Colon Cancer Has Spread to the Liver

[zalue]

Hi,

My father is 65 and was diagnosed with colon cancer a few weeks ago. He had been short of breath for a few months, but they couldn't figure out why. However, a fecal blood test was positive and a subsequent colonoscopy found the tumor in the upper colon.

He had it surgically removed (it was the size of a softball) last week. About one half his colon was removed, with no signs of cancer in the nearby abdomen. However, the surgeon found a golf ball sized mass on the liver that he assumes was a metastasis. The biopsy of the mass and the lymph nodes that were removed are still pending.

My dad is home from surgery and his nausea and breathlessness seem improved. However, he is anxious to commence treatment. He has been told that he will receive chemo for the liver. He hopes his surgeon will refer him to an oncologist when he meets with him in 5 days to remove the stitches. His surgeon has led my dad to believe this is curable. My dad's brother and a maternal male cousin both died of colon cancer. My dad is morbidly obese and has been a heavy lifetime drinker.

1. How long after his surgery should he wait until starting chemo?
2. Is it best to wait for the oncologist the surgeon recommends? The surgeon specializes in surgical oncology.
3. Is chemo the best/only treatment for his condition, or would liver resection be better?
4. What type of chemo should he be given?
5. He really hasn't had a "1st Opinion" yet -- the surgeon said he wanted to discuss all this in street clothes after the surgery -- but should my dad seek a "2nd Opinion"? He's old school, and thinks it's an insult to the doc...
6. Should my dad have any baseline lung/liver scans before starting treatment?
7. Is the hope the surgeon gave my dad false? It seems, though it hasn't been officially staged, that my dad has stage IV colon cancer. The five-year survival rates seems pretty low to me if that's the case...

Thanks,

B  

[HeinrikMD]

Hi,

Yes, while it seems like a long time, it would be best to allow enough healing on the surgical site. Some patients are able to start treatment by 4 weeks, less than that seems too short. The chemotherapy will lower some of the elements of his blood that are required for wound healing and hence we need to allow some time for that. If he is a candidate for a drug called Avastin, then this drug in particular directly interferes with wound healing and so we need some time. Stay positive.

[zalue]

Hi Dr. Heinrik,

Thanks for the quick reply.

One possible clarification: the liver tumor in the above scenario was NOT removed at the time the colon tumor was excised. It's still there.

Do you still recommend 6-8 weeks as the average time to commence chemo on the liver?

Thanks,

B

[HeinrikMD]

Hi,

While it is important to have one doctor specifically in charge or primarily responsible, a team approach to the management would be able to explore all the options that are reasonable. In this setting, second opinions are actually the norm than the exception.

You are correct that stage 4 colon cancers in general have a poor 5 year survival rate. There is however, a subset of patients with liver as the solitary site of metastasis, in which the survival is much improved if the surgery is feasible. By definition, you need to establish that liver is indeed the only site of metastasis, so the scans as baseline are important indeed.

Chemotherapy is usually given within the first 6 to the first 8 weeks after surgery. Giving chemotherapy would allow an exploration of the cancer’s responsiveness to treatment. If the chemo is given and the tumor shrinks, this is taken as a sign that the cancer responds to this kind of treatment. The importance of this step, is that even if the liver mass was amenable to surgical resection, it would be important to have an adjunctive treatment. IF there is proof that the adjunctive treatment works, then all the better. Hence, there is an opportunity to do just that. The question then, is not which is better chemotherapy or surgery, but rather, surgery can provide cure but may not be enough (may not be durable enough, due to early recurrence) without chemotherapy. Since you want maximal tumor shrinkage, chemotherapy would probably include several agents, three or four. Five agents may not provide any additional benefit.

Stay positive.