shrink
the tumors. If they shrink enough, surgery may
be an option. If your doctors think that surgery
might be possible for you, the size of the tumor
should be checked about every two months during
chemotherapy.
Surgery still not an option
If chemotherapy didn’t shrink the tumors enough to
be removed with surgery, you can continue systemic
therapy. The systemic therapy regimens that may be
used are found in Part 7, Treatment guide: Systemic
therapy.
Surgery is now an option
If chemotherapy worked well enough and the cancer
can now be removed with surgery, you will have
surgery to remove the tumor(s). You may have the
surgeries at the same time or separately. If you were
being treated with bevacizumab, it should be stopped
6 weeks before surgery. It increases your risk for
stroke and bleeding, especially if you’re older than
65. Bevacizumab can be restarted 6 to 8 weeks after
surgery. Otherwise, it can slow healing.
After surgery, most people will need more systemic
therapy, although the regimen may be different from
what you had before surgery. However, no further
treatment will be an option for some people. When
there are no signs of cancer, you can resume follow-
up care and monitoring for the return of cancer.
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NCCN Guidelines for Patients®:
Colon Cancer, 2018
5 Metastatic cancer
Metastases at recurrence
Surgical treatment options
There are two options that include surgery to treat
colon cancer that had spread to the liver or lungs
at recurrence. Surgery is only an option if all the
tumors can be totally removed. If your doctor thinks
your liver will be too small after the part with cancer
is removed, you may need to have it enlarged.
This is done using a procedure called portal vein
embolization. This blocks the blood vessel to the liver
tumor, which causes the healthy part of the liver to
grow larger.
The treatment pathways also include chemotherapy,
either before or after surgery. Instead of
chemotherapy given by infusion (the most common
way), putting the chemotherapy medicine directly into
your liver using HAI may be an option. NCCN experts
advise that HAI should only be received at treatment
centers with experience in this method.
The treatment options are described next and shown
in Guide 12.
Guide 11. Nonsurgical options
You had chemotherapy with FOLFOX or CAPEOX within the past 12 months
Treatment options
May be given with
Notes
Chemotherapy with FOLFIRI regimen
• Bevacizumab (preferred)
• Ziv-aflibercept
• Ramucirumab
---
Chemotherapy with irinotecan
• Bevacizumab (preferred)
• Ziv-aflibercept
• Ramucirumab
---
Chemotherapy with FOLFIRI regimen
• Cetuximab
• Panitumumab
For normal KRAS/NRAS genes only
Chemotherapy with irinotecan
• Cetuximab
• Panitumumab
For normal KRAS/NRAS genes only
Nivolumab
Ipilimumab
For dMMR/MSI-H tumors only
Pembrolizumab
---
For dMMR/MSI-H tumors only
Irinotecan + cetuximab + vemurafenib
---
BRAF V600E mutation positive
Irinotecan + panitumumab + vemurafenib
---
BRAF V600E mutation positive
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NCCN Guidelines for Patients®:
Colon Cancer, 2018
5 Metastatic cancer
Metastases at recurrence
Option 1
This option starts with surgery to remove the
metastases. Instead of removing the metastases
with surgery, another option is to treat them using
local therapy (image-guided ablation or SBRT). While
surgery is preferred by NCCN experts to remove the
metastases, local therapy may be appropriate for
patients with many small metastases. After surgery,
you will likely have a CT scan (with contrast) of your
chest, abdomen, and pelvis.
The next phase of this treatment option is
chemotherapy. FOLFOX and CAPEOX are preferred
regimens if you haven’t had any chemotherapy
before, but capecitabine and 5-FU/LV are options as
well. If you have had chemotherapy before, a watch-
and-wait approach (no treatment) is an option. This
is preferred by NCCN experts for people who had
previous chemotherapy that included oxaliplatin.
Another option is to begin a systemic therapy
regimen in Part 7, Treatment guide: Systemic
therapy.
Option 2
This option starts with chemotherapy to try to shrink
the metastases. FOLFOX or CAPEOX are preferred
regimens, but capecitabine and 5-FU/LV are options
as well. After 2 to 3 months of chemotherapy, the
next step is surgery to remove the metastases. After
surgery, you will likely have a CT scan (with contrast)
of your chest, abdomen, and pelvis.
Treatment after surgery is based on the success of
treatment before surgery. If the chemotherapy you
had before surgery worked, you can restart that
treatment or take FOLFOX. Together, chemotherapy
given before and after surgery should not exceed
6 months. A third option is taking a watch-and-wait
approach (no treatment).
If chemotherapy before surgery didn’t work, you
have two options. One option is to begin a systemic
therapy regimen in Part 7, Treatment guide: Systemic
therapy. The other option is taking a watch-and-wait
approach (no treatment).
After surgery, most people will need more systemic
therapy. However, no further treatment will be an
option for some people. When there are no signs
of cancer, you can resume follow-up care and
monitoring for the return of cancer.
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NCCN Guidelines for Patients®:
Colon Cancer, 2018
5 Metastatic cancer
Review
Review
† Cancer that has spread to areas far from where
it started is called a metastasis. Colon cancer
most often spreads to the liver, and sometimes
the lungs.
† Metastases may already be present when you
first learn that you have colon cancer. This is
stage IV colon cancer. Metastases may also
occur if the cancer re-appears during follow-up
care.
† Some colon cancers with metastases can be
treated with surgery. Local therapy may be
used along with surgery or be used by itself.
Chemotherapy should also be part of treatment.
† Most colon cancers with metastases cannot
be treated with surgery. In most cases,
chemotherapy is advised. Targeted therapy
may be added.
Guide 12. Surgical options for metastases at recurrence
Option 1
First treatment options
Next treatment options
• Metastasectomy, with or without local treatment
(preferred)
• Local treatment only
If you haven’t had any chemotherapy:

◦ FOLFOX (preferred)

◦ CAPEOX (preferred)

◦ Capecitabine

◦ 5-FU/LV
If you’ve had chemotherapy:

◦ Observation

◦ Systemic therapy in Part 7
Option 2
First treatment options
Next treatment options
Chemotherapy
• FOLFOX (preferred)
• CAPEOX (preferred)
• Capecitabine
• 5-FU/LV
• Metastasectomy, with or
without local treatment
(preferred)
• Local treatment only
If chemotherapy worked:

◦ Restart same chemotherapy
regimen

◦ FOLFOX regimen

◦ Observation
If chemotherapy didn’t work:

◦ Systemic therapy in Part 7

◦ Observation
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NCCN Guidelines for Patients®:
Colon Cancer, 2018
6
Follow-up care
53 Monitoring for the return of
cancer
54 Your primary care doctor
54 Help with side effects
55 Living healthy
56 Review
53
NCCN Guidelines for Patients®:
Colon Cancer, 2018
6 Follow-up care
Monitoring for the return of cancer
Follow-up care starts when there are no
signs of cancer after treatment. It is also
called survivorship care. In addition to
monitoring for the return of cancer, follow-
up care includes managing side effects,
staying connected with your primary care
doctor, and living a healthy lifestyle.
