Colon cancer

The panel believes that a multidisciplinary approach is necessary for managing colorectal cancer. The panel endorses the concept that treating patients in a clinical trial has priority over standard or accepted therapy. The recommended surgical procedure for resectable colon cancer is an en bloc resection and adequate lymphadenectomy. Adequate pathologic assessment of the resected lymph nodes is important, with a goal of evaluating at least 12 nodes when possible. Adjuvant therapy with FOLFOX (category 1), 5-FU/LV (category 2A), or capecitabine (category 2A) is recommended for patients with stage III disease and as an option for patients with high-risk stage II disease (category 2A for all 3 treatment options). Patients with metastatic disease in the liver or lung should be considered for surgical resection if they are candidates for surgery and if complete resection (RO) or ablation can be achieved. Preoperative chemotherapy can be considered as initial therapy in patients with synchronous or metachronous resectable metastatic disease (neoadjuvant) or when a response to chemotherapy can convert a patient from an unresectable to a resectable state. Adjuvant chemotherapy should be considered after resection of liver or lung metastases. The recommended posttreatment surveillance program for patients with colon cancer includes serial CEA determinations; periodic chest, abdominal, and pelvic CT scans; and colonoscopic evaluations. Recommendations for patients with previously untreated disseminated metastatic disease represent a continuum of care in which lines of treatment are blurred rather than discrete. Principles to consider at initiation of therapy include preplanned strategies for altering therapy in both the presence and absence of disease progression, and plans for adjusting therapy for patients who experience certain toxicities. Recommended initial therapy for advanced or metastatic disease includes bevacizumab plus FOLFOX, FOLFIRI, CapeOX, or 5-FU/LV. Patients with progressive disease treated with a 5-FU-based or capecitabine-based regimen as initial therapy should be treated with second- or third-line chemotherapy consisting of FOLFIRI, CapeOX, FOLFOX, or irinotecan alone or, in the case of irinotecan and FOLFIRI, in combination with cetuximab. Monotherapy with either cetuximab or panitumumab is also an option after first or second progression.