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Understanding treatment for bowel cancer and how it is delivered

Last modified: March 1, 2022

What are the treatment options for bowel cancer? Treatment options

The primary treatment options for bowel cancer (also known as colorectal cancer) include surgery, radiation therapy, chemotherapy, targeted therapy and immunotherapy. The type of treatment you receive will depend on a number of different considerations, such as if you have colon cancer or rectal cancer, the cancer’s stage, your overall health and your treatment preferences. This page aims to give you a comprehensive overview of how bowel cancer treatment works in the private health system.

Types of bowel cancer treatmentTypes of treatment

Surgery

Radiation therapy

Chemotherapy

Targeted therapy

Immunotherapy

Clinical trials

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Colonoscopy for bowel cancerColonoscopy

A colonoscopy can both diagnose and treat bowel cancer. The procedure involves inserting a colonoscope (a tube with a camera attached) into the anus, through to the rectum and colon. 

Colonoscopies are used for many different purposes.

Diagnosis

  • Assess for abnormalities – Look at the lining of the bowel for tumours or areas of inflammation or bleeding
  • Biopsy – Collect a sample of tissue for analysis

Treatment

  • Polypectomy – Remove small growths (called polyps) in the bowel’s lining
  • Stent insertion – Placement of a plastic tube to relieve an obstruction inside the bowel
  • Haemostasis –  To stop bleeding
  • Local Excision – To remove cancerous tissue

Local excision

Local excisions are commonly used for early-stage rectal cancer. Methods include:

  • Transanal excision (TAE) – This procedure involves the removal of cancer from the lower rectal wall, including any surrounding rectal tissue. This is done through making minor incisions into the rectum
  • Transanal endoscopic microsurgery (TEMS) – Specialised equipment is inserted into the anus to remove cancers in the upper rectum which may not be accessible through a transanal excision
  • Transanal minimally invasive surgery (TAMIS) – Specialised equipment is inserted into the anus to remove the rectal cancer with minimal invasion

Surgery for bowel cancerSurgery

Surgery for bowel cancer is performed to remove cancerous tissue and relieve symptoms when the cancer has advanced. Most people with bowel cancer will receive surgery as their primary form of treatment. The two approaches for surgery, performed under general anaesthesia, include:

  • Open colectomy – where a long incision is made through the skin and abdominal wall to access your colon or rectum cancer. Typically half of the colon on the side of your tumour is removed e.g. left sided colon cancers have a left colectomy
  • Keyhole (laparoscopic) colectomy – a minimally invasive procedure that uses three to four small incisions to access the colon or rectum cancer. Keyhole procedures result in less postoperative pain and complications, shorter hospital stay, and faster recovery compared to open colectomy

Even though they both fall under bowel cancer, colon cancer and rectal cancer are unique and are treated differently.

Colectomy

A colectomy (also known as a colorectal resection) is a major surgery that involves the removal of all or part of the colon and/or rectum, including nearby lymph nodes.

Colectomies used for colon cancer

Hemicolectomy Sigmoid colectomy Subtotal or total colectomy Proctocolectomy High anterior resection

Hemicolectomy

The right or left section of the colon is removed.

Sigmoid colectomy

The sigmoid is removed.

 

Subtotal or total colectomy

All of the colon is removed.

 

Proctocolectomy

All of the colon and rectum is removed.

High anterior resection

The upper rectum and part of the colon is removed, alongside nearby lymph nodes and fatty tissue.

Colectomies used for rectal cancer

High anterior resection Abdominoperineal resection or excision (APR or APE) Ultra-low anterior resection Colonic J-pouch

High anterior resection

The lower part of the colon and upper part of the rectum are removed, including nearby lymph nodes.

Abdominoperineal resection or excision (APR or APE)

The sigmoid colon, rectum and the anus are removed. This requires a permanent stoma.

Ultra-low anterior resection

The lower colon and all the rectum are removed. This includes nearby lymph nodes and tissue.

Colonic J-pouch

An internal j-pouch is made from the bowel’s lining to work as the rectum.

Depending on the type of colectomy you receive, your surgeon may make a cut between both ends of your cancer and reconnect them back together (called an anastomosis). Sometimes, the ends of the bowel may not be able to be joined together. In these cases, a new opening will be made in your abdomen. An opening in the large bowel is known as a colostomy, whereas an opening in the small bowel is referred to as an ileostomy. The opening itself is called a stoma. 