Monitoring for the return of
cancer
Staying alert for the return of cancer is just as
important as treating it. If cancer does come back,
catching it early will give you the best chance
of beating it. The tests recommended by NCCN
experts to monitor for the return of colon cancer are
described below and shown in Guide 13.
Follow-up care for stage II, III, or IV colon cancer is
also explained on the next page.
Guide 13. Follow-up cancer care
Follow-up test
Stage I
Stage II, III, and IV
Medical history and
physical exam
Not needed on a regular basis if you don’t
have symptoms
Every 3–6 months for first 2 years, then
every 6 months for 3 more years
CEA blood test
Not needed on a regular basis if you don’t
have symptoms
Every 3–6 months for first 2 years, then
every 6 months for 3 more years
CT of chest,
abdomen, and pelvis
If you don’t have any symptoms, imaging
tests aren’t needed on a regular basis.
Your doctor may order imaging tests if he
or she thinks the cancer may have come
back or spread.
Stage II and III: Every 6–12 months for 5
years
Stage IV: Every 3–6 months for first 2
years, then every 6–12 months for 3 more
years
Colonoscopy
Colonoscopy one year after treatment
• If no advanced adenoma, repeat in 3
years, then every 5 years
• If advanced adenoma, repeat in 1 year
No prior total colonoscopy: 3–6 months
after treatment
Prior total colonoscopy: 1 year after
treatment
• If no advanced adenoma, repeat in 3
years, then every 5 years
• If advanced adenoma, repeat in 1 year
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NCCN Guidelines for Patients®:
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6 Follow-up care
Your primary care doctor
Primary ce | Side effect help
† Medical history and physical exams. Get this
care every 3 to 6 months for the first 2 years,
then every 6 months for another 3 years.
† CEA blood tests are mainly used to detect the
return of cancer. CEA levels should be tested
every 3 to 6 months for 2 years. If results are
normal for 2 years, get tested every 6 months
for another 3 years.
† CT scans may help find metastases. Scans of
your chest, abdomen, and pelvis are advised.
Get these scans every 3 to 6 months for the
first 2 years, then every 6 to 12 months for 3
more years. CT should be done with both IV
and oral contrast. CT images may be unclear or
not possible. In this case, MRI of the abdomen
and pelvis with non-contrast CT of the chest is
an option. PET/CT is not recommended.
† Ongoing colonoscopies are also part of
follow-up care. You may never have had a
total colonoscopy if your gut was blocked. If
so, get a colonoscopy within 3 to 6 months
after treatment. If you had a total colonoscopy
before, get tested 1 year after treatment. You’ll
need a colonoscopy less often if results are
normal. The next test is advised in 3 years.
If these results are normal, get tested every
5 years. If an advanced adenoma is found,
another colonoscopy within 1 year is advised.
Advanced adenomas include polyps with a
ruffled structure (villous), a polyp larger than the
width of a AAA battery (>1 cm), or a polyp with
pre-cancerous cells (high-grade dysplasia).
Your primary care doctor
After finishing cancer treatment, your primary care
doctor will play an important role in your care. Your
cancer doctor and primary doctor should work
together to make sure you get the follow-up care you
need. Your oncologist should develop a survivorship
care plan that includes:
† A summary of all cancer-related treatment(s)
you’ve had (surgeries, chemotherapy, radiation,
etc.)
† A description of the late- and long-term side-
effects you could have
† Recommendations for monitoring for the return
of cancer
† Information on when your care will be
transferred to your primary care physician. The
plan should also outline specific responsibilities
for both your cancer doctor and your PCP
(primary care physician).
† Recommendations on your overall health and
well-being.
Help with side effects
† If you have diarrhea often, or if you can’t
control your peeing or bowel movements
(incontinence), the following things may help:
• Anti-diarrheal agents
• Laxatives
• Changing your diet
• Strengthening your pelvic floor
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NCCN Guidelines for Patients®:
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6 Follow-up care
Living healthy
• Wearing protective undergarments
† The chemotherapy drug oxaliplatin can cause
nerve damage to your fingers and toes. This
means that you may have cramping, tingling, or
pain in these areas. If you have painful nerve
damage, a drug called duloxetine may provide
some relief.
† If you have an ostomy, you may want to join
an ostomy support group. Another option is
to see a health care provider that specializes
in ostomy care, such as an ostomy nurse. To
prevent damage to the ostomy, it’s a good idea
to consult with an ostomy professional before
undertaking any vigorous physical activity.
Living healthy
There are a few steps you can take that will make a
big difference in your overall health.
† Keep up with other aspects of your health. This
includes:
• Getting screened for other types of cancer.
Your primary care doctor should tell you
what cancer screening tests you should have
based on your gender, age, and risk level.
• Getting other recommended health care
for your age and gender, such as blood
pressure screening, hepatitis C screening,
and immunizations (such as the flu shot).
† Maintain a healthy body weight. The best ways
to do this are:
Figure 13
Experts recommend eating a healthy
diet, especially one that includes a
lot of plant-based foods (veggies,
fruits, and whole grains).
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6 Follow-up care
Review
• Exercising at a moderate intensity for at least
30 minutes most days of the week. If you
have an ostomy or nerve pain, your doctor
may recommend doing low-intensity exercise
or exercising fewer days per week.
• Eating a healthy diet with lots of plant-based
foods.
• Drinking little to no alcohol. This means no
more than 1 drink/day for women, and no
more than 2 drinks/day for men.
† If you are a smoker, quit! Your doctor will be
able to provide (or refer you for) counseling on
how to stop smoking.
Review
† Follow-up care should address both your
physical and emotional well-being.
† Monitoring for the return of stage II, III, and IV
colon cancer includes having regular physical
exams, CT scans, colonoscopies, and CEA
blood tests.
† Your cancer doctor and primary care doctor
should work together to make sure you get the
follow-up care you need. The recommended
care for you should be laid out in a survivorship
care plan.
† It’s very important to live a healthy lifestyle after
cancer. This means drinking less alcohol, eating
a healthy diet, exercising, quitting smoking, and
keeping up with other aspects of your health.
Figure 14
Cutting back on alcohol is an important part of
staying healthy. Experts recommend no more
than 1 drink per day for women, and no more
than 2 drinks per day for men.
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7
Treatment guide:
Systemic therapy
58 Oxaliplatin
60
Irinotecan
62 FOLFOXIRI
64 5-FU and capecitabine
66 Least toxic regimens
67 Review
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7 Systemic therapy
Oxaliplatin
This chapter presents the systemic
therapy pathways used to treat advanced
colon cancer. If one regimen doesn’t work
or stops working, there are other options
that may work for you. These are called
second- and third-line regimens. Some
of the options depend on what treatment
you’ve had before.
