Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.)
Treatment decisions should be made with reference to the TNM classification system, rather than the older Dukes or the Modified Astler-Coller classification schema.
The American Joint Committee on Cancer (AJCC) and a National Cancer Institute-sponsored panel recommended that at least 12 lymph nodes be examined in patients with colon and rectal cancer to confirm the absence of nodal involvement by the tumor.[2,3,4] This recommendation takes into consideration that the number of lymph nodes examined...
Wide surgical resection and anastomosis. The role of laparoscopic techniques [1,2,3,4] in the treatment of colon cancer was examined in a multicenter prospective randomized trial (NCCTG-934653, now closed) comparing laparoscopic-assisted colectomy (LAC) to open colectomy. The quality-of-life component of this trial has been published and minimal short-term quality-of-life benefits with LAC were reported.[Level of evidence: 1iiC]
Following surgery, patients should be considered for entry into a carefully controlled clinical trial. The GRECCR-03 and NCRI-QUASAR1 trials evaluated the use of systemic or regional chemotherapy or biologic therapy. Adjuvant therapy is not indicated for most patients unless they are entered into a clinical trial.
The potential value of adjuvant chemotherapy for patients with stage II coloncancer remains controversial. Although subgroups of patients with stage II colon cancer may be at higher-than-average risk for recurrence (including those with anatomic features such as tumor adherence to adjacent structures, perforation, complete obstruction, or with biologic characteristics such as aneuploidy, high S-phase analysis, or deletion of 18q),[5,6,7] evidence is inconsistent that adjuvant 5-fluorouracil (5-FU)-based chemotherapy is associated with an improved overall survival (OS) compared to surgery alone. Investigators from the National Surgical Adjuvant Breast and Bowel Project (NSABP) have indicated that the reduction in risk of recurrence by adjuvant therapy in patients with stage II disease is of similar magnitude to the benefit seen in patients with stage III disease treated with adjuvant therapy, though an OS advantage has not been established.
A meta-analysis of 1,000 stage II patients whose experience was amalgamated from a series of trials indicates a 2% advantage in disease-free survival (DFS) at 5 years when adjuvant therapy-treated patients treated with 5-FU-leucovorin are compared with untreated controls.[Level of evidence: 1iiDii
Recently, the Cancer Care Ontario Practice Guideline Initiative Gastrointestinal Cancer Disease Site Group undertook a meta-analysis of the English language published literature consisting of randomized trials where adjuvant chemotherapy was compared with observation for patients with stage II colon cancer. The mortality risk ratio was 0.87 (95% CI, 0.75-1.01; P = .07). Based on these data, the American Society of Clinical Oncology issued a guideline stating "direct evidence from randomized controlled trials does not support the routine use of adjuvant chemotherapy for patients with stage II colon cancer."
Features in patients with stage II colon cancer that are associated with an increased risk of recurrence include inadequate lymph node sampling, T4 disease, involvement of the visceral peritoneum, and a poorly differentiated histology. The decision to use adjuvant chemotherapy for patients with stage II colon cancer is complicated and requires thoughtful consideration for both patients and their physicians.