Stomas divert faecal waste out of the body. This waste is collected through a colostomy or ileostomy bag that is fixed around the stoma. A stoma can be temporary or permanent. 

Radiation therapy for bowel cancerRadiation therapy

Radiation is a common treatment option for rectal cancer but is not generally used for colon cancer. It is typically delivered over the pelvic area in combination with chemotherapy. Types of radiation therapy commonly used for people with bowel cancer include:

Chemotherapy for bowel cancerChemotherapy

Chemotherapy uses a range of drugs to destroy and slow the growth of bowel cancer. These drugs may be delivered at any stage of your bowel cancer treatment. 

Learn more about chemotherapy and how it is delivered.

Chemotherapy for bowel cancer is delivered in multiple sessions called cycles. This means you will have one to three weeks of rest between receiving an injection or infusion. Your care team will walk you through how many cycles you may need for your course of treatment, with most people completing chemotherapy in a period of four to six months. 

Common chemotherapy medicines

There are a number of different chemotherapy drugs that are used to treat bowel cancer. These drugs are typically combined based on your bowel cancer’s stage and how far it has spread throughout your body. Some of the drugs used include:

Capecitabine 5-fluorouracil Irinotecan Oxaliplatin

Capecitabine

This is an antimetabolite chemotherapy drug that works by interfering with some of the processes involved in making cell DNA, causing cancer cells to slow or stop growing. Capecitabine may be used as neoadjuvant therapy, alongside radiation therapy prior to surgery, or as adjuvant therapy following surgery and for the treatment of advanced (metastatic) bowel cancer. It can be given alone as a single therapy or in combination with other chemotherapy or targeted therapy drugs. It is usually taken orally as a tablet twice daily and repeated every three weeks.

5-fluorouracil

This is an antimetabolite chemotherapy drug that stops cancer cells from being able to make DNA, slowing and stopping their growth. 5-flourouracil is used as neoadjuvant therapy, alongside radiation therapy prior to surgery, or as adjuvant therapy following surgery and for the treatment of advanced (metastatic) bowel cancer. It is typically given together with calcium leucovorin, a drug which helps to increase its effectiveness, and may be combined with other chemotherapy drugs. 5-flourouracil can be given by intravenous infusion over several hours or as a continuous pump over 24-46 hours.

Irinotecan

This chemotherapy drug works by blocking an enzyme called topoisomerase I, which plays an important role in the production of DNA in cells. When cancer cells are unable to make DNA, this causes them to stop growing and die. Irinotecan is used in the treatment of advanced (metastatic) bowel cancer and is commonly given in combination with other chemotherapy drugs or targeted therapy drugs. It is usually given by intravenous infusion over several hours and can be repeated weekly or up to every three weeks.

Oxaliplatin

This drug is a platinum compound that works by preventing the production of DNA and RNA by cancer cells, so that they are unable to divide and grow. It is given by intravenous infusion, often in combination with other chemotherapy drugs (e.g. 5-fluorouracil and calcium leucovorin), with each infusion taking several hours. Oaxliplatin is used in the treatment of advanced (metastatic) bowel cancer and as adjuvant chemotherapy following surgery to help destroy any remaining cancer cells.

Targeted therapies for bowel cancerTargeted therapies

Targeted therapies use specialised drugs to destroy specific proteins or genes in bowel cancer cells. 

Targeted therapies are only effective for certain colon and rectal cancers, and are generally used to treat advanced bowel cancers. Your care team will examine the make-up of your cancer cells to determine if targeted therapies are suitable for you.

Common targeted therapy medicines

Common targeted therapy drugs used to treat bowel cancer include:

Bevacizumab Cetuximab Panitumumab Regorafenib Encorafenib

Bevacizumab

This is a monoclonal antibody that kills cancer cells by blocking the activity of a protein called VEGF (vascular endothelial growth factor) that is needed to provide essential nutrients to cancer. It is used to treat advanced (metastatic) bowel cancer where surgery is not possible and is usually given together in combination with other chemotherapy drugs. It is given as an intravenous infusion every 21 days, with the first infusion taking around 90 minutes and subsequent infusions taking around 10 minutes.

