Treatment

Your treatment options depend on the stage of colorectal cancer, your overall health and your preferences about treatment. In metastatic disease, the location and extent of the cancer is also an important consideration. In all cases, treatment should be individualized for you. Although cancers are classified into particular stages, each person is unique.

You do not have to rush to make a decision, so consider the options carefully. Ask questions if you do not understand any aspect of treatment or the terms your doctors are using. Research shows that cancer survivors of all educational levels and backgrounds can have a hard time communicating with their health care team. One of the best ways to improve communication with your health care team is to prepare your visits so that you can best make use of the time.

A treatment plan is a way to deal with both the short and long term goals of managing your cancer. There are several treatment options for colorectal cancer, depending on the cancer location, stage and the patient’s age and general health. People with colorectal cancer have time for second opinions and to talk through all of their options with their doctors and develop a treatment plan that best fits their needs.

Colorectal Cancer Treatment Options

Surgery

Surgery is usually the first treatment for Colon Cancer. The goal of the surgery is to remove as much of the cancer from the body as possible. Cancer that is small and has not spread beyond the colon where it started (Stage I), may be cured by surgery alone.

There are different types of surgery for colon cancer. Each one has advantages and disadvantages. Discuss with your healthcare team which type of surgery might be best for you. Consider seeking out a surgeon who is certified in colorectal surgery.

Following is a list of the procedures for Colon Cancer:

Open Laparotomy with Partial Colectomy (Bowel Resection)
- In this operation, the surgeon makes a long cut in the abdomen, removes the section of colon containing the cancer along with surrounding tissue and lymph nodes, and sews or staples the cut ends together.

Laparoscopic-Assisted Colectomy - In this operation, small cuts are made to insert special surgical instruments and a small light and camera that let the surgeon see inside the abdomen. This technique avoids the larger open cut, but it requires special training, takes longer than open laparotomy, and is more expensive. Hospital recovery time is a bit shorter, and you may need less pain medicine after surgery.

Ostomy (Colostomy, Ileostomy) - If your surgeon needs to bypass a significant part of your colon or remove the muscle at the opening of your rectum, he or she will create an ostomy. This procedure makes a new path for stool and other waste by creating a stoma (opening in your abdomen) and connecting the end of your colon or small intestine to the opening. An ostomy pouch that fastens to your skin over the stoma is used to collect waste. 
A colostomy bypasses part of the large intestine (colon), and is used more frequently in rectal cancer than in colon cancer. An ileostomy bypasses the entire colon and is made at the end of the small intestine (ileum). Ileostomy output is liquid. Output from a colostomy may be semi-solid or solid depending on where the ostomy is created. Some ostomies are reversible after the surgery heals and some will be permanent.

Surgery for Rectal Cancer

Surgical options for Rectal Cancer depend on the location of the tumor in the rectum, its size, and whether or not lymph nodes are involved. The goals of surgery are to remove as much of the cancer from the body as possible and to preserve the anal sphincter (the muscle that controls bowel movements) and good bowel function whenever possible.

Following is a list of procedures for Rectal Cancer:

Local Excision - This surgery is for very small rectal tumors. If the cancer is small and has not grown beyond the inner layers of the rectum where it started, it may be removed through the anus. This is also called transanal excision.

Ostomy (Colostomy, Ileostomy) - If your cancer requires removal of significant parts of your rectum and anus, your surgeon may perform a colostomy.

Low Anterior Resection (LAR) - This surgery is used to remove the tumor and lymph nodes when the cancer is located high in the rectum, above the anus. The cut ends of the rectum are sewed or stapled back together. Stool (solid waste) can then pass normally through the anus, so you don’t need a colostomy. Sometimes the surgeon will create a temporary ostomy so that the rectum can heal.

Total Mesorectal Resection (TME) - This surgery is a specialized technique that removes the rectum as well as fat, blood vessels, and lymph nodes around it in one careful piece. Studies have shown that TME is good for lowering the risk of the cancer coming back in the same place. TME is now accepted as the standard of care for rectal surgery.

Sphincter-Sparing Surgery - This procedure uses special techniques that may help to remove even low rectal tumors successfully without injuring or removing the anal sphincter, which means you’re less likely to need a permanent colostomy. Chemotherapy and radiation before surgery may further reduce the need to remove the anal sphincter.

Abdominoperineal Resection (APR) - This surgery treats tumors that are in the lower part of the rectum closer to the anus. The tumor, rectum, anus and anal sphincter are all removed. This procedure usually results in a colostomy.

Complete or Partial Pelvic Exenteration - This is the most radical form of surgery for rectal cancer. It may be necessary to remove cancer that has spread to nearby organs such as the bladder, ovaries, cervix or vagina. 

Complementary and Alternative Medicine (CAM)

Today, many medical centers and cancer treatment centers combine standard therapy with a broad range of other treatments that are considered complementary or alternative medicine (CAM). No matter what options you explore, it is essential to discuss any new treatments or practices you may be considering with your oncologist.

Although many alternative therapies promise hope when conventional treatment fails, be cautious about false hope. Alternative therapy refers to treatments that are promoted as options to be used instead of conventional therapy. So far, there is no alternative therapy for colorectal cancer that has been scientifically tested and found to be effective.

