Treatment for advanced bowel cancer

Different treatments can be used to treat advanced bowel cancer. Your treatment will depend on:

• where the cancer is
• the treatment you have already had
• your general health
• the results of tests on the bowel cancer cells
• your preferences.

It is sometimes possible to control advanced bowel cancer for a long time. In some people, it might be possible to cure the advanced bowel cancer. Your doctors can talk to you about the aim of your treatment.

If the cancer is only in 1 area of the body, your doctors may suggest treatment with surgery, radiotherapy or ablation. Ablation uses extreme temperatures to destroy cancer cells.

If the cancer affects more than 1 area of the body, you may have treatment with anti-cancer drugs. These treat cancer wherever it is in the body. Sometimes a combination of treatments is used.

We understand that having advanced cancer and its treatment can be a difficult time for people. We are here to support you. If you have any questions or want more information you can:

• call the Macmillan Support Line for free on 0808 808 00 00
• chat to our specialists online
• visit our bowel cancer forum to talk to people who have been affected by bowel cancer, share your experience, and ask an expert your questions.

Some people can have surgery to remove advanced cancer. This is most commonly used to remove bowel cancer that has spread to the liver or the lungs. 

This is not suitable for everyone.  It cannot be done if the cancer has spread anywhere else in the body and you have to be well enough to cope with major surgery. 

It might be possible to have an operation called a liver resection to remove the affected part or parts of the liver with surgery.  The remaining liver can grow bigger and work as it did before.  You might have chemotherapy before surgery to help to shrink the cancer. 

Occasionally, surgery may be possible to remove a secondary cancer in the lungs.  It is usually only done if the secondary cancer is small, or is in one area of the lung. 

Surgery can sometimes be used to treat advanced cancer in other parts of the body. 

The peritoneum is a layer of tissue (membrane) that covers the organs in the tummy (abdomen). If the cancer has spread to the peritoneum only, you may be offered surgery to remove the cancer. 

You then have a treatment called hyperthermic intraperitoneal chemotherapy (HIPEC). HIPEC involves having chemotherapy put into the tummy. This treatment is only suitable for a small number of people.

Sometimes cancer can narrow the bowel, which stops poo (stools) from passing through. This is called a blocked bowel or bowel obstruction. Some people need surgery to remove the obstruction. Surgery aims to remove the blocked section of bowel.

Targeted therapy drugs target something in or around a cancer cell that is helping it grow and survive.

Targeted therapy is sometimes used to treat colon or rectal cancer that has spread to other parts of the body. You may have it on its own or with chemotherapy. 

A number of different targeted therapy drugs can be used to treat advanced bowel cancer. Your doctor may arrange tests on the bowel cancer cells to find out if they have changes in certain genes. This can tell them which drugs may be suitable. 

Not all of these drugs may be available on the NHS. Your doctor will explain if they think a particular treatment will be helpful for you. 

They can advise you whether it is available on the NHS and what can happen if it is not. We have more information about what you can do if a treatment is not available.

The following types of targeted therapy may be used to treat advanced bowel cancer. 

The following monoclonal antibodies may be used to treat advanced bowel cancer:

• cetuximab (Erbitux^®)
• panitumumab (Vectibix^®).

They may be used if the cancer cells have both a normal RAS gene and proteins on their surface called epidermal growth factor receptors (EGFRs).

You have both drugs as a drip into a vein (intravenously). You may have them with chemotherapy.

Angiogenesis inhibitors (AIs) stop a tumour from developing new blood vessels. Without a good blood supply, the tumour does not get the oxygen and nutrients it needs. This may slow the tumour’s growth. Sometimes it may cause it to shrink.

A number of AIs may be used to treat advanced bowel cancer. These include:

• bevacizumab (Avastin^®)
• aflibercept (Zaltrap®)
• ramucirumab (Cyramza®)
• regorafenib (Stivarga®).

