Which treatment for advanced bowel cancer

• A quick guide to what's on this page
• What advanced colorectal cancer is
• Local spread
• Secondary spread (metastasis)
• Treatments for advanced bowel cancer
• Surgery for advanced bowel cancer
• Chemotherapy for advanced bowel cancer
• Radiotherapy for advanced bowel cancer
• Biological therapies for advanced bowel cancer
• Deciding about treatment

Advanced colorectal cancer means the cancer has spread to other parts of the body from where it started in the bowel or back passage. Your cancer may be advanced when it is first diagnosed. Or it may come back some time after you are first treated. This is called recurrent cancer. The cancer can spread

• Locally into tissues close to the bowel
• To other parts of the body, such as the liver or lungs

Local spread means the cancer has broken through the wall of the bowel and so cancer cells have spread into surrounding tissues in the abdomen or pelvis.

Cancer that has spread to another part of the body is called secondary cancer or metastastic cancer. This means the bowel cancer cells have travelled through the lymphatic system or bloodstream and become trapped in another part of the body. They have then started to grow there.

Remember - the important thing is where the cancer started. Having bowel cancer cells in your liver doesn't mean you have liver cancer. You have bowel cancer that has spread - it is also called secondary bowel cancer. This is important because your doctor needs to use treatments that work on bowel cancer cells - not liver cancer cells.

This diagram shows how blood flows from the bowel to the liver. It helps to explain why the liver is the most common place for bowel cancer to spread. The next most common site of spread is the lungs.

Once a bowel cancer has spread to another part of the body, it is unlikely to be curable. But treatment can often keep it under control for quite a long time. The choice of treatment depends on

• The type of cancer you have
• The size and number of secondaries and where they are in the body
• The treatment you have already had

You are most likely to have chemotherapy. In some circumstances you may have surgery. Newer, experimental treatments are being researched, including monoclonal antibodies.

Surgery can be used in some situations to treat advanced colorectal cancer

• To slow the cancer
• When the bowel is blocked
• To remove secondary cancer

There is more information on our page about surgery for advanced bowel cancer.

Chemotherapy to shrink a cancer and control symptoms is called palliative chemotherapy. A research review in 2004 found there was good evidence that chemotherapy helped people with advanced bowel cancer to live longer. But they couldn’t say whether the treatment improved their quality of life or not. You can read this review of chemotherapy in advanced bowel cancer in the Cochrane Library. It was written for researchers and specialists so is not in plain English.

To treat advanced bowel cancer, you have chemotherapy either into a vein in your arm or as a tablet. You may hear your doctor talk about 1st line and 2nd line chemotherapy. 1st line chemotherapy is the treatment given first. 2nd line chemotherapy is given if the 1st line treatment does not control your cancer. In August 2005, NICE (the National Institute for Health and Clinical Excellence) approved the following options for 1st line chemotherapy for advanced bowel cancer

• Fluorouracil as an injection or through a drip, often with another drug called folinic acid
• Irinotecan with Fluorouracil and folinic acid
• Oxaliplatin with Fluorouracil

If you have had Fluorouracil before, your specialist may suggest irinotecan on its own. Or they may suggest tablet forms of fluorouracil - capecitabine or Uftoral.

So you may have any one of these drug combinations when you are first diagnosed with advanced bowel cancer. There is more about chemotherapy for advanced bowel cancer in this section of CancerHelp UK.

Doctors sometimes use radiotherapy to shrink a lump or tumour in the bowel that is causing pain. This is called palliative radiotherapy. Radiotherapy is not used much for colon cancers but may be used for rectal cancers. Internal radiotherapy may be used for secondaries in the liver. It has been approved by the National Institute for Clinical Excellence (NICE) as a treatment for people who cannot have their liver secondaries surgically removed. There is more information about this on our what's new in bowel cancer page.

Cetuximab (Erbitux) is licensed in the UK for people who have bowel cancer that has spread. Studies have shown that it can help some people with advanced bowel cancer to live longer when it is added to chemotherapy treatment. It can also improve their quality of life. It is usually used with a chemotherapy drug called irinotecan. In May 2009, the National Institute for Health and Clinical Excellence (NICE) approved Erbitux as a first treatment for advanced bowel cancer. It is used for people who have a normal k-ras gene and where the cancer has spread only to the liver. Around 65% of people with advanced colorectal cancer have normal k-ras gene tumours.

Some biological therapies are very new and it will be some time before we know how well they work. Others, such as the monoclonal antibodies bevacizumab (Avastin) and panitumumab (Vectibix), are licensed for advanced colorectal cancer but have not yet been given approval by NICE for use on the NHS. There is more information about these treatments in the what's new in bowel cancer section of CancerHelp UK.

All new treatments have to go through the clinical trials process and this takes some years. To search for bowel cancer trials, visit our clinical trials database and select 'bowel' from the drop down menu of cancer types.

It can be difficult to decide which treatment to try, or whether to have treatment at all, when you have an advanced cancer. You will need to consider your quality of life while you are having the treatment. This includes side effects as well as stresses such as travelling back and forth to the hospital. Most importantly, you will need to understand what your doctor hopes to achieve with different treatments you are being offered.

Your doctor will talk through the options with you. There may also be a counsellor or specialist nurse at the hospital you can talk to. You may also want to discuss things with a close relative or friend.

It can be helpful to talk over difficult decisions with someone who is outside your circle of family and friends.  If you would like to talk to someone outside your own friends and family, look on our bowel cancer organisations page. To find out more about counselling look in the 'what is counselling?' section.