Colorectal Cancer: Treatments

The primary treatment for cancers of the colon and rectum is surgery. For cancers that have not spread, surgery alone often provides a cure.  Our surgeons are international leaders in removing lesions which have spread, particularly to the liver.  Increasingly, we are now able to provide a cure to selected patients in this situation.

Depending on the location and stage of your cancer, the doctor may recommend chemotherapy and/or radiation therapy either before or after surgery.

Surgery

If cancer is confined within a polyp that can be completely removed through the colonoscope, no other therapy may be necessary. However, follow-up colonoscopies at one to three year intervals are advised.

Colectomy The vast majority of people who develop colon cancer will require surgical resection (removal) of a segment of the colon or rectum. During this procedure, known as "colon resection" or "colectomy," the surgeon often eliminates between 8 to 12 inches of the colon.

The adjoining mesentery (a membrane that connects the intestine to the abdomen, and contains both blood vessels and lymph nodes) is removed as well. This is because colon cancers can involve the lymph nodes and invade the blood vessels directly.

Because the colon is on average five feet long and because tumors can develop anywhere along its length, the segment to be removed will vary from patient to patient.
The procedure can be performed either laparoscopically (using small incisions and special miniaturized instruments) or via an open surgery called laparotomy.

Laparoscopic surgery Laparoscopic surgery is the standard of care for the majority of colorectal procedures. The Division of Colorectal Surgery at NewYork-Presbyterian/Columbia University Medical Center uses laparoscopic techniques for 90 percent of its colon surgeries. Compared to open surgery, the benefits of laparoscopy include: less postoperative pain and therefore less pain medication, faster healing for a quicker return home, and smaller, less noticeable scars.

Our surgeons have earned national and international recognition for their expertise in minimally invasive and laparoscopic surgery, and routinely train other surgeons across the country. Our overall surgical outcomes are highly favorable compared to national averages.

During laparoscopic surgery, the surgeon utilizes a small incision through which a "port" is placed to inflate the abdominal cavity with gas. A camera is then introduced through the port to help visualize the inside of the abdominal cavity on a television monitor. Surgery is performed with instruments through additional ports placed via small incisions in the abdominal wall.

After the surgery, the two remaining ends of the bowel are joined together to reconnect the intestine. This reconnection is called an anastomosis.

What is a stoma, and will I need a one?

A stoma, commonly referred to as a colostomy or ileostomy, is an artificial opening in the abdomen created during surgery that allows elimination of stool after the operation. It is necessary if passage to the anus is interrupted after the operation. .The colostomy may be temporary, to give the colon a chance to heal, or permanent (in 10 to 15 percent of cases) if the lower part of the rectum has been removed. In most cases, if a stoma will be permanent, your surgeon will be able to tell you this prior to the procedure. Caring for a stoma is enhanced by specially-trained nurses called "enterostomal" therapists. They help teach you about stoma care, skin care, and appliance management. They can also introduce you to other patients with stomas ("stomates") so that you can learn from their experiences. The length of hospital stay for colorectal surgery varies from 4 to 10 days depending on the individual and the type of surgery.

Robotic Surgery

Our surgeons are also experts in robotic colorectal surgery, an emerging technology which is currently unavailable in most centers. According to Dr. Steven Lee-Kong, the first surgeon trained to perform robotic colorectal surgery at NYP/Columbia, robotic assistance gives colorectal surgeons important technical advantages: "There are nerves in the pelvis that control sexual and bladder function. This technology allows us to more carefully identify and preserve those nerves," he explains. Benefits to patients undergoing colorectal surgery are under study in clinical trials, including a multi-center trial comparing the outcomes of robotic and conventional techniques.

During robotic surgery, the surgeon sits at a console that includes a large, high definition computer screen and controls to manipulate the surgical instrumentation. Across the room at the operating table, narrow arms with tiny surgical tools and a miniature camera are inserted through two to four tiny incisions in the patient’s abdomen. From the console, the surgeon has an excellent magnified view and can move the instrumentation to carefully perform each step of the operation.

More information can be found here: www.columbiasurgery.org/colorectal/index.html

Chemotherapy

Chemotherapy (chemo) drugs are given to kill colorectal cancer cells.

Systemic chemotherapy drugs are injected into a vein or given by mouth. These drugs enter the bloodstream and reach all areas of the body. This treatment is useful for cancers that have spread beyond the colon.

Chemotherapy given before surgery (sometimes with radiation) to shrink the cancer before operating is called neoadjuvant therapy.

Chemotherapy given after surgery to keep the cancer from growing back is called adjuvant therapy.

Chemotherapy can also be used to treat colorectal cancers that have spread to the liver or the lungs.

Chemotherapy drugs are usually given in cycles, with each period of treatment followed by a period of rest, allowing the body time to recover. These drugs are often used in combination to treat colorectal cancer:

  • 5-Fluorouracil (5-FU), often given with the vitamin folinic acid
  • Capecitabine (Xeloda®), in pill form
  • Irinotecan (Camptosar®)
  • Oxaliplatin (Eloxatin®)

Targeted Therapies

Targeted therapies focus on the gene and protein changes in cells that cause cancer work differently from standard chemotherapy drugs. They are effective for more advanced cancers.

VEGF targeted drugs Bevacizumab (Avastin®) and regorafenib (Stivarga®) both target a protein called vascular endothelial growth factor (VEGF). VEGF helps tumors form new blood vessels to get nutrients (a process known as angiogenesis).

Bevacizumab is given as infusions into a vein (IV) every two or three weeks, while regorafenib is a pill.

EGFR targeted drugs Cetuximab (Erbitux®) and panitumumab (Vectibix®) are both antibodies that target the epidermal growth factor receptor (EGFR), a molecule on the surface of cancer cells that helps them grow.

Both of these drugs are given by IV infusion, either once a week or every other week. Roughly four out of ten colorectal cancers have mutations (defects) in the KRAS gene rendering these drugs ineffective.

Radiation Therapy

With advanced radiation therapy techniques doctors can better target tumors while reducing the radiation to nearby healthy tissues. Here at HICCC our radiation oncology experts have the ability to provide “state of the art” treatments for colorectal disease.

Your radiation oncologist will design the optimal treatment plan with you to ensure you achieve the best outcomes. Treatment delivery can be daily, weekly, every other day, and or single fraction.

If radiation treatment is recommended, a radiation oncologist will work with our radiation oncology team to create a course of treatment. At Columbia University Irving Medical Center treatment modalities available and most commonly used for this cancer are External Beam Radiation Therapy, 3D Conformal Radiotherapy, and Intensity modulated radiation therapy (IMRT).