Oxaliplatin
Guide 14 maps a treatment path that starts with
oxaliplatin. If you see a chemotherapy regimen that
has “OX” in it (for example, FOLFOX or CAPEOX),
that means the regimen includes oxaliplatin.
FOLFOX and CAPEOX are the two options for first-
line treatment. Bevacizumab may be added to either
regimen. Cetuximab or panitumumab can be added
to FOLFOX to treat tumors with normal KRAS/NRAS
genes that are in the left side of the colon.
Oxaliplatin can harm your nervous system. Stopping
oxaliplatin—but not the other drugs—after 3 months
of use may prevent harm. Keep taking the other
drugs for 6 months. If the cancer progresses,
oxaliplatin may be restarted if it was stopped due to
side effects. You should only restart if the side effects
have ended.
Capecitabine in the CAPEOX regimen can cause a
side effect known as hand-foot syndrome. Symptoms
include redness, swelling, and pain on the palms
of the hands, bottoms of feet, or both. Sometimes
blisters appear. Your dose of capecitabine may be
changed at the earliest signs of hand-foot syndrome.
Second-line options
An oxaliplatin-based regimen may not prevent the
cancer from getting worse. If this happens, you have
several options:
† Chemotherapy:
• FOLFIRI regimen, with or without targeted
therapy. The targeted therapies cetuximab
and panitumumab should only be added if
you have normal KRAS/NRAS genes.
•
Irinotecan, with or without targeted therapy.
The targeted therapies cetuximab and
panitumumab should only be added if you
have normal KRAS/NRAS genes. For people
with a BRAF V600E mutation, vemurafenib
and either cetuximab or panitumumab are
given with irinotecan.
† Immunotherapy:
• Pembrolizumab (only for dMMR/MSI-H
tumors)
• Nivolumab, with or without ipilimumab (only
for dMMR/MSI-H tumors)
Third-line and beyond
If the cancer progresses again, one of the second-
line treatments may be an option. If not, your options
include:
† Chemotherapy with trifluridine and tipiracil
† Targeted therapy with regorafenib
† Joining a clinical trial
† Supportive care for relief from symptoms
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7 Systemic therapy
Oxaliplatin
Guide 14. Oxaliplatin pathway
First-line regimens
Notes
FOLFOX ±
• Bevacizumab
---
• Cetuximab
For left-side tumors with normal KRAS/NRAS genes
• Panitumumab
For left-side tumors with normal KRAS/NRAS genes
CAPEOX ±
Bevacizumab
---
Second-line regimens
Notes
FOLFIRI ±
• Bevacizumab
---
• Ziv-aflibercept
---
• Ramucirumab
---
• Cetuximab
Only for normal KRAS/NRAS genes
• Panitumumab
Only for normal KRAS/NRAS genes
Irinotecan ±
• Bevacizumab
---
• Ziv-aflibercept
---
• Ramucirumab
---
• Cetuximab
Only for normal KRAS/NRAS genes
• Panitumumab
Only for normal KRAS/NRAS genes
• Cetuximab and vemurafenib
For people with the BRAF V600E mutation
• Panitumumab and vemurafenib
For people with the BRAF V600E mutation
Pembrolizumab
---
Only for dMMR/MSI-H tumors
Nivolumab ±
Ipilimumab
Only for dMMR/MSI-H tumors
Third-line regimens and beyond
• Some second-line regimens if not received before
• Join a clinical trial
• Regorafenib
• Best supportive care
• Trifluridine + tipiracil
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7 Systemic therapy
Irinotecan
Irinotecan
Guide 15 maps a treatment path that starts with
FOLFIRI. If you see a chemotherapy regimen that
has “IRI” in the name (for example, FOLFIRI OR
FOLFOXIRI), it means that the regimen includes
irinotecan.
Targeted therapy with bevacizumab, cetuximab,
or panitumumab may be given with FOLFIRI.
Cetuximab and panitumumab should only be given
for people with left-side tumors and normal KRAS/
NRAS genes.
Irinotecan should be used with caution and at a low
dose if you have Gilbert’s disease or high bilirubin
levels in your blood. Gilbert’s disease impairs the
liver from correctly processing bilirubin.
Second-line options
FOLFIRI may not prevent the cancer from getting
worse. If this happens, you have several options:
† Chemotherapy:
• FOLFOX regimen, with or without
bevacizumab
• CAPEOX regimen with bevacizumab
•
Irinotecan and a targeted therapy.
The targeted therapies cetuximab and
panitumumab should only be added if you
have normal KRAS/NRAS genes. For people
with a BRAF V600E mutation, vemurafenib
and either cetuximab or panitumumab are
given with irinotecan.
† Immunotherapy:
• Pembrolizumab (only for dMMR/MSI-H
tumors)
• Nivolumab, with or without ipilimumab (only
for dMMR/MSI-H tumors)
Third-line and beyond
If the cancer progresses again, one of the second-
line treatments may be an option. If not, your options
include:
† Chemotherapy with trifluridine and tipiracil
† Targeted therapy with regorafenib
† Joining a clinical trial
† Supportive care for relief from symptoms
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7 Systemic therapy
Irinotecan
Guide 15. Irinotecan pathway
First-line regimens
Notes
FOLFIRI ±
• Bevacizumab
---
• Cetuximab
For left-side tumors with normal KRAS/NRAS genes
• Panitumumab
For left-side tumors with normal KRAS/NRAS genes
Second-line regimens
Notes
FOLFOX ±
Bevacizumab
---
CAPEOX +
Bevacizumab
---
Irinotecan +
• Cetuximab
Only for normal KRAS/NRAS genes
• Panitumumab
Only for normal KRAS/NRAS genes
• Cetuximab and vemurafenib
For people with the BRAF V600E mutation
• Panitumumab and vemurafenib
For people with the BRAF V600E mutation
Pembrolizumab
---
Only for dMMR/MSI-H tumors
Nivolumab ±
Ipilimumab
Only for dMMR/MSI-H tumors
Third-line regimens and beyond
• Some second-line regimens if not received before
• Join a clinical trial
• Regorafenib
• Best supportive care
• Trifluridine + tipiracil
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FOLFOXIRI
FOLFOXIRI
Guide 16 maps a treatment path that starts with
the FOLFOXIRI regimen. This regimen includes
leucovorin, fluorouracil, oxaliplatin, and irinotecan. It
is an intense regimen and will be too harsh for some
people. Bevacizumab (a targeted therapy) may be
given with FOLFOXIRI.
Second-line options
FOLFOXIRI may not prevent the cancer from getting
worse. If this happens, there are several options:
† Chemotherapy:
•
Irinotecan and a targeted therapy.
