Research into treating bowel cancer

• A quick guide to what's on this page
• Why research?
• Chemotherapy
• Radiotherapy
• Surgery
• Follow up after surgery

• Relieving a blocked bowel
• Destroying liver secondaries
• Biological therapies
• Resveratrol before surgery
• Symptoms of cancer that has come back

Research goes on all the time into how best to treat bowel cancer. Usually doctors test new drugs in people with advanced bowel cancer first. If a new treatment helps with advanced bowel cancer, it may work for early stage bowel cancer. So it is then tested in clinical trials to see if it lowers the risk of the cancer coming back.

Doctors would like to be able to identify who is most at risk of their bowel cancer coming back. People at lowest risk may not need such intensive treatment as those at higher risk. At the moment, we don't know for sure who is most at risk. All treatments have side effects. Doctors know that some people are putting up with side effects from treatment they may not really need.

Many clinical trials are testing different combinations of chemotherapy drugs, different doses, or different ways of giving treatment. The aim of this type of research is to find better ways of treating bowel cancer with chemotherapy. There is information here about

• Chemotherapy after surgery for bowel cancer (adjuvant chemotherapy)
• Chemotherapy before surgery for bowel cancer (neoadjuvant chemotherapy)
• Chemotherapy for bowel cancer that has spread
• Hand foot syndrome caused by capecitabine
• PET scans to check how chemo is working

Chemotherapy after surgery for bowel cancer (adjuvant chemotherapy)

Fluorouracil, FOLFOX or capecitabine are currently the standard chemotherapies used to reduce the chance of bowel cancer coming back after surgery. The AVANT trial is looking at whether adding a biological therapy called bevacizumab to standard chemotherapy can make the chemotherapy work better. This trial has closed and we are waiting for the results. The QUASAR2 trial is funded by Cancer Research UK and is looking at whether adding a biological therapy called bevacizumab (Avastin) to capecitabine (Xeloda) chemotherapy can make the chemotherapy work better.

The SCOT trial is looking into whether having just 12 weeks of chemotherapy can work as well as having 24 weeks treatment, and reduce the side effects. You may be able to join this trial if you are having surgery for stage 2 or stage 3 bowel cancer, and are due to have chemotherapy afterwards. People on this trial will either have OxMdG (oxaliplatin, fluorouracil, and folinic acid) or XELOX (oxaliplatin and capecitabine) chemotherapy. Your doctor will decide which combination of chemotherapy you have, but neither you nor your doctor can decide whether you will have 12 or 24 weeks of treatment. There is more information about this trial on our clinical trials database.

Chemotherapy before surgery for bowel cancer (neoadjuvant chemotherapy)

Many people with bowel cancer have chemotherapy after surgery. The FOxTROT trial is looking at whether giving some chemotherapy before surgery helps to stop the cancer coming back. Doctors think that the chemotherapy may shrink the tumour and make it easier to remove. They also want to know if it works better at killing off any cancer cells that have already spread, than giving chemo after surgery. This trial is also looking at whether adding a monoclonal antibody called panitumumab to chemotherapy can help people with early bowel cancer. Trials have already shown that panitumumab (Vectibix) can help some people with advanced bowel cancer to live longer and have a better quality of life.

You may be able to enter the FOxTROT trial if you have bowel cancer that has started to grow outside the bowel wall, or into nearby body organs. You cannot enter this trial if your cancer has already spread to another part of your body, or if you are going to have radiotherapy treatment. Everyone on this trial will have 24 weeks treatment with either OxMdG chemotherapy or OxCap chemotherapy. OxMdG is oxaliplatin, 5FU and folinic acid. OxCap is oxaliplatin and capecitabine. Some people on the trial will have 6 weeks of their chemotherapy before surgery, the others will have all their chemotherapy after surgery. Some people will have panitumumab as well as the chemotherapy. The researchers want to find out which combination of drugs, and which order of treatment, works best to stop this type of cancer coming back.

The EXCITE trial is looking at having cetuximab (Erbitux), capecitabine (Xeloda) and irinotecan (Campto) with radiotherapy before surgery for rectal cancer that has spread into the surrounding tissues. Cetuximab is a biological therapy and capecitabine and irinotecan are chemotherapy drugs. Doctors want to see how much this combination of treatment helps to shrink the cancer before surgery and what the side effects are.

You can find more information about these trials on our clinical trials database.

