Research into treating bowel cancer

Research goes on all the time into how best to treat bowel cancer. Usually doctors test new drugs in people with advanced bowel cancer first. If a new treatment helps with advanced bowel cancer, it may work for early stage bowel cancer as well. It is then tested in clinical trials to see if it lowers the risk of an early stage cancer coming back.

Doctors would like to be able to identify who is most at risk of their bowel cancer coming back. People at lowest risk may not need such intensive treatment as people at higher risk. At the moment, we don't know for sure who is most at risk so some people have treatment they may not need. All treatments have side effects. So it is important that people don't have treatment that may not be helping them.

Many clinical trials are testing chemotherapy drugs, using different combinations, different doses, or different ways of giving them. The aim of this type of research is to find better ways of treating bowel cancer with chemotherapy. You can find information about individual trials on our clinical trials  database. There is information here about

• Chemotherapy after surgery for bowel cancer (adjuvant chemotherapy)
• Chemotherapy before surgery for bowel cancer (neoadjuvant chemotherapy)
• Chemotherapy for bowel cancer that has spread
• Hand foot syndrome caused by capecitabine
• PET scans to check how chemo is working

Chemotherapy after surgery for bowel cancer (adjuvant chemotherapy)

Fluorouracil, FOLFOX or capecitabine are the standard chemotherapy drugs doctors use to lower the risk of bowel cancer coming back after surgery. The QUASAR 2 trial is funded by Cancer Research UK and is looking at whether adding a biological therapy called bevacizumab (Avastin) to capecitabine (Xeloda) chemotherapy can lower this risk even further.

The SCOT trial is looking into whether having 12 weeks of chemotherapy works as well as having 24 weeks of chemotherapy. Having less chemotherapy could mean fewer or milder side effects. You may be able to join this trial if you are having surgery for stage 2 or stage 3 bowel cancer, and are due to have chemotherapy afterwards. People on this trial will either have OxMdG (oxaliplatin, fluorouracil, and folinic acid) or XELOX (oxaliplatin and capecitabine) chemotherapy.

Chemotherapy before surgery for bowel cancer (neoadjuvant chemotherapy)

Many people with colon cancer have chemotherapy after surgery. The FOxTROT trial is looking at whether giving some chemotherapy before surgery helps to stop the cancer coming back. Doctors think that the chemotherapy before surgery may shrink the tumour and make it easier to remove. It may may also help to kill off cells that have already spread.

Researchers for the FOxTROT trial want to find out if chemotherapy works better before or after surgery. This trial is also looking at whether adding a monoclonal antibody called panitumumab (Vectibix) to chemotherapy can help people with early bowel cancer. Trials have already shown that panitumumab can help some people with advanced bowel cancer to live longer and have a better quality of life.

The ARISTOTLE trial is for cancer of the back passage (rectum) that has spread into surrounding tissues.  The trial is looking at adding irinotecan to standard capecitabine chemotherapy with radiotherapy. You have this treatment before having surgery to remove the cancer. The researchers want to find out if adding irinotecan to standard treatment stops or helps to delay the cancer coming back after surgery. They also want to find out more about the side effects.

The EXCITE trial is looking at having cetuximab (Erbitux), capecitabine (Xeloda) and irinotecan (Campto) with radiotherapy before surgery for rectal cancer. It is also for people whose cancer has spread into tissues around the rectum. Cetuximab is a biological therapy and capecitabine and irinotecan are chemotherapy drugs. Some chemotherapy drugs make cancer cells more sensitive to radiotherapy. Doctors want to see if this combination of treatments helps to shrink the cancer before surgery, and what the side effects are.

Chemotherapy for bowel cancer that has spread

The CINATRA trial is a small trial looking at a new chemotherapy drug called patupilone for people with advanced bowel cancer that has spread to another part of the body. You may be able to join this trial if you have already had treatment with oxaliplatin, irinotecan and either raltitrexed or a fluoropyrimidine. Fluoropyrimidine drugs include fluorouracil, capecitabine, and tegafur with uracil (Uftoral). The doctors want to see if patupilone can stop or control the growth of the cancer. They are also checking the type of changes in the cancer cells' DNA to see if patupilone works better for certain types of bowel cancer.

The MESH trial is looking at whether the chemotherapy drug methotrexate can help people with a particular gene fault called MSH2 who have bowel cancer that has spread.

There is a trial looking at a new type of chemotherapy called EZN-2208 with or without the biological therapy cetuximab. The trial is for people who have bowel cancer that has spread. EZN-2208 has been developed from the chemotherapy drug irinotecan.

The FOCUS 3 trial is looking at blood samples from people having chemotherapy for bowel cancer. Differences in certain genes and proteins can affect the way cancers grow and spread. The differences can also affect how well chemotherapy works. So the trial is looking at many proteins and the DNA in the liquid part of the blood (serum). The researchers hope this will help us to find the best type of chemotherapy for each person.

One trial is comparing a new drug called HA-Irinotecan with standard irinotecan chemotherapy. Some people with bowel cancer that has spread have irinotecan with fluorouracil (also known as 5FU) and a vitamin called folinic acid. This combination of drugs is called FOLFIRI chemotherapy. HA-Irinotecan combines irinotecan with a substance called hyaluronic acid (HA). HA can help to get more irinotecan into cancer cells. The aims of the trial are to see if HA-Irinotecan works better than irinotecan and to learn more about the side effects. You can find detailed information about the HA-Irinotecan trial on our clinical trials database.

Hand foot syndrome caused by capecitabine

Capecitabine is a form of the chemotherapy drug fluorouracil that you take as a tablet. It is used to treat bowel cancer. One of the side effects of this and similar drugs is hand foot syndrome, or palmar plantar syndrome. The palms of your hands and the soles of your feet may become red, sore or numb. This can be painful.

