Chemotherapy and Other Systemic Therapies for Colon Cancer

MSK is a leader in developing new systemic therapies for treating colon cancer.
MSK nurse Elisa Goldberg, wearing scrubs, talks to a patient in an infusion suite at the David H. Koch Center for Cancer Care.
Clinical nurse Elisa Goldberg in an infusion suite at the David H. Koch Center for Cancer Care.
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Overview

Colon cancer chemotherapy (chemo), targeted therapy, and colon cancer immunotherapy are called systemic therapies. They travel through the bloodstream to treat cancer cells anywhere in the body.

Colon cancer treatment depends on the cancer’s stage, location, and the tumor’s traits. If the cancer has not spread, most often you’ll have surgery. Your care team may also recommend systemic therapies to help treat the cancer. 

You may have neoadjuvant (NEE-oh-A-joo-vant) therapy, which is systemic therapy you get before colon cancer surgery. Neoadjuvant therapy shrinks tumors so they’re easier to remove during surgery. It also lowers the chance the cancer will spread. 

You may have adjuvant (A-joo-vunt) therapy, which is systemic therapy you get after colon cancer surgery. It’s used to kill any cancer cells that may be left in your colon or the rest of your body. Adjuvant therapy can lower the risk of colon cancer coming back or spreading. 

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Chemotherapy for colon cancer

What is chemotherapy (chemo)?

Chemotherapy (chemo) is a treatment that uses strong medicine to stop or slow cancer cells from growing. Chemo can be taken by mouth as pills. Chemo can be injected (put) through a drip into your vein. The medicines travel in your bloodstream to kill cancer cells anywhere in the body.  

In general, these medicines treat colon cancer by affecting how cancer cells grow and spread. 

There are many types of chemotherapy medicines, and they do not work in the same way. They have different doses and schedules. Some are used alone, others along with other medicines. There also are differences in how well chemo medicines work. 

Your care team will talk with you about the best options. 

Chemotherapy medicines and regimens

If chemotherapy is a part of your treatment, your medical oncologist (cancer doctor) will recommend a chemotherapy plan. It’s also called a chemotherapy regimen (REH-jih-men).  

This treatment plan tells you important details, including: 

  • Which medicines you’ll get.
  • The order in which you’ll get them.
  • The dose (amount) of each drug.
  • How often and how long you’ll need chemotherapy. 

Genetic testing for colon cancer tumors

At MSK, everyone with advanced colon cancer has their tumor tested using MSK-IMPACT ®. It’s a genetic testing tool only offered at MSK. This testing looks for the most common mutations linked to colon cancer. 

Genomic testing tells us which mutations may have caused the colon cancer. This information lets us target those genes for treatment.   

MSK-IMPACT finds genetic changes and other tumor traits that other tests can miss. We routinely test for changes in more than 500 genes. We’ll also look for a genomic condition called microsatellite instability. 

Some standard chemotherapy drugs do not work well on tumors with certain genetic changes. MSK-IMPACT tests for these mutations.  

When we know which mutations caused the colon cancer, we can choose the best chemotherapy drugs or other treatments. Some chemotherapy works better or worse on tumors that have certain mutations. 

Microsatellite stability or mismatch repair in colon cancer tumors

We may do genetic testing on the colon cancer tumor for genetic changes (mutations).  

We’ll look for mismatch repair deficiency (dMMR) or microsatellite instability–high (MSI-H). They mean there are higher numbers of mutations within each cancer cell.  

MSI-H/dMMR makes the tumor less likely to respond to standard chemotherapy. It’s more likely to respond to immunotherapy. 

About 15 to 20 out of every 100 people with early-stage colorectal cancer have MSI-H/dMMR tumors.  

THE MSK DIFFERENCE

Our Integrative Medicine and Wellness Service offers complementary, natural, and holistic treatments. They include acupuncture, meditation, massage therapy, yoga, and exercise. Without using prescription drugs, integrative therapies can help manage the side effects of cancer treatment. 

