In co-operation with the European Society of Digestive Oncology (ESDO)
Modern multidisciplinary approaches to the treatment of advanced colorectal cancer (CRC) have led to dramatic improvements in patient survival, and brought the possibility of achieving a cure within reach for some late-stage patients. Professor Philippe Rougier from the European Hospital George Pompidou in Paris, France, speaking on behalf of United European Gastroenterology (UEG), says he believes that the evolution of better diagnostic and surgical procedures, combined with more effective medical treatments, has helped to substantially reduce the risk of recurrence and improve survival rates in patients with stage III colon cancer. “The efficacy of medical treatments for advanced CRC has improved greatly since 1957, when 5-FU was first synthesised,” he said. “Today, medical treatments are contributing substantially to improved clinical outcomes, with many stage III patients and some patients with metastatic CRC achieving a cure.”
Medical management of advanced CRC
The chemotherapy agent 5-FU has been used to treat CRC for around 40 years. The chemotherapy treatments irinotecan and oxaliplatin were developed in the 1990s, with targeted therapies such as anti-angiogenic and anti-growth factor medications becoming available during the early 2000s. Since 2004, the combination chemotherapy regimen known as FOLFOX (which includes folinic acid [FOL], 5-FU [F] and oxaliplatin [OX]) has become a standard chemotherapy treatment after colorectal surgery and, when given for 6 months,1 it has been shown to halve the risk of cancer recurrence and improve 5-year survival rates to around 75%.
“Patients with stage III colon cancer are at high risk of recurrence because of the presence of lymph node metastases,” explains Prof. Rougier. “However, after complete excision of the primary tumour, chemotherapy regimens such as FOLFOX have now made it possible for us to cure more patients with this advanced-stage disease.”
Prof. Rougier believes that, unfortunately, the toll on the patient’s quality of life with FOLFOX and other powerful chemotherapy regimens is currently unacceptable and that more work needs to be done to recognise and reduce the impact of chemotherapy treatments on the individual. With this in mind, an important clinical trial is currently underway to compare 3 and 6 months of FOLFOX treatment, with the aim of reducing the regimens overall toxicity burden.
“As most stage III colon cancer patients are cured after optimal surgery and adjuvant chemotherapy, the long-term quality of life of the individual is of major concern,” says Prof. Rougier. “Some patients are forced to give up their jobs while they are receiving treatment, which can have detrimental effects on their future career prospects and financial stability. Many patients often live with high levels of anxiety about a recurrence and this, too, can negatively impact quality of life. We need to consider all aspects of a patient’s life – their family, work and social life – when we are planning and managing their treatment.”
Improved outlook for patients with CRC metastases
Patients with CRC metastases have, in the past, had a life expectancy of just 6 months. Today, thanks to modern chemotherapy and targeted treatments directed against angiogenesis or tumour cell membrane receptors, the median survival for patients with metastases is approximately 2 years and almost 20% will live for 5 years or longer after their treatment.2 The surgical resection of metastases has contributed enormously to this improved prognosis, with 25% of patients with isolated metastases now candidates for potentially curative resection surgery.
“These resections can be facilitated by efficient chemotherapies and targeted treatments and result in a 5-year survival rate of around 50% and a cure rate of around 20% in patients with CRC metastases,” says Prof. Rougier. “These outstanding results have justified the development of a specialised multidisciplinary approach to the management of digestive cancers and ultimately led to the formation of our organisation, ESDO.”3
Prof. Rougier says that, despite these significant improvements in the treatment and outcomes of advanced colon cancer, he would rather have fewer advanced patients to treat and see the resources spared put to alternative use.
“All the progress achieved in the treatment of advanced colon cancer has been at an enormous cost in terms of patient and societal burden,” he says. “For this reason, we must continue to put all our efforts into systematic screening for the early detection of CRC, the treatment of benign polyps and superficial cancers, and the identification and monitoring of at-risk families.”
1. André T, Boni C, Navarro M et al. Improved overall survival with oxaliplatin, fluorouracil, and leucovorin as adjuvant treatment in stage II or III colon cancer in the MOSAIC trial. J Clin Oncol 2009;27(19):3109-16.
2. Kopetz S, Chang GJ, Overman MJ et al. Improved survival in metastatic colorectal cancer is associated with adoption of hepatic resection and improved chemotherapy. J Clin Oncol 2009;27(22):3677-83.
3. Rougier P, Legoux JL, Lepage C et al. Hepato-gastroenterologists and oncologists are complementary in the management of digestive cancers. Dig Liver Dis 2011;43(8):583-4.