You have bevacizumab, aflibercept and ramucirumab into a vein as an infusion (intravenously). You take regorafenib as tablets.

Only regorafenib is available on the NHS. Aflibercept given with chemotherapy is available in Scotland. Your doctors can discuss this with you.

Cancer growth inhibitors block the chemical signals that cancer cells need to grow and divide. This may slow the growth of a cancer.

Encorafenib (Braftovi^®) is given with the targeted drug cetuximab. Encorafenib and cetuximab are used if the cancer cells have a normal RAS gene and a gene change called a BRAF V600E mutation. 
You take encorafenib as capsules.

Some targeted therapy drugs can cause an allergic reaction. This may happen when the drug is being given or shortly afterwards. Signs of an allergic reaction include:

• flu-like symptoms, such as shivering
• an itchy skin rash
• feeling breathless
• swelling of the face and mouth.

An allergic reaction is more common with the first 2 of doses of the drug, but it can happen after this. To reduce the risk, you will have the first dose over a few hours. Your nurse will closely monitor you during the infusion.

The most common side effect of cetuximab and panitumumab is a skin rash. Other side effects include diarrhoea, hair changes and sore eyes.

High blood pressure is the most common side effect of bevacizumab, aflibercept, ramucirumab and regorafenib. There is also a small risk they may cause a hole (perforation) in the bowel.

When encorafenib is given with cetuximab, the most common side effects are feeling sick, diarrhoea and skin changes.

If you have any side effects during treatment, you should always tell your cancer doctor or specialist nurse.

Ablation uses extreme temperatures to destroy cancer cells. There are 2 different types of ablation used for advanced bowel cancer:

• radiofrequency ablation
• microwave ablation.

Radiofrequency ablation and microwave ablation use heat to destroy cancer cells. They are types of thermal ablation. 

Thermal ablation involves putting an electrode (like a needle) into the tumour. Heat is then sent through the electrode. The extreme heat destroys the cancer cells. As the cancer cells die, the treated area shrinks and becomes scar tissue.

You have the treatment in the hospital scanning department or an operating theatre. A doctor called a radiologist uses a scan (for example, ultrasound or CT scan) to see where the tumours are. Guided by the scan, they put 1 or more electrodes through the skin into the tumour or tumours. They then send heat through the electrodes.

You can have thermal ablation treatment more than once. Your healthcare team can tell you whether it is suitable for you. 

A type of ablation called irreversible electroporation (IRE or NanoKnife™) may be used for secondary cancer in the liver. Your doctor can tell you more about this treatment and whether they think it is suitable for you. IRE is only available in a few hospitals in the UK. 

Selective internal radiation therapy (SIRT) uses radioactive beads to treat cancer in the liver. SIRT is also called radioembolisation. 

A doctor injects tiny radioactive beads into the bloodstream. They stick permanently in the small blood vessels in and around the liver tumour. They block the blood vessels to the tumour. This stops the blood supply to the tumour so it does not get the oxygen and nutrients it needs. 

The beads also produce radiation, which damages the cancer cells. The radiation from each bead only affects cancer cells that are very nearby. The beads lose their radiation quickly. They stay in the body permanently, but this does not cause any problems.

SIRT is only suitable for some secondary liver cancers. It is not always available on the NHS. Your cancer team will tell you whether it is available for you. You may have to travel to a specialist hospital to have it. 

We have more information about SIRT. It includes planning for treatment and side effects.

Chemoembolisation is when chemotherapy drugs are injected into blood vessels to block the blood flow to the cancer cells. It can be used to treat some secondary liver cancers.

A doctor injects a chemotherapy drug into the blood vessel that goes into the liver. The drug blocks the arteries and cuts off the blood supply to the tumour. Chemoembolisation is sometimes called transarterial chemoembolisation (TACE). 

Your doctor can tell you whether chemoembolisation is a suitable treatment for you and if it is available.

We have more information about chemoembolisation. It includes how the treatment is given and side effects.