Your care team will make a treatment plan. It’s based on the type of cancer you have and how far the cancer has spread:
Chemotherapy for early-stage colon cancer
Your care team may recommend chemotherapy before colon surgery (neoadjuvant chemotherapy) or after colon surgery (adjuvant chemotherapy). 
Chemotherapy for early-stage colon cancer

Your care team may recommend chemotherapy before colon surgery (neoadjuvant chemotherapy) or after colon surgery (adjuvant chemotherapy). 

Here are some reasons we may recommend chemotherapy for early-stage colon cancer: 

  • Chemo raises the chance your surgeon will remove all of the cancer.
  • Chemo shrinks the tumor so it’s easier to remove during surgery.
  • Chemo kills colon cancer cells that remain after surgery, so there’s less chance the cancer will come back.

Here’s more information about chemotherapy treatment for early-stage colon cancer.

Chemotherapy for stages 0, 1, or 2 colon cancer

Surgery is the standard treatment for people with stage 0 or stage 1 colon cancer. You will not need chemotherapy before or after surgery. 

Some people with stage 2 colon cancer may need chemotherapy before or after surgery.  

In general, you’ll have chemo if you have mismatch repair proficient (pMMR) or microsatellite stable (MSS) colon cancer. It’s the most common type of colon cancer. 

Chemotherapy is not recommended if stage 2 colon cancer is microsatellite instability–high (MSI-H)/mismatch repair deficient (dMMR).   

Chemotherapy is recommended for some people with stage 2 colon cancer if there’s a higher chance the cancer will come back. Your doctor will talk with you about whether chemo is right for you. You’ll have chemo for 3 to 6 months. 

Up Next
Chemotherapy for stage 3 colon cancer
Chemotherapy for early-stage colon cancer

Your care team may recommend chemotherapy before colon surgery (neoadjuvant chemotherapy) or after colon surgery (adjuvant chemotherapy). 

Here are some reasons we may recommend chemotherapy for early-stage colon cancer: 

  • Chemo raises the chance your surgeon will remove all of the cancer.
  • Chemo shrinks the tumor so it’s easier to remove during surgery.
  • Chemo kills colon cancer cells that remain after surgery, so there’s less chance the cancer will come back.

Here’s more information about chemotherapy treatment for early-stage colon cancer.

Chemotherapy for stages 0, 1, or 2 colon cancer

Surgery is the standard treatment for people with stage 0 or stage 1 colon cancer. You will not need chemotherapy before or after surgery. 

Some people with stage 2 colon cancer may need chemotherapy before or after surgery.  

In general, you’ll have chemo if you have mismatch repair proficient (pMMR) or microsatellite stable (MSS) colon cancer. It’s the most common type of colon cancer. 

Chemotherapy is not recommended if stage 2 colon cancer is microsatellite instability–high (MSI-H)/mismatch repair deficient (dMMR).   

Chemotherapy is recommended for some people with stage 2 colon cancer if there’s a higher chance the cancer will come back. Your doctor will talk with you about whether chemo is right for you. You’ll have chemo for 3 to 6 months. 

Up Next
Chemotherapy for stage 3 colon cancer
Chemotherapy for stage 3 colon cancer
Most people with stage 3 colon cancer will have chemotherapy. Most often, you’ll have it after surgery, but your care team may recommend it before surgery.    
Chemotherapy for stage 3 colon cancer

Most people with stage 3 colon cancer will have chemotherapy. Most often, you’ll have it after surgery, but your care team may recommend it before surgery.

People with stage 3 microsatellite instability–high (MSI-H)/ mismatch repair deficient (dMMR) colon cancer may also need either: 

  • Chemotherapy after surgery.
  • Immunotherapy before surgery. 

You may have chemo for 3 to 6 months. The most common chemotherapy regimens for stage 3 colon cancers are: 

  • FOLFOX (5-FU, leucovorin, and oxaliplatin)
  • CAPOX (capecitabine and oxaliplatin)
  • 5-FU with leucovorin or capecitabine alone   
Up Next
Treatment for metastatic (stage 4) colon cancer
Chemotherapy for stage 3 colon cancer

Most people with stage 3 colon cancer will have chemotherapy. Most often, you’ll have it after surgery, but your care team may recommend it before surgery.

People with stage 3 microsatellite instability–high (MSI-H)/ mismatch repair deficient (dMMR) colon cancer may also need either: 

  • Chemotherapy after surgery.
  • Immunotherapy before surgery. 