The targeted therapies cetuximab and
panitumumab should only be added if you
have normal KRAS/NRAS genes. For people
with a BRAF V600E mutation, vemurafenib
and either cetuximab or panitumumab are
given with irinotecan.
• Trifluridine + tipiracil
† Targeted therapy with regorafenib
† Immunotherapy:
• Pembrolizumab (only for dMMR/MSI-H
tumors)
• Nivolumab, with or without ipilimumab (only
for dMMR/MSI-H tumors)
Cetuximab or panitumumab may be options for
tumors with normal KRAS/NRAS genes. Cetuximab
or panitumumab may be received with irinotecan.
If you’re unable to take irinotecan, you may take
panitumumab or cetuximab alone.
Third-line and beyond
If the cancer progresses again, one of the second-
line treatments may be an option. Other options
include:
• Joining a clinical trial
• Supportive care for relief from symptoms
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7 Treatment guide: Systemic therapy Review
Syste
ic herapy
FOLFOXIRI
Guide 16. FOLFOXIRI pathway
First-line regimens
Notes
FOLFOXIRI ±
Bevacizumab
---
Second-line regimens
Notes
Irinotecan +
• Cetuximab
Only for normal KRAS/NRAS genes
• Panitumumab
Only for normal KRAS/NRAS genes
• Cetuximab and vemurafenib
For people with the BRAF V600E mutation
• Panitumumab and vemurafenib
For people with the BRAF V600E mutation
Regorafenib
---
---
Trifluridine + tipiracil
---
---
Pembrolizumab
---
Only for dMMR/MSI-H tumors
Nivolumab ±
Ipilimumab
Only for dMMR/MSI-H tumors
Third-line regimens and beyond
• Some second-line regimens if not received before
• Join a clinical trial
• Best supportive care
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7 Systemic therapy
5-FU and capecitabine
5-FU and capecitabine
Guide 17 maps a treatment path that starts with
two intense but less harsh regimens. One of the
first-line regimens is 5-FU/LV. This regimen includes
fluorouracil and leucovorin. Receiving 5-FU by
infusion is preferred over bolus injection. The second
option is capecitabine. Bevacizumab may be added
to either regimen.
The side effects of these regimens aren’t usually as
bad as those caused by oxaliplatin or irinotecan. So,
if the cancer progresses, you should start supportive
care if the side effects were too harsh. If not too
harsh, second-line options may be of help.
Second-line options
If the cancer progresses, there are several options:
† Chemotherapy with:
• FOLFOX regimen, with or without
bevacizumab
• CAPEOX regimen, with or without
bevacizumab
• FOLFIRI regimen, with or without a targeted
therapy
•
Irinotecan, with or without a targeted therapy
•
Irinotecan and oxaliplatin, with or without
bevacizumab
† Immunotherapy:
• Pembrolizumab (only for dMMR/MSI-H
tumors)
• Nivolumab, with or without ipilimumab (only
for dMMR/MSI-H tumors)
Third-line and beyond
If the cancer progresses again, there are multiple
options. Some of the second-line treatments may
be an option if not received before. Other options
include:
† Chemotherapy:
•
Irinotecan, with or without a targeted therapy.
The targeted therapies cetuximab and
panitumumab should only be added if you
have normal KRAS/NRAS genes. For people
with a BRAF V600E mutation, vemurafenib
and either cetuximab or panitumumab are
given with irinotecan.
• Trifluridine + tipiracil
† Targeted therapy with regorafenib
† Joining a clinical trial
† Supportive care for relief from symptoms
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7 Systemic therapy
5-FU and capecitabine
Guide 17. 5-FU and capecitabine pathway
First-line options
Notes
5-FU/leucovorin ±
Bevacizumab
---
Capecitabine ±
Bevacizumab
---
Second-line options
Notes
FOLFOX ±
Bevacizumab
---
CAPEOX ±
Bevacizumab
---
FOLFIRI ±
• Bevacizumab
---
• Ziv-aflibercept
---
• Ramucirumab
---
Irinotecan ±
• Bevacizumab
---
• Ziv-aflibercept
---
• Ramucirumab
---
Irinotecan + oxaliplatin ±
Bevacizumab
---
Pembrolizumab
---
Only for dMMR/MSI-H tumors
Nivolumab ±
Ipilimumab
Only for dMMR/MSI-H tumors
Third-line and beyond options
Notes
Irinotecan ±
• Cetuximab and vemurafenib
For people with the BRAF V600E mutation
• Panitumumab and vemurafenib
For people with the BRAF V600E mutation
• Cetuximab
Only for normal KRAS/NRAS genes
• Panitumumab
Only for normal KRAS/NRAS genes
• Regorafenib
• Trifluridine + tipiracil
• Some second-line regimens if not received before
• Join a clinical trial
• Best supportive care
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7 Treatment guide: Systemic therapy Least toxic regimens
Least toxic regimens
Chemotherapy can be very harsh on your body and
can have many unpleasant side effects. The negative
effects of chemotherapy are worse with some drugs
and regimens more than others. Your treatment team
will consider whether certain regimens would be too
harsh for you. If this is the case, there are regimens
that may be less harmful to you. These are shown in
Guide 18.
Chemotherapy with 5-FU and leucovorin (with or
without bevacizumab) is an option. Another option is
capecitabine with or without bevacizumab. Targeted
therapy (cetuximab or panitumumab) may be an
option. These drugs treat tumors with normal KRAS/
NRAS genes that are in the left side of the colon.
If the tumor is dMMR or MSI-H, treatment with
immunotherapy may be an option.
If your ability to do activities improves with one of
the regimens shown in Guide 18, your doctor may
recommend that you continue treatment with one
of the stronger regimens described earlier in this
chapter. If you are not able to tolerate the regimens
shown in Guide 18, beginning supportive care is
an option. Supportive care isn’t meant to treat the
cancer, but rather to help with symptoms and make
you more comfortable.
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7 Treatment guide: Systemic therapy Review
Review
† There are five pathways used to treat advanced
colon cancer.
† The oxaliplatin pathway starts with either
FOLFOX or CAPEOX.
† The irinotecan pathway starts with FOLFIRI.
† The FOLFOXIRI pathway starts with both
oxaliplatin and irinotecan.
† The 5-FU/LV and capecitabine pathway starts
with intense but less harsh regimens.
† The least toxic pathway starts with regimens
likely to be the least harmful to you.
Guide 18. Least toxic systemic therapy options
Treatment options
Regimens that may be used
Notes
Chemotherapy
• 5-FU + leucovorin
• Capecitabine
---
Chemotherapy + targeted therapy
• 5-FU + leucovorin + bevacizumab
• Capecitabine + bevacizumab
---
Targeted therapy
• Cetuximab
• Panitumumab
Only for left-sided tumors with
normal KRAS/NRAS genes
Immunotherapy
• Nivolumab
• Pembrolizumab
• Nivolumab + ipilimumab
Only for dMMR/MSI-H tumors
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8
Making treatment decisions
69
It’s your choice
69 Questions to ask your doctors
74 Weighing your options
75 Websites
75 Review
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8 Making treatment decisions
It’s your choice
Having cancer is very stressful. While
absorbing the fact that you have cancer,
you have to learn about tests and
treatments. In addition, the time you have
to accept a treatment plan feels short.
