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NCCN Guidelines for Patients



Colon Cancer, Version 1.2017


Metastatic disease

Metastases at recurrence

another option. However, NCCN experts prefer

surgery over local therapy.

Results of primary treatment should be assessed

with CT with contrast. Scans of your chest, abdomen,

and pelvis are needed. Imaging should be done prior

to adjuvant treatment.

Adjuvant treatment is based on the success of

neoadjuvant treatment. If neoadjuvant chemotherapy

worked, you may re-start that treatment or take

FOLFOX. Together, chemotherapy given before and

after surgery should not exceed 6 months. A third

option is observation.

If neoadjuvant treatment didn’t work, you may

have two options. One option is chemotherapy.

Targeted therapy may be added but more research

is needed. Regimens are listed in Part 6. Six months

of chemotherapy is preferred. The second option is



Instead of systemic chemotherapy, HAI may be an

option. Systemic 5-FU/LV may be added. NCCN

experts advise that this option should only be

received at treatment centers with much experience

in this method. More research is needed to learn how

well this treatment works.

Guide 15

lists nonsurgical options for liver or lung

metastases present at recurrence. Options are based

on your history of chemotherapy. Options for people

who had FOLFOX or CAPEOX in the past 12 months

are explained below. Options for everyone else are

listed in Part 6.

FOLFOX or CAPEOX ≥12 months

Two options are FOLFIRI and irinotecan. Targeted

therapy may be added. Bevacizumab is preferred

but other options are ziv-aflibercept or ramucirumab.

If the tumor has normal


genes, other

options are to add panitumumab or cetuximab to

chemotherapy. However, these drugs won’t likely

work if the tumor has a



The cancer cells may have a dMMR system or

MSI-H. The MMR system is explained in Part 2. In

this case, nivolumab or pembrolizumab may be an


After chemotherapy

For some people, chemotherapy may greatly

shrink the tumors. If they shrink enough, surgery

to cure the cancer may be an option. Most people

with metastatic colon cancer won’t be able to have

surgery. If surgery is possible, tests to assess the

tumor size are advised every two months during


Bevacizumab should be stopped 6 weeks before

surgery. It increases your chance for a stroke,

bleeding, and other arterial events. These events

are even more likely if you are older than 65 years.

Bevacizumab can be re-started 6 to 8 weeks after

surgery. Otherwise, it can slow healing.

After surgery, more chemotherapy is advised.

Chemotherapy received before and after surgery

should not exceed 6 months. Targeted therapy may

be added but more research is needed. Read Part 6

for options.