NCCN
GUIDELINESFOR PATIENTS

2024

®

Colon Cancer®

NATIONAL COMPREHENSIVE CANCER NETWORK

Presented with support fromFOUNDATION
Guiding Treatment. Changing Lives.

Available online at
NCCN.org/patientguidelinesÜColon Cancer

About the NCCN Guidelines for Patients®

Did you know that top cancer centers across the UnitedStates work together to improve cancer care? This
alliance of leading cancer centers is called the National
Comprehensive Cancer Network® (NCCN®).
Cancer care is always changing. NCCN develops
evidence-based cancer care recommendations used by health care providers
worldwide. These frequently updated recommendations are the NCCN Clinical
Practice Guidelines in Oncology (NCCN Guidelines®). The NCCN Guidelines forPatients plainly explain these expert recommendations for people with cancer
and caregivers.

These NCCN Guidelines for Patients are based on the NCCN
Clinical Practice Guidelines in Oncology (NCCN Guidelines®)for Colon Cancer,
Version 1.2024 — January 29, 2024.

View the NCCN Guidelines

Find an NCCN Cancer

for Patients free online

Center near you

NCCN.org/patientguidelines

NCCN.org/cancercenters

Connect with us
NCCN Guidelines for Patients®
Colon Cancer, 20241

Colon Cancer

Supporters®

NATIONAL COMPREHENSIVE CANCER NETWORKFOUNDATION
Guiding Treatment. Changing Lives.

NCCN Guidelines for Patients are supported by funding from the
NCCN Foundation®
NCCN Foundation gratefully acknowledges the following
corporate supporters for helping to make available these NCCN
Guidelines for Patients: Amgen Inc., Exact Sciences, Pfizer Inc.,and Taiho Oncology, Inc.
NCCN independently adapts, updates, and hosts the NCCN
Guidelines for Patients. Our corporate supporters do not participate
in the development of the NCCN Guidelines for Patients and are notresponsible for the content and recommendations contained therein.

Additional support is provided byFight Colorectal Cancer (Fight CRC) is a leading patient-empowerment and advocacy organization providingbalanced and objective information on colon and rectal cancer research, treatment, and policy. Serving as
relentless champions of hope, focused on funding promising, high-impact research endeavors while equipping
advocates to influence legislation and policy for the collective good. Learn more at fightcolorectalcancer.org,
and follow on social media @FightCRC!

To make a gift or learn more, visit online or email
NCCNFoundation.org/donate

NCCN Guidelines for Patients®
Colon Cancer, 2024

PatientGuidelines@ NCCN.org

2

Colon Cancer

Contents
4

Colon cancer basics

7

Testing and treatment planning

13

Treatment for non-metastatic cancer

22

Treatment for metastatic cancer

35

Survivorship

40

Making treatment decisions

48

Words to know

50

NCCN Contributors

51

NCCN Cancer Centers

54

Index

© 2024 National Comprehensive Cancer Network, Inc. All rights reserved. NCCN
Guidelines for Patients and illustrations herein may not be reproduced in any form forany purpose without the express written permission of NCCN. No one, including doctors
or patients, may use the NCCN Guidelines for Patients for any commercial purposeand may not claim, represent, or imply that the NCCN Guidelines for Patients that havebeen modified in any manner are derived from, based on, related to, or arise out of the
NCCN Guidelines for Patients. The NCCN Guidelines are a work in progress that may be
redefined as often as new significant data become available. NCCN makes no warranties
of any kind whatsoever regarding its content, use, or application and disclaims any
responsibility for its application or use in any way.

NCCN Guidelines for Patients®
Colon Cancer, 2024

NCCN Foundation seeks to support the millions of patients and their families affectedby a cancer diagnosis by funding and distributing NCCN Guidelines for Patients. NCCN
Foundation is also committed to advancing cancer treatment by funding the nation’s
promising doctors at the center of innovation in cancer research. For more details and thefull library of patient and caregiver resources, visit NCCN.org/patients.
National Comprehensive Cancer Network (NCCN) and NCCN Foundation
3025 Chemical Road, Suite 100, Plymouth Meeting, PA 19462 USA

3

1Colon cancer basics
5

The colon

6

Polyps6

Key points

NCCN Guidelines for Patients®
Colon Cancer, 20244

Colon cancer basics » The colon

Colon cancer is common and

The term colorectal cancer is used to describe
cancers that form in either the colon or
rectum. While these cancers are similar, theirtreatment is different. The focus of this guideis colon cancer. For information on rectal
cancer treatment, see the NCCN Guidelines
for Patients: Rectal Cancer at NCCN.org/
patientguidelines and on the NCCN Patient
Guides for Cancer app.

treatable. Many cancers thatstart in the colon can be cured,
especially when found early.

The colon
The colon makes up most of the large intestine(bowel). In the colon water is absorbed fromeaten food, turning it into feces or stool. Afterleaving the colon, stool moves into the rectum.
The rectum is the last 6 inches or so of thelarge bowel. Stool is held here until it leaves
the body through an opening called the anus.

The colon
The start of the colon is apouch called the cecum.
Sticking out from thececum is the appendix.
This skinny tube is about
the size of a finger and isclosed at one end. The restof the colon has 4 main
sections: the ascending,transverse, descending,and sigmoid colon.

NCCN Guidelines for Patients®
Colon Cancer, 20245

Colon cancer basics » Polyps » Key points

PolypsKey points

Polyps are non-cancerous growths that formon the inner lining of the colon and rectum.
The most common type is called an adenoma.
While it may take many years, adenomas
can become invasive colon cancer. Cancer
that forms in an adenoma is called an
adenocarcinoma. This is the most common
type of colon cancer. Polyps that rarely
turn into cancer include hyperplastic andinflammatory polyps.

This guide discusses the following key topics
about colon cancer diagnosis and treatment.
Testing and treatment planning

Testing the tumor for a biomarker (feature)
called mismatch repair deficiency (dMMR)
Treatment planning based on mismatch
repair status and results of other testingNon-metastatic cancer

While most polyps do not become cancer,
almost all colon cancers start in a polyp.
Removing polyps can prevent cancer before
it starts. Most can be removed during acolonoscopy using a minor surgical procedure
called a polypectomy. Polyps can also be
tested to make sure that cancer has notalready started to develop.

Treatment for polyps with cancer
Colectomy (surgery) for non-metastaticcolon cancer
Chemotherapy after colectomy (for all stage
3 cancers and some stage 2 cancers)

Metastatic cancer

For more information, see the NCCN
Guidelines for Patients: Colorectal Cancer
Screening at NCCN.org/patientguidelines andon the NCCN Patient Guides for Cancer app.







Expanded biomarker testing to identify
targetable features of the cancer
The use of local therapies to treat liver andlung tumors
Systemic therapy for metastatic cancer

Survivorship

NCCN Guidelines for Patients®
Colon Cancer, 2024

6



Help for long-term side effects



Maintaining healthy habitsResources

2

Testing and treatment planning8

Mismatch repair testing

8

Family health history

9

Blood tests

10

Imaging

11

Fertility and family planning12

Key points

NCCN Guidelines for Patients®
Colon Cancer, 2024

7

Testing and treatment planning » Mismatch repair testing » Family health history

Family health history

This chapter describes testing andother care needed to create yourYour doctor will ask about the health historyof your biological (related by blood) family
members. Those with a first-degree relativewith colorectal cancer are more likely to havethis cancer compared to the average person.

treatment plan. All colon cancers
should be tested for mutations(changes) in genes that fix
damaged DNA, called mismatch

Most colon cancers occur for unknown
reasons. While rare, some people are bornwith a disorder that makes them more likely
to get colon and other cancers. These arecalled inherited cancer syndromes. Two suchconditions include Lynch syndrome and familial
adenomatous polyposis (FAP).

repair (MMR) genes.

Most colon cancers are found duringcolonoscopy. It is common to have anothercolonoscopy to thoroughly examine the colonand look for other possible areas of cancer.
This is called a diagnostic colonoscopy.

People born with Lynch syndrome are at highrisk of developing colon, endometrial, andovarian cancers. Lynch syndrome is caused
by inherited mutations of the MMR genes.
For cancers found to have the dMMR/MSI-H
biomarker, testing for Lynch syndrome isrecommended.

Mismatch repair testing
Mismatch repair (MMR) or
microsatellite instability (MSI)
testing is recommended for everyone
diagnosed with colon cancer. Thisfeature of some colon cancers is a type ofbiomarker. Biomarkers are targetable changesof a cancer that help guide your treatment.

FAP causes hundreds to thousands of polyps
to form in the colon and rectum. The polyps
start as benign growths, but over time canbecome invasive colon cancer. Cancer often
develops by age 50 in people with classic FAP.
A milder form (attenuated FAP) causes fewer
polyps and usually starts later in life.

Testing involves analyzing a piece of thecolon tumor in a lab. Depending on themethod used, an abnormal result is called
either microsatellite instability-high (MSI-H) or
mismatch repair deficient (dMMR). Tumors that
do not have these changes are referred to as
microsatellite stable (MSS) or mismatch repair
proficient (pMMR).

If an inherited syndrome is suspected, yourdoctor will refer you to a genetic counselor.
This expert can speak with you and yourfamily about testing for syndromes related tocolon cancer. To be tested, you must provide
a sample of blood or saliva. A pathologist tests
the sample for gene mutations that cause
these syndromes. It is important to meet witha genetic counselor before having any genetic
testing.

If the cancer is dMMR/MSI-H, you will also be
tested for an inherited condition called Lynch
syndrome, described next.
NCCN Guidelines for Patients®
Colon Cancer, 2024

8

Testing and treatment planning » Blood tests“

Blood tests
The following tests are not used alone todiagnose colon cancer, but abnormal results
may signal health problems.