Parts 1 through 7 described the cancer
and treatment options. This chapter aims
to help you make decisions that are in line
with your beliefs, wishes, and values.
It’s your choice
The role each person wants in choosing his or her
treatment differs. You may feel uneasy about making
treatment decisions. This may be due to a high level
of stress. It may be hard to hear or know what others
are saying. Stress, pain, and drugs can limit your
ability to make good decisions. You may feel uneasy
because you don’t know much about cancer. You’ve
never heard the words used to describe cancer,
tests, or treatments. Likewise, you may think that
your judgment isn’t any better than your doctors’.
Letting others decide which option is best may make
you feel more at ease. But, whom do you want to
make the decisions? You may rely on your doctors
alone to make the right decisions. However, your
doctors may not tell you which option to choose if
you have multiple good options. You can also have
loved ones help. They can gather information, speak
on your behalf, and share in decision-making with
your doctors. Even if others decide which treatment
you will receive, you still have to agree by signing a
consent form.
On the other hand, you may want to take the lead
or share in decision-making. Most patients do. In
shared decision-making, you and your doctors
share information, weigh the options, and agree on
a treatment plan. Your doctors know the science
behind your plan but you know your concerns and
goals. By working together, you are likely to get a
higher quality of care and be more satisfied. You’ll
likely get the treatment you want, at the place you
want, and by the doctors you want.
Questions to ask your doctors
You may meet with experts from different fields of
medicine. Strive to have helpful talks with each
person. Prepare questions before your visit and ask
questions if the person isn’t clear. You can also take
notes and get copies of your medical records.
It may be helpful to have your spouse, partner, family
member, or a friend with you at these visits. A patient
advocate or navigator might also be able to come.
They can help to ask questions and remember what
was said. Suggested questions to ask include:
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8 Making treatment decisions
What’s my diagnosis and prognosis?
What’s my diagnosis and prognosis?
It’s important to know that there are different types of cancer. Cancer can greatly differ even when
people have a tumor in the same organ. Based on your test results, your doctors can tell you which
type of cancer you have. He or she can also give a prognosis. A prognosis is a prediction of the pattern
and outcome of a disease. Knowing the prognosis may affect what you decide about treatment.
1. Where did the cancer start? In what type of cell? Is this cancer common?
2. What is the cancer stage? Does this stage mean the cancer has spread far?
3. Is this a fast- or slow-growing cancer?
4. What tests do you recommend for me?
5. Where will the tests take place? How long will the tests take and will any test hurt?
6. What if I am pregnant?
7. How do I prepare for testing?
8. Should I bring a list of my medications?
9. Should I bring someone with me?
10. How often are these tests wrong?
11. Would you give me a copy of the pathology report and other test results?
12. Who will talk with me about the next steps? When?
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8 Making treatment decisions
What are my options?
What are my options?
There is no single treatment practice that is best for all people. There is often more than one treatment
option along with clinical trial options. Your doctor will review your test results and recommend
treatment options.
1. What will happen if I do nothing?
2. Can I just carefully monitor the cancer?
3. Do you consult NCCN recommendations when considering options?
4. Are you suggesting options other than what NCCN recommends? If yes, why?
5. Do your suggested options include clinical trials? Please explain why.
6. How do my age, health, and other factors affect my options? What if I am pregnant?
7. Which option is proven to work best?
8. Which options lack scientific proof?
9. What are the benefits of each option? Does any option offer a cure or long-term cancer control?
Are my chances any better for one option than another? Less time-consuming? Less expensive?
10. What are the risks of each option? What are possible complications? What are the rare and common
side effects? Short-lived and long-lasting side effects? Serious or mild side effects? Other risks?
11. How do you know if treatment is working?
12. What are my options if my treatment stops working?
13. What can be done to prevent or relieve the side effects of treatment?
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8 Making treatment decisions
What does each option require of me?
What does each option require of me?
Many patients consider how each option will practically affect their lives. This information may be
important because you have family, jobs, and other duties to take care of. You also may be concerned
about getting the help you need. If you have more than one option, choosing the option that is the
least taxing may be important to you:
1. Will I have to go to the hospital or elsewhere? How often? How long is each visit?
2. What do I need to think about if I will travel for treatment?
3. Do I have a choice of when to begin treatment? Can I choose the days and times of treatment?
4. How do I prepare for treatment? Do I have to stop taking any of my medicines? Are there foods I
will have to avoid?
5. Should I bring someone with me when I get treated?
6. Will the treatment hurt?
7. How much will the treatment cost me? What does my insurance cover?
8. Will I miss work or school? Will I be able to drive?
9. Is home care after treatment needed? If yes, what type?
10. How soon will I be able to manage my own health?
11. When will I be able to return to my normal activities?
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8 Making treatment decisions
What is your experience?
What is your experience?
More and more research is finding that patients treated by more experienced doctors have better
results. It is important to learn if a doctor is an expert in the cancer treatment he or she is offering.
1. Are you board certified? If yes, in what area?
2. How many patients like me have you treated?
3. How many procedures like the one you’re suggesting have you done?
4. Is this treatment a major part of your practice?
5. How many of your patients have had complications?
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8 Making treatment decisions
Weighing your options
Weighing your options
Deciding which option is best can be hard. Doctors
from different fields of medicine may have different
opinions on which option is best for you. This can be
very confusing. Your spouse or partner may disagree
with which option you want. This can be stressful.
In some cases, one option hasn’t been shown to
work better than another. Some ways to decide on
treatment are discussed next.
2nd opinion
The time around deciding a treatment is very
stressful. People with cancer often want to get
treated as soon as possible. They want to make
their cancer go away before it spreads farther. While
cancer can’t be ignored, usually there is time to think
about and choose which option is best for you.
You may wish to have another doctor review your
test results and suggest a treatment plan. This is
called getting a 2nd opinion. You may completely trust
your doctor, but a 2nd opinion about which option is
best can help.
Copies of the pathology report, a DVD of the
imaging tests, and other test results need to be sent
to the doctor giving the 2nd opinion. Some people
feel uneasy asking for copies from their doctors.
However, a 2nd opinion is a normal part of cancer
care.
When doctors have cancer, most will talk with more
than one doctor before choosing their treatment.
What’s more, some health plans require a 2nd
opinion. If your health plan doesn’t cover the cost
of a 2nd opinion, you have the choice of paying for it
yourself.