Chemotherapy for bowel cancer that has spread

There is a small trial of a new chemotherapy drug called patupilone for people whose bowel cancer has spread. You may be able to join this trial if you have already been treated with oxaliplatin, irinotecan and either raltitrexed or a fluoropyrimidine drug (a group of drugs including fluorouracil or 5FU, capecitabine, tegafur with uracil (Uftoral)). The doctors want to see if patupilone can stop or control the growth of the cancer. They are also checking the type of changes in the cancer cells' DNA, to see if patupilone works better for certain types of bowel cancer.

The MESH trial is looking at whether the chemotherapy drug methotrexate can help people with a particular gene fault who have bowel cancer that has spread.

ou can find more information about these trials on our clinical trials database.

Hand foot syndrome caused by capecitabine

Capecitabine is a form of the chemotherapy drug fluouracil (5FU) that you take as a tablet. It is used to treat bowel cancer. One of the side effects of this and similar drugs is hand foot syndrome, or palmar plantar syndrome. The palms of your hands and the soles of your feet may become red, sore or numb. They can get quite painful. Doctors often prescribe a tablet called pyridoxine (vitamin B6) to help control this effect. But there isn't much evidence to show how well pyridoxine works. A trial, called CAPP-IT has been trying to find the best dose of pyridoxine for people with bowel cancer taking capecitabine. This trial is no longer recruiting patients, and we are waiting for the results.

PET scans to check how chemotherapy is working

Another small trial is looking at using a new PET scan technique, to see how well chemotherapy is working for patients with bowel cancer that has spread to the liver. The new PET scans will be compared with standard PET scans, as well as CT or ultrasound scans. You can find more information about this on our clinical trials database. Choose 'bowel' from the drop down menu of cancer types.

We know that radiotherapy, along with surgery, can help to stop rectal cancer from coming back. We also know that having fluorouracil chemotherapy along with radiotherapy can make it work better for rectal cancer. The chemotherapy makes the cancer cells more sensitive to radiation. Some trials are looking at giving chemotherapy with radiotherapy before or after surgery for rectal cancer. One trial called Chronicle has been trying to find out if giving chemotherapy after chemoradiation and surgery will help reduce the chance of rectal cancer coming back. This trial is no longer recruiting patients, and we are waiting for the results.

A large trial in the UK called FIREFOX is looking at using a type of internal radiotherapy (sirspheres) for people with liver secondaries that cannot be surgically removed. During this treatment, millions of very tiny ‘beads’ (microspheres) are injected into the liver. Each bead is coated with a radioactive substance. This gives a dose of radiotherapy to the liver tumours for a few days. The trial is looking at whether the treatment can shrink liver secondaries and make it possible to remove them with surgery. It is also looking at the side effects of this treatment.

Surgery is one of the main treatments for bowel cancer. Keyhole (or laparoscopic) surgery is carried out by making smaller cuts in your abdomen (tummy), and putting surgical instruments and a camera through these holes to do the operation. We know that keyhole surgery is as good as standard surgery for removing and curing bowel cancer. There is now a trial to find out if people who have keyhole surgery recover quicker from their operation, and get fewer complications such as infections. There is more information about this trial on our clinical trials database.

Surgeons have developed a new type of surgery for people with liver tumours in parts of the liver that are dangerous or usually impossible to treat with surgery - for example, when the tumour is very close to major veins that connect to the liver. This type of surgery is very new and experimental and is used when the patient would die if they did not have the surgery. There is a risk of dying from the surgical operation. The operation involves removing the liver from the body, cutting away the diseased tissue, and then putting back the healthy liver tissue. Doctors call this 'ex-vivo hepatic resection and reimplantation for liver cancer'.

The National Institute for Health and Clinical Excellence (NICE) has issued guidance to the NHS in England, Wales, Scotland and Northern Ireland about this surgery. They say that there is limited evidence for the safety of this type of operation and it is not clear how well it works but it may be helpful for some people with liver cancer. People having the procedure must receive full information about the possible risks and benefits.

Some specialists see their patients regularly after treatment has finished, but some do not. Follow-up varies a lot between different hospitals, and doctors are not sure what is best. Seeing patients more often and having certain tests may help the doctors to diagnose a recurrence of bowel cancer earlier. But having regular tests can be stressful for patients. And there is limited evidence so far that diagnosing a recurrence of bowel cancer earlier will improve survival rates. The FACS trial aims to find the best way to follow up patients after treatment for bowel cancer. The trial has closed and we are waiting for the results.

