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NCCN Guidelines for Patients



Colon Cancer, Version 1.2017


Overview of cancer treatments

Targeted therapy


Ramucirumab attaches to VEGF receptors on the

outside of endothelial cells. This blocks VEGF from

attaching. No growth signals caused by VEGF are


Ramucirumab is given by infusion. It takes 60

minutes to receive the full dose. Ramucirumab is

always given with chemotherapy. It is given every

two weeks on the first day of chemotherapy.

Common side effects of ramucirumab are high blood

pressure and diarrhea. Serious side effects include

bleeding, blood clots, holes in the gut, abnormal

passage between body parts, and slow wound



Regorafenib attaches to VEGF receptors on the

inside of endothelial cells. This blocks growth signals

from the receptor. Regorafenib may also attach to

surface receptors within cancer cells and stop growth


Regorafenib is made as a pill that is taken once

a day. However, it is taken in cycles consisting of

treatment days followed by a period of no treatment.

The cycle for regorafenib consists of 3 weeks of

treatment then 1 week of no treatment. The cycle is

then repeated.

Common side effects of regorafenib include feeling

tired or week, fever, and diarrhea. Your hands

and feet may become red and have pain. This

is called hand-foot skin reaction. It is important

to remove calluses on hands and feet before

starting regorafenib. Rare but serious side effects

of regorafenib include severe liver damage, heart

attack, and blindness.


Ziv-aflibercept works by acting as a decoy. VEGF

thinks ziv-aflibercept is a surface receptor and

attaches to it. Thus, ziv-aflibercept traps VEGF so

it is unable to bind to the real receptor. Hence its

other name is VEGF-trap. By trapping VEGF, growth

signals caused by VEGF within endothelial cells

won’t be started.

Ziv-aflibercept is given by infusion in about 1 hour

every two weeks. Ziv-aflibercept is given with


Common side effects include diarrhea, mouth sores,

high blood pressure, feeling tired, voice changes,

and nose bleeds. You may also experience blood

clots, urinary tract infection, and darkening of the

skin. Rare but serious side effects include stroke,

holes in the intestine, bleeding in the brain or lungs,

and kidney damage.

EGFR pathway

Cell growth is started by growth signals. EGFR is one

of the surface receptors in colon cancer cells that can

trigger growth signals. When EGF (






actor) attaches to EGFR, the chemical pathway that

sends growth signals is turned on.

Some people with colon cancer have abnormal

changes in their gene that controls EGFRs. These

changes cause the cancer cells to have too many

EGFRs. For a small group of people, the EGFRs

may be overactive.

With too many or overactive EGFRs, new cancer

cells form quickly. There are two medicines used

to block the growth signals from EGFRs.


Figure 12

. These medicines don’t work if the cancer

cells have mutations in






Cetuximab treats colon cancer by attaching to the

ends of EGFRs that are outside of the cell. Thus,

EGF is blocked from attaching and triggering growth

signals. Cetuximab also attracts immune cells that

help to kill the cancer cells.