Colorectal Cancer treatment options in the UK

Colorectal cancer, encompassing cancers of the colon and rectum, is one of the most prevalent forms of cancer globally, including in the UK. Early diagnosis and treatment are crucial for improving survival rates and quality of life. In the UK, patients have access to a range of advanced treatment options tailored to their specific needs. This blog explores the various treatment modalities available for colorectal cancer in the UK, highlighting the latest advancements and the roles of different healthcare professionals in providing comprehensive care.

1. Surgery for Colorectal Cancer

A. Colon Resection

Colon resection is the most frequently performed surgical procedure for colorectal cancer. This operation involves the removal of the section of the colon affected by cancer along with adjacent lymph nodes to ensure that any potentially cancerous cells are also removed. The surgery is often performed with the goal of achieving clear margins, which means no cancer cells are left at the edges of the removed tissue. The resection can be done as an open surgery or using minimally invasive techniques, depending on various factors such as the tumor's location and the patient's overall health.

B. Laparoscopic Surgery

Laparoscopic surgery, also known as minimally invasive surgery, involves making several small incisions in the abdomen rather than one large incision. A laparoscope—a thin, flexible tube with a camera—is inserted through one of these incisions, allowing the surgeon to view the interior of the abdomen on a monitor. Specialized instruments are then used to remove the tumor and any affected lymph nodes. This technique is associated with less postoperative pain, a shorter hospital stay, and quicker recovery compared to traditional open surgery.

C. Robotic Surgery

Robotic surgery is an advanced form of laparoscopic surgery that utilizes robotic systems to enhance precision and control during the operation. The surgeon operates the robotic arms via a console, which allows for greater dexterity and accuracy in complex procedures. Robotic surgery can be particularly beneficial for delicate or difficult-to-reach areas, offering advantages such as reduced blood loss, minimal scarring, and a faster recovery period. This method combines the benefits of minimally invasive surgery with enhanced technological capabilities for improved outcomes.

2. Chemotherapy for Colorectal Cancer

A. Adjuvant Chemotherapy

Adjuvant chemotherapy is administered after the primary treatment, typically surgery, to eliminate any remaining cancer cells that could not be removed or that may have spread to other parts of the body. The goal of adjuvant chemotherapy is to reduce the risk of cancer recurrence and improve long-term survival rates. It is generally recommended for patients with stage II or III colorectal cancer, depending on the specific characteristics of their disease. Common drugs used in adjuvant chemotherapy include fluorouracil (5-FU), leucovorin, and oxaliplatin.

B. Neoadjuvant Chemotherapy

Neoadjuvant chemotherapy is given before surgery to shrink tumors, making them easier to remove and potentially increasing the chances of a successful surgical outcome. This approach can be particularly useful for patients with locally advanced or large tumors. By reducing the size of the tumor, neoadjuvant chemotherapy may also help preserve more of the healthy colon tissue and improve the likelihood of preserving bowel function. In some cases, it can also make the tumor less likely to invade surrounding tissues or spread to other organs. Common regimens for neoadjuvant chemotherapy may include combinations of fluorouracil (5-FU), leucovorin, and oxaliplatin.

C. Palliative Chemotherapy

Palliative chemotherapy is focused on improving the quality of life for patients with advanced colorectal cancer who may not benefit from curative treatments. The primary goals of palliative chemotherapy are to relieve symptoms, such as pain or obstruction, and to manage cancer-related complications. It can also help slow the progression of the disease and extend survival. Unlike curative chemotherapy, palliative treatments are tailored to the patient’s comfort and may involve drugs such as irinotecan, capecitabine, or a combination of other chemotherapeutic agents, depending on the specific needs and response of the patient.

3. Radiotherapy for Colorectal Cancer

A. External Beam Radiotherapy

External beam radiotherapy involves targeting the cancerous area with high-energy rays from outside the body. This technique uses a machine that directs focused radiation beams at the tumor site. External beam radiotherapy is often used in combination with chemotherapy to enhance its effectiveness, particularly for rectal cancer. It helps to shrink tumors before surgery (neoadjuvant therapy) or to eliminate any remaining cancer cells after surgery (adjuvant therapy). The treatment is typically administered in daily sessions over several weeks. It is precise and aims to minimize damage to surrounding healthy tissues while maximizing the dose to the cancerous area.

B. Brachytherapy

Brachytherapy, also known as internal radiotherapy, involves placing radioactive material directly inside or very close to the tumor. This approach allows for a high dose of radiation to be delivered to the cancerous tissue while limiting exposure to surrounding healthy tissues. Brachytherapy is less commonly used for colorectal cancer compared to external beam radiotherapy but may be considered in specific cases. It can be used as a palliative treatment to control local symptoms or in combination with other therapies to manage tumors that are not easily accessible through external radiation. The placement of radioactive sources can be temporary or permanent, depending on the treatment plan and the nature of the cancer.

