Which treatment for advanced bowel cancer
This page tells you about treating bowel cancer that has spread. You can find information about
- A quick guide to what's on this page
- What advanced colorectal cancer is
- Local spread
- Secondary spread (metastasis)
- Treatments for advanced bowel cancer
- Chemotherapy for advanced bowel cancer
Treatments for advanced bowel cancer
Advanced colorectal cancer means the cancer has spread to other parts of the body from where it started in the bowel (colon) or back passage (rectum). Your cancer may be advanced when it is first diagnosed. Or the cancer may come back some time after you were first treated.
Once a bowel cancer has spread to another part of the body it is unlikely to be curable. But treatment can often keep the cancer under control for quite a long time. The choice of treatment depends on the cancer type, the number of secondary cancers and where they are, and the treatment you have already had.
You may have chemotherapy or radiotherapy to shrink a cancer and control symptoms. In some situations, your specialist may suggest surgery to treat advanced bowel cancer.
There are specialised surgical treatments that doctors sometimes use to destroy bowel cancer spread to the liver (liver secondaries). These treatments include hepatic artery chemoembolisation, radiofrequency ablation, cryotherapy, microwave ablation and laser therapy.
Newer types of biological therapy drugs, such as bevacizumab (Avastin) and cetuximab (Erbitux), are licensed for advanced bowel cancer. Cetuximab is approved for treatment on the NHS for some people, but bevacizumab is not.
Deciding about treatment
It can be difficult to decide which treatment to try, or whether to have treatment at all, when you have an advanced cancer. It is important to understand what the treatment can do for you. You will also need to consider your quality of life while having the treatment. Your doctor will talk through the options with you. There may be a counsellor or specialist nurse you can talk to. You may also want to discuss things with a close relative or friend.
Some people feel they would like to get an opinion from a second doctor before they decide on their treatment. If you would like a second opinion, you can ask your specialist or your GP to refer you.
You can view and print the quick guides for all the pages in the treating bowel cancer section.
Advanced colorectal cancer means that the cancer has spread to other parts of the body from where it started in the bowel (colon) or back passage (rectum). Your cancer may be advanced when it is first diagnosed. Or the cancer may come back some time after you were first treated. When cancer comes back after treatment it is called recurrent cancer. The cancer can spread
Cancer that has spread to another part of the body is called secondary cancer or metastatic cancer. The bowel cancer cells have travelled through the lymphatic system or bloodstream to another part of the body. The cells have then settled and started to grow there.
Remember the most important thing is where the cancer started. Having bowel cancer cells in your liver doesn't mean that you have liver cancer. You have bowel cancer that has spread – it is also called secondary bowel cancer. This is important because your doctor needs to use treatments that work on bowel cancer cells – not treatment for liver cancer.
This diagram shows how blood flows from the bowel to the liver. It helps to explain why the liver is the most common place for bowel cancer to spread. The next most common site of spread is the lungs.
Once a bowel cancer has spread to another part of the body it is unlikely to be curable. But treatment can often keep it under control for quite a long time. The choice of treatment depends on
- The type of cancer you have
- The size and number of secondary cancers and where they are in the body
- The treatment you have already had
Chemotherapy to shrink a cancer and control symptoms is called palliative chemotherapy. To treat advanced bowel cancer, you have chemotherapy either into a vein in your arm or as a tablet. If the first type of chemotherapy you have (called 1st line treatment) does not control your cancer, you can usually have a different type of chemotherapy (2nd line treatment). The National Institute for Health and Clinical Excellence (NICE) has guidelines for giving 1st line chemotherapy for advanced bowel cancer. They have approved
- Fluorouracil as an injection or through a drip, often with another drug called folinic acid
- Irinotecan with fluorouracil and folinic acid
- Oxaliplatin with fluorouracil and folinic acid
- Oxaliplatin and capecitabine
If you have had fluorouracil before, your specialist may suggest irinotecan on its own. Or they may suggest tablet forms of fluorouracil, such as capecitabine or Uftoral.
You may have any one of these drug combinations when you are first diagnosed with advanced bowel cancer. There is more about this on our page about chemotherapy for advanced bowel cancer.