You may have chemo for 3 to 6 months. The most common chemotherapy regimens for stage 3 colon cancers are: 

  • FOLFOX (5-FU, leucovorin, and oxaliplatin)
  • CAPOX (capecitabine and oxaliplatin)
  • 5-FU with leucovorin or capecitabine alone   
Up Next
Treatment for metastatic (stage 4) colon cancer
Treatment for metastatic (stage 4) colon cancer
Stage 4 colon cancer is metastatic cancer that has spread. 
Treatment for metastatic (stage 4) colon cancer

Metastatic colon cancer is cancer that has spread. Most often, we treat stage 4 colon cancer with 1 or more of these options:

  • Chemotherapy
  • Targeted therapy
  • Immunotherapy

You may also have surgery if the cancer has not spread far. But surgery may not be the best first treatment if it has spread to other organs. 

Instead, systemic therapy may be a better option if the tumor is not causing problems in your bowel. It’s better because you: 

  • Avoid the risk of complications (problems) from surgery.
  • Can start cancer treatment throughout your whole body right away.

Systemic therapy may be the only treatment for colon cancer that has spread throughout the body. 

These are the chemotherapy regimens for stage 4 colon cancer:  

  • FOLFOX (5-FU, leucovorin, and oxaliplatin) 
  • CAPOX (capecitabine and oxaliplatin) 
  • FOLFIRI (5-FU, leucovorin, and irinotecan) 
  • FOLFIRINOX or FOLFOXIRI (5-FU, leucovorin, oxaliplatin and irinotecan) 
  • 5-FU with leucovorin or capecitabine alone 
  • Trifluridine and tipiracil (Lonsurf) 
Hepatic artery infusion chemotherapy for colon cancer that has spread to the liver

Hepatic artery infusion (HAI) is a kind of chemotherapy. 

Hepatic (heh-PA-tik) means the liver. Colon cancer most often spreads to the liver through the bloodstream. 

HAI delivers chemotherapy drugs right to the liver. The drugs go into the liver through the hepatic artery, which supplies blood to the liver.

The drugs go through a tiny pump that’s implanted (put) under the skin in the lower abdomen (belly). HAI delivers treatment right to the tumor, which limits side effects. It can shrink tumors so they can be removed with surgery. 
Treatment for metastatic (stage 4) colon cancer

Metastatic colon cancer is cancer that has spread. Most often, we treat stage 4 colon cancer with 1 or more of these options:

  • Chemotherapy
  • Targeted therapy
  • Immunotherapy

You may also have surgery if the cancer has not spread far. But surgery may not be the best first treatment if it has spread to other organs. 

Instead, systemic therapy may be a better option if the tumor is not causing problems in your bowel. It’s better because you: 

  • Avoid the risk of complications (problems) from surgery.
  • Can start cancer treatment throughout your whole body right away.

Systemic therapy may be the only treatment for colon cancer that has spread throughout the body. 

These are the chemotherapy regimens for stage 4 colon cancer:  

  • FOLFOX (5-FU, leucovorin, and oxaliplatin) 
  • CAPOX (capecitabine and oxaliplatin) 
  • FOLFIRI (5-FU, leucovorin, and irinotecan) 
  • FOLFIRINOX or FOLFOXIRI (5-FU, leucovorin, oxaliplatin and irinotecan) 
  • 5-FU with leucovorin or capecitabine alone 
  • Trifluridine and tipiracil (Lonsurf) 
Hepatic artery infusion chemotherapy for colon cancer that has spread to the liver

Hepatic artery infusion (HAI) is a kind of chemotherapy. 

Hepatic (heh-PA-tik) means the liver. Colon cancer most often spreads to the liver through the bloodstream. 

HAI delivers chemotherapy drugs right to the liver. The drugs go into the liver through the hepatic artery, which supplies blood to the liver.

The drugs go through a tiny pump that’s implanted (put) under the skin in the lower abdomen (belly). HAI delivers treatment right to the tumor, which limits side effects. It can shrink tumors so they can be removed with surgery. 