Bowel cancer is sometimes diagnosed because it causes a blockage in the bowel, which makes you feel very unwell. In this situation, you would usually have emergency surgery to relieve the blockage, and allow your bowel to start working again. Doctors often treat bowel cancer with surgery. But emergency surgery is more difficult than surgery that is planned. There is a higher risk of complications after surgery and it is more likely that you will need to have a colostomy (a stoma).

In this trial, the researchers want to see if it is possible to put a stent into the bowel to relieve the blockage (endoluminal stenting). The stent opens up the bowel so that the waste from food you have digested can pass through.

If this works, your specialist will then have time to plan the best treatment for you. And you will be able to get a bit better before you have surgery. Most people will go on to have an operation, but depending on the results of the tests you have, your specialist may decide you should not have surgery.

Doctors want to find out if stenting before you have an operation can reduce the complications of surgery, reduce the number of people who need a stoma, and help people to live longer.

You may be able to join this trial if you have suspected bowel cancer that is causing a blockage on the left side of your bowel. People on this trial will be divided into 2 groups. One group will have a stent put into their bowel, the other group will have emergency surgery. Neither you nor your doctor will be able to choose which group you go into. If you are put in the group to have a stent, but there are problems with the procedure, you will still need to have emergency surgery.

Many people are not fit enough to have surgery for bowel cancer that has spread to the liver. So doctors have developed treatments that can destroy (ablate) the secondary tumours. Treatments include

• Radiofrequency ablation (RFA)
• Cryotherapy
• Laser therapy
• Microwave therapy

These techniques are described on our the page about specialised surgical treatments for liver secondaries.

A UK trial is comparing chemotherapy with or without radiofrequency ablation for bowel cancer that has spread to the liver. It is called the CLOCC trial. It has now finished recruiting patients and so we are waiting for results.

Biological therapies are treatments that use natural body substances or drugs made from natural body substances. There is detailed information about biological therapies in the about cancer treatment section of CancerHelp UK. Current research for colorectal cancer is looking at

• Cetuximab (Erbitux)
• Bevacizumab (Avastin)
• Panitumumab (Vectibix)
• Pazopanib

Cetuximab (Erbitux)

Cetuximab (Erbitux) is a biological therapy that blocks a growth factor called epidermal growth factor (EGF). Some bowel cancer cells have EGFR receptors. When triggered, the EGF receptors tell the cell to grow and divide into more cells. So, cetuximab is a growth factor blocker. Before you can have cetuximab, you may have tests on your cancer to make sure the cells have the epidermal growth factor receptor (EGFR). Trials have shown that giving cetuximab with chemotherapy makes the chemotherapy work better. Further studies are planned to find the best way of combining cetuximab with chemotherapy. Studies have shown that cetuximab does not work in people whose bowel cancer has a genetic change called a k-ras mutation. Around 4 out of 10 people (40%) with bowel cancer have a k-ras mutation.

A trial called COIN-B is looking into whether cetuximab works better with chemotherapy when it is given in 12 week courses, or when it is given continuously.

The New EPOC trial is looking at cetuximab for bowel cancer that has spread to the liver, but can be removed. Everyone on this trial has chemotherapy for 12 weeks. They have oxaliplatin and either fluorouracil with folinic acid, or capecitabine. The cancer is removed from the liver and then people have another 12 weeks chemotherapy. While having chemo, some people take cetuximab, the rest will not. This is to see if the cetuximab and chemotherapy work better together than the chemo on its own.

A trial called CRYSTAL found that adding cetuximab to FOLFIRI chemotherapy, for bowel cancer that has spread, reduced the risk of the cancer progressing compared to the chemotherapy on its own. But cetuximab only helped people whose bowel cancer did not have a k-ras mutation.

The trial looked at giving cetuximab with chemotherapy to people as a first treatment for bowel cancer that has spread. This trial is no longer recruiting patients, and we are waiting for the results.

Bevacizumab (Avastin)

Bevacizumab (Avastin) is a biological therapy that has been licensed in the UK to treat advanced bowel cancer. The license is for bevacizumab with either fluorouracil and folinic acid or with irinotecan, fluorouracil and folinic acid. It is also licensed in Europe for use with capecitabine or oxaliplatin for bowel cancer that has spread

Avastin blocks a growth factor protein called VEGF. VEGF triggers blood vessel growth or ‘angiogenesis’. All cancers need to grow their own blood supply. Avastin stops tumours from making blood vessels. In January 2007, the National Institute for Health and Clinical Excellence (NICE) ruled that bevacizumab should not be routinely available on the NHS as a first treatment option for bowel cancer that has spread. The equivalent body in Scotland, the SMC (Scottish Medicines Consortium) issued similar guidance in 2006 and 2008.