A research review found there was good evidence that chemotherapy helped people with advanced bowel cancer to live longer. But the researchers couldn’t say whether the treatment improved people's quality of life or not. You can read this review of chemotherapy in advanced bowel cancer in the Cochrane Library. It was written for researchers and specialists so is not in plain English.
Doctors sometimes use external beam radiotherapy to shrink a lump or tumour in the bowel that is causing pain. This is called palliative radiotherapy. They don't use radiotherapy much for colon cancers but may use it for rectal cancers.
Your specialist may suggest a type of internal radiotherapy called selective internal radiation therapy (SIRT) for secondary cancer in the liver. This has been approved by the National Institute for Health and Clinical Excellence (NICE) as a treatment for people who cannot have their liver secondaries surgically removed. There is information about research into internal radiotherapy on our bowel cancer research page.
Your specialist may suggest surgery to treat advanced bowel cancer
- To slow the cancer
- When the bowel is blocked
- To remove secondary cancer
There is detailed information about these operations on our page about surgery for advanced bowel cancer.
If the tumour in your bowel is causing symptoms it may be sensible to operate, to remove as much of it as possible. This type of operation is called debulking.
Specialised surgical treatments may be able to destroy bowel cancer that has spread to the liver (liver secondaries). These treatments include
- Hepatic artery chemoembolisation – blocking liver blood vessels to give a high chemotherapy dose to the cancer
- Radiofrequency ablation – using radio waves to destroy the cancer cells
- Radiofrequency assisted surgery – using radio waves and surgery
- Cryotherapy – freezing the cancer cells
- Microwave ablation – using micro waves to destroy the cancer
- Laser therapy – using a laser to destroy the cancer cells
- Alcohol injection – injecting alcohol into the cancer to destroy the cells
There is detailed information about these specialised surgical treatments on our page about surgery for advanced bowel cancer.
Biological therapies are drugs that help the body to control the growth of cancer cells. A biological therapy called cetuximab (Erbitux) is licensed in the UK for people who have bowel cancer that has spread. We know from research that it can help some people with advanced bowel cancer to live longer when added to standard chemotherapy treatment. It can also improve quality of life. Doctors usually give biological therapies for advanced bowel cancer along with the chemotherapy drugs fluorouracil, oxaliplatin, or irinotecan.
The National Institute for Health and Clinical Excellence (NICE) in England and the Scottish Medicines Consortium (SMC) in Scotland have approved cetuximab in combination with chemotherapy. It is for people who have a normal k-ras gene in their cancer cells and where the cancer has spread only to the liver. Around 65 out of every 100 people with advanced bowel cancer (65%) have normal k-ras gene tumours.
Some biological therapies are very new and it will be some time before we know how well they work. Others, such as the monoclonal antibodies bevacizumab (Avastin) and panitumumab (Vectibix), are licensed for advanced bowel cancer. In December 2010, NICE said that bevacizumab with chemotherapy should not be available as a treatment in the NHS for people with advanced bowel cancer. Panitumumab is currently being assessed by NICE. There is more information about these treatments in the bowel cancer research section.
All new treatments have to go through the clinical trials process and this takes some years. To search for bowel cancer trials, visit our clinical trials database and select 'bowel' from the dropdown menu of cancer types.
It can be difficult to decide which treatment to try, or whether to have treatment at all, when you have an advanced cancer. You will need to consider your quality of life while you are having the treatment. The side effects of treatment, as well as stresses such as travelling back and forth to the hospital, can have a big effect on your quality of life. Your doctor will explain what they hope to achieve with the different treatments they offer you.
Your doctor will talk to you about all the options. There may also be a counsellor or specialist nurse at the hospital you can talk to. You may also want to discuss things with a close relative or friend. It can be helpful to talk over difficult decisions with someone outside your circle of family and friends. If you would like to contact someone, look at our bowel cancer organisations page. To find out more about counselling, look in the counselling section.
If you want to find people to share experiences with people on line, you could use CancerChat, our online forum. Or go through MyWavelength. This is a free service that aims to put people with similar medical conditions in touch with each other.
Some people feel they would like to get an opinion from a second doctor before they decide on their treatment. If you would like a second opinion, you can ask your specialist or your GP to refer you. It can be better to arrange a second opinion through your specialist because then they can send all your notes and test results with you.
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