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How to Manage Side Effects During Cancer Treatment: Fatigue, Hair Loss, Skin Care and More  

Learn ways to prevent or cope with the side effects of chemotherapy and radiation. They can include fatigue (feeling very tired), hair loss, nausea, and skin rashes.  

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Colon cancer chemotherapy side effects

Chemotherapy most often works by attacking cells that divide very fast. It can harm cancer cells. But it also can harm healthy cells that divide fast, such as cells that make your hair grow.  

That’s why hair loss can be a side effect of some, but not all, chemotherapy. MSK offers  scalp cooling as a way to help with hair loss. It involves wearing a cold cap on your head before, during, and after getting chemo. 

Other possible side effects from colon cancer chemotherapy are:  

  • Fatigue (feeling very tired).
  • Nausea (feeling like throwing up).
  • Vomiting (throwing up).
  • Not wanting to eat.
  • Neuropathy (numbness or tingling in hands and feet).
  • Low blood counts.
  • Chest pain and fever. These are less common. Get treatment right away. 

Some side effects go away soon. Some can be long-term, such as neuropathy.  

We have more information on managing the side effects of chemo. 

We have ways to help manage nausea during chemotherapy.  

Our supportive care team will manage the symptoms and side effects of cancer treatment. 

Rehabilitation medicine doctor Jesuel Padro-Guzman is with his patient at MSK in New York City. 
Chemotherapy-Induced Peripheral Neuropathy (CIPN) may start during chemotherapy or months after treatment ends. 
Rehabilitation medicine doctor Jesuel Padro-Guzman cares for many people with CIPN, a common side effect of chemotherapy. This nerve problem can cause weakness, numbness, pain, and tingling. It’s sometimes called chemo feet and chemo hands. 
Learn more  

Which MSK locations offer chemotherapy?

Where you get chemotherapy depends on the kind you’re getting, where you live, and other things. 

You may have your treatment at home, at your doctor’s office, in the hospital, or at one of our MSK regional locations.  

We know your life is busy and it’s stressful to fit chemotherapy sessions into your schedule. We offer chemotherapy at our locations  in: 

  • New York City
  • Long Island
  • Brooklyn
  • Westchester County
  • New Jersey 

Immunotherapy for colon cancer

What is immunotherapy?

Immunotherapy is a form of cancer treatment. It boosts your immune system’s natural ability to fight cancer. Your immune system attacks cancer cells, much the same way it attacks bacteria or viruses.   

Immunotherapy drugs release a brake on the immune system so it can start a stronger attack against cancer.   

MSK is always working to make cancer immunotherapy better. There are now a few immunotherapy drugs to treat colon cancer with MSI-H/dMMR tumors. 

We may use these drugs alone or with chemotherapy. Immunotherapy is given through an IV during a visit.  

You may be able to join immunotherapy research studies, also known as clinical trials. Some of these trials may offer early access to promising immunotherapy treatments.   

Immunotherapy most often is used to treat stage 4 colon cancer. But it can also work on some early-stage colon cancers. 

Immunotherapy may also help treat a rare type of colon cancer caused by mutations in the genes POLE and POLD. 

Which immunotherapy drugs treat colon cancer?

Immunotherapy can treat microsatellite instability–high (MSI-H) or deficient mismatch repair (dMMR) colon cancer tumors.  

About 5 out of every 100 people with metastatic colorectal cancer have tumors with MSI-H/dMMR.   

A type of immunotherapy drug called immune checkpoint inhibitors help the body’s immune cells kill cancer cells. Checkpoint inhibitor drugs target and block proteins called PD-1 and CTLA-4. These drugs help your immune system fight colorectal cancer cells.  

Immunotherapy drugs to treat colon cancer include: 

  • Pembrolizumab (Keytruda®)
  • Nivolumab (Opdivo)
  • Dostarlimab (Jemperli) 
  • Ipilimumab (Yervoy®) 

Colon cancer immunotherapy side effects

The most common side effects are caused by the immune system having a strong reaction to normal tissues. Side effects often are related to inflammation (swelling) in normal tissues. They can include: 

  • Skin problems, such as a rash or itching. 
  • Chills, fever, fatigue (feeling very tired), and other flu-like symptoms. 
  • Diarrhea (loose poop). 
  • Trouble breathing.
  • Harm to the thyroid gland, treated by pills you must take all your life.
  • Swollen liver or pancreas.
  • Pain from swollen joints.  

