Metastatic colorectal cancer

Metastasis means that the cancer cells have spread beyond the colon or rectum to other organs. Metastatic colorectal cancer is also referred to as advanced colorectal cancer or stage 4 (IV) colorectal cancer. 

Recent advances in colorectal cancer treatment have improved outcomes for patients with metastatic disease. Treatment options will depend on different factors, such as how far the cancer cells have spread and what organs have been affected. In colorectal cancer, the liver and lungs are common sites of metastasis.

Surgery may be used to remove the primary tumour in the colon or rectum as well as metastatic tumours that have spread to surrounding organs such as the liver and lungs. Chemotherapy, targeted therapies and radiation therapy may be used to shrink tumours before surgery to increase successful removal (resection). Depending on the extent of the colon and rectum that are affected by cancer, a colostomy may be necessary. In such cases, the affected colon/rectum is surgically removed, and the healthy portion of the remaining colon is attached to a surgical opening in the belly (abdomen). Waste is collected from this opening to the outside of the body and stored in a bag that is attached to the skin.

Sometimes, chemotherapy  will be used before surgery (neoadjuvant chemotherapy) and following surgery (adjuvant chemotherapy) to help to control the cancer and improve the successful surgical removal of the tumours.
Hepatic arterial infusion (HAI) delivers chemotherapy drugs directly to the liver using a very small pump that is inserted below the skin of the lower belly (abdomen). This type of chemotherapy may help to shrink liver metastases before surgery so they can be removed more easily, after surgery to kill any remaining cancer cells, or instead of surgery if the liver tumours are too difficult to be removed surgically.

Interventional radiology treatments use imaging techniques, such as ultrasound, x-ray, CT and MRI to perform minimally-invasive procedures to selectively treat colorectal cancer metastases. They can include ablation, which uses a highly focused energy source delivered through a needle directly to the tumours to destroy them, or radioembolization, which uses a thin, flexible tube to inject radioactive beads to selectively destroy liver metastases.

Targeted therapies  attack specific genes and proteins in cancer cells, causing them to die. Molecular testing is an important part of the management of metastatic colorectal cancer. By identifying which biomarkers are present in an individual’s tumour, the most tailored treatment option can be selected. For example, knowing one’s RAS status will help to predict a tumour’s response to a class of targeted therapies known as epidermal growth factor receptor (EGFR) inhibitors.

Immunotherapy  (also referred to as checkpoint inhibitors) works by activating the body’s own immune system to attack cancer cells. Molecular testing to identify the microsatellite status of the tumour is essential to determine whether immunotherapies will be effective.

Clinical trials are research studies conducted in people to test the safety and efficacy of new treatments. Patients can discuss with their healthcare team about whether clinical trials are a possible treatment option for their cancer.

How you might feel

Learning about advanced cancer can be shocking. It’s normal to have feelings of uncertainty and fear, and to have nothing else on your mind.

You and your family and friends have a lot of information and support available to you. It can be helpful to have information about your cancer and your treatment options. Many people find that knowing more about their situation makes coping easier.

Have a conversation with your healthcare provider about:

Understanding the goals and objectives of your treatment options

Your healthcare provider may use some treatments to slow, stop, or eliminate the cancer. He or she may also suggest supportive care to help manage symptoms and side effects. For example, if a cancer treatment causes nausea, there are different ways to avoid or reduce nausea, such as a prescription medication.

During your discussion of colorectal cancer treatment options with your healthcare provider, it is important to have an understanding of the goals and objectives of each treatment in your care plan. This will help you make the best treatment decision for you.

Cancer treatments, also called cancer therapies, have two goals: to cure or to control cancer.

Curative cancer treatments. When therapies are used to eliminate cancer, they are called “curative cancer treatments. Supportive or palliative care to manage symptoms and side effects are also part of a treatment plan to cure cancer.

Palliative cancer treatments. Sometimes cancer cannot be cured. This does not mean that the cancer cannot be treated and controlled for a period of time. Cancer treatments are called “palliative cancer treatments” if they are used to control the cancer. This is because the treatments help to relieve symptoms and side effects for as long as possible. Helping you live as well as possible for as long as possible is the goal of palliative cancer care.

Take time to understand the medical goals for your treatment. Process the information your healthcare team gives you and ask questions. Make sure you understand the goals, expected benefits, and possible risks of the recommended treatments. During this discussion, your doctor will be able to tell you whether the recommended cancer treatment is curative or palliative.

Making decisions about cancer treatment – other factors to consider

Depending on what is important to you, you may want to consider other factors when making decisions about your treatment options. These may include.

Getting a second opinion. Most people choose to get a second or third opinion from another oncologist. Different oncologists may have different experiences with different types of treatment, including clinical trials, or with the specific type of cancer that you have. Getting a second or third opinion is common. It can help you feel more confident about your treatment plan and the oncologist you choose.

Talk about clinical trials. Your care team or clinical trials navigator can help you determine if clinical trials are right for you based on your diagnosis and other health factors. 

Talk about your decisions with someone you trust. Some people find it helpful to share their thoughts and concerns with people they trust. This may include family and friends, an oncology social worker, another person with cancer, or a clergy member or spiritual advisor. 

Survival

Some people who have advanced cancer want to know what the outlook is for them and how their cancer and care is going to progress. This is different for everyone. Your cancer specialist has all the information about you and your cancer. You may want to prepare a list of questions to ask your healthcare provider or nurse navigator. Colorectal Cancer Canada support specialists are also available to discuss your concerns and connect you with resources in your community and with others who have experienced advanced colorectal cancer.

Emotional, mental health, and mood changes

Coping with emotions and challenges is an important part of living with metastatic cancer. These can vary from person to person and at different times. Here are some things to consider:

Support for loved ones and caregivers

Your family and friends may also be in need of help with coping. Having a family member or friend with metastatic cancer can be a challenge, especially for the people who are helping to care for you. They can try some of the coping skills listed above. Your healthcare team as well as Colorectal Cancer Canada may suggest other tips. For example, there are support groups for family members of people with cancer and resources to help discuss cancer with children. See our Support services for more information.