Research into bevacizumab is continuing in the UK. It was tested with chemotherapy in a large phase 3 trial. People who had the combined treatment lived on average 5 months longer than people who had chemotherapy alone. So far, this treatment is only for advanced bowel cancer. We don't know yet if it will help earlier stage bowel cancer.

The BOXER trial is looking at giving bevacizumab with oxaliplatin and capecitabine to people whose bowel cancer has spread to the liver but nowhere else in the body. It is hoped that the cancer in the liver will shrink to the point where it can be removed by surgery. This trial has closed and we are waiting for results.

A large study called QUASAR 2 is looking to see whether adding bevacizumab to capecitabine after surgery (adjuvant treatment) helps people to live longer. You can find out more about these trials on our clinical trials database. Pick 'Bowel: back passage (rectum) or large bowel (colon)' from the drop down menu of cancer types. Or type the name of the trial into the ‘free text search’ box.

Panitumumab (Vectibix)

Panitumumab (also known as Vectibix) is another type of monoclonal antibody. It has been approved in Europe for treating some people with bowel cancer that has spread, if the cancer cells have EGF receptors, and standard chemotherapy has not worked. In Scotland, the SMC (Scottish Medicines Consortium) does not recommend panitumumab for treating advanced bowel cancer in this situation. In Wales, the All Wales Medicines Strategy Group (AWMSG) does not recommend panitumumab for people with bowel cancer that has spread.

The PICCOLO trial is looking at how effective panitumumab is as a treatment for bowel cancer that has come back. People on this trial will either have a standard course of irinotecan, irinotecan with panitumumab, or irinotecan with ciclosporin. Ciclosporin is not an anticancer drug, but doctors think it might reduce the side effects of irinotecan. Panitumumab is also being given as part of the FOxTROT trial into chemotherapy before surgery for bowel cancer.

You can find more information about these trials on our clinical trials database.

Pazopanib

Pazopanib is a new type of tyrosine kinase inhibitor. It is taken as a tablet and stops tumour cells developing blood vessels. It has been used to treat kidney and ovarian cancer and is in early stage clinical trials for advanced bowel cancer.

Using antibodies to target other treatment

Scientists can attach poisons or radioactive atoms to monoclonal antibodies. The antibodies carry the treatment straight to the cancer cells. The researchers hope that this targeted treatment will be work better than regular chemotherapy or radiotherapy. The treatment may also mean other healthy cells in your body don't get damaged, so there could be fewer side effects.

One trial for people with advanced bowel cancer looked at using a monoclonal antibody known as A5B7. A5B7 targets the tumour marker CEA, produced by some colorectal cancer cells. Researchers have used this antibody, with radioactive iodine attached to it, in combination with another new drug called combretastatin (CA4P). Combretastatin damages the blood vessels in the cancer. The aim of this trial is to find out how well combretastatin works and monitor the side effects of the two drugs when given together. This trial is no longer recruiting patients and we are waiting for the results.

Resveratrol is a type of chemical called an antioxidant. It occurs naturally in some foods, such as grapes and peanuts. Antioxidants can stop the genes inside cells becoming damaged, and may help to prevent cancer. In the laboratory, resveratrol has been shown to help kill bowel cancer cells. Doctors want to find out more about what happens to resveratrol in the body after it is eaten or drunk. A small study has been looking at what effect resveratrol might have on bowel cancer cells in the body. People on this trial take resveratrol for 8 days before their operation. Then the tumour cells are examined in the laboratory. This study is no longer recruiting patients and we are waiting for the results.

A study is looking at symptoms which could be caused by cancer coming back after treatment.

After treatment for cancer of the breast, lung, prostate or bowel, you have follow up appointments with your specialist doctor. But after a few years, if you stay well, these appointments may stop. You are then asked to see your GP if you have any new symptoms, or are worried about anything.

Researchers are looking back at the medical notes of people who have gone to their GP with symptoms some time after cancer treatment. They will look at people whose cancer had come back as well as people whose symptoms were caused by something else. The trial aims to find common symptoms of cancer recurrence to help doctors spot the signs that cancer may have come back. There are more details on our clinical trials database. Choose bowel from the drop down menu of cancer types to find bowel cancer trials.