Colorectal resection vs chemotherapy in stage IV colorectal cancer

Stage IV colon cancers have spread from the colon to distant organs and tissues. Colon cancer most often spreads to the liver, but it can also spread to other places like the lungs, brain, peritoneum (the lining of the abdominal cavity), or to distant lymph nodes.



In most cases surgery is unlikely to cure these cancers. But if there are only a few small areas of cancer spread (metastases) in the liver or lungs and they can be removed along with the colon cancer, surgery may help you live longer. This would mean having surgery to remove the section of the colon containing the cancer along with nearby lymph nodes, plus surgery to remove the areas of cancer spread. Chemo is typically given after surgery, as well. In some cases, hepatic artery infusion may be used if the cancer has spread to the liver.



If the metastases cannot be removed because they’re too big or there are too many of them, chemo may be given before surgery (neoadjuvant chemo). Then, if the tumors shrink, surgery may be tried to remove them . Chemo might be given again after surgery. For tumors in the liver, another option may be to destroy them with ablation or embolization.



If the cancer has spread too much to try to cure it with surgery, chemo is the main treatment. Surgery might still be needed if the cancer is blocking the colon or is likely to do so. Sometimes, such surgery can be avoided by putting a stent (a hollow metal tube) into the colon during a colonoscopy to keep it open. Otherwise, operations such as a colectomy or diverting colostomy (cutting the colon above the level of the cancer and attaching the end to an opening in the skin on the belly to allow waste out) may be used.



If you have stage IV cancer and your doctor recommends surgery, it’s very important to understand the goal of the surgery ─ whether it’s to try to cure the cancer or to prevent or relieve symptoms of the cancer.



Most people with stage IV cancer will get chemo and/or targeted therapies to control the cancer. Some of the most commonly used regimens include:



FOLFOX: leucovorin, 5-FU, and oxaliplatin (Eloxatin)


FOLFIRI: leucovorin, 5-FU, and irinotecan (Camptosar)


CAPEOX or CAPOX: capecitabine (Xeloda) and oxaliplatin


FOLFOXIRI: leucovorin, 5-FU, oxaliplatin, and irinotecan


One of the above combinations plus either a drug that targets VEGF, (bevacizumab [Avastin], ziv-aflibercept [Zaltrap], or ramucirumab [Cyramza]), or a drug that targets EGFR (cetuximab [Erbitux] or panitumumab [Vectibix])


5-FU and leucovorin, with or without a targeted drug


Capecitabine, with or without a targeted drug


Irinotecan, with or without a targeted drug


Cetuximab alone


Panitumumab alone


Regorafenib (Stivarga) alone


Trifluridine and tipiracil (Lonsurf)


The choice of regimens depends on several factors, including any previous treatments you’ve had and your overall health.



If one of these regimens is no longer working, another may be tried. For people with certain tumor changes in the MMR genes, another option after initial chemotherapy might be treatment with an immunotherapy drug such as pembrolizumab (Keytruda) or nivolumab (Opdivo).



For advanced cancers, radiation therapy can also be used to help prevent or relieve symptoms in the colon from the cancer such as pain. It might also be used to treat areas of spread such as in the lungs or bone. It may shrink tumors for a time, but it’s not likely to cure the cancer. If your doctor recommends radiation therapy, it’s important that you understand the goal of treatment.

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