If the two opinions are the same, you may feel more
at peace about the treatment you accept to have.
If the two opinions differ, think about getting a 3rd
opinion. A 3rd opinion may help you decide between
your options. Choosing your cancer treatment is a
very important decision. It can affect your length and
quality of life.
Support groups
Besides talking to health experts, it may help to talk
to other people who have walked in your shoes. At
support groups, you can ask questions and hear
about the experiences of other people with colon
cancer. Find a support group at the websites listed
on the next page.
Compare benefits and downsides
Every option has benefits and downsides. Consider
these when deciding which option is best for you.
Talking to others can help identify benefits and
downsides you haven’t thought of. Scoring each
factor from 0 to 10 can also help since some factors
may be more important to you than others.
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8 Making treatment decisions
Websites | Review
Websites
American Cancer Society
cancer.org/cancer/colonandrectumcancer/
detailedguide/index
Cancer Support Community
cancersupportcommunity.org
Colorectal Cancer Alliance
ccalliance.org
Fight Colorectal Cancer
FightColorectalCancer.org
National Cancer Institute (NCI)
cancer.gov/types/colorectal
National Coalition for Cancer Survivorship
canceradvocacy.org/toolbox
NCCN for Patients®
nccn.org/patients
Review
† Shared decision-making is a process in which
you and your doctors plan treatment together.
† Asking your doctors questions is vital to getting
the information you need to make informed
decisions.
† Getting a 2nd opinion, attending support groups,
and comparing benefits and downsides may
help you decide which treatment is best for you.
As a caregiver I provide comfort and support where no one else can,
being the foundation my wife needs for her treatment and her care.
– Frederick
Caregiver
“
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Glossary
77 Dictionary
81 Acronyms
77
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Dictionary
Dictionary
abdomen
The belly area between the chest and pelvis.
ablation
Treatment using radiofrequency or cold to destroy cancer
cells.
adenocarcinoma
Cancer in cells that line organs and make fluids or
hormones.
adenoma
The most common type of polyp and is the most likely to
form cancer cells. Also called adenomatous polyps.
adjuvant treatment
Treatment that is given to lower the chances of the cancer
returning.
adventitia
The outer layer, in some places, of the colon wall.
angiolymphatic invasion
Cancer has spread into the tumor’s lymph or blood vessels.
anus
The opening at the end of the digestive system that allows
stool to pass out of the body.
bilirubin
A substance in the body that causes bodily fluids to be
yellow.
biopsy
Removal of small amounts of tissue or fluid to be tested for
disease.
bolus
A fast injection of a drug.
boost
An extra dose of radiation to a specific area of the body.
cancer grade
How closely the cancer cells look like normal cells.
cancer stage
Rating of the growth and spread of tumors.
carcinoembryonic antigen (CEA)
A protein that gets released by some tumors and can be
detected in blood as a tumor marker.
carcinoma in situ
Cancer that has not grown into tissue that could allow
cancer cells to spread. It is a noninvasive cancer.
catheter
A flexible tube inserted in the body to give treatment or drain
fluid from the body.
chemotherapy
Drugs that stop the life cycle of cells so they don’t increase
in number.
clinical stage
The rating of the extent of cancer based on tests before
treatment.
clinical trial
Research on a test or treatment to assess its safety or how
well it works.
colectomy
Surgery to remove a part of the colon.
colon
The hollow organ in which eaten food turns from a liquid into
a solid form.
colonoscope
A thin, long tube with a light and camera used to see the
colon.
colonoscopy
Insertion of a thin tool into the colon to view or remove
tissue.
colostomy
Surgery to connect a part of the colon to the outside of the
abdomen and that allows stool to drain into a bag.
complete blood count (CBC)
A test of the number of blood cells.
computed tomography (CT)
A test that uses x-rays from many angles to make a picture
of the inside of the body.
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Dictionary
contrast
A dye put into your body to make clearer pictures during
imaging tests.
deoxyribonucleic acid (DNA)
A very thin and long molecule that contains genetic code.
Also called the “blueprint of life.”
diagnosis
To identify a disease.
digestive system
A set of organs in the body that changes food into small
parts for the body to use as energy.
embolization
Blockage of blood flow to a tumor with beads that emit either
chemotherapy or radiation.
endoscopic polypectomy
Surgery to remove a polyp during a colonoscopy.
enema
Injection of liquid into the rectum to clear the bowel.
epithelium
Tissue that lines the colon wall.
esophagus
The tube-shaped digestive organ between the mouth and
stomach.
external beam radiation therapy (EBRT)
Treatment with radiation received from a machine outside
the body.
familial adenomatous polyposis (FAP)
An inherited medical condition that increases the odds of
colon cancer.
gene
Coded instructions in cells for making new cells and
controlling how cells behave.
general anesthesia
A controlled loss of wakefulness from drugs.
hereditary non-polyposis colon cancer (HNPCC)
An inherited medical condition that increases the odds of
colon cancer. Also called Lynch syndrome.
hives
Itchy, swollen, and red skin caused by the body ridding itself
of an invader.
hyperplastic polyp
A polyp that grows fast and is often found in the last part of
the colon.
imaging test
A test that makes pictures of the insides of the body.
inflammatory bowel disease
A medical condition that causes the intestine to swell.
inflammatory polyp
A polyp that often grows after the intestine swells.
infusion
A method of giving drugs slowly through a needle into a
vein.
intensity-modulated radiation therapy (IMRT)
Radiation therapy that uses small beams of different
strengths based on the thickness of the tissue.
intraoperative radiation therapy (IORT)
Radiation therapy that is given inside the body at the end of
an operation.
invasive cancer
Cancer cells have grown into the second layer of the colon
wall.
lamina propria
Connective tissue within the mucosa of the colon wall.
large intestine
The digestive organ that prepares unused food for leaving
the body.
laxative
Drugs used to clean out the intestines.
lymph
A clear fluid containing white blood cells.
lymph node
Small groups of special disease-fighting cells located
throughout the body.
lymphadenectomy
Surgery to remove lymph nodes.
magnetic resonance imaging (MRI)
A test that uses a magnetic field and radio waves to make
pictures of the insides of the body.
medical history
All health events and medications taken to date.
