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Colon

6. Treatment Options by Stage Based on Current Evidence

Revised 05 Sept 2012

Stage 0

Cancer is limited to mucosa without invasion of the lamina propria

Endoscopic polypectomy with clear margins.

Segmental colectomy for lesions not amenable to local excision.

Stage I: T1-2, N0, M0

Segmental colectomy.
No role for adjuvant chemotherapy or radiotherapy.

Stage II: T3-4, N0, M0

Segmental colectomy.
The potential value of adjuvant chemotherapy for unselected patients with stage II colon
cancer remains controversial.
Accepted high risk features associated with an increased risk of recurrence in patients
with stage II colon cancer include: inadequate lymph node sampling (<12 nodes), T4
disease, clinical perforation, complete obstruction and poor differentiation.
The presence of high levels of tumour microsatellite instability (MSI-H) is associated with
a favourable prognosis and lack of benefit with adjuvant 5FU chemotherapy in this

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setting. MSI-H is present in an estimated 20% of stage II colon cancers and is associated
with clinical features of female gender, proximal colon location, poorly differentiated
mucinous histology and the presence of tumour infiltrating lymphocytes. Patients with
stage II MSI-H colon cancer should not be offered adjuvant chemotherapy.
Early referral for a consultation with a medical oncologist for assessment and discussion
of adjuvant chemotherapy for patients with stage II colon cancer is highly recommended.
Adjuvant chemotherapy should start as close to four weeks post-op as possible.
Appropriately selected patients with high-risk T3N0 (stage IIA) colon cancer may be
candidates for 6 months of adjuvant capecitabine (GIAJCAP).
Appropriately selected patients with T4N0 (stage IIB) colon cancer may be candidates
for 6 months of capecitabine (GIAJCAP) or modified FOLFOX6 (GIAJFFOX) per
oncologist’s discretion.
Consider treatment on a clinical trial, if available.
No role for adjuvant radiotherapy.

Stage III low-risk: T1-3, N1, M0

Segmental colectomy.
3 months of adjuvant 5-fluorouracil and oxaliplatin chemotherapy is recommended. A
duration of 3 months has been demonstrated to have comparable efficacy in low-risk
stage III disease with less neurotoxicity when compared to the previous standard of 6
months of oxaliplatin-containing chemotherapy (ASCO stage III guideline 2019, IDEA
Final results update, ASCO 2020).
Adjuvant chemotherapy should start as close to four weeks post-op as possible.
Standard of care options include 3 months of CAPOX (4 cycles) or modified FOLFOX6 (6
cycles). 3 months of oxaliplatin-containing chemotherapy is associated with significantly
less neurotoxicity. For patients treated with mFOLFOX6, treatment for greater than 3
months (to maximum of 6 months) may be considered if the treating oncologist feels the
benefits outweigh the risks.
For patients unsuitable for oxaliplatin,6 months of capecitabine would be offered
Please refer to current treatment protocols for indications, dosing and eligibility criteria.
Consider treatment on a clinical trial, if available.
No established role for adjuvant radiotherapy.

Stage III high-risk: T4 and/or N2, M0

Segmental colectomy.

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Six months of adjuvant 5-fluorouracil and oxalplatin chemotherapy has been

demonstrated in multiple randomized studies to improve disease-free and overall
survival in patients with stage III colon cancer.
Adjuvant chemotherapy should start as close to four weeks post-op as possible.
Standard of care options include 6 months CAPOX (8 cycles) or modified FOLFOX6 (12
cycles), or 6 months of capecitabine alone (for patients unsuitable for oxailplatin).
Please refer to current treatment protocols for indications, dosing and eligibility criteria.
Consider treatment on a clinical trial, if available.
No established role for adjuvant radiotherapy.

Stage IV: any T, any N, M1

Segmental resection (with or without anastomosis) or proximal diversion of obstructing

or bleeding primary tumours in selected patients
Resection or ablation of isolated metastases: liver or lung in selected patients; referral to
BC Cancer for multi-disciplinary assessment is recommended.
Palliative radiation therapy or stereotactic body radiation therapy (SBRT) in selected
patients.
Palliative chemotherapy has been shown to significantly improve survival in patients with
unresectable metastatic colorectal cancer achieving an estimated median overall survival
of 24 to 28 months as compared to less than 6 months with supportive care alone.
Currently approved chemotherapeutic agents for metastatic colon cancer include:
capecitabine, 5-fluorouracil (5-FU), irinotecan and oxaliplatin.
The most commonly used regimens are:

1. oxaliplatin with 5-FU (FOLFOX) or capecitabine (CAPOX)

2. irinotecan with 5-FU (FOLFIRI) or capecitabine (CAPIRI)
3. capecitabine monotherapy

The choice and sequence of chemotherapy is determined by disease-related factors,

patient factors and patient preferences as assessed by the medical oncologist.
Currently approved targeted therapies include: bevacizumab, cetuximab, and
panitumumab.
Bevacizumab is recommended for use in combination with first-line FOLFIRI
chemotherapy (FOLFOX may be considered in selected circumstances). It may also be
considered for use in combination with second-line doublet chemotherapy for those
patients who did not receive it in first-line.
Cetuximab or panitumumab is indicated in patients with previously treated metastatic
colorectal cancer with wild-type K-ras gene (i.e. tumour K-ras gene is not mutated).

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Please refer to current treatment protocols for indications, dosing and eligibility criteria.
Consider treatment on a clinical trial, if available.
Symptom management, best supportive care, and involvement of palliative care services
as indicated by patient’s clinical status.

SOURCE: Colon ( http://www.bccancer.bc.ca/health-professionals/clinical-resources/cancer-management-

manual/gastrointestinal/colon )
Page printed: 2023-05-02 . Unofficial document if printed. Please refer to SOURCE for latest information.
Copyright © 2023 BC Cancer. All Rights Reserved.

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