I was diagnosed in the ER at age
44, 58 days after my wedding, andI faced biases and unexpectedchallenges. I had to fight to get carebecause I was dismissed for morethan a year for so many different
reasons. My journey taught me
this: never give up, explore every
reasonable option, and prioritize
your mental health. Your life is the
only one you have, so be true toyourself. Before any diagnosis, put
on your life jacket first—take careof yourself. Get screened, know
your family history. When facingcolorectal cancer, the best care
begins with self-care."Complete blood countCancer and other health problems can cause
low or high blood cell counts. A complete bloodcount (CBC) measures the number of whiteblood cells, red blood cells, and platelets in a
blood sample. White blood cells help the bodyto fight infection. Red blood cells carry oxygen
throughout the body. Platelets help wounds
heal by forming blood clots.

Chemistry profile
Also known as a comprehensive metabolic
panel (CMP), this group of tests provides
information about how well your kidneys, liver,and other organs are working.

CEA blood test
Carcinoembryonic antigen (CEA) is a protein
found in blood. The level of CEA is often higher
than normal in people with colon cancer,
especially if the cancer has spread to otherorgans.

ctDNA
There is growing interest in circulating tumor
DNA (ctDNA) testing for people with earlystage colon cancer. Also called a liquidbiopsy, this test looks for small pieces of DNA
released by tumor cells into the blood. It can
detect microscopic disease that may remainin the body after colectomy. This information
may be helpful in predicting the risk of thecancer returning or other outcomes. But more
information is needed, and at this time ctDNA
testing is only recommended as part of aclinical trial.

Monitoring CEA can be helpful even when
the cancer is only in the colon and the levelis normal, because the level will rise if thecancer later spreads to other organs. However,monitoring CEA is not helpful for everyone,even if the cancer has spread. People whoare pregnant and those who smoke may havehigher CEA levels.

NCCN Guidelines for Patients®
Colon Cancer, 2024

9

Testing and treatment planning » Imaging

Imagingallergic reaction. Tell your doctor if you’ve had
problems with contrast in the past.

Imaging tests can show areas of cancer inside
the body. A radiologist interprets the images
and conveys the results to your oncologist.
Your care team will tell you how to prepare foryour scans. If you get nervous in tight spaces,
let them know. You may be offered a type of
medicine called a sedative to help you relax.

MRI
Magnetic resonance imaging (MRI) is not often
used to plan treatment for colon cancer. Your
doctor may order an MRI to get a better look at
the liver or rectum, or if the CT scan results areunclear.

CT

Getting an MRI is much like getting a CT scan.
In some cases, the area of the body being
imaged is placed within a narrowed coil device
that looks like a brace. It covers your bodyfrom below your chest to the top of your legs.
It sends and receives radio waves. Straps may
be used to help you stay in place. An MRI may
cause your body to feel warm. If MRI is being
used to better see cancer near the rectum,
an enema may be needed. Or a gel may beinserted into the rectum beforehand.

Computed tomography (CT) is the main
imaging test used to see colon cancer in the
body. During the scan you will lie face-up
on a table that moves through a tunnel-likemachine. You will be able to hear and speakwith a technician at all times.
A substance called contrast is used to makethe pictures clearer. It is injected into your vein
and mixed with a liquid to drink. You may feelflushed or get hives. Some people have an

CT scanCT with contrast is themain imaging test used todetermine the extent of coloncancer in the body. CT takes
many pictures of the insideof the body using x-rays.
A computer combines the
x-rays to make one detailed
picture.

NCCN Guidelines for Patients®
Colon Cancer, 2024

10

Testing and treatment planning » Fertility and family planning

Fertility and family planning
For unknown reasons, colon cancer is being
diagnosed more often in young adults. Somecancer treatments make it hard or impossible
to have children. If you are interested in
potentially having children in the future, tell
your care team. They will discuss any fertilityrelated risks of your treatment plan with you.
Some methods for preserving (keeping) fertility
before cancer treatment are described below.
Your doctor may refer you for counseling about
fertility preservation options.

For more information on fertility
and family planning, see the
NCCN Guidelines for Patientsfor Adolescent and Young
Adult Cancer at NCCN.org/
patientguidelines and on the NCCN
Patient Guides for Cancer app.

Sperm banking
Sperm banking stores semen for later use by
freezing it in liquid nitrogen. The medical term
for this is semen cryopreservation.

Egg freezing
Unfertilized eggs can be removed, frozen, andstored for later use. This is called egg freezingor oocyte cryopreservation.

Ovarian tissue banking
This method involves removing part or all of an
ovary and freezing the part that contains theeggs. The frozen tissue that contains the eggs
can later be unfrozen and put back in the body.

NCCN Guidelines for Patients®
Colon Cancer, 2024

11

Testing and treatment planning » Key points

Key points

related risks of treatment and options forpreserving fertility.

Mismatch repair testingAll colon cancers should be tested formismatch repair deficiency (dMMR) or
high microsatellite instability (MSI-H).
Testing for this biomarker involves
analyzing a piece of the colon tumor in alab.
Cancers that do not have thesebiomarkers are called microsatellite stable(MSS) or mismatch repair proficient(pMMR).

Let us know what
you think!
Please take a moment tocomplete an online survey
about theNCCN Guidelines for Patients.

Family health history

Inherited syndromes related to coloncancer include Lynch syndrome andfamilial adenomatous polyposis.

NCCN.org/patients/response

Everyone with colon cancer should be
asked about their family health history.

Blood tests
A complete blood count (CBC), chemistry
profile, and carcinoembryonic antigen(CEA) test are recommended as part ofinitial testing.

ImagingCT with contrast is the main imaging test
used to determine the extent of coloncancer in the body.

Fertility and family planningYoung adults diagnosed with colon cancer
should be counseled about fertility-

NCCN Guidelines for Patients®
Colon Cancer, 2024

12

3Treatment for non-metastatic
cancer14

Polyps with cancer

15

Invasive cancer

19

Chemotherapy after surgery

20

Surveillance21

Key points

NCCN Guidelines for Patients®
Colon Cancer, 2024

13

Treatment for non-metastatic cancer » Polyps with cancer

Polyps with cancer

Colon cancer often forms inpolyps on the lining of the colon,

A polyp is an overgrowth of cells on the inner
lining of the colon wall. The most common typeis called an adenoma. While it may take many
years, adenomas can become invasive coloncancer. Cancer that starts in an adenoma iscalled an adenocarcinoma.

but can also form as lesions.
This chapter explains treatment
for cancer that has not spread toareas far from the colon.

There are 2 main shapes of polyps.
Pedunculated polyps are shaped likemushrooms and stick out from the colon wall.
They have a stalk and round top. Sessile
polyps are flatter and do not have a stalk. A
polyp in which cancer has just started to growis called a malignant (cancerous) polyp.
Most polyps can be removed during acolonoscopy, using a minor surgical procedure
called a polypectomy.

Colon polyps
Polyps are growths on
the inner lining of thebowel wall. Some look
like mushrooms andstick out from the colon
wall. These are calledpedunculated polyps.
Others are flatter and do
not have a stalk. These
are called sessile polyps.

NCCN Guidelines for Patients®
Colon Cancer, 2024

14

Treatment for non-metastatic cancer » Invasive cancer

Invasive cancer

Often, no further treatment is needed after
a polypectomy. In other cases, surgery(resection) of a bigger piece of the colon isneeded. This depends on:For cancers not found early enough to be
removed by polypectomy, colectomy (colon
surgery) is needed. Surgery is only an option if
the colon tumor can be completely removed. If
you cannot have surgery first, see page 19.

The size and shape of the polyp(pedunculated or sessile),

The polypectomy results, and

The results of testing the removed tissue.

Colectomy
A colectomy is a surgery that removes the partof the colon with cancer. After the cancerous
part is removed, the two healthy ends of theremaining colon are sewn or stapled together.
At least 12 lymph nodes near the tumor will be
removed and tested for cancer, in addition to
any nodes that look abnormal to the surgeon.

Before deciding whether resection is needed
after a polypectomy, your doctor will review
the results of testing with you and discuss youroptions.

A colectomy can be done in two ways. The
open method removes tumor tissue through a

Colectomy
Surgery for colon cancer is called colectomy. It involves removing the cancerous part of thecolon. The two healthy ends of the remaining colon are then attached to each other.

NCCN Guidelines for Patients®
Colon Cancer, 2024

15

Treatment for non-metastatic cancer » Invasive cancer

large cut in your abdomen. The minimallyinvasive method involves making a few small
cuts. Tools are inserted through the cuts to see
and remove part of your colon.

of the abdomen. This opening is called a
stoma. Stool exits the body through the stoma
and enters a bag attached to the skin. Thisis typically only needed for a short time. For
colon cancer surgery, the colostomy can often
be reversed with another operation. Colostomy
is also known as diversion because it diverts(redirects) the flow of stool.

The tissue removed during surgery is sent toa pathologist. The pathologist determines how
far the cancer has grown within the colon wall.
They also test the removed lymph nodes forcancer. These results are used to assign thecancer a stage. The stage helps determine
whether you need chemotherapy after surgery.
At the time of colectomy, some people may
also have a procedure called a colostomy. Thisis done in cases where it may not be safe toreconnect the remaining sections of colon. In
a colostomy, the remaining upper part of thecolon is attached to an opening on the surface

Colostomy
If the two healthy ends of the remaining colon cannot be safely reconnected after the cancer
is removed, a colostomy may be performed. A colostomy connects a part of the colon to theoutside of the abdomen. This creates an opening in your abdomen that allows stool to passthrough. For colon cancer surgery, it is rare for a colostomy not to be reversed with anotheroperation.