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Dictionary
metastasectomy
Surgery to remove cancer that has spread far from the first
tumor.
metastasis
The spread of cancer cells from the first (primary) tumor to a
distant site.
microsatellite instability (MSI)
Errors in a small DNA part that happen when DNA is making
a copy of itself.
microsatellite instability-high (MSI-H)
The presence of 2 or more MSI markers.
mismatch repair deficient (dMMR)
Abnormal changes in genes that contain instructions for
making proteins that fix errors in DNA.
mismatch repair (MMR) proteins
Proteins that correct DNA errors that occur when copies of
DNA are being made.
mucosa
The first, inner layer of the colon wall.
mucus
A sticky, thick liquid that moisturizes or lubricates.
muscularis mucosae
A thin layer of muscle within the mucosa of the colon wall.
muscularis propria
The third layer of the colon wall made mostly of muscle.
mutation
An abnormal change in the instructions within cells for
making and controlling cells.
needle biopsy
Removal of tissue or fluid samples from the body with a
needle.
neoadjuvant treatment
Treatment given before the main treatment used to cure
disease. Also called preoperative treatment.
noninvasive cancer
Cancer cells have not grown into the second layer of the
colon wall.
observation
A period of testing for cancer growth.
parietal peritoneum
The outer layer of tissue lining around the abdomen.
pathologic stage
A rating of the extent of cancer based on tests given after
treatment.
pathologist
A doctor who’s an expert in testing cells and tissue to find
disease.
pedunculated polyp
A polyp shaped like a mushroom with a stalk.
pelvis
The area between the hip bones.
perineural invasion
Spread of cancer into nearby nerves.
physical exam
A review of the body by a health expert for signs of disease.
polyp
An extra growth of tissue from the epithelium of the colon
wall.
portal vein embolization
The blood vessel to the liver tumor is blocked causing the
healthy part of the liver to grow larger.
positron emission tomography (PET)
Use of radioactive material to see the shape and function of
body parts.
positron emission tomography/computed
tomography (PET/CT)
A test that uses radioactive material and x-rays to view the
shape and function of organs and tissues.
primary tumor
The first mass of cancer cells in the body.
prognosis
The pattern and outcome of a disease.
progression
The growth or spread of cancer after being tested or treated.
radiation therapy
The use of high-energy rays to destroy cancer cells.
radiologist
A doctor who specializes in reading imaging tests.
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Dictionary
rectum
An organ in the digestive system that holds stool until
expelled from the body.
recurrence
The return of cancer after a cancer-free period.
serosa
The outer layer, in some places, of the colon wall that
makes fluid so that organs can slide against one another;
also called the visceral peritoneum.
sessile polyp
A polyp that is flat.
side effect
An unplanned physical or emotional response to treatment.
small intestine
The digestive organ that absorbs nutrients from eaten food.
stereotactic body radiation therapy (SBRT)
Radiation therapy that uses precise, high-dose beams.
stool
Unused food passed out of the body; also called feces.
submucosa
The second layer of the colon wall made mostly of
connective tissue.
subserosa
A thin layer of connective tissue that makes fluid.
supportive care
Treatment for the symptoms or health conditions caused by
cancer or cancer treatment.
surface receptor
A protein found in the membrane of cells.
surgical margin
The normal tissue around the edge of a tumor that is
removed during surgery.
targeted therapy
Drugs that stop the action of molecules that start the growth
of cancer cells.
three-dimensional conformal radiation therapy
(3D-CRT)
Radiation therapy that uses beams that match the shape of
the tumor.
total colonoscopy
Insertion of a thin tool into the colon to view the entire colon
and, if needed, remove tissue.
tumor budding
A group of 5 or fewer cancer cells separate from the main
tumor.
tumor deposit
The presence of tiny tumors where the lymph drains from
the tumor.
ultrasound
A test that uses sound waves to take pictures of the insides
of the body.
villous polyp
A polyp with a ruffled structure.
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Acronyms
Acronyms
3D-CRT
three-dimensional conformal radiation therapy
AJCC
American Joint Committee on Cancer
CBC
complete blood count
CEA
carcinoembryonic antigen
CT
computed tomography
dMMR
mismatch repair deficient
DNA
deoxyribonucleic acid
EBRT
external beam radiation therapy
FAP
familial adenomatous polyposis
FDA
U.S. Food and Drug Administration
HAI
hepatic arterial infusion
HNPCC
hereditary non-polyposis colon cancer
IMRT
intensity-modulated radiation therapy
IORT
intraoperative radiation therapy
MMR
mismatch repair
MRI
magnetic resonance imaging
MSI
microsatellite instability
MSI-H
microsatellite instability-high
MSI-L
microsatellite instability-low
NCCN®
National Comprehensive Cancer Network®
PET
positron emission tomography
PET/CT
positron emission tomography/computed tomography
SBRT
stereotactic body radiation therapy
TNM
tumor, node, metastasis

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NCCN Guidelines for Patients®:
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NCCN Panel Members
NCCN Panel Members for
Colon Cancer
Al B. Benson, III, MD/Chair
Robert H. Lurie Comprehensive Cancer
Center of Northwestern University
Alan P. Venook, MD/Vice-Chair
UCSF Helen Diller Family
Comprehensive Cancer Center
Mahmoud M. Al-Hawary, MD
University of Michigan Rogel Cancer Center
Mustafa A. Arain, MD
UCSF Hellen Diller Family
Comprehensive Cancer Center
Yi-Jen Chen, MD, PhD
City of Hope National Medical Center
Kristen K. Ciombor, MD
Vanderbilt-Ingram Cancer Center
Stacey Cohen, MD
Fred Hutchinson Cancer Research Center/
Seattle Cancer Care Alliance
Harry S. Cooper, MD
Fox Chase Cancer Center
Dustin Deming, MD
University of Wisconsin
Carbone Cancer Center
Paul F. Engstrom, MD
Fox Chase Cancer Center
Ignacio Garrido-Laguna, MD, PhD
Huntsman Cancer Institute
at the University of Utah
Jean L. Grem, MD
Fred & Pamela Buffett Cancer Center
Sarah Hoffe, MD
Moffitt Cancer Center
Joleen Hubbard, MD
Mayo Clinic Cancer Center
Steven Hunt, MD
Siteman Cancer Center at Barnes-
Jewish Hospital and Washington
University School of Medicine
Ahmed Kamel, MD
University of Alabama at Birmingham
Comprehensive Cancer Center
Natalie Kirilcuk, MD
Stanford Cancer Institute
Smitha Krishnamurthi, MD
Case Comprehensive Cancer Center/
University Hospitals Seidman Cancer
Center and Cleveland Clinic Taussig
Cancer Institute
Wells A. Messersmith, MD
University of Colorado Cancer Center
Jeffrey Meyerhardt, MD
MPH Dana-Farber Cancer Institute
Eric D. Miller, MD, PhD
The Ohio State University Comprehensive
Cancer Center - James Cancer Hospital
and Solove Research Institute
Mary F. Mulcahy, MD
Robert H. Lurie Comprehensive Cancer
Center of Northwestern University
James D. Murphy, MD, MS
UC San Diego Moores Cancer Center
Steven Nurkin, MD, MS
Roswell Park Cancer Institute
Michael J. Overman, MD
The University of Texas
MD Anderson Cancer Center
Katrina Pedersen, MD, MS
Siteman Cancer Center at Barnes-
Jewish Hospital and Washington
University School of Medicine
Leonard Saltz, MD
Memorial Sloan Kettering Cancer Center
David Shibata, MD
The University of Tennessee
Health Science Center
John M. Skibber, MD
The University of Texas
MD Anderson Cancer Center
Constantinos T. Sofocleous, MD, PhD
Memorial Sloan Kettering Cancer Center
Elena M. Stoffel, MD, MPH
University of Michigan Rogel Cancer Center
Eden Stotsky-Himelfarb, BSN, RN
The Sidney Kimmel Comprehensive Cancer
Center at Johns Hopkins
Christopher G. Willett, MD
Duke Cancer Institute

NCCN Staff
Kristina M. Gregory, RN, MSN, OCN
Vice President/Clinical Information Operations
Lisa Gurski, PhD
Oncology Scientist/ Senior Medical Writer
* Reviewed the clinical content of this book.
