NCCN Guidelines for Patients
Colon Cancer, Version 1.2017
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
option. If these drugs don’t work, your next options
include other second-line options listed above.
Third-line and beyond
If the cancer progresses again, one of the 3 second-
line treatments may be an option. If not, your options
may include regorafenib or trifluridine with tipiracil.
There may also be a clinical trial that you could join.
Supportive care may give you relief from symptoms.
maps a treatment path that starts with
FOLFIRI. After FOLFIRI, there are other options for
second-line treatment and beyond. Some of these
options depend on what treatment you’ve had before.
Irinotecan is part of the FOLFIRI regimen. It should
be used with caution and at a low dose if you have
Gilbert’s disease. Gilbert’s disease is a health
problem that people are born with. The disease
impairs the liver from correctly processing bilirubin.
Irinotecan should be used with caution and at a low
dose if you have high bilirubin levels in your blood for
Targeted therapy may be added to FOLFIRI.
Bevacizumab may help treat colon cancer.
Cetuximab or panitumumab may help treat tumors
genes that are in the left side of the
colon. However, neither are likely to work if a
mutation is present.
FOLFIRI may not prevent the cancer from
progressing. If this happens, you may start to take
an oxaliplatin regimen—FOLFOX or CAPEOX.
Bevacizumab may be added.
Cetuximab or panitumumab may be options for
tumors with normal
genes. Tumors can be in
any part of the colon. You must not have received
either drug before. Cetuximab or panitumumab may
be received with irinotecan. If you’re unable to take
Guide 17. Irinotecan pathway
What are first-line options?
• FOLFIRI ±
◦◦ Cetuximab or panitumumab for left-side tumors
What are second-line options?
• FOLFOX or CAPEOX ± bevacizumab
• Irinotecan + cetuximab or panitumumab 1) for
tumors with normal
genes and 2) if
neither drug was received before
• Cetuximab or panitumumab 1) for tumors with
genes and 2) if neither drug
was received before
• Pembrolizumab or nivolumab if dMMR or MSI-H
What are third-line and beyond options?
• Some second-line regimens if not received before
• Trifluridine + tipiracil
• Clinical trial
• Best supportive care