4. Targeted Therapy for Colorectal Cancer

A. Monoclonal Antibodies

Monoclonal antibodies are designed to target specific molecules involved in cancer cell growth and survival. These drugs can block the signals that cancer cells use to grow or mark cancer cells for destruction by the immune system. For colorectal cancer, several monoclonal antibodies are used:

i. Bevacizumab (Avastin): This drug targets vascular endothelial growth factor (VEGF), which helps tumors form new blood vessels. By inhibiting VEGF, bevacizumab aims to starve the tumor of nutrients and oxygen, slowing its growth. It is commonly used in combination with chemotherapy for advanced stages of colorectal cancer.

ii. Cetuximab (Erbitux): Cetuximab targets the epidermal growth factor receptor (EGFR), which is involved in cell division and growth. By binding to EGFR, cetuximab can inhibit the growth of cancer cells. It is typically used for metastatic colorectal cancer with specific genetic profiles and in combination with chemotherapy.

B. Tyrosine Kinase Inhibitors

Tyrosine kinase inhibitors work by blocking specific enzymes called tyrosine kinases that are involved in cancer cell signalling and proliferation. These drugs interfere with the cancer cell's ability to grow and spread by disrupting the signalling pathways. Key tyrosine kinase inhibitors used in colorectal cancer include:

i. Regorafenib (Stivarga): This drug inhibits multiple kinases involved in tumor growth and blood vessel formation. It is used for patients with metastatic colorectal cancer that has progressed despite other treatments.

ii. Cabozantinib (Cabometyx): Although more commonly used for other cancers, cabozantinib can also be effective in colorectal cancer by targeting multiple kinases involved in tumor growth and spread.

Targeted therapies often complement other treatments, such as chemotherapy, and are selected based on the molecular and genetic characteristics of the tumor. They offer a more personalized approach to cancer treatment, focusing on the specific pathways and mechanisms that are driving the cancer’s progression.

5. Immunotherapy for Colorectal Cancer

A. Checkpoint Inhibitors

Checkpoint inhibitors are a type of immunotherapy that helps the immune system recognize and attack cancer cells. They work by blocking proteins that prevent immune cells from attacking cancer, thereby enhancing the body’s natural immune response against tumors. For colorectal cancer, checkpoint inhibitors are particularly used in cases with specific genetic characteristics:

i. Pembrolizumab (Keytruda): Pembrolizumab targets the programmed cell death protein 1 (PD-1) receptor on immune cells. By blocking PD-1, pembrolizumab helps to enhance the immune system's ability to recognize and destroy cancer cells. It is especially effective in patients with microsatellite instability-high (MSI-H) or mismatch repair-deficient (dMMR) tumors, which are more likely to respond to this treatment.

ii. Nivolumab (Opdivo): Nivolumab also targets PD-1, similar to pembrolizumab. It works by blocking the interaction between PD-1 and its ligands, thereby enabling T cells to attack cancer cells more effectively. Nivolumab is used in cases of colorectal cancer with MSI-H or dMMR characteristics, often after other treatments have been exhausted.

Checkpoint inhibitors represent a significant advancement in the treatment of colorectal cancer, particularly for those with advanced or recurrent forms of the disease. Their effectiveness is generally linked to the presence of specific genetic mutations or alterations in the tumor, which makes them a more targeted approach compared to traditional therapies.

6. Hormone Therapy for Colorectal Cancer

Hormone therapy is generally less common in the treatment of colorectal cancer compared to other cancers, such as breast or prostate cancer, where hormones play a more direct role in cancer growth. However, in certain specific cases, hormone therapy may be considered for colorectal cancer, particularly when other treatment options are not suitable or have failed.

Role in Colorectal Cancer

In colorectal cancer, hormone therapy is not a standard treatment but may be used in certain scenarios:

• For Specific Subtypes or Cases: Some research suggests that hormone receptors may be present in a subset of colorectal cancer cases, although this is less common. In such cases, hormone therapy might be explored, particularly in clinical trials or experimental settings.

Types of Hormone Therapy:

• Anti-Estrogen Therapy: Drugs like tamoxifen or aromatase inhibitors are more commonly used in breast cancer but may be investigated for colorectal cancers with hormone receptor expression.

In general, hormone therapy for colorectal cancer is considered on a case-by-case basis and is not part of the standard treatment regimen. Most patients with colorectal cancer receive a combination of surgery, chemotherapy, radiotherapy, and targeted therapies as their primary treatment options.

7. Palliative Care

Palliative care focuses on alleviating symptoms and enhancing the quality of life for patients with advanced colorectal cancer. It encompasses pain management through medications and therapies tailored to individual needs, ensuring patient comfort. Nutritional support is provided to maintain strength and health, addressing issues related to appetite and digestion. Emotional support is integral, offering counselling and psychological care to help patients and families cope with the challenges of the disease. This comprehensive approach aims to address the physical, emotional, and psychological aspects of living with advanced cancer.

8. Clinical Trials

Clinical trials provide patients with access to innovative treatments and new therapies that are not yet widely available. These trials play a critical role in advancing colorectal cancer care by evaluating new drugs, treatment combinations, and techniques. Participation in clinical trials can offer patients potential benefits, such as improved efficacy or fewer side effects compared to standard therapies. They also contribute valuable data to the development of future treatments and enhance understanding of the disease. Patients should consult with their healthcare team to explore suitable clinical trial opportunities and understand the potential risks and benefits.

The UK offers a range of treatment options for colorectal cancer, from traditional methods like surgery and chemotherapy to newer approaches such as targeted therapy and immunotherapy. The choice of treatment depends on the stage of cancer, the patient’s overall health, and individual preferences. For the best outcomes, a multidisciplinary team approach is often employed, integrating the expertise of surgeons, oncologists, radiologists, and other specialists.