NCCN Guidelines for Patients®
Colon Cancer, 2024

16

Treatment for non-metastatic cancer » Invasive cancer

Bowel blockage
In rare cases, a tumor may grow so large thatit blocks the flow of stool. There are several
ways to deal with a blockage. One option is acolectomy that also unblocks the bowel. This is
known as a one-stage colectomy.

Your care team will give you
information on:

A second option is colectomy with colostomy.
This is typically only needed for a short time.
Another possibility is that a colostomy may
be done first, followed by a second surgery to
remove the cancer.
Lastly, in rare cases, a mesh metal tube calleda stent may be placed first, followed by asecond surgery to remove the cancer. The
stent keeps the colon open, allowing gas andstool to pass.

Staging
The cancer stage describes the extent ofcancer in the body. Having a general idea ofthe structure of the colon wall is helpful forunderstanding how colon cancer is staged.
The colon wall is made of layers of tissue.
Cancer starts in the innermost layer thatcomes in contact with food. This layer is called
the mucosa.

How to prepare for surgery•

What to expect during and after surgery•

Recovery•Possible short- and long-term side
effects of colectomy, including:¬

Leaking from the spot where thecolon was reconnected (anastomotic
leak)

¬

Changes in bowel habits¬

Bowel blocked by scar tissue¬

Organs pushing through tissues
or muscles weakened by surgery(hernia)

Cancer cells can also break off from the colon
tumor and travel through lymph or blood tonearby lymph nodes.

The next layer is the submucosa. It is made ofconnective tissue and contains mucus glands,
blood and lymph vessels, and nerves. The
submucosa is followed by a layer of muscle
called the muscularis propria. The outer, fourthlayer is called serosa (or adventitia).

The American Joint Committee on Cancer(AJCC) tumor, node, metastasis (TNM) system
is used to stage colon cancer. In the AJCC
system, the following key pieces of information
about the cancer are used to give it a stage:If left untreated, cancer cells grow through thelayers of the colon wall, towards the insideof the abdomen. The cancer can then invade
structures or organs outside of the colon.
NCCN Guidelines for Patients®
Colon Cancer, 2024•

17

Treatment for non-metastatic cancer » Invasive cancer

If you can’t have surgery first

T: How far the tumor has grown into or
through the colon wall

Having surgery first is not always an option. It
may not be possible because of the locationof the tumor, or because of other healthproblems. In this case, systemic therapy(chemotherapy or immunotherapy) is given
first. Systemic therapy may also be given
first for advanced cancers, or cancer that has
spread to lymph nodes.

N: Whether any lymph nodes have cancer
M: Whether the cancer has spreadto areas or organs outside the colon(metastasized)

The T, N, and M scores are combined toassign the cancer one of the following stages:
0, I (1), II (2), III (3), or IV (4). The stages are
explained below.

If this approach is planned, chemotherapy
is recommended for pMMR/MSS cancers.
Immunotherapy with a checkpoint inhibitor
is preferred for dMMR/MSI-H cancers.
Immunotherapy increases the activity of yourimmune system, improving your body’s ability
to find and destroy cancer cells.

Stage 0
There are abnormal cells on the innermost
layer of the colon wall. These abnormal cells
may become cancer and spread into deeper
layers of the colon wall. Stage 0 colon cancer
is also called carcinoma in situ of the colon.

Checkpoint inhibitors recommended for use
before colectomy in dMMR/MSI-H cancers
include:Stage 1
The cancer has grown into either the secondor third layer of the colon wall. There is nocancer in nearby lymph nodes or in areas
outside the colon.

Stage 2The cancer has grown into, or beyond, thefourth layer of the colon wall. There is nocancer in nearby lymph nodes or in areas
outside the colon.

Nivolumab (Opdivo) with or without
ipilimumab (Yervoy)

Sometimes radiation therapy (alone or withchemotherapy) is given along with systemic
therapy for unresectable cancers.
For more information on the side effects
of checkpoint inhibitors, see the NCCN
Guidelines for Patients: Immunotherapy Side
Effects: Immune Checkpoint Inhibitors at
NCCN.org/patientguidelines and on the NCCN
Patient Guides for Cancer app.

Stage 3The cancer has spread from the colon to
nearby lymph nodes or there are tumor
deposits. Tumor deposits are small tumors in
the fat around the colon.
Stage 4The cancer has spread to areas outside thecolon and nearby lymph nodes. Colon cancer
spreads most often to the liver and/or lungs.
NCCN Guidelines for Patients®
Colon Cancer, 2024

Pembrolizumab (Keytruda)

18

Treatment for non-metastatic cancer » Chemotherapy after surgery

Chemotherapy after surgery
Side effects

Chemotherapy is the use of medicine to killcancer cells. It is a type of systemic therapy.
Chemotherapy is usually given intravenously.
This means the medicine is slowly infused
into the bloodstream through a vein. It travels
through the bloodstream to reach cells
throughout the body.

Systemic therapy kills both cancer cells
and healthy cells. The damage to healthy
cells can cause hair loss, cracked skin,mouth sores, and other side effects.
Managing side effects is a shared effort
between you and your care team. It is
important to speak up about bothersome
side effects, such as nausea and vomiting.
Ask about your options for managing or
relieving the effects of treatment.

Chemotherapy is given in cycles of treatmentdays followed by days of rest. This allows yourbody to recover between cycles. Cycles vary inlength depending on which drugs are used.

Stage 1More information on supportive care isavailable at NCCN.org/patientguidelines
and on the NCCN Patient Guides forCancer app.

Chemotherapy is not recommended after
colectomy for stage 1 cancers.

Stage 2
Chemotherapy is not recommended after
colectomy for stage 2A and 2B dMMR/MSI-H
cancers, but may be given for some stage 2C
dMMR/MSI-H cancers.
Chemotherapy is recommended after
colectomy for some stage 2 pMMR/MSS
cancers. It is most helpful for cancers witha high risk of recurrence (returning after
treatment). Your doctor will consider thefeatures and risk factors of the cancer
to determine if recurrence is likely. If
chemotherapy is planned, recommended
regimens include capecitabine and5-fluorouracil (5-FU)/leucovorin. These are
given for 6 months. FOLFOX and CAPEOX
are recommended options for high-risk
cancers. FOLFOX is given for 6 months;
CAPEOX for 3 months.

NCCN Guidelines for Patients®
Colon Cancer, 2024

Stage 3Chemotherapy is recommended after
colectomy for all stage 3 colon cancers.
Preferred regimens include CAPEOX andFOLFOX. Other recommended options include
capecitabine and 5-FU.
Chemotherapy is typically given for 3 to 6
months. The length of treatment depends on
the regimen and the risk of recurrence.

19

Treatment for non-metastatic cancer » Surveillance

Surveillance

tests may be ordered if your doctor thinks thecancer may have come back or spread.

Follow-up testing is started when there are nosigns of cancer after treatment. It can help findnew cancer growth early.

Stages 2 and 3
In addition to colonoscopy, surveillance forstages 2 and 3 colon cancer includes physicalexams, carcinoembryonic antigen (CEA)
blood tests, and CT scans. The recommended
schedule for surveillance testing is shown in
Guide 1.

Stage 1
A colonoscopy is recommended 1 year after
surgery for stage 1 cancers. If the results arenormal, your next colonoscopy should be in 3
years, and then every 5 years. If a concerningor high-risk adenoma is found, your nextcolonoscopy will be needed within 1 year.

In addition to surveillance testing, a range ofother care is important for cancer survivors.
For more information, see Chapter 5:
Survivorship.

If you don’t have any symptoms, other testing
is not needed on a regular basis. Imaging

Guide 1
Stages 2 and 3 – Surveillance after treatment
Physical exam and
CEA blood test

CT of chest, abdomen,
and pelvis

First 2 years: Every 3 to 6 months
Next 3 years: Every 6 months

Every 6 to 12 months for 5 years

You did not have a total colonoscopy at diagnosis:
Colonoscopy is recommended 3 to 6 months after surgery.
Colonoscopy

NCCN Guidelines for Patients®
Colon Cancer, 2024

You had a total colonoscopy at diagnosis:
Colonoscopy is recommended 1 year after surgery. If no advanced
adenomas are found, repeat in 3 years. After that, repeat every 5
years.

20

Treatment for non-metastatic cancer » Key points

Key points

Surveillance

Polyps with cancer

No further treatment is needed for amalignant pedunculated polyp that wasremoved in one piece and found to be low
risk.



Malignant sessile polyps are more
likely to return after polypectomy thanpedunculated polyps. Surgery andobservation are options for sessile polyps.

Invasive cancer










Colectomy is needed for cancer that is
not found early enough to be removed bypolypectomy. If surgery is not possible,
systemic therapy is recommended.
If the cancer is advanced or has spreadto lymph nodes, chemotherapy or
immunotherapy may be given before
surgery.
Chemotherapy is not recommended after
surgery for stage 1 cancers.
Chemotherapy is recommended after
surgery for stage 2 pMMR/MSS cancers
that are at high risk of recurrence.
Chemotherapy is recommended after
surgery for all stage 3 cancers.

NCCN Guidelines for Patients®
Colon Cancer, 2024

21

Colonoscopies are used to check forrecurrence after treatment for stage 1colon cancer. You may also have physicalexams and CEA blood tests.
Surveillance for stages 2 and 3 coloncancer includes physical exams, CEA
blood tests, colonoscopies, and CT
scans.