Doctors often prescribe a tablet called pyridoxine (vitamin B6) to help control hand foot syndrome. But there isn't much evidence to show how well pyridoxine works. A small Korean trial recently found that it did not help people taking capecitabine for bowel cancer. A UK trial called CAPP-IT is now looking into this.

PET scans to check how chemotherapy is working

There is a trial using a new PET scan technique, to see how well chemotherapy is working for people with bowel cancer that has spread to the liver. The new PET scans are compared with standard PET scans, as well as CT or ultrasound scans.

You can find more chemotherapy trials for bowel cancer on our clinical trials database. Go to the advanced trials search and choose 'bowel' from the dropdown menu of cancer types and 'chemotherapy' from the list of treatment types. If you want to see all the trials, tick the boxes for closed trials and trial results.

There is a lot of research into radiotherapy for bowel cancer. There are trials looking at

• Giving chemotherapy alongside radiotherapy
• Radiotherapy during surgery
• Selective internal radiation therapy for secondary bowel cancer
• Reducing bowel radiotherapy side effects

Giving chemotherapy alongside radiotherapy

We know that radiotherapy, along with surgery, can help to stop rectal cancer from coming back. We also know that having fluorouracil (5FU) chemotherapy can help radiotherapy to work better for rectal cancer. The chemotherapy makes the cancer cells more sensitive to radiation. Some trials are looking at giving chemotherapy with radiotherapy before or after surgery for rectal cancer. 

The CHRONICLE trial is trying to find out whether having chemotherapy after chemoradiation and surgery helps to lower the risk of rectal cancer coming back. 

Radiotherapy during surgery

A phase 1 trial in Dundee is looking at radiotherapy during surgery for cancer of the back passage (rectum). Radiotherapy during surgery is called intra operative radiotherapy (IORT). This trial is looking at a new type of intra operative radiotherapy called the photon radiosurgery system (PRS) that uses low energy X-rays. The trial aims to find out about the safety of PRS and see how well it works. The researchers also want to learn about the effects of PRS on cancer tissue and healthy tissue.

Selective internal radiation therapy for secondary bowel cancer

In 2011 the National Institute for Health and Clinical Excellence (NICE) approved a type of internal radiotherapy (sirspheres) for people with bowel cancer spread to the liver that cannot be surgically removed. During the treatment, millions of very tiny beads (microspheres) are injected into the liver. Each bead is coated with a radioactive substance. This gives a dose of radiotherapy to the liver tumours over a few days. The treatment is also called radio embolisation or SIRT. 

NICE advised that SIRT is safe to use and can shrink liver tumours. But we need more research to see if SIRT can help people live longer and reduce symptoms. The large UK FOXFIRE trial is looking at whether SIRT can shrink bowel cancer tumours in the liver and make it possible to remove them with surgery. It is also looking at the side effects of this treatment.

Reducing bowel radiotherapy side effects

Researchers are looking at ways of reducing side effects of bowel radiotherapy. There is a trial looking at whether eating more or less fibre reduces radiotherapy side effects to the bowel. The trial is for people having treatment to the area between their hip bones (the pelvis). Pelvic radiotherapy can inflame the bowel lining and cause loose stool, diarrhoea and difficulty controlling your bowels. The researchers want to find out whether diets high or low in fibre are better for people having radiotherapy and whether they can reduce the side effects.

You can find radiotherapy trials for bowel cancer on our clinical trials database. Go to the advanced trials search and choose 'bowel cancer' from the dropdown list of cancer types and 'radiotherapy' from the dropdown list of treatment types.

Surgery is one of the main treatments for bowel cancer. Researchers are looking at how surgery can be improved. There are trials looking at

• Tests to show which treatment people need after surgery 
• Keyhole and robotic surgery
• Timing of surgery
• New operations for cancer spread to the liver

Tests to show which treatment people need after surgery

The PARSC study is using a new test to help find the risk of stage 2 cancer of the large bowel (colon) coming back after surgery. The test looks at the actions of genes in the cancer cells. Doctors hope that this will help them to know who needs to have chemotherapy after surgery. 

Keyhole and robotic surgery

A newer type of surgery called keyhole (or laparoscopic) surgery is carried out by making small cuts in your abdomen (tummy), and putting surgical instruments and a camera through these holes to do the operation. We know that keyhole surgery is as good as standard surgery for removing and curing bowel cancer. The EnROL trial is looking to see if people who have keyhole surgery recover quicker from their operation and have fewer complications, such as infections. 

The ROLARR trial is looking at using a robotic system for keyhole surgery to remove cancer of the back passage (rectal cancer). The trial wants to find out if robotic assisted keyhole surgery is as good as, or better than, standard keyhole surgery for removing rectal cancers.

Timing of surgery

There is a trial looking at the timing of rectal cancer surgery. The researchers want to find out whether it is best to do surgery 6 to 8 weeks after chemoradiation treatment or whether it is safe to delay the surgery. The aim of the trial is to see if the cancer shrinks even further if surgery is delayed, so you can have a smaller operation. 

There is another trial looking at the best time for surgery after radiotherapy or chemoradiation for rectal cancer. The trial is aiming to compare the size of the cancer 6 weeks and 12 weeks after finishing radiotherapy or chemoradiation.  This will help surgeons to know how long they need to wait before operating, to get the best results from the radiotherapy or chemoradiation.

The ISAAC trial is looking at removing the original (primary) area of cancer in the bowel or back passage before chemotherapy. It is for people with bowel cancer that has spread (advanced bowel cancer). The aