Treatment of Stage II of Colon Cancer

Understand biomarker testing, surgery, adjuvant chemotherapy and precision cancer medicines for stage II colon cancer.

Treatment of Stage II of Colon Cancer

Medically reviewed by C.H. Weaver M.D. Medical editor 08/2018

Following surgical removal of colon cancer, the cancer is referred to as stage II if the final pathology report shows that the cancer has penetrated the wall of the colon into the abdominal cavity, but does not invade any of the local lymph nodes and cannot be detected in other locations in the body.

Stage II adenocarcinoma of the colon is a common and curable cancer. Depending on features of the cancer, 60-75% of patients are cured without evidence of cancer recurrence following treatment with surgery alone. stage II cancer can be further divided into two stages, stage IIA and IIB. In stage IIA, the tumor has grown through the outermost layers of the colon but is confined to the colon. In stage IIB, the tumor has grown through the colon wall and has extended to adjacent tissues or organs. In both stages, there are no lymph nodes containing tumor cells and no distant metastases.1,2

Despite undergoing complete surgical removal of the cancer, 25-40% of patients with stage II colon carcinoma experience recurrence of their cancer because some cancer cells had spread outside the colon and were not removed by surgery. Additional treatment is needed to eliminate these cancer cells.3

The following is a general overview of the management of stage II colon cancer. Each person with colon cancer is different, and the specific characteristics of your condition will determine how it is managed. The information on this Web site is intended to help educate you about treatment options and to facilitate a shared decision-making process with your treating physician.

Systemic Adjuvant Therapy

The delivery of systemic treatment following local treatment with surgery is referred to as “adjuvant” therapy and may include chemotherapy or precision cancer medicines. Systemic adjuvant chemotherapy is commonly recommended for some patients with stage II and most patients with stage III colon cancer. The goal of systemic adjuvant therapy is to reduce the risk of cancer recurrence.1,2,3,4

Adjuvant chemotherapy may improve disease-free survival, but does not appear to improve overall survival, among all patients with stage II colon cancer,1 but may be considered for some patients, particularly those whose cancers have high-risk features.2

Characteristics that may indicate a higher risk of recurrence include the following:3,4

  • High grade cells on pathologic exam
  • Less than 12 lymph nodes sampled during surgery
  • Perforation or obstruction of the colon due to cancer
  • Stage IIB tumors (tumor has extended beyond the wall of the colon)

The overall health of the patient must also be considered when weighing the risks and benefits of adjuvant therapy. Patients with fewer other health problems (such as diabetes, obesity or heart disease) will better tolerate adjuvant chemotherapy.

Oncotype DX Testing

A newer test that may help guide treatment decisions for patients with stage II colon cancer is the OncotypeDX (link to this http://news.cancerconnect.com/oncotype-dx-predicts-recurrence-risk-in-stage-ii-and-stage-iii-colon-cancer/) colon cancer test. This estimates the risk of cancer recurrence by evaluating the activity of certain genes in a sample of tumor tissue. Risk of recurrence can vary greatly among patients with stage II colon cancer, and use of the Oncotype DX test in combination with other markers of risk may help to individualize treatment decisions.5

Treatment of the Elderly

A large percentage of patients with colon cancer are 65 years or older. Sometimes elderly patients and/or their physicians may believe that treatment will be more toxic for elderly patients than it is for their younger counterparts. Due to this perceived intolerability of therapy, elderly patients often do not receive optimal treatment. The results of several clinical trials however confirms that elderly patients with colon cancer who are in otherwise good health tolerate chemotherapy as well as younger patients and experience improved survival from its use.6

Strategies to Improve Treatment

Several new chemotherapy and biological drugs demonstrate promising activity for the treatment of colon cancer. Clinical research is ongoing to develop new multi-drug treatment regimens that incorporate new anti-cancer therapies for use as adjuvant treatment. Eloxatin® (oxaliplatin) and Xeloda® (capecitabine) are medicines that have been approved for the treatment of stage III colon cancer and may provide benefit in the adjuvant treatment of stage II disease.7,8,9

Precision Cancer Medicines

The purpose of precision cancer medicine is to define the genomic alterations in the cancers DNA that are driving that specific cancer. Precision cancer medicine utilizes molecular diagnostic testing, including DNA sequencing, to identify cancer-driving abnormalities in a cancer’s genome. Once a genetic abnormality is identified, a specific targeted therapy can be designed to attack a specific mutation or other cancer-related change in the DNA programming of the cancer cells. Precision cancer medicine uses targeted drugs and immunotherapies engineered to directly attack the cancer cells with specific abnormalities, leaving normal cells largely unharmed. Precision medicines are being developed for the treatment of colon cancer and patients should ask their doctor about whether testing is appropriate.

Erbitux® (cetuximab): Erbitux is a type of precision cancer medicine called a monoclonal antibody. It works by binding to a protein receptor located on many cancer cells called the epidermal growth factor receptor (EGFR). EGFR is involved in cellular growth and replication, and by targeting EGFR, the spread of cancer can be reduced or delayed.

Erbitux administered alone or with the chemotherapy drug Camptosar® (irinotecan) has been shown to improve survival for patients with advanced, EGFR-positive colorectal cancer that has progressed on first line therapy.10,11

Advances in Surgery for Colon Cancer

Surgical removal of cancer remains an integral part of the treatment strategy for patients with stage II colon cancer and many patients are cured with this treatment alone. Conventional surgery involves opening the pelvis and/or abdomen to gain access to the large intestine. As with any surgery, there are risks associated with removing cancer, including infection, blood loss, and other possible complications of surgery.