Cetuximab

This is a monoclonal antibody that works by inhibiting a protein called epidermal growth factor receptor (EGFR) that promotes the growth of cancer cells. It is used to treat advanced (metastatic) bowel cancer in patients who have tested positive for a RAS wild-type mutation. It may be given alone or together with other chemotherapy drugs, such as irinotecan. It is given by infusion every two weeks, with the first infusion taking around 90 minutes and subsequent infusions taking around 60 minutes.

Panitumumab

This is a monoclonal antibody that binds to and blocks the action of epidermal growth factor receptor (EGFR) which is present in excessive amounts of bowel cancer cells. It is used to treat advanced (metastatic) bowel cancer in patients who have tested positive for a RAS wild-type mutation. It is given by intravenous infusion every two to three weeks, with each infusion taking around 30 to 60 minutes.

Regorafenib

This is a tyrosine kinase inhibitor drug that targets multiple proteins on the surface of bowel cancer cells, stopping their supply of essential nutrients and preventing their growth. It is used to treat advanced (metastatic) bowel cancer and is taken orally as a tablet once daily for 21 days out of every 28 days.

Encorafenib

This is a type of targeted therapy known as a BRAF inhibitor that works by targeting a specific protein receptor on cancer cells called BRAF V600E. Where there is a BRAF V600E mutation present on the surface of bowel cancer cells, they grow in a rapid and uncontrolled way. Encorafenib targets and block this mutated receptor, stopping and slowing the growth of cancer cells. It is only effective in people who have tested positive for the BRAF V600E mutation.

Immunotherapy for bowel cancerImmunotherapy

Immunotherapy trains the immune system to recognise and fight bowel cancer cells that are hiding behind your body’s natural defences. It is commonly used when your bowel cancer has come back after initial treatment or has spread to other areas in the body. 

Common immunotherapy medicines

Common immunotherapy drugs which are used to treat bowel cancer include:

Pembrolizumab Nivolumab

Pembrolizumab

This is a type of immunotherapy drug that works by attaching to a protein receptor on immune system T cells called PD-1, stimulating them to recognise and attack cancer cells. It is used to treat advanced (metastatic) bowel cancer, recurrent bowel cancer and bowel cancer in people who have tested positive for a mutation in a mismatch repair (MMR) gene. It is usually given as an intravenous infusion every 21 days, with each infusion taking around 30 minutes.

Nivolumab

This is a monoclonal antibody which targets the PD-1 protein and is used to treat advanced (metastatic) bowel cancer, recurrent bowel cancer and bowel cancer in people who have tested positive for a mutation in a mismatch repair (MMR) gene. It is given by intravenous infusion every two weeks, with each infusion taking around 60 minutes.

Clinical trials for bowel cancer

Icon offers a wide range of clinical trials providing patients with access to new and evolving treatments. Clinical trials offer hope and opportunity and contribute to breakthroughs in treatment for future cancer patients. 

See current bowel cancer clinical trials delivered by Icon Cancer Centre.

Treatment by stage of bowel cancerTreatment by stage

When you are diagnosed with bowel cancer, your oncologist will develop your treatment plan as part of a multidisciplinary team based on the stage of your cancer and whether you have colon cancer or rectal cancer.

Colon cancerColon cancer

  • Early (Stage I or II) colon cancer

    Surgery is typically used as the first step in treatment for early-stage colon cancer. You may have a local excision, your polyps removed or a partial colectomy in advanced cases to remove a portion of your colon. If the cancer has grown into the wall of the colon, your doctor may also recommend chemotherapy.

  • Locally advanced (Stage III) colon cancer

    Treatment for locally advanced colon cancer will usually involve surgery (colorectal resection) and chemotherapy. If you can’t have surgery or have an advanced cancer that can’t be completely removed through surgery, you may receive chemotherapy and radiation therapy treatment.

  • Advanced (Stage IV) colon cancer

    Treatment for advanced colon cancer usually focuses on palliative care rather than curing the disease. Your care will be tailored to you and your preferences so that you can live as comfortably as possible. Some options include surgery, chemotherapy, targeted therapies, immunotherapy and radiation therapy. Clinical trials can also play an important role in treatment for advanced colon cancer.