4

Treatment for metastatic
cancer
23

Biomarker testing

23

Local therapies

26

Stage 4 cancer in the liver or lungs

28

Stage 4 cancer in the abdomen

29

Surveillance

30

Distant recurrence32

Clinical trials

34

Key points

NCCN Guidelines for Patients®
Colon Cancer, 2024

22

Treatment for metastatic cancer » Biomarker testing » Local therapies

Local therapies

Colon cancer spreads mostoften to the liver, sometimes toYour treatment options may include local
therapies. These are treatments that target
liver and lung tumors directly.

the lungs, and less often to theabdomen or other areas. Cancer
that has metastasized by the time

Some are interventional oncology/radiology
techniques, also known as image-guided
therapies. These techniques use imaging,such as ultrasound or computed tomography(CT), to deliver minimally invasive cancer
treatments. Using imaging during theprocedure allows your doctor to precisely
target the tumor(s).

it is diagnosed is stage 4.

Biomarker testing
Biomarkers are targetable features of acancer. They are often mutations (changes)
in particular genes. When possible, biomarker
testing is performed on a piece of tumor tissue
removed during a biopsy or surgery. If this isn't
possible, a sample of blood can be tested. Allmetastatic colon cancers should be tested forthe following biomarkers:

A team of experts can determine the best local
therapy for your metastatic tumor(s). To learn if
surgery or treatment with other local therapies
is an option, your case should be evaluatedby a multidisciplinary team of experts. The
team should include a surgeon experienced
in removing liver and lung tumors and aninterventional oncologist/radiologist.

Mismatch repair deficiency/highmicrosatellite instability (dMMR/MSI-H) (ifnot already performed)

RAS (KRAS and NRAS) mutations



BRAF mutations

HER2 amplification

Resection
Surgery to remove liver and/or lung tumors iscalled resection. Resection is often preferred
for removing colon cancer that has spread tothese organs.
Image-guided thermal ablation (described on
the next page) may be used:

Testing for many biomarkers at one time iscalled next-generation sequencing (NGS).
NGS can find other, rare biomarkers forwhich targeted treatments may be available,
including:

POLE/POLD1 mutations

RET fusions



NTRK fusions

NCCN Guidelines for Patients®
Colon Cancer, 2024

With resection, if surgery is not expected
to completely remove the tumors
Instead of resection, if the tumors are
small and can be completely destroyed

If a liver resection is needed, your liver may
need to be enlarged first. This is done using
a minimally invasive procedure called portal
23

Treatment for metastatic cancer » Local therapies

Liver-directed therapies

vein embolization. An interventional radiologist
inserts a catheter into certain veins in the liver.
This blocks the blood vessel to the liver tumor,
causing the healthy part of the liver to grow.

Embolization
If the cancer has spread only (or mainly) to theliver, treatment with intra-arterial liver-directed
therapies may be an option. These therapies
may be considered for liver tumors that:

Ablation
Image-guided thermal ablation destroys small
liver or lung tumors. A specialized needle isplaced directly into or next to the target tumor.
This probe delivers targeted energy to thetumor while minimizing damage to surrounding
normal tissue.



Didn't improve (or stopped improving)with chemotherapy, andCannot be resected or ablated.

Intra-arterial therapies treat liver tumors withchemotherapy beads (chemoembolization)
or radioactive spheres (radioembolization).
If radiation spheres are used, it is known as
selective internal radiation therapy (SIRT)
or transarterial hepatic radioembolization(TARE). These procedures are performed byinterventional oncologists/radiologists.

Radiofrequency and microwave ablation
are commonly used methods that kill cancer
cells using heat. Cold energy (cryoablation)
is used sometimes, mostly for lung tumors.
Less common types include irreversible
electroporation (“nanoknife”) and laser
ablation.

A catheter is inserted into an artery in your leg
or wrist and guided to the liver tumor(s). Oncein place, the spheres or beads are injected into
the blood vessel leading to the tumor. Theycollect inside the tumor and deliver radiation or
chemotherapy, causing the cancer cells to die.

Thermal ablation may be used in addition tosurgery, or alone for small tumors that can be
fully removed. It will only be used if all visible
areas of cancer can be destroyed. Ablation
may be performed by either an interventional
radiologist or a surgeon. Sometimes it can bedone in a single session in the interventional
radiology department.

The chemotherapy beads can also work to
starve the tumor by stopping its blood supply.
The chemotherapy or radiation further damage
the cancer cells and cause the tumor to shrink.
When embolization with chemotherapy is
not an option, small beads may be used tophysically block blood supply to the tumor. Thisis called bland embolization.
HAIC
Hepatic arterial infusion chemotherapy (HAIC)
is chemotherapy given directly to the liver. It is
often given in addition to standard intravenous
chemotherapy. Using a port or pump that is

NCCN Guidelines for Patients®
Colon Cancer, 2024

24

Treatment for metastatic cancer » Local therapies

usually placed during surgery to remove liver
tumors, the drugs are funneled directly into theartery leading to the liver. HAIC should only be
performed by medical oncologists at treatment
centers with experience in this method.

In SBRT, high doses of radiation are delivered
to metastatic tumor(s) using very precise
beams. The radiation comes from a large
machine outside the body. The radiation
passes through skin and other tissue to reachthe tumor(s). Treatment with SBRT is typicallycomplete in 5 or fewer sessions, calledfractions.

Stereotactic body radiation
therapy
Stereotactic body radiation therapy (SBRT)
is a highly specialized type of external beam
radiation therapy (EBRT). It may be used totreat colon cancer that has spread to the liver,lungs, or bone.

Stereotactic body radiation
therapy (SBRT)SBRT may be used to treat coloncancer that has spread to theliver, lungs, or bone. High dosesof radiation are delivered to ametastatic site or sites using
very precise beams. Treatment
is typically given in 5 or fewer
sessions.

NCCN Guidelines for Patients®
Colon Cancer, 2024

25

Treatment for metastatic cancer » Stage 4 cancer in the liver or lungs

Stage 4 cancer in the liveror lungs

Recommended first-line regimens are listed
below. The targeted therapy bevacizumab(Avastin) may be added to any of theseregimens:

When possible, surgery and systemic therapy
is the recommended treatment approach forthese cancers. The choice of systemic therapy(chemotherapy or immunotherapy) depends
on the mismatch repair (MMR) status of thecancer.
Surgery involves colectomy to remove thecolon tumor. The liver or lung tumors areresected when the colectomy is performed, orlater as a separate surgery. If the metastatic
tumors are small, removing or destroying themwith local therapies may be an option—alone
or with surgery.

FOLFIRIFOLFOXCAPEOXFOLFIRINOX

For some pMMR/MSS cancers, FOLFIRIor FOLFOX may be given with a targeted
therapy—either panitumumab (Vectibix) or
cetuximab (Erbitux). These regimens are
only recommended for tumors without RAS(KRAS or NRAS) or BRAF mutations.
While uncommon, systemic therapy may
shrink the tumors enough to be removed withsurgery and/or local therapies. After surgery,most people will have more systemic therapy.
In some cases, observation or a short courseof chemotherapy may be possible.

pMMR/MSS cancer
Your doctor may recommend 2 to 3 monthsof chemotherapy before, after, or between
surgeries. This is in addition to thechemotherapy that is recommended foreveryone after surgery, called adjuvant
chemotherapy.

If the tumors do not become resectable during
first-line therapy, systemic therapy is typicallycontinued. The goal is to slow the growth andspread of the cancer.

The goal of adjuvant chemotherapy is to kill
any cancer cells that may remain in the body.
Either FOLFOX or CAPEOX is preferred.
Capecitabine and 5-FU/leucovorin are also
options if needed. After chemotherapy,
surveillance begins.

If the cancer progresses, the regimen you
receive next may be different from what you
had before. The choice will depend on priorsystemic therapy you’ve had and how well
you are expected to tolerate certain regimens.
Another important factor is whether the tumor
has any biomarkers. Regimens targeting
specific biomarkers are listed in Guide 2 on
the next page.

If all areas of cancer cannot be removed
with surgery and/or local therapies,
stage 4 colon cancer is treated with systemic
therapy. Systemic therapy given first is calledfirst-line therapy.

NCCN Guidelines for Patients®
Colon Cancer, 2024

26

Treatment for metastatic cancer » Stage 4 cancer in the liver or lungs

dMMR/MSI-H or POLE/POLD1mutated cancer

If the cancer progresses through all available
regimens, recommended options if you are
eligible include:The preferred treatment approach forresectable stage 4 dMMR/MSI-H or POLE/
POLD1-mutated cancers is immunotherapy
followed by surgery. Immunotherapy is
only recommended if you haven’t alreadyhad treatment with a checkpoint inhibitor.
Recommended options include:

Targeted therapy with fruquintinib(Fruzaqla)
Chemotherapy with trifluridine and tipiracil(Lonsurf)
Targeted therapy with regorafenib(Stivarga)All are tablets taken by mouth. The targeted
therapy bevacizumab may be given with
Lonsurf.

Nivolumab (Opdivo), which may be given
with ipilimumab (Yervoy)

Pembrolizumab (Keytruda)



Dostarlimab-gxly (Jemperli)

Guide 2
Biomarker-based treatments for pMMR/MSS cancers
BRAF V600E mutation

Encorafenib + (cetuximab or panitumumab)

HER2 amplification••

Trastuzumab (Herceptin) + pertuzumab, lapatinib, or tucatinib
Fam-trastuzumab deruxtecan-nxki (Enhertu)

KRAS G12C mutation••

Sotorasib (Lumakras) + cetuximab or panitumumab
Adagrasib (Krasati) + cetuximab or panitumumab

NTRK gene fusion••

Entrectinib (Rozlytrek)
Larotrectinib (Vitrakvi)

RET gene fusion

Selpercatinib (Retevmo)

NCCN Guidelines for Patients®
Colon Cancer, 2024

27

Treatment for metastatic cancer » Stage 4 cancer in the abdomenStage 4 cancer in theabdomen

Another recommended treatment approachfor these cancers is surgery followed bychemotherapy. Either FOLFOX or CAPEOX is
preferred. Capecitabine and 5-FU/leucovorin
are also options if needed.

Some people with metastatic colon cancer
will also form tumors in the layer of tissue thatlines the abdomen, called the peritoneum.
The peritoneum covers most of the abdominalorgans.

If all areas of cancer cannot be removed
with surgery and/or local therapies, stage 4colon cancer is treated with systemic therapy.
If you are a candidate and haven’t had
immunotherapy, treatment with a checkpoint
inhibitor is recommended. Your doctor will
check the extent of the cancer every 2 to 3
months. Surgery may become possible. Or you
may continue immunotherapy or switch to adifferent systemic therapy.

In most cases, systemic therapy is given withthe goal of relieving or preventing symptoms.
The regimen you receive will depend onwhether the tumor has any biomarkers andhow well you are expected to tolerate certain
systemic therapies.
Tumors growing in or around the bowel canblock stool from moving and leaving the body.
In this case, the bowel needs to be unblocked
before starting systemic therapy. This is doneusing one of several surgical techniques, orwith a mesh metal tube called a stent.

If you’ve already had immunotherapy, anothertype of systemic therapy is recommended.

Cytoreductive surgery and HIPEC
In a small number of people, cytoreductive
surgery and/or hyperthermic intraperitoneal
chemotherapy (HIPEC) may be treatment
options. But research is needed on whether
the benefits of these treatments outweighthe possible harms. They are only usedin specialized centers and under certain
circumstances.
Cytoreductive surgery involves surgicallyremoving all visible tumors. If the tumor cannot
be separated from the surface of an organ,
the organ may also need to be removed. In
HIPEC, a heated chemotherapy solution is put
directly into the abdominal cavity through small
tubes called catheters.
NCCN Guidelines for Patients®
Colon Cancer, 2024

28

Treatment for metastatic cancer » Surveillance“

Surveillance
Surveillance after treatment for stage 4 coloncancer includes:Colonoscopies

Physical exams



It's OK to have bad days but
don't let yourself stay there.
A positive attitude goes along way.”

Carcinoembryonic antigen (CEA) blood
tests
Computed tomography (CT) scans

The recommended schedule for surveillance
testing is shown in Guide 3.
In addition to surveillance testing, a range ofother care is important for cancer survivors.
For more information, see Chapter 5:
Survivorship.

Guide 3
Surveillance after treatment for stage 4 colon cancer
Physical exam and
CEA blood test

First 2 years: Every 3 to 6 months

CT of chest, abdomen,
and pelvis

First 2 years: Every 3 to 6 months

Next 3 years: Every 6 months

Next 3 years: Every 6 to 12 months
You did not have a total colonoscopy at diagnosis:
Colonoscopy is recommended 3 to 6 months after surgery.

Colonoscopy

NCCN Guidelines for Patients®
Colon Cancer, 2024

You had a total colonoscopy at diagnosis:
Colonoscopy is recommended 1 year after surgery. If no advanced
adenomas are found, repeat in 3 years. After that, repeat every 5
years.

29

Treatment for metastatic cancer » Distant recurrence

Distant recurrence

For cancers without biomarkers, chemotherapy
with FOLFIRI or irinotecan is a recommended
first-line option. A biologic may be given withchemotherapy. Biologics include bevacizumab,
ziv-aflibercept, ramucirumab, cetuximab, andpanitumumab.

After treatment for non-metastatic coloncancer, the cancer may return and spread tothe liver, lungs, or other areas. This is calleda distant recurrence. Treatment with surgery
and/or local therapies is recommended if all of
the tumors can be totally removed. But, this is
uncommon, and most distant recurrences aretreated with systemic therapy.

Resectable pMMR/MSS cancer
If you have received treatment withchemotherapy, one recommended
option is resection (and/or treatment withlocal therapies) first, followed by either
chemotherapy or observation. Observation
is preferred for those who have already had
treatment with oxaliplatin.

Systemic therapy may shrink the tumors
enough to be removed with surgery. If yourdoctor thinks this might be possible, the sizeof the tumors will be checked about every 2months during systemic therapy. If the cancer
does not become resectable, systemic therapy
is typically continued. The goal is to slow thegrowth and spread of the cancer.

A second option is 2 to 3 months ofchemotherapy first, followed by resection(and/or treatment with local therapies). Morechemotherapy may follow.

Specific recommendations are provided below
according to the mismatch repair status of thecancer and whether resection is possible.

If you have not had any chemotherapy,
resection (and/or treatment with local
therapies) is often performed first, followed bychemotherapy. FOLFOX and CAPEOX are
preferred for chemotherapy. Capecitabine and5-FU/leucovorin are also options if needed.

Unresectable pMMR/MSS cancer
If you’ve had recent treatment with FOLFOX
or CAPEOX, you should not have morechemotherapy that includes oxaliplatin.
Oxaliplatin can cause serious nerve damage.
Your options for systemic therapy will
depend, in part, on whether the cancer has
any biomarkers. Therapies targeting thebiomarkers listed below are available:


HER2 amplification



KRAS G12C mutation



BRAF mutations



NTRK gene fusion

RET gene fusion

NCCN Guidelines for Patients®
Colon Cancer, 2024

A second option for those who haven’t
had any chemotherapy is 2 to 3 months ofchemotherapy first, followed by resection
and/or treatment with local therapies. Morechemotherapy may follow.

30

Treatment for metastatic cancer » Distant recurrence

Unresectable dMMR/MSI-H or
POLE/POLD1-mutated cancer
If you are a candidate and haven’t had
immunotherapy, treatment with a checkpoint
inhibitor is recommended. Your doctor will
check the extent of the cancer every 2 to 3
months. Surgery may become possible. Or,
you may continue immunotherapy or switch toa different systemic therapy.

Supportive care is available foreveryone with cancer. It isn't
meant to treat the cancer, butrather to help with symptoms andmake you more comfortable.

If you’ve already had immunotherapy, anothertype of systemic therapy is recommended.
This may be oxaliplatin-based chemotherapy
such as FOLFOX or CAPEOX. Or, if thecancer has any other biomarkers, targeted
therapy may be an option.

A second option is 2 to 3 months ofchemotherapy first, followed by resection.
More chemotherapy may follow.

Resectable dMMR/MSI-H or POLE/
POLD1-mutated cancer
There are 2 options for treating resectable,
distant recurrences of dMMR/MSI-H cancer.
Local therapies may be used together withresection, or used alone for very small tumors.
If you have not had immunotherapy,
recommended options include:Immunotherapy, followed by observation
or resection
Resection followed by chemotherapy

If you have received checkpoint inhibitor
immunotherapy, one recommended
option is resection first, followed by either
chemotherapy or observation. Observation isrecommended for those who have already had
treatment with oxaliplatin.

NCCN Guidelines for Patients®
Colon Cancer, 2024

31

Treatment for metastatic cancer » Clinical trials

Clinical trials

Who can enroll?
Every clinical trial has rules for joining, called
eligibility criteria. The rules may be about age,cancer type and stage, treatment history, or
general health. These requirements ensurethat participants are alike in specific ways
and that the trial is as safe as possible for theparticipants.

A clinical trial is a type of medical researchstudy. After being developed and tested ina laboratory, potential new ways of fighting
cancer need to be studied in people. If foundto be safe and effective in a clinical trial, adrug, device, or treatment approach may
be approved by the U.S. Food and Drug
Administration (FDA).

Informed consent

Everyone with cancer should carefully consider
all of the treatment options available for theircancer type, including standard treatments andclinical trials. Talk to your doctor about whethera clinical trial may make sense for you.

Clinical trials are managed by a group of
experts called a research team. The researchteam will review the study with you in detail,including its purpose and the risks andbenefits of joining. All of this information is also
provided in an informed consent form. Readthe form carefully and ask questions before
signing it. Take time to discuss with family,
friends, or others whom you trust. Keep inmind that you can leave and seek treatment
outside of the clinical trial at any time.

PhasesMost cancer clinical trials focus on treatment.
Treatment trials are done in phases.








Phase 1 trials study the safety andside effects of an investigational drug ortreatment approach.

Start the conversation

Phase 2 trials study how well the drug or
approach works against a specific type ofcancer.

Don’t wait for your doctor to bring up clinical
trials. Start the conversation and learn about
all of your treatment options. If you find a study
that you may be eligible for, ask your treatment
team if you meet the requirements. Try not tobe discouraged if you cannot join. New clinical
trials are always becoming available.

Phase 3 trials test the drug or approachagainst a standard treatment. If theresults are good, it may be approved by
the FDA.
Phase 4 trials study the long-term
safety and benefit of an FDA-approved
treatment.

NCCN Guidelines for Patients®
Colon Cancer, 2024

32

Treatment for metastatic cancer » Clinical trials

Frequently asked questions
There are many myths and misconceptions
surrounding clinical trials. The possible
benefits and risks are not well understood bymany with cancer.

Finding a clinical trial

Will I get a placebo?
Placebos (inactive versions of real medicines)
are almost never used alone in cancer clinical
trials. It is common to receive either a placebowith a standard treatment, or a new drug witha standard treatment. You will be informed,
verbally and in writing, if a placebo is part of aclinical trial before you enroll.

In the United States
NCCN Cancer Centers
NCCN.org/cancercenters
The National Cancer Institute (NCI)
cancer.gov/about-cancer/treatment/
clinical-trials/search

Are clinical trials free?
There is no fee to enroll in a clinical trial. The
study sponsor pays for research-related costs,
including the study drug. You may, however,
have costs indirectly related to the trial, suchas the cost of transportation or child care due
to extra appointments. During the trial, youwill continue to receive standard cancer care.
This care is billed to—and often covered by—insurance. You are responsible for copays andany costs for this care that are not covered byyour insurance.

NCCN Guidelines for Patients®
Colon Cancer, 2024

Worldwide
The U.S. National Library of Medicine(NLM)
clinicaltrials.gov

Need help finding a clinical trial?
NCI’s Cancer Information Service (CIS)
1.800.4.CANCER (1.800.422.6237)
cancer.gov/contact

33

Treatment for metastatic cancer » Key points

Key points



Biomarker testingEveryone with metastatic colon cancer
should have biomarker tumor testing that
includes dMMR/MSI-H (if not alreadydone), RAS and BRAF mutations, andHER2 amplification.









Treatment options for metastatic coloncancer may include local therapies,
such as image-guided thermal ablationand stereotactic body radiation therapy(SBRT).



Most distant recurrences are treated withsystemic therapy.

Clinical trials provide access toinvestigational treatments that may, intime, be approved by the U.S. Food andDrug Administration (FDA).

“

These treatments may be used in addition
to or in place of surgery if all areas ofcancer can be removed.
To learn if surgery or treatment with otherlocal therapies is an option, your caseshould be evaluated by a multidisciplinary
team of experts.

As the care partner for my stage
IV husband, I would share that you
must advocate for them. However,be respectful of their feelings andensure you’re communicating yourresearch/questions with them. I
always reviewed my list of questions
and concerns with my husband on
the way to our appointments in case
I had something on my list that hemight not want asked or answered.”

When possible, treatment with surgery
and systemic therapy is recommended.
The choice of chemotherapy or
immunotherapy depends on the mismatch
repair status of the cancer.

NCCN Guidelines for Patients®
Colon Cancer, 2024

The return and spread of stage 1, 2, or 3colon cancer to areas far from the colon iscalled a distant recurrence.

Clinical trials

Stage 4 colon cancerFor colon cancer that has spread to theperitoneum, systemic therapy is usually
given. The goal is to relieve or prevent
symptoms.

Distant recurrence

Next-generation sequencing (NGS) can
find other rare biomarkers for whichtargeted treatments may be available,
including: POLE/POLD1 mutations; RET
fusions; and NTRK fusions.

Local therapies for liver and lungtumorsStage 4 cancer that cannot be removed
with surgery and/or local therapies istreated with systemic therapy.

34

5

Survivorship
36

Your primary care doctor

36

Help with side effects

37

Paying for care

38

Healthy habits

39

More information

39

Key points

NCCN Guidelines for Patients®
Colon Cancer, 2024

35

Survivorship » Your primary care doctor » Help with side effects

Help with side effects

Survivorship focuses on thephysical, emotional, and financial

Colon cancer survivors may experience both
short- and long-term health effects of cancer
and its treatment. The effects depend in parton the treatment(s) received. Surgery, anticancer medicines, and radiation therapy all
have unique potential side effects.

issues faced by cancer survivors.
Managing the long-term side
effects of cancer and its treatment,
staying connected with yourprimary care doctor, and living

Diarrhea or incontinencea healthy lifestyle are important

Colon surgery can cause changes to yourbowel habits. You may experience changes
in the frequency or urgency of your bowel
movements. Diarrhea refers to having frequent
and watery bowel movements. Incontinenceis the inability to control urination (urinary
incontinence) or bowel movements (fecal
incontinence). The following may help withthese side effects:

parts of survivorship.

Your primary care doctor
After finishing cancer treatment, your primarycare doctor will play an important role in yourcare. Your oncologist (cancer doctor) andprimary care physician (PCP) should work
together to make sure you get the followup care you need. Ask your oncologist for a
written survivorship care plan. Ideally, the plan
will include:












Anti-diarrhea medicines



Changing your dietStrengthening your pelvic floorWearing protective undergarments

Nerve damage

A summary of your cancer treatment
history

The chemotherapy drug oxaliplatin candamage nerves in your fingers and toes.
Symptoms include numbness, cramping,tingling, or pain in these areas. Acupunctureand heat may help. If you have painful nerve
damage, a drug called duloxetine (Cymbalta)
may help.

A description of possible late- and longterm side effects
Recommendations for monitoring for the
return of cancer
Information on when your care will betransferred to your PCP

Ostomy care

Clear roles and responsibilities for yourcancer doctor and your PCP

If you have an ostomy, you may want to join
an ostomy support group. Another option is to

Recommendations on your overall healthand well-being

NCCN Guidelines for Patients®
Colon Cancer, 2024

36

Survivorship » Paying for care“see a health care provider that specializes inostomy care, such as an ostomy nurse.
People with ostomies can still live very active
lifestyles. However, it’s a good idea to talkto an ostomy professional before doing any
intense physical activity.

I am a stage III colon cancer
survivor. I would recommend
taking it one day at a time, 1 hour
if necessary. Get a second opinion
to feel confident in your treatment
plan. Lastly, connect with others
who have been where you are.
Peer support (whether patient or
caregiver) as you navigate yourcancer journey is invaluable.”

Paying for care
Cancer survivors face a unique financial
burden. Paying for doctor visits, tests, andtreatments can become unmanageable,
especially for those with little or no healthinsurance. You may also have costs notdirectly related to treatment, such as travel
expenses and the cost of childcare or missed
work.
The term financial toxicity is used to describe
the problems patients face related to the costof medical care. Financial toxicity can affectyour quality of life and access to needed healthcare. If you need help paying for your cancer
care, financial assistance may be available.
Talk with a patient navigator, your treatment
team’s social worker, and your hospital’s
financial services department. Some of theresources listed on page 46 contain helpful
information on paying for cancer care.

NCCN Guidelines for Patients®
Colon Cancer, 2024

37

Survivorship » Healthy habits

Healthy habits

Diet and exercise
Try to exercise for at least 150 minutes per
week. Alcohol may increase the risk of certain
cancers. Drink little to no alcohol.

It is important to keep up with other aspectsof your health after cancer treatment. Steps
you can take to help prevent other healthproblems and to improve your quality of life aredescribed next.

A low glycemic load (GL) diet may help
prevent the return of colon cancer. Low GL
foods cause a slower and smaller rise in blood
sugar levels compared to other carbohydratecontaining foods. Talk to your doctor about alow glycemic load diet.

Cancer screening and other care
Get screened for other types of cancer, suchas breast, prostate, and skin cancer. Your
primary care doctor can advise you on whichscreening tests you should have based onyour age and risk level.

Aspirin
Talk to your doctor about the possible risks andbenefits of long-term aspirin therapy to help
prevent the return of colorectal cancers.

Other health care
Get other recommended health care foryour age, such as blood pressure screening,
hepatitis C screening, and immunizations (likethe flu shot).

Quit smoking
If you smoke or vape, quit! Your doctor will beable to provide (or refer you for) counseling on
how to stop smoking.

Experts recommend eatinga diet that includes a lot ofplant-based foods, suchas vegetables, fruits, andwhole grains.

NCCN Guidelines for Patients®
Colon Cancer, 2024

38

Survivorship » More information » Key points

More information

Key points

For more information on cancer survivorship,
the following are available at NCCN.org/
patientguidelines:







Survivorship Care for Healthy Living
Survivorship Care for Cancer-Related
Late and Long-Term Effects



These resources address many topics relevant
to cancer survivors, including:Anxiety, depression, and distressFatigue



Pain



Sexual health

Sleep problems



Healthy lifestyles



Immunizations

Employment, insurance, and disability
concerns

NCCN Guidelines for Patients®
Colon Cancer, 2024

39

Survivorship focuses on the physical,
emotional, and financial issues unique tocancer survivors.
Ideally, your oncologist and primary caredoctor will work together to provide thefollow-up care you need.
A survivorship care plan is helpful intransitioning your care to your primarycare doctor.
Healthy habits, including exercising andeating right, play an important role inhelping to prevent other diseases andsecond cancers.

6

Making treatment decisions
41

It’s your choice

41

Questions to ask

46

Resources

NCCN Guidelines for Patients®
Colon Cancer, 2024

40

Making treatment decisions » It’s your choice » Questions to ask

It’s important to be comfortable

and share concerns with your care team. If you
take the time to build a relationship with yourcare team, it will help you feel supported when
considering options and making treatment
decisions.

with the cancer treatment you
choose. This choice starts withhaving an open and honest
conversation with your care team.

Second opinion
It is normal to want to start treatment as soon
as possible. While cancer can’t be ignored,
there is time to have another doctor review
your test results and suggest a treatment plan.
This is called getting a second opinion, and it’sa normal part of cancer care. Even doctors get
second opinions!

It’s your choice
In shared decision-making, you and your careteam share information, discuss the options,and agree on a treatment plan. It starts with anopen and honest conversation between you
and your care team.

Things you can do to prepare:Treatment decisions are very personal. Whatis important to you may not be important tosomeone else. Some things that may play arole in your decision-making:What you want and how that might differ
from what others want

Check with your insurance company
about its rules on second opinions. Theremay be out-of-pocket costs to see doctors
who are not part of your insurance plan.
Make plans to have copies of all yourrecords sent to the doctor you will see foryour second opinion.

Your religious and spiritual beliefs

Support groupsYour feelings about certain treatmentsYour feelings about pain or side effects

Many people diagnosed with cancer findsupport groups to be helpful. Support groups
often include people at different stagesof treatment. Some people may be newly
diagnosed, while others may be finished withtreatment. If your hospital or community doesn’t
have support groups for people with cancer,
check out the websites listed in this book.



Cost of treatment, travel to treatment
centers, and time away from school orwork
Quality of life and length of life
How active you are and the activities thatare important to you

Questions to ask

Think about what you want from treatment.
Discuss openly the risks and benefits of specifictreatments and procedures. Weigh options
NCCN Guidelines for Patients®
Colon Cancer, 2024

Possible questions to ask your care team arelisted on the following pages. Feel free to use
these questions or come up with your own.
41

Making treatment decisions » Questions to ask

Questions about treatment
1. Do you consult NCCN recommendations when considering options?
2. Are you suggesting options other than what NCCN recommends? If yes, why?
3. Do your suggested options include clinical trials? Please explain why.
4. How do my age, health, and other factors affect my options?
5. What if I am pregnant, or planning to become pregnant in the future?
6. What are the benefits and risks of each option? Does any option offer a cure or longterm cancer control?
7. How much will treatment cost? What does my insurance cover?
8. How long do I have to decide about treatment?
9. Who can I call on weekends or non-office hours if I have an urgent problem with mycancer or my cancer treatment?
10. Can you give me a copy of my pathology report and other test results?

NCCN Guidelines for Patients®
Colon Cancer, 2024

42

Making treatment decisions » Questions to ask

Questions about non-metastatic colon cancer
1. Is the cancer mismatch repair deficient (dMMR) or microsatellite instability-high(MSI-H)?
2. Am I a candidate for surgery (colectomy)? Why or why not?
3. How much of my colon will be removed? How many lymph nodes will be removed?
4. Will I need a colostomy? If so, will it be temporary?
5. Which side effects of surgery are most likely?
6. Am I a candidate for minimally invasive surgery?
7. Will I need chemotherapy or immunotherapy after surgery? For how long?
8. How do I prepare for surgery? Do I have to stop taking any of my medicines? Are there
foods I will have to avoid?
9. When will I be able to return to my normal activities?
10. How likely is the cancer to return after treatment with surgery?

NCCN Guidelines for Patients®
Colon Cancer, 2024

43

Making treatment decisions » Questions to ask

Questions about stage 4 colon cancer
1. Where has the cancer spread?
2. Am I a candidate for surgery? If not, is it possible that I’ll become a candidate?
3. Does my cancer have any biomarkers? How does this affect my options?
4. What treatment will I have before, during, or after surgery?
5. Am I a candidate for treatment with local therapies? Did an interventional oncologist/
radiologist review my case?
6. Which systemic therapy regimen do you recommend for me? Why?
7. How will you know if systemic therapy is working? What if it stops working?
8. What is my prognosis?
9. What can be done to prevent or relieve the side effects of treatment?
10. Am I a candidate for a clinical trial? Do you know of one I can join?

NCCN Guidelines for Patients®
Colon Cancer, 2024

44

Making treatment decisions » Questions to ask

Questions about resources and support
1. Who can I talk to about help with housing, food, and other basic needs?
2. What help is available for transportation, childcare, and home care?
3. How much will I have to pay for treatment?
4. What help is available to pay for medicines and treatment?
5. What other services are available to me and my caregivers?
6. How can I connect with others and build a support system?
7. How can I find in-person or online support?
8. Who can help me with my concerns about missing work or school?
9. Who can I talk to if I don’t feel safe at home, at work, or in my neighborhood?
10. How can I get help to stop smoking or vaping?

NCCN Guidelines for Patients®
Colon Cancer, 2024

45

Making treatment decisions » Resources

Resources
Cancer Hope Network
Cancerhopenetwork.org

share with us.

Colorectal Cancer Alliance
ccalliance.org
Fight Colorectal Cancer
fightcolorectalcancer.org

Take our survey,
and help make the
NCCN Guidelines for Patients
better for everyone!

FORCE Facing Our Risk of Cancer
Empoweredfacingourrisk.org

NCCN.org/patients/comments

Love Your Buns
Loveyourbuns.org
National Coalition for Cancer Survivorshipcanceradvocacy.org
Paltown
Paltown.org
Triage Cancer
Triagecancer.org
U.S. National Library of Medicine Clinical
Trials Databaseclinicaltrials.gov

NCCN Guidelines for Patients®
Colon Cancer, 2024

46

Ü

NCCN Guidelines for Patients®
Colon Cancer, 202447

Words to know

Words to know
ablationA type of local therapy used to destroy tumors
in the liver or lungs. Also called image-guided
thermal ablation.

colonoscopy
Insertion of a thin tool into the colon to view or
remove tissue.
colostomy
Surgery to connect a part of the colon to theoutside of the abdomen and that allows stool
to drain into a bag.

adenocarcinoma
Cancer in cells that line organs and makefluids or hormones. The most common type ofcolon cancer.

embolization
Blockage of blood flow to a tumor with beads
that emit either chemotherapy or radiation.

adenoma
The most common type of colon polyp.
Most likely to form cancer cells. Also calledadenomatous polyps.

external beam radiation therapy (EBRT)
Treatment with high-energy rays received froma machine outside the body.

biomarkers
Specific features of cancer cells used to guidetreatment. Biomarkers are often mutations(changes) in the DNA of the cancer cells.

familial adenomatous polyposis (FAP)
An inherited cancer syndrome that increases
the risk of colon cancer.

CAPEOXA chemotherapy regimen that includes
capecitabine and oxaliplatin.

FOLFIRI
A chemotherapy regimen used for someadvanced colon cancers. Includes leucovorincalcium, fluorouracil, and irinotecan.

carcinoembryonic antigen (CEA)
A protein that gets released by some tumorsand can be detected in blood.

FOLFIRINOX
A chemotherapy regimen used for someadvanced colon cancers. Includes leucovorincalcium (folinic acid), fluorouracil, irinotecan,
and oxaliplatin.

carcinoma in situ
Abnormal cells on the innermost layer of thecolon wall. These cells may become cancer
and spread into deeper layers of the colonwall.
colectomy
Surgery to remove a part of the colon.

FOLFOXA chemotherapy regimen that includes
leucovorin calcium, fluorouracil, andoxaliplatin.

colon
The first and longest section of the large
bowel. Unused food is turned into stool in thecolon.

interventional oncology/radiology
A medical specialty that uses imaging
techniques to deliver minimally invasive cancer
treatments.

NCCN Guidelines for Patients®
Colon Cancer, 2024

48

Words to know

large intestine (bowel)
A long tube-shaped organ that forms the lastpart of the digestive system. Includes thecolon, rectum, and anus.

like mushrooms with a stalk. Sessile polyps
are flat.
portal vein embolization
A minimally invasive procedure to enlarge thehealthy part of the liver before a liver resection.

lymph
A clear fluid containing white blood cells.

recurrence
The return of cancer after a cancer-free period.

lymphadenectomy
Surgery to remove lymph nodes.
lymph node
Small groups of special disease-fighting cells
located throughout the body.

stereotactic body radiation therapy (SBRT)A specialized type of radiation therapy used totreat colon cancer that has spread to the liver,lungs, or bone.

metastasectomy
Surgery to remove cancer that has spread far
from the first tumor.

supportive care
Treatment for the symptoms or healthconditions caused by cancer or its treatment.

metastasis
The spread of cancer cells from the first(primary) tumor to a distant site.

unresectable
Cancer that cannot be removed safely bysurgery.

mismatch repair deficiency (dMMR)/highmicrosatellite instability (MSI-H)
A biomarker (feature) of some colon cancers
that is used to guide treatment. All coloncancers should be tested for this biomarker.
mismatch repair proficient (pMMR)/
microsatellite stable (MSS)
Describes cancers that do not have themismatch repair deficiency (dMMR) biomarker.
pathologist
A doctor who specializes in testing cells andtissue to find disease.
POLE/POLD1 mutation
A biomarker (feature) of some colon cancers.
Recommended as part of comprehensive
biomarker testing for metastatic colon cancer.
polyp
An overgrowth of cells on the inner lining of thecolon wall. Pedunculated polyps are shaped

NCCN Guidelines for Patients®
Colon Cancer, 2024

49

NCCN Contributors

NCCN Contributors
This patient guide is based on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Colon Cancer,
Version 1.2024 – January 29, 2024. It was adapted, reviewed, and published with help from the following people:
Dorothy A. Shead, MS

Senior Director
Patient Information Operations

Erin Vidic, MA

Senior Medical Writer, Patient Information

Laura Phillips

Graphic Design Specialist

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Colon Cancer Version 1.2024 weredeveloped by the following NCCN Panel Members:
Al B. Benson, III, MD/Chair

Robert H. Lurie Comprehensive Cancer
Center of Northwestern University

Alan P. Venook, MD/Vice-ChairUCSF Helen Diller Family
Comprehensive Cancer Center

Mohamed Adam, MD

UCSF Helen Diller Family
Comprehensive Cancer Center

Kimberly L. Johung, MD, PhD

Yale Cancer Center/Smilow Cancer Hospital

Nora Joseph, MD

University of Michigan Rogel Cancer Center

Natalie Kirilcuk, MD

Stanford Cancer Institute

Smitha Krishnamurthi, MD

Yi-Jen Chen, MD, PhD

City of Hope National Medical Center

Case Comprehensive Cancer Center/
University Hospitals Seidman Cancer
Center and Cleveland Clinic Taussig
Cancer InstituteKristen K. Ciombor, MD*Midhun Malla, MD, MS

Vanderbilt-Ingram Cancer Center

Stacey Cohen, MD

Fred Hutchinson Cancer Center

Harry S. Cooper, MD

Fox Chase Cancer Center

Dustin Deming, MD
University of Wisconsin
Carbone Cancer Center

Ignacio Garrido-Laguna, MD, PhD
Huntsman Cancer Instituteat the University of Utah

O’Neal Comprehensive
Cancer Center at UAB

Jennifer K. Maratt, MD, MS

Indiana University Melvin and Bren Simon
Comprehensive Cancer Center

Wells A. Messersmith, MD

University of Colorado Cancer Center

Jeffrey Meyerhardt, MD, MPH
Dana-Farber Brigham and
Women’s Cancer Center*Eric D. Miller, MD, PhD

Katrina Pedersen, MD, MS

Siteman Cancer Center at BarnesJewish Hospital and Washington
University School of Medicine*Leonard Saltz, MD

Memorial Sloan Kettering Cancer Center

Charles Schneider, MD

Abramson Cancer Centerat the University of Pennsylvania

David Shibata, MD

The University of Tennessee
Health Science Center*Benjamin Shogan, MD

The UChicago Medicine
Comprehensive Cancer Center

John M. Skibber, MD

The University of Texas
MD Anderson Cancer Center

Constantinos T. Sofocleous, MD, PhD

Memorial Sloan Kettering Cancer Center*Anna Tavakkoli, MD, MSc
UT Southwestern Simmons
Comprehensive Cancer Center

Jean L. Grem, MD*Christopher G. Willett, MD

Fred & Pamela Buffett Cancer Center

The Ohio State University Comprehensive
Cancer Center - James Cancer Hospitaland Solove Research InstitutePaul Haste, MD

Mary F. Mulcahy, MD

Mayo Clinic Comprehensive Cancer Center

Indiana University Melvin and Bren Simon
Comprehensive Cancer Center

J. Randolph Hecht, MD

UCLA Jonsson
Comprehensive Cancer Center

Sarah Hoffe, MD

Robert H. Lurie Comprehensive Cancer
Center of Northwestern University

Steven Nurkin, MD, MS

Roswell Park Comprehensive Cancer Center

Michael J. Overman, MD

Moffitt Cancer Center

The University of Texas
MD Anderson Cancer Center

Steven Hunt, MD

Aparna Parikh, MD, MS

Siteman Cancer Center at BarnesJewish Hospital and Washington
University School of Medicine

Hisham Hussan, MD

Mass General Cancer Center

Hitendra Patel, MD

UC San Diego Moores Cancer Center

UC Davis Comprehensive Cancer Center* Reviewed this patient guide. For disclosures, visit NCCN.org/disclosures.
NCCN Guidelines for Patients®
Colon Cancer, 202450

Duke Cancer Institute

Christina Wu, MD

NCCN
Lisa Gurski, PhD

Manager, Licensed Clinical Content

Frankie Jones

Guidelines Layout Specialist

Jenna Snedeker, MS, ASCP
Associate Scientist/Medical Writer

NCCN Cancer Centers

NCCN Cancer Centers
Abramson Cancer Centerat the University of Pennsylvania

Robert H. Lurie Comprehensive Cancer Centerof Northwestern University

Case Comprehensive Cancer Center/
University Hospitals Seidman Cancer Center andCleveland Clinic Taussig Cancer Institute

Roswell Park Comprehensive Cancer Center

Philadelphia, Pennsylvania
800.789.7366 • pennmedicine.org/cancer

Chicago, Illinois
866.587.4322 • cancer.northwestern.edu
Buffalo, New York877.275.7724 • roswellpark.org

Cleveland, Ohio
UH Seidman Cancer Center
800.641.2422 • uhhospitals.org/services/cancer-services
CC Taussig Cancer Institute866.223.8100 • my.clevelandclinic.org/departments/cancer
Case CCC
216.844.8797 • case.edu/cancer

Siteman Cancer Center at Barnes-Jewish Hospitaland Washington University School of Medicine
St. Louis, Missouri
800.600.3606 • siteman.wustl.edu

St. Jude Children’s Research Hospital/
The University of Tennessee Health Science Center

City of Hope National Medical Center
Duarte, California
800.826.4673 • cityofhope.org

Memphis, Tennessee866.278.5833 • stjude.org
901.448.5500 • uthsc.edu

Dana-Farber/Brigham and Women’s Cancer Center |Mass General Cancer Center

Stanford Cancer InstituteStanford, California
877.668.7535 • cancer.stanford.edu

Boston, Massachusetts
617.732.5500 • youhaveus.org
617.726.5130 • massgeneral.org/cancer-center

The Ohio State University Comprehensive Cancer Center James Cancer Hospital and Solove Research Institute

Duke Cancer Institute

Columbus, Ohio
800.293.5066 • cancer.osu.edu

Durham, North Carolina
888.275.3853 • dukecancerinstitute.org

The Sidney Kimmel Comprehensive
Cancer Center at Johns Hopkins

Fox Chase Cancer Center
Philadelphia, Pennsylvania
888.369.2427 • foxchase.org

Baltimore, Maryland
410.955.8964
www.hopkinskimmelcancercenter.org

Fred & Pamela Buffett Cancer Center

The UChicago Medicine Comprehensive Cancer Center

Omaha, Nebraska
402.559.5600 • unmc.edu/cancercenter

Chicago, Illinois
773.702.1000 • uchicagomedicine.org/cancer

Fred Hutchinson Cancer Center

The University of Texas MD Anderson Cancer CenterSeattle, Washington
206.667.5000 • fredhutch.org

Houston, Texas844.269.5922 • mdanderson.org

Huntsman Cancer Institute at the University of Utah

UC Davis Comprehensive Cancer Center

Salt Lake City, Utah
800.824.2073 • healthcare.utah.edu/huntsmancancerinstitute

Sacramento, California
916.734.5959 • 800.770.9261
health.ucdavis.edu/cancer

Indiana University Melvin and Bren Simon
Comprehensive Cancer Center

UC San Diego Moores Cancer Center

Indianapolis, Indiana
888.600.4822 • www.cancer.iu.edu

La Jolla, California
858.822.6100 • cancer.ucsd.edu

Mayo Clinic Comprehensive Cancer Center

UCLA Jonsson Comprehensive Cancer Center

Phoenix/Scottsdale, Arizona
Jacksonville, Florida
Rochester, Minnesota
480.301.8000 • Arizona
904.953.0853 • Florida
507.538.3270 • Minnesota
mayoclinic.org/cancercenter

Los Angeles, California
310.825.5268 • cancer.ucla.edu

UCSF Helen Diller Family
Comprehensive Cancer Center
San Francisco, California
800.689.8273 • cancer.ucsf.edu

Memorial Sloan Kettering Cancer Center

University of Colorado Cancer Center

New York, New York
800.525.2225 • mskcc.org

Aurora, Colorado
720.848.0300 • coloradocancercenter.org

Moffitt Cancer Center

University of Michigan Rogel Cancer Center

Tampa, Florida
888.663.3488 • moffitt.org

Ann Arbor, Michigan
800.865.1125 • rogelcancercenter.org

O’Neal Comprehensive Cancer Center at UAB

University of Wisconsin Carbone Cancer Center

Birmingham, Alabama
800.822.0933 • uab.edu/onealcancercenter

NCCN Guidelines for Patients®
Colon Cancer, 2024

Madison, Wisconsin
608.265.1700 • uwhealth.org/cancer

51

NCCN Cancer Centers

UT Southwestern Simmons
Comprehensive Cancer Center

Dallas, Texas
214.648.3111 • utsouthwestern.edu/simmons

Vanderbilt-Ingram Cancer Center
Nashville, Tennessee
877.936.8422 • vicc.org

Yale Cancer Center/Smilow Cancer Hospital
New Haven, Connecticut
855.4.SMILOW • yalecancercenter.org

We want yourfeedback!
Our goal is to provide helpful andeasy-to-understand information
on cancer.
Take our survey to let us knowwhat we got right and what we
could do better.
NCCN.org/patients/feedback

NCCN Guidelines for Patients®
Colon Cancer, 2024

52

Notes

Notes

NCCN Guidelines for Patients®
Colon Cancer, 2024

53

IndexIndex
ablation 24
aspirin 38
BRAF gene mutation 23, 26–27, 30
cancer staging 17
carcinoembryonic antigen (CEA) 9
circulating tumor DNA (ctDNA) 9
clinical trial 32–33
colostomy 16
familial adenomatous polyposis (FAP) 8
fertility 11
HER2 23, 27, 30
HIPEC 28
immunotherapy 18, 27–28, 31
KRAS G12C gene mutation 27, 30
Lynch syndrome 8
microsatellite instability-high/mismatch
repair deficient (MSI-H/dMMR) 6, 8, 18–19,
23, 27, 31
next-generation sequencing (NGS) 23
NRAS gene mutation 23, 26
polyp 6, 8, 14–15
stereotactic body radiation therapy (SBRT)
25
supportive care 19, 31
surveillance 20, 29
survivorship 35–39

NCCN Guidelines for Patients®
Colon Cancer, 2024

54

Ü

NCCN
GUIDELINESFOR PATIENTS®

Colon Cancer
2024
To support the NCCN Guidelines for Patients, visit
NCCNFoundation.org/Donate

3025 Chemical Road, Suite 100
Plymouth Meeting, PA 19462
215.690.0300

NCCN.org/patients – For Patients | NCCN.org – For Clinicians
PAT-N-1730-0724