Clinical trials have shown that a less invasive surgical technique, called laparoscopic surgery, may be more tolerable than and similarly effective as conventional surgery. Laparoscopic surgery involves the placement of small probes into the area of surgery. The probes contain cameras and instruments for removing the cancer. The surgeon performs the surgery through the probes while watching his or her movements captured by the camera and projected on a large screen. This type of procedure prevents the need for large surgical incisions, and may be associated with fewer complications, especially infections (abdominal infections, urinary tract infections and pneumonia). In addition, patients undergoing laparoscopic surgery generally experience less discomfort post-operatively and have a quicker recovery time (return to normal activities).12,13,14

When choosing between open and laparoscopic abdominal surgery, patients and their doctors must weigh the potential short-term benefits of laparoscopic surgery with a possible small increase in cancer recurrence that may be associated with laparoscopic resection. Patients may choose based on their own health and the expertise and recommendations of their surgeon.

Avastin® (bevacizumab): Avastin is type of targeted therapy that slows or prevents the growth of new blood vessels, a process called angiogenesis. Cancer cells require food, oxygen, and proteins in order to grow and spread. New blood vessels are necessary to deliver these essential components of cellular growth. Avastin starves cancer cells by inhibiting angiogenesis. Avastin has been shown to improve outcomes among patients with metastatic colon cancer,15 and is being studied among patients with earlier-stage colon cancer as well.

References

1 Figuerdo A, Coombes ME, Mukherjee S. Adjuvant therapy for completely resected stage II colon cancer.Cochrane Database of Systematic Reviews. 2008;(3):CD005390.

2 Benson AB, Schrag D, Somerfield MR. American Society of Clinical Oncology recommendations on adjuvant chemotherapy for stage II colon cancer. Journal of Clinical Oncology. 2004;15:3408-19.

3 Benson A, Schrag D, Somerfield M, et al. American Society of Clinical Oncology recommendations on adjuvant chemotherapy for stage II colon cancer. Journal of Clinical Oncology. 2004; 22: 3408-3419.

4 Figueredo A, Charette M, Maroun J, et al. Adjuvant therapy for stage II colon cancer: A systematic review from the Cancer Care Ontario Program in Evidence-based Care’s Gastrointestinal Cancer Disease Site Group. Journal of Clinical Oncology. 2004;22: 3395-3407.

5 O’Connell M, Lee M, Lopatin M et al. Validation of the 12-gene colon cancer recurrence score (RS) in NSABP C07 as a predictor of recurrence in stage II and III colon cancer patients treated with 5FU/LV (FU) and 5FU/LV+oxaliplatin (FU+Ox). Paper presented at: 2012 Annual Meeting of the American Society of Clinical Oncology; June 1-5, 2012;Chicago,IL. Abstract 3512.

6 D Sargent, R Goldberg, J MacDonald, et al. Adjuvant Chemotherapy for Colon Cancer (CC) Is Beneficial Without Significantly Increased Toxicity in Elderly Patients (Pts): Results from a 3351 Pt Meta -Analysis. Proceedings from the 36th annual meeting of the American Society of Clinical Oncology. Blood. 2000;19: Abstract #933.

7 Twelves C, Wong A, Nowacki M, et al. Capecitabine as Adjuvant Treatment for Stage III Colon Cancer. New England Journal of Medicine. 2005; 352:2696-2704.

8 Andre T, Boni C, Mounedji-Boudiaf, et al. Oxaliplatin, Fluorouracil, and Leucovorin as Adjuvant Treatment for Colon Cancer. New England Journal of Medicine. 2004;350:2343-2351.

9 Twelves C, Wong A, Nowacki M, et al. Capecitabine as Adjuvant Treatment for Stage III Colon Cancer.New England Journal of Medicine. 2005; 352:2696-2704.

10 Cunningham D, Humblet Y, Siena S, et al. Cetuximab Monotherapy and Cetuximab plus Irinotecan in Irinotecan-Refractory Metastatic Colorectal Cancer. New England Journal of Medicine 2004;351:337-345.

11 Hriesik C, Ramanathan R, Hughes S. Update for Surgeons: recent and noteworthy changes in therapeutic regimens for cancer of the colon and rectum. Journal of the American College of Surgeons2007; 205: 468-478.

12 Mirza MS, Longman RJ, Farrokhyar F, et al. Long-term outcomes for laparoscopic versus open resection of nonmetastatic colorectal cancer. Journal of Laparoendoscopic Advances in Surgical Technique2008;18(5):679-685.

13 Bilimoria KY, Bentrem DJ, Merkow RP, et al. Laparoscopic-assisted vs. Open Colectomy for Cancer: Comparison of Short-term Outcomes from 121 Hospitals. Journal of Gastrointestinal Surgery [early online publication]. June, 2008.

14 Nelson H, Sargent D, Wie H, et al. A Comparison of Laparoscopically Assisted and Open Colectomy for Colon Cancer. New England Journal of Medicine 2004;350:2050-2059.

15 Hurwitz H, Fehrenbacher L, Novotny W, et al. Bevacizumab plus Irinotecan, Fluorouracil, and Leucovorin for Metastatic Colorectal Cancer. New England Journal of Medicine. 2004;350:2335-2342.

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