Rectal cancerRectal cancer

  • Early (Stage I) rectal cancer

    Like colon cancer, early-stage rectal cancer is usually treated with either a polypectomy, local excision or transanal endoscopic microsurgery (TEM). Alternatively, a more invasive treatment may be needed, such as a low anterior resection or abdominoperineal resection.

  • Locally advanced (Stage II or III) rectal cancer

    Treatment for locally advanced rectal cancer will typically involve both chemotherapy and radiation therapy, followed by surgery. Depending on where your cancer is, the surgical procedure you have can vary. The most common surgeries are a low anterior resection, abdominoperineal resection or proctectomy with colo-anal anastomosis (where the colon is connected to the anus). After surgery, you may receive more chemotherapy depending on your needs.

  • Advanced (Stage IV) rectal cancer

    Depending on the spread of cancer, treatment for advanced rectal cancer may include surgery and chemotherapy. Most commonly chemotherapy and targeted therapy are used as part of systemic treatment. In some cases, radiation therapy is used as a palliative treatment.

ReferencesReferences

For a full list of references, click here.
  1. Cancer Council. (2021). Understanding Bowel Cancer: A guide for people with cancer, their families and friends. Retrieved on 4/11/2021 from https://www.cancer.org.au/assets/pdf/understanding-bowel-cancer-booklet#_ga=2.267437454.1465856641.1636327525-1283567243.1630475325
  2. American Cancer Society. (2020). Surgery for Colon Cancer. Retrieved on 4/11/2021 from https://www.cancer.org/cancer/colon-rectal-cancer/treating/colon-surgery.html
  3. American Cancer Society. (2020). Surgery for Rectal Cancer. Retrieved on 4/11/2021 from https://www.cancer.org/cancer/colon-rectal-cancer/treating/rectal-surgery.html
  4. Net. (2021). Colorectal Cancer: Types of Treatment. Retrieved on 4/11/2021 from https://www.cancer.net/cancer-types/colorectal-cancer/types-treatment
  5. American Cancer Society. (2020). Radiation Therapy for Colorectal Cancer. Retrieved on 28/10/2021 from https://www.cancer.org/cancer/colon-rectal-cancer/treating/radiation-therapy.html
  6. American Cancer Society. (2020). Chemotherapy for Colorectal Cancer. Retrieved on 4/11/2021 from https://www.cancer.org/cancer/colon-rectal-cancer/treating/chemotherapy.html
  7. National Cancer Institute. (2021). Colon Cancer Treatment (PDQ®)–Patient Version. Retrieved on 28/10/2021 from https://www.cancer.gov/types/colorectal/patient/colon-treatment-pdq
  8. National Cancer Institute. (2021). Rectal Cancer Treatment (PDQ®)–Patient Version. Retrieved on 28/10/2021 from https://www.cancer.gov/types/colorectal/patient/rectal-treatment-pdq
  9. American Cancer Society. (2020). Immunotherapy for Colorectal Cancer. Retrieved on 3/11/2021 from https://www.cancer.org/cancer/colon-rectal-cancer/treating/immunotherapy.html
  10. American Cancer Society. (2020). Treatment of Colon Cancer, by Stage. Retrieved on 9/11/2021 from https://www.cancer.org/cancer/colon-rectal-cancer/treating/by-stage-colon.html
  11. American Cancer Society. (2020). Treatment of Rectal Cancer, by Stage. Retrieved on 9/11/2021 from https://www.cancer.org/cancer/colon-rectal-cancer/treating/by-stage-rectum.html
  12. Cancer Institute of NSW. Anticancer Drugs Treatments: Bowel Cancer. Retrieved 12 Jan 12 2022 from https://www.eviq.org.au/patients-and-carers/anticancer-drug-treatments/bowel-cancer
  13. ESMO Patient Guides. Colorectal Cancer: A Guide for Patients. Retrieved 12 Jan 2022 from https://www.esmo.org/for-patients/patient-guides/colorectal-cancer
  14. Bowel Cancer Australia. Chemotherapy. Retrieved 12 Jan 2022 from https://www.bowelcanceraustralia.org/chemotherapy
  15. Golshani, Gol, and Yue Zhang. “Advances in immunotherapy for colorectal cancer: a review.” Therapeutic advances in gastroenterology 13 1756284820917527. 1 Jun. 2020, doi:10.1177/1756284820917527
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