Treatment

Colorectal Cancer Nomogram This prediction tool calculates the probability of being disease-free from colon cancer five to ten years after surgery more

Surgery is a common treatment for many stages of colorectal cancer. In cases where the cancer is found fairly early, surgical removal of the tumor can lead to a cure. Many colorectal cancer patients naturally are concerned about preserving normal bowel, urinary, and sexual function after treatment, and at Memorial Sloan-Kettering, we are continually developing and refining new techniques to evaluate such function in people who have had major restorative colorectal surgery.

Surgery for Colon Cancer

Occasionally, the cancer may be limited to a portion of a polyp. Many such patients are cured by polyp removal alone, usually during a colonoscopy.

In other patients with cancer of the colon, surgery is more extensive and involves removal of the segment of the colon that contains the tumor as well as nearby lymph nodes to which the cancer might have spread. This procedure, called a hemi-colectomy, may require removal of several inches of the bowel. In most such cases, the bowel is reconstructed by sewing or stapling together the two ends of the remaining bowel. Fortunately, the body tolerates such surgery quite well, and bowel function usually returns to normal in just a few months. There is usually no need for a permanent colostomy bag to collect wastes, though sometimes surgeons create a temporary colostomy to allow the colon to heal before it is allowed to resume its normal functions.

Minimally Invasive Surgery for Colorectal Cancer

Advances in laparoscopic technology and fiber optics allow surgeons to perform complex procedures through small incisions. Miniature video cameras and long thin instruments are utilized. Memorial Sloan-Kettering currently performs a significant portion of colorectal surgeries laparoscopically, and our surgeons have some of the most extensive training and experience in this procedure.

The general advantage of laparoscopy is related to the smaller incisions employed: an open (conventional) surgery incision could be 20-25 centimeters (8-10 inches), which can be brought down to 3 to 4 centimeters (1.5 to 2 inches) in laparoscopic colorectal surgery. Patients recover quicker and appear to return to their usual activities faster following these minimally invasive procedures. The technique is already used to treat benign abdominal diseases such as appendicitis, hiatal hernia, and gallbladder disease and is now being applied to cancers.

Long-term outcome following laparoscopic surgery for colon cancer has been studied in numerous multicenter trials such as the one sponsored by the National Institutes of Health (NIH) and results will be forthcoming shortly. Surgeons at Memorial Sloan-Kettering are investigating the potential benefits of laparoscopic surgery in both colon and rectal cancer patients.

Surgery for Rectal Cancer

Surgery for rectal cancer is often more complex. Small cancers in the rectum that have not grown through the wall of the bowel are often treated with local removal of the growth (similar to a lumpectomy for breast cancer, in that as little as possible of the surrounding healthy tissue is removed), with or without radiation therapy. Local excision -- removal of superficial cancers and a small amount of nearby tissue from the wall of the rectum -- can be performed through the anus using special equipment and fiberoptic lighting. Tumors that require more extensive local excision can be performed through a small incision in the back, just above the anus.

Some cancers that have grown through the wall of the rectum or involve the lymph nodes may require more extensive surgery. Memorial Sloan-Kettering surgeons have pioneered the use of a technique called "sharp mesorectal excision" for such patients. This approach allows the delicate removal of all cancerous tissue in and around the rectum, but carefully avoids severing the nerves that are involved in sexual and urinary function, and also allows most patients to avoid a permanent colostomy. Such nerve-preserving surgery is the standard of care at Memorial Sloan-Kettering.

In some patients, such as men with large prostate glands, such techniques may not be feasible, and "coloanal reconstruction" is needed. This approach allows the surgeon to remove the rectum, but avoids the need for a permanent colostomy by sewing the upper colon directly to the anus with the use of specialized equipment. Memorial Sloan-Kettering surgeons found that in some such cases, the upper colon was too small to provide an adequate rectal reservoir, so they developed a way to construct an internal colon pouch (the "J-Pouch"). During this procedure, surgeons loop two sections of the lower colon upon itself and open up the wall between them to create a larger reservoir for storing wastes, essentially replacing the rectum.

Transanal Endoscopic Microsurgery

Memorial Sloan-Kettering surgeons are applying minimally invasive surgical techniques for both treatment and reconstruction. For example, transanal endoscopic microsurgery -- surgery performed through small incisions with the guidance of a narrow tube with a camera at its tip -- is being explored to remove rectal cancers less invasively.

Surgery to Remove Metastases

Surgery may also be performed to remove metastases -- cancerous tissue in other organs to which the colorectal cancer has spread. Liver metastases -- the spread of cancer cells to the liver -- are common in patients with colorectal cancer. About 15 percent of patients have liver metastases when they are first diagnosed with cancer, and 50 to 75 percent of patients with advanced disease go on to develop liver metastases. Some of these patients are treated by surgically removing part of the liver. Others undergo cryosurgery, in which the tumors are frozen but not removed. Surgery may also be done to remove metastases in the lungs.

Memorial Sloan-Kettering doctors are leaders in the development and use of preoperative treatment regimens as part of a concerted, overall effort towards sphincter preservation rather than the use of permanent colostomies.

Many patients will be free of all cancer following surgery. However, in some patients, microscopic tumor cells that were not detectable before or during surgery will eventually grow. As a result, many patients, such as those whose cancer has spread to the lymph nodes, now receive chemotherapy (for colon cancer) or chemotherapy and radiation therapy (for rectal cancer) in addition to surgery. Such "adjuvant" therapy increases the chances for a complete cure by destroying microscopic accumulations of cancer cells before they have an opportunity to grow larger. At Memorial Sloan-Kettering, we commonly deliver adjuvant therapy after surgery. In advanced metastatic cancer, radiation therapy may also be used to relieve symptoms such as intestinal blockage, bleeding, or pain.

Chemotherapy drugs used to treat colorectal cancer include 5-fluorouracil, leucovorin, irinotecan, and capecitabine. Research at Memorial Sloan-Kettering helped establish the efficacy of irinotecan, the first new drug for colorectal cancer in 40 years. In some patients, this drug reduced metastatic tumors when other treatment failed. Our researchers led an international trial demonstrating that irinotecan in combination with fluorouracil and leucovorin was more effective first-line therapy for advanced colorectal cancer, and they are now leading a large study to evaluate the combination's effectiveness in earlier-stage colorectal cancer.

For selected patients whose rectal cancer has recurred in the pelvis after surgery and radiation therapy, Memorial Sloan-Kettering also offers a technique called intraoperative radiation therapy (IORT). The surgeon removes the tumor, and while still in the operating room, the patient receives a high dose of radiation. Because the radiation therapy is done during the surgical procedure, and can be delivered to a precisely defined area in the pelvis, it is possible to use a higher-than-usual -- and therefore more effective -- dose of radiation.

Find a Clinical Trial Find out about new research studies for colorectal cancer more

New approaches to colorectal cancer treatment at Memorial Sloan-Kettering include preparative chemoradiation therapy prior to surgery and an intrahepatic pump to deliver chemotherapy for patients whose cancer has spread to the liver.

Such research protocols are sometimes offered to eligible patients through the clinical trial process. For up-to-date details about current clinical trials at Memorial Sloan-Kettering, please visit our clinical trial database.

Combination Chemoradiation Therapy Prior to Surgery

In patients with rectal cancer, adjuvant chemotherapy is often combined with radiation therapy. Specialists at Memorial Sloan-Kettering have developed a chemoradiation therapy regimen known as preoperative "combined modality therapy." By giving the therapy before surgery, doctors can shrink the tumor, allowing for reconstruction of the bowel and usually avoiding the need for a permanent colostomy. This technique has resulted in an overall cure rate of more than 70 percent for all patients seen with rectal cancer, and a local recurrence rate of only 10 percent.

Intrahepatic Pump for Advanced Colorectal Cancer

Patients whose disease has spread to the liver benefit from a comprehensive program that includes physicians from colorectal surgery, liver surgery, and medical oncology, who work together to maximize long-term survival. Those whose disease cannot be treated with surgery may receive chemotherapy through an innovative liver pump that delivers drugs directly to the liver, rather than to the entire body. Memorial Sloan-Kettering's colorectal and liver physicians have pioneered these novel treatment approaches.