Stage II

Overview

Following surgical removal of colon cancer, the cancer is referred to as Stage II if the final pathology report shows that the cancer has penetrated the wall of the colon into the abdominal cavity, but does not invade any of the local lymph nodes and cannot be detected in other locations in the body.

Stage II adenocarcinoma of the colon is a common and curable cancer. Depending on features of the cancer, 60-75% of patients are cured without evidence of cancer recurrence following treatment with surgery alone. Stage II cancer can be further divided into two stages, Stage IIA and Stage IIB. In Stage IIA, the tumor has grown through the outermost layers of the colon but is confined to the colon. In Stage IIB, the tumor has grown through the colon wall and has extended to adjacent tissues or organs. In both stages, there are no lymph nodes containing tumor cells and no distant metastases.

Despite undergoing complete surgical removal of the cancer, 25-40% of patients with Stage II colon carcinoma experience recurrence of their cancer. Typically, cancer recurs because there are small amounts of cancer that had spread outside the colon and were not removed by surgery. These cancer cells cannot be detected with any of the currently available tests. Undetectable areas of cancer outside the colon are referred to as micrometastases. The presence of micrometastases causes the relapses that follow surgical treatment. An effective treatment is needed to eliminate micrometastases and improve cure rates of Stage II cancer. Efforts are currently underway to find such a therapy.

The following is a general overview of the diagnosis and treatment of stage II 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

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 improves outcomes among patients with Stage III colon cancer, but the benefits among patients with Stage II colon cancer are less clear. A review of previously published clinical trials reported that adjuvant chemotherapy may improve disease-free survival, but does not appear to improve overall survival, among patients with Stage II colon cancer.1 Routine use of adjuvant chemotherapy is not recommended for patients with Stage II colon cancer, but it may be considered for some patients, particularly those whose cancers have high-risk features.2

Characteristics that may indicate a higher risk of recurrence include the following:3 4

  • High grade cells on pathologic exam
  • Less than 12 lymph nodes sampled during surgery
  • Perforation or obstruction of the colon due to cancer
  • Stage IIB tumors (tumor has extended beyond the wall of the colon)

The overall health of the patient must also be considered when weighing the risks and benefits of adjuvant therapy. Patients with fewer other health problems (such as diabetes, obesity or heart disease) will better tolerate adjuvant chemotherapy.

Oncotype DX Testing

A newer test that may help guide treatment decisions for patients with Stage II colon cancer is the Oncotype DX® colon cancer test. This test—which is similar to a test that is commonly used for patients with early-stage breast cancer—is performed after surgery but before final decisions are made about adjuvant (post-surgery) therapy. The test estimates the risk of cancer recurrence by evaluating the activity of certain genes in a sample of tumor tissue. Risk of recurrence can vary greatly among patients with Stage II colon cancer, and use of the Oncotype DX test in combination with other markers of risk may help to individualize treatment decisions.

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 explore the risks and benefits 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 fluorouracil plus leucovorin or fluorouracil 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 tolerate chemotherapy as well as younger patients.5

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References

1 Figuerdo A, Coombes ME, Mukherjee S. Adjuvant therapy for completely resected stage II colon cancer.Cochrane Database of Systematic Reviews. 2008;(3):CD005390.

2 Benson AB, Schrag D, Somerfield MR. American Society of Clinical Oncology recommendations on adjuvant chemotherapy for stage II colon cancer. Journal of Clinical Oncology. 2004;15:3408-19.

3 Benson A, Schrag D, Somerfield M, et al. American Society of Clinical Oncology recommendations on adjuvant chemotherapy for stage II colon cancer. Journal of Clinical Oncology. 2004; 22: 3408-3419.

4 Figueredo A, Charette M, Maroun J, et al. Adjuvant therapy for stage II colon cancer: A systematic review from the Cancer Care Ontario Program in Evidence-based Care’s Gastrointestinal Cancer Disease Site Group. Journal of Clinical Oncology. 2004;22: 3395-3407.

5 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.