We can safely manage most side effects if we treat them early. Sometimes, side effects can harm you. This can happen if they’re not treated right away and affect vital (very important) organs, such as the lungs.  

MSK doctors are experts in  caring for people who have side effects from immunotherapy.  

Gastrointestinal oncologist Dr. Luis Diaz talks with an MSK patient.
Immunotherapy has proven successful in treating (some) patients with colon and rectal cancer that has metastasized, meaning spread to other tissues.
Gastrointestinal oncologist Dr. Luis Diaz co-led MSK research on immunotherapy for people with a type of tumor that has a certain genetic makeup. Immunotherapy worked well on these tumors.
Learn more

Targeted therapies for colon cancer

What is targeted therapy?

Targeted therapies are cancer treatments that target a tumor’s gene changes (mutations or variants). It’s a personal treatment plan just for the type of cancer you have. Targeted therapy medicines most often are given by mouth in pill form or through an IV into your vein.  

You may have a few targeted therapy medicines, or targeted therapy along with chemotherapy. 

Targeted therapies also are called personal medicine, precision medicine, or precision oncology. 

Colon cancer research is finding more drugs that work by targeting certain proteins in cancer cells. These proteins are made by abnormal (not normal) genes and make colon cancer cells grow and divide.  

Targeted drugs attack the abnormal proteins in cancer cells. They slow or stop their growth. Most healthy cells are not affected.  

Targeted therapy is used in treating metastatic (stage 4) colon cancer. Some targeted therapies are being tested in clinical trials for early-stage colon cancer.

Genomic testing for targeted therapy

Genomic testing tells us which mutations may have caused the colon cancer. This information lets us target those genes for treatment.   

Hereditary gene testing tells us if you were born with a gene mutation that raises your chance of getting colon cancer. Hereditary means genes passed on from parents to children. Mismatch repair deficient /microsatellite instability–high colon cancers often are hereditary.   

Genomic testing tells us if a tumor has mutated cancer cells. These mutations are not inherited, and they make cancer grow.   

At MSK, genetic testing is a routine part of diagnosis for people who have advanced colon cancer. This testing can be done on tumor tissue. We also can test your blood samples we collect during a visit. 

Some chemotherapy and immunotherapy drugs work better or worse on tumors that have certain mutations.   

Targeted therapy drugs target: 

  • KRAS
  • Vascular endothelial growth factor (VEGF)
  • Epidermal growth factor receptor (EGFR) 
  • BRAF
  • HER2 
  • NTRK
  • RET 

Colon cancer targeted therapies side effects

Targeted therapies in general do not cause hair loss. Targeted therapies also are much less likely to have other common side effects of chemotherapy, such as low blood counts.  

Common side effects of targeted therapy can include:  

  • Fatigue (feeling tired) 
  • Gastrointestinal (stomach and intestinal) problems. They include nausea (feeling like throwing up) and diarrhea (loose bowel movement).  

Some targeted therapy drugs have other side effects because they target proteins also found in normal cells. For example, drugs that target EGFR can cause a rash. 

Your care team will talk with you about what side effects to expect. They have a lot of experience in managing side effects. They offer treatments that can help you feel better. Examples are drugs that help with nausea, and  integrative medicine treatments.  

THE MSK DIFFERENCE

MSK had a leading role in researching a new treatment approach that combines 2 targeted therapy drugs. It helps people with colorectal cancer whose tumors carry a mutation called BRAF V600E. We also pioneered a new targeted therapy treatment for advanced colon cancer caused by a gene mutation called KRAS-G12C. 

Jon Desjardins, who had immunotherapy at MSK after colorectal cancer surgery, is outdoors and smiling.
I’m alive because of this trial, and I think it’s a miracle drug. 
Colon cancer survivor Jon Desjardins had a liquid biopsy to look for tiny bits of tumor DNA in blood. He joined research for people who had circulating tumor DNA (ctDNA) after cancer treatment. MSK gave Jon immunotherapy and has tested his blood for ctDNA every 6 months. It comes back clear every time. 
Read his story
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