Complementary therapy refers to supportive methods that are used to complement, or add to, mainstream treatments. For example, a panel of scientists brought together by the National Institutes of Health concluded that acupuncture is effective in treating nausea due to anesthesia or chemotherapy, and can also relieve pain and fatigue in some patients.

Integrative therapy refers to the combined offering of conventional and complementary therapies. The combined approach of integrative medicine may be used to control pain, relieve anxiety, and improve quality of life. For example, you might consider a proven complementary therapy for nausea in place of or in addition to standard anti-nausea drugs. To date, however, there is no scientific data to prove that complementary or alternative therapy alone can cure cancer.

Targeted or Biological Treatments

One of the most exciting approaches to cancer treatment today is the expanding area of targeted therapies. Unlike chemotherapy, targeted therapies are designed to attack cancer cells directly, with less effect on healthy tissues.

Targeted therapies aim to interfere with the growth of cancer cells and the molecular pathways that signal the cancer development process, without disrupting the functions of normal cells and tissues. There are several of these newer types of treatment available now for treating advanced colon and rectal cancer:

Epidermal Growth Factor Receptor (EGFR) Inhibitors
- Epidermal growth factor receptors are naturally occurring cell proteins that sit on the surface of cells that appear to aid in the growth of cancer cells, thereby causing tumors to grow. EGFR inhibitors work by blocking EGF receptors. Cetuximab and Panitumumab are examples of treatments that are epidermal growth factor receptor inhibitors.

Vascular Endothelial Growth Factor Receptor (VEGFr) Inhibitors - Vascular endothelial growth factor receptor inhibitors work by preventing the ability of cancer cells to stimulate the growth of blood vessels, thereby slowing or stopping cancer cell growth. Bevacizumab is an example of a vascular endothelial growth factor receptor inhibitor.


Chemoradiation
Chemoradiation refers to combination treatment with both radiation and chemotherapy. It may be used to treat rectal cancer, usually either before or after surgery, and occasionally both before and after.

Chemoradiation decreases the chance that the tumor will come back. When used before surgery, chemoradiation has been shown to improve survival, and can sometimes shrink the tumor so that it's easier to remove. This sometimes will make it possible to preserve the anal sphincter and avoid 
a colostomy.

Radiation is given in a specialized radiation oncology facility 5 days a week for several weeks. During this time, you also get chemotherapy, either 5-FU or Capecitabine. The radiation and chemotherapy are given during the same time period because studies have found that chemotherapy improves the effectiveness of the radiation.

Chemotherapy
Chemotherapy involves using drugs to kill cells in the body that are dividing and growing rapidly. These include cancer cells, but may also include cells related to hair and nail growth, bone marrow cells, and cells in the digestive system. This is why chemotherapy sometimes causes side effects in those parts of the body.

Chemotherapy may be given into the vein (intravenously) or, in some cases, by mouth (orally). 
Either way, the drugs reach almost all parts of the body where they may kill or inhibit the growth of cancer cells.

In early-stage disease, chemotherapy is given to try to kill any cancer cells that may be left in the body after surgery. In advanced disease, chemotherapy is given to stop or slow the growth of the cancer for as long as possible.

There are three general types of chemotherapy that you may get for colorectal cancer:

Adjuvant Chemotherapy
- given to someone who has had all visible evidence of the cancer removed by surgery. The goal of adjuvant therapy is to kill any remaining cancer cells that might have been left behind but were too small to be detected during surgery or on scans. The use of adjuvant chemotherapy can improve survival for patients with stage III and some stage II colon and rectal cancers. Adjuvant chemotherapy is also given to patients with stage IV or recurrent disease who have had all visible disease removed.

Neoadjuvant Chemotherapy - this form of chemotherapy is received before surgery. Neoadjuvant chemoradiation (chemotherapy combined with radiation) is commonly used for treating locally advanced rectal cancer. Neoadjuvant chemotherapy may also be used to treat patients with stage IV or recurrent disease, to shrink the primary tumor or metastases so that they are easier to remove.

Palliative Chemotherapy - this is given to patients with stage IV or recurrent disease to slow the progression of the cancer. The main reason for getting this treatment is to delay tumor progression, prolong survival, as well as ease pain or other symptoms. 


Clinical Trials

A clinical trial is a research study that evaluates new treatment options. There are different kinds of clinical trials, ranging from small trials looking only at the safety of a new drug to large trials that compare the benefits of new treatments to existing treatments In hundreds or thousands of patients.

Participating in a clinical trial offers close monitoring and oversight by a medical team. Clinical trials may also give you access to a new type of treatment or a new way of getting treatment.

Participation in a clinical trial also helps researchers develop newer and better treatments for colorectal cancer that may help you and many people around the world and in future generations. Your healthcare team can provide you with information about clinical trials available at your treatment center. 

If you’re considering a clinical trial, you and your doctor will review information about the trial in a document called the “informed consent,” which explains the treatment you will receive. The informed consent will also explain your rights, including your right to withdraw from the trial at any time without compromising your medical care.

Social networking and online support groups are important tools. Reaching out to others who have or have had similar experiences can provide you with valuable insights. Check out Cancer Support Community's The Living Room for more information on clinically faciliated support online. 

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