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Treatment of stage 4 metastatic colon cancer

Colon cancer is a common and lethal disease. It is estimated that approximately 141,210 new cases of large bowel cancer will be diagnosed in the United States in 2011, including about 101,000 colon and 40,000 rectal cancers.   Colon cancer mortality has been progressively declining since 1990 at a rate of about 3 percent per year.

Screening with fecal occult blood testing, colonoscopy, or radiology can lead to diagnosis at an earlier stage of disease and therefore reduce mortality. 

Symptoms of colon cancer are typically due to growth of the tumor into the lumen of the colon or adjacent structures. As a result, symptomatic presentation is often a manifestation of relatively advanced colon cancer. The majority of patients presenting with symptomatic colon cancer have blood in the stool, abdominal pain, otherwise unexplained iron deficiency anemia and/or a change in bowel habits


Staging of Colon Cancer:


Preoperative clinical staging is best accomplished by physical examination (with particular attention to ascites, hepatomegaly and lymphadenopathy), CT scan of the abdomen and pelvis, and chest imaging. Although frequently obtained preoperatively, liver enzymes may be normal in the setting of small hepatic metastases and are not a reliable marker for exclusion of liver involvement. The single most common liver test abnormality associated with liver metastases is an elevation in the serum alkaline phosphatase level.

Serum CEA levels should be obtained preoperatively in patients with demonstrated colorectal cancer to aid surgical treatment planning, assessment of prognosis and follow-up. Elevated preoperative CEA levels that do not normalize following surgical resection imply the presence of persistent disease and the need for further evaluation.


Treatment of Colon Cancer:


Surgical resection is the primary treatment modality for colon cancer, and outcome is most closely related to the extent of disease at presentation. 

If patient however has metastatic disease spread to other parts of the body, your medical oncologist may recommend starting chemotherapy first before considering surgical resection of the colon cancer.

Palliative Chemotherapy for Advanced Metastatic Colon Cancer:


For patients who are able to tolerate it, we suggest a chemotherapy doublet (FOLFOX, XELOX, or FOLFIRI) rather than a single agent or a triplet regimen containing both irinotecan and oxaliplatin.

FOLFOX and FOLFIRI have similar first-line efficacy, and the decision to use one or the other should mainly be based on the expected toxicity profile of both regimens. Most American clinicians start with FOLFOX. Although less widely used, at least in the US, FOLFIRI may be preferred in patients with a preexisting neuropathy, or if the development of a severe sensory neuropathy might jeopardize their livelihood (eg, in a professional musician).

For patients receiving oxaliplatin, supplemental cal-mag infusions (1 g calcium gluconate plus 1 g magnesium sulfate) 30 minutes pre- and post-oxaliplatin may protect against some forms of neurotoxicity. Given the lack of definitive evidence that cal-mag interferes with antitumor efficacy (at least in metastatic disease) and the absence of other effective neuroprotectants, it is reasonable to do this in patients being treated in a palliative setting.

Regardless of whether an oxaliplatin-based or an irinotecan-based chemotherapy regimen is selected, we suggest adding bevacizumab to the first-line

The potential for improved outcomes from adding avastin to first-line therapy must be balanced against the potential for serious treatment-related toxicity. In particular, the use of bevacizumab in elderly patients with a history of an arterial thromboembolic event within 6 to 12 months must be individualized.

Because of the risk of impaired wound healing, bowel perforation, and fistula formation, at least 28 days should elapse between major surgery and administration of bevacizumab, except in emergency situations. This recommendation does not apply to minor procedures such as implantation of a venous access device.

For selected patients (eg, those with wild-type K-ras tumors, and a contraindication to Avastin) adding cetuximab or panitumumab to a first-line  irinotecan-based therapy is a reasonable option. There is also benefit to adding panitumumab to a first-line oxaliplatin based regimen, while the benefit of adding cetuximab to a first-line oxaliplatin-based regimen is unclear

For patients who are not candidates for an intensive first-line oxaliplatin or irinotecan-based regimen, we suggest 5-FU plus LV or capcitabine.

Survival Rates of Colon Cancer Based on Staging:


Five-year survival rates according to tumor stage at diagnosis (using the older 2002 AJCC staging criteria for 119,363 patients with colon cancer reported to the SEER (Surveillance, Epidemiology and End Results) database between 1991 and 2000 were as follows:

  • Stage I (T1-2 N0) — 93 percent
  • Stage IIA (T3N0) — 85 percent
  • Stage IIB (T4N0) — 72 percent
  • Stage IIIA (T1-2 N1) — 83 percent
  • Stage IIIB (T3-4 N1) — 64 percent
  • Stage IIIC (N2 disease) — 44 percent

These are simply statistics and do not imply how you as the patient will do with the same stage of cancer.   It is always best to remain hopeful and optimistic.


 TNM staging for colorectal cancer

Primary tumor (T)
TXPrimary tumor cannot be assessed
T0No evidence of primary tumor
TisCarcinoma in situ: intraepithelial or invasion of lamina propria*
T1Tumor invades submucosa
T2Tumor invades muscularis propria
T3Tumor invades through the muscularis propria into pericolorectal tissues
T4aTumor penetrates to the surface of the visceral peritoneum•
T4bTumor directly invades or is adherent to other organs or structures•Δ
Regional lymph node (N)◊
NXRegional lymph nodes cannot be assessed
N0No regional lymph node metastasis
N1Metastasis in 1-3 regional lymph nodes
N1aMetastasis in one regional lymph node
N1bMetastasis in 2-3 regional lymph nodes
N1cTumor deposit(s) in the subserosa, mesentery, or nonperitonealized pericolic or perirectal tissues without regional nodal metastasis
N2Metastasis in four or more regional lymph nodes
N2aMetastasis in 4-6 regional lymph nodes
N2bMetastasis in seven or more regional lymph nodes
Distant metastasis (M)
M0No distant metastasis
M1Distant metastasis
M1aMetastasis confined to one organ or site (eg, liver, lung, ovary, nonregional node)
M1bMetastases in more than one organ/site or the peritoneum
Anatomic stage/prognostic groups§
IVAAny TAny NM1a--
IVBAny TAny NM1b--


Here, Dr. Tony Talebi discusses general concepts of colon cancer with Dr. Caio Rocha Lima, professor of medicine at the University of Miami including chemotherapy for colon cancer, colon cancer awareness month, colon cancer symtoms, warning signs of colon cancer, colon cancer screening, stage 4 colon cancer, symptons of colon cancer, chemo for colon cancer, stage four colon cancer, colon cancer diet, how to check for colon cancer, what are symptoms of colon cancer,stage iv colon cancer, colon cancer bowel movements, preventing colon cancer, colon cancer support groups, colon cancer foundation, sigmoid colon cancer, about colon cancer, cure for colon cancer, facts about colon cancer, colon cancer warning signs, colon cancer hereditary, metastatic colon cancer, signs of colon cancer in men, colon cancer hereditary, surgery for colon cancer, colon cancer definition, advanced colon cancer, colon cancer com, can colon cancer be cured, diet for colon cancer, treating colon cancer, colon cancer color, can colon cancer be cured, treating colon cancer, colon cancer surgery, symptoms colon cancer women, is colon cancer hereditary, stage 3 colon cancer life expectancy, signs and symptoms of colon cancer


Dr. Caio Rocha Lima Credentials:

Board Certifications
American Board of Internal Med-Medical Oncology

Practice Locations
University of Miami Sylvester Comprehensive Cancer Center

Professor of Medicine

Co-leader of Phase I clinical trials