Stage III Colon Cancer

Overview

Following surgical removal of colon cancer, the cancer is classified as Stage III if the final pathology report shows that the cancer has penetrated the wall of the colon into the abdominal cavity and invaded any of the local lymph nodes, but cannot be detected in other locations in the body. Stage III adenocarcinoma of the colon is a common and curable cancer. Depending on the features of the cancer, 40-50% of patients are cured without evidence of cancer recurrence following treatment with surgery alone.

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Despite undergoing complete surgical removal of the cancer, half of patients with Stage III colon carcinoma experience recurrence of their cancer. This is due to the presence of small amounts of cancer that have spread outside the colon, called micrometastases. It is important to realize that many patients with Stage III disease have micrometastases that are not removed by surgery. These cancer cells cannot be detected with any currently available tests. An effective treatment is needed to eliminate micrometastases and improve the cure rates of Phase III cancer. Efforts are currently underway to find such a therapy.

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The following is a general overview of the diagnosis and treatment of stage III colon cancer. Each person with colon cancer is different, and the specific characteristics of your condition will determine how it is managed. The information on this Web site is intended to help educate you about treatment options and to facilitate a shared decision-making process with your treating physician.

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Adjuvant Chemotherapy Treatment

The delivery of cancer treatment following local treatment with surgery is referred to as “adjuvant” therapy and may include chemotherapy, radiation therapy, and/or targeted therapy. Adjuvant chemotherapy is administered to patients with Stage III colon cancer for the purpose of reducing the risk of cancer recurrence.

Adjuvant treatment with chemotherapy has been shown to reduce the risk of tumor relapse and improve survival among patients with Stage III colon cancer. Since the 1980’s, the mainstay of chemotherapy treatment has been a combination of 5-flourouracil (5-FU) and leucovorin (LV). More recently, researchers have evaluated the effects of combining 5-FU/LV with other drugs.

Adding Eloxatin® (oxaliplatin) to 5-FU/LV appears to improve outcomes. Eloxatin is a platinum-based chemotherapy drug that was FDA-approved for the adjuvant treatment of Stage III colon cancer in 2004. The combination of Eloxatin with 5-FU/LV may be abbreviated FOLFOX or FLOX, depending on exactly how the drugs are given.

In two large trials, adding Eloxatin increased 3-year disease free survival by 5-7%. The first trial compared 2,246 patients receiving either FU/LV or FU/LV plus Eloxatin. In patients with Stage III disease, three year disease-free survival was 72% in the FU/LV plus Eloxatin group, compared with 65% in the FU/LV group.[1] A more recent trial (NSABP C-07) of 2,492 patients demonstrated 3-year disease free survival rates of 76% in patients receiving FU/LV plus Eloxatin compared with 72% in patients receiving FU/LV.[2]

Xeloda® (capecitabine) is another treatment that has been FDA-approved for the adjuvant treatment of patients with Stage III colon cancer. Xeloda is a form of the chemotherapy drug 5-FU that is administered orally as a pill, rather than into a vein.

In the treatment of colorectal cancer, Xeloda appears to work as well as 5-FU/LV with fewer side effects.[3],[4] In addition, oral administration is more convenient since it requires fewer clinic visits—patients receiving Xeloda will make a minimum of eight trips to their clinic, whereas those on 5-FU may make up to 30 trips.[5]

Treatment of the Elderly

A large percentage of patients with colon cancer are 65 years or older. Sometimes elderly patients and/or their physicians may believe that believe that treatment will be more toxic for elderly patients than it is for their younger counterparts. Due to this perceived intolerability of therapy, elderly patients often do not receive optimal treatment.

To assess the effects of chemotherapy by age, researchers analyzed data from 7 separate clinical trials that were conducted to evaluate adjuvant chemotherapy in patients with Stage II or III colon cancer. Patients were divided into four age groups: 50 years and younger, 51 to 60 years, 61 to 70 years and 70 years and older. In these trials, patients received either surgery alone or surgery followed by adjuvant chemotherapy consisting of either 5-FU plus leucovorin or 5-FU plus levamisole. Five years following treatment, the overall survival rate was 71% for patients treated with adjuvant chemotherapy versus only 64% for those treated with surgery alone. There were no differences in survival rates between the age groups. The incidence of side effects from adjuvant chemotherapy was not increased in the elderly, except for one clinical trial reporting a higher rate of leukopenia (low white blood cell levels) in the elderly group. The analysis from this large sum of data confirms that elderly patients with colon cancer who are in otherwise good health have improved survival with adjuvant chemotherapy and tolerate this treatment regimen as well as younger patients.[6]

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References


[1]Andre T, Boni C, Mounedji-Boudiaf, et al. Oxaliplatin, Fluorouracil, and Leucovorin as Adjuvant Treatment for Colon Cancer. New England Journal of Medicine. 2004;350:2343-2351.

[2] Kuebler JP, Wieand HS, O’Connell MJ, et al. Oxaliplatin combined with weekly bolus fluorouracil and leucovorin as surgical adjuvant chemotherapy for stage II and III colon cancer: results from NSABP C-07. Journal of Clinical Oncology. 2007;25(16):2198-204.

[3] Twelves C, Wong A, Nowacki M, et al. Capecitabine as Ajuvant Treatment for Stage III Colon Cancer. New England Journal of Medicine. 2005; 352:2696-2704.

[4] Cassidy J, Douillard JY, Twelves C, et al. Pharmacoeconomic analysis of adjuvant oral capecitabine vs intravenous 5-FU/LV in Dukes’ C colon cancer: the X-ACT trial. British Journal of Cancer. 2006;94(8):1122-9.

[5] Twelves C, Wong A, Nowacki M, et al. Capecitabine as Ajuvant Treatment for Stage III Colon Cancer. New England Journal of Medicine. 2005; 352:2696-2704.

[6] D Sargent, R Goldberg, J MacDonald, et al. Adjuvant Chemotherapy for Colon Cancer (CC) Is Beneficial Without Significantly Increased Toxicity in Elderly Patients (Pts): Results from a 3351 Pt Meta -Analysis. Proceedings from the 36th annual meeting of the American Society of Clinical Oncology. Blood. 2000;19: Abstract #933

Strategies to Improve Treatment

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