For disclosures, visit www.nccn.org/about/disclosure.aspx.
*
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NCCN Guidelines for Patients®:
Colon Cancer, 2018
NCCN Member Institutions
Abramson Cancer Center
at the University of Pennsylvania
Philadelphia, Pennsylvania
800.789.7366
pennmedicine.org/cancer
Fred & Pamela Buffett Cancer Center
Omaha, Nebraska
800.999.5465
nebraskamed.com/cancer
Case Comprehensive Cancer Center/
University Hospitals Seidman Cancer
Center and Cleveland Clinic Taussig
Cancer Institute
Cleveland, Ohio
800.641.2422 • UH Seidman Cancer Center
uhhospitals.org/seidman
866.223.8100 • CC Taussig Cancer Institute
my.clevelandclinic.org/services/cancer
216.844.8797 • Case CCC
case.edu/cancer
City of Hope National Medical Center
Los Angeles, California
800.826.4673
cityofhope.org
Dana-Farber/Brigham and
Women’s Cancer Center
Massachusetts General Hospital
Cancer Center
Boston, Massachusetts
877.332.4294
dfbwcc.org
massgeneral.org/cancer
Duke Cancer Institute
Durham, North Carolina
888.275.3853
dukecancerinstitute.org
Fox Chase Cancer Center
Philadelphia, Pennsylvania
888.369.2427
foxchase.org
Huntsman Cancer Institute
at the University of Utah
Salt Lake City, Utah
877.585.0303
huntsmancancer.org
Fred Hutchinson Cancer
Research Center/Seattle
Cancer Care Alliance
Seattle, Washington
206.288.7222 • seattlecca.org
206.667.5000 • fredhutch.org
The Sidney Kimmel Comprehensive
Cancer Center at Johns Hopkins
Baltimore, Maryland
410.955.8964
hopkinskimmelcancercenter.org
Robert H. Lurie Comprehensive Cancer
Center of Northwestern University
Chicago, Illinois
866.587.4322
cancer.northwestern.edu
Mayo Clinic Cancer Center
Phoenix/Scottsdale, Arizona
Jacksonville, Florida
Rochester, Minnesota
800.446.2279 • Arizona
904.953.0853 • Florida
507.538.3270 • Minnesota
www.mayoclinic.org/cancercenter
Memorial Sloan Kettering
Cancer Center
New York, New York
800.525.2225
mskcc.org
Moffitt Cancer Center
Tampa, Florida
800.456.3434
moffitt.org
The Ohio State University
Comprehensive Cancer Center -
James Cancer Hospital and
Solove Research Institute
Columbus, Ohio
800.293.5066
cancer.osu.edu
Roswell Park Comprehensive
Cancer Center
Buffalo, New York
877.275.7724
roswellpark.org
Siteman Cancer Center at Barnes-
Jewish Hospital and Washington
University School of Medicine
St. Louis, Missouri
800.600.3606
siteman.wustl.edu
St. Jude Children’s Research Hospital
The University of Tennessee
Health Science Center
Memphis, Tennessee
888.226.4343 • stjude.org
901.683.0055 • westclinic.com
Stanford Cancer Institute
Stanford, California
877.668.7535
cancer.stanford.edu
University of Alabama at Birmingham
Comprehensive Cancer Center
Birmingham, Alabama
800.822.0933
www3.ccc.uab.edu
UC San Diego Moores Cancer Center
La Jolla, California
858.657.7000
cancer.ucsd.edu
UCSF Helen Diller Family
Comprehensive Cancer Center
San Francisco, California
800.689.8273
cancer.ucsf.edu
University of Colorado Cancer Center
Aurora, Colorado
720.848.0300
coloradocancercenter.org
University of Michigan
Rogel Cancer Center
Ann Arbor, Michigan
800.865.1125
mcancer.org
The University of Texas
MD Anderson Cancer Center
Houston, Texas
800.392.1611
mdanderson.org
University of Wisconsin
Carbone Cancer Center
Madison, Wisconsin
608.265.1700
uwhealth.org/cancer
Vanderbilt-Ingram Cancer Center
Nashville, Tennessee
800.811.8480
vicc.org
Yale Cancer Center/
Smilow Cancer Hospital
New Haven, Connecticut
855.4.SMILOW
yalecancercenter.org
NCCN Member Institutions
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NCCN Guidelines for Patients®:
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NCCN Member Institutions
Index
Index
2nd opinion 74–75
ablation 31, 33, 46, 50
BRAF mutation 14, 21–22, 44, 48–49, 58–66
cancer staging 12
carcinoembryonic antigen (CEA) 14, 18, 22, 48,
53–54
carcinoma in situ 12
chemotherapy 26–27, 32–33, 37–40, 42, 44–51,
54–55, 58, 60–67
clinical trial 32–33, 58–65
colectomy 24–25, 33, 36–39, 42, 46–47, 49
colonoscopy 11, 14, 16–17, 36–37, 48, 53–54,
complete blood count (CBC) 18, 22
computed tomography (CT) 14,16,18–19, 46–48,
50, 53–54, 56
digestive tract 8–9
familial adenomatous polyposis (FAP) 15–16, 22
hereditary non-polyposis colon cancer (HNPCC)
15, 21–22
immunotherapy 29, 45, 58, 60–67
KRAS/NRAS genes 14, 21–22, 44, 48–49, 58–67
lymphadenectomy 25, 33, 36–39, 41–42
Lynch syndrome 15, 21–22
medical history 14, 22, 53–54
metastasectomy 25, 33, 47, 51
microsatellite instability (MSI) 14, 21, 40–41,
48–49, 58–67
mismatch repair (MMR) 14, 21, 40–41, 48–49,
58–67
NCCN Member Institutions 83
NCCN Panel Members 82
polypectomy 11–12, 37, 42
polyp 11–12, 15–17, 24, 35–37, 42, 54
radiation therapy 30–33, 37–39, 54
shared decision–making 69, 75
supportive care 58–66
survivorship 53–54, 56
targeted therapy 28, 33, 44–45, 48, 51, 58–67
Ü
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