Magnified image of metastatic colon cancer cells

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According to the National Cancer Institute (NCI), colorectal cancer is the second leading cause of cancer deaths in the United States. The death rate has been falling for decades thanks to stronger colon cancer screening practices, but still only about 4 out 10 colorectal cancers are found in an early stage before the disease has spread. Twenty to 25 percent of patients have metastases at the time of diagnosis, while 50 to 60 percent will go on to develop metastases as the disease progresses.

Despite these numbers, the outlook of metastatic colon cancer patients has greatly improved thanks to new approaches for treating the disease in its later stages. These are the innovative treatments that the UM Cancer Network regularly utilizes.

Led by the University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, one of the nation's NCI-designated Comprehensive Cancer Centers, the UM Cancer Network bridges the gap between cancer patients and nationally-renowned experts that create tailored, multidisciplinary treatment plans designed to improve quality of life and overall outcomes.

"One thing that makes the UM Cancer Network different than a community hospital is our ability to address advanced cases. This is particularly true when the cancer has spread to the liver or the peritoneal membrane and complex, multimodal interventions are required," says Cherif Boutros, MD, associate professor of surgery at the University of Maryland School of Medicine (UMSOM), and chief of surgical oncology at UM Baltimore Washington Medical Center. Boutros also serves as the medical director of the Tate Cancer Center.

Here are some of the unique ways that the UM Cancer Network tackles metastatic colon cancer head-on.

Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Network physicians utilize CRS paired with HIPEC to treat patients whose cancer spread is limited to the peritoneal cavity. "This complex procedure addresses not only visible cancer metastases, but also any microscopic disease that may remain," says Nader Hanna, MD, professor of surgery at UMSOM and medical director of the Cancer Institute at UM St. Joseph Medical Center.

Despite the extensive nature of the operation, many patients return home between seven to ten days after the procedure.

The median survival CRS-HIPEC patients falls in the range between 45 and 60 months -- a significant increase compared to the chemotherapy-only treatments, where the survival rate falls between 24 to 36 months.

Additionally, CRS-HIPEC can improve patient pain scores. "Debulking and removing the ascites can relieve abdominal distention and bowel obstructions that cause nausea and vomiting. This translates to better quality of life," says Boutros.

The University of Maryland Medical Center (UMMC) is one of the few places in the state to offer this specialized treatment. "We have performed over 550 cases since we started the program in 2004. University of Maryland has become regionally, nationally, and internationally known for the procedure," says Hanna.

Percutaneous Ablation

Surgical resection is not possible for many metastatic colon cancer patients. Metastases are often located in inaccessible areas near major organs or vascular structures. This can be particularly problematic for liver metastases, which over 50 percent of colorectal cancer patients will develop.

Fortunately, non-surgical liver-directed therapies such as percutaneous ablation can provide a minimally-invasive yet effective mode of treatment. Percutaneous ablation techniques -- which utilize microwave ablation, cryoablation, or irreversible electroporation (IRE) -- are most effective when treating a small quantity of lesions that are no larger than three to five centimeters in size.

"Having precise placement of percutaneous needles and ablations allows you to prevent any injury to adjacent structures." says Nabeel Akhter, MBBS, assistant professor at UMSOM and director of interventional oncology at UMMC.

"It also allows for a much faster recovery period than the standard open surgery or even laparoscopic ablation techniques. Patients can immediately start or return to systemic therapies," he says.

While these treatments have varied applications depending on the nature of the metastases, all can have positive outcomes when applied to the correct patient. For example, a recent CLOCC study revealed that radiofrequency ablation combined with systemic therapies greatly improved disease progression and overall survival rates in the long-term.

Intra-Arterial Therapies

Intra-arterial therapies are another set of effective non-surgical, liver-directed treatments that can be helpful for metastatic disease. These treatments -- including transarterial chemoembolization (TACE) and transarterial radioembolization (TARE) -- are best applied in patients with diffuse metastases.

Both intra-arterial therapies involve directing large quantities of either chemotherapy drugs or radiation to the lesions. These procedures, both minimally-invasive, allow precise delivery to the tumor. "We inflict less damage on non-targeted areas of the liver, which can preserve normal liver function for a long period of time and improve overall quality of life," says Akhter.

Outcomes for both of these methods have been promising versus chemotherapy alone. A recent SIRFLOX study even showed that 80 percent of the 530 patients treated with TARE saw a significant decrease in tumor size. Additionally, this study resulted in a complete remission rate of 11 percent compared to the 1.7 percent of patients that only received chemotherapy.

"Many of these treatments are not readily available at all centers. You need to partner with a center that has the expertise and experience in performing these precision-based therapies," says Akhter.

Intra-arterial therapies can be delivered simultaneously with percutaneous ablation techniques at UMMC's advanced hybrid CT and fluoro rooms.

Multidisciplinary Treatment Plans

Each patient referred to the UM Cancer Network receives an individual evaluation of their condition by a multidisciplinary tumor board.

"Every single patient is different according to the extent of the disease, the response to the chemotherapy, and other comorbidities. All of this is taken all into consideration on a case-by-case level when creating a treatment plan," says Boutros.

The UM Cancer Network's multidisciplinary approach brings together the unique expertise of surgical oncologists, medical oncologists, radiation oncologists, interventional radiologists, endocrinologists, genetic counselors, and others to create the most inclusive plan possible.

"Our treatment plans are comprehensive in that they reach beyond standard of care and even treatment modalities. Patients can understand everything from A to Z in terms of the treatments they should receive, their monitoring plan, and their survival recommendation," says Hanna.

Once more specialized treatments are provided within the UM Cancer Network's facilities, the patient receives systemic treatments like chemotherapy and attends follow-up appointments for monitoring at their local community hospital.

Academic Resources

The UM Cancer Network's connection to an academic medical center provides access to resources to help create the best treatment plan possible.

For metastatic colon cancer that has spread to the liver, the multidisciplinary tumor board utilizes the LiverMet Survey. This database follows the course and results of treatment of over 30,000 patients and provides insight into the best treatment options for this specific condition.

"The LiverMet Survey helps us confirm our approach. We can tell patient what we expect to happen if we follow similar treatment plans, because we followed similar patients on a large scale and found certain results," Boutros says.

Additionally, the multidisciplinary tumor boards can recommend patients for a variety of clinical trials for metastatic colon cancer.

Refer a patient today to be evaluated by the UM Cancer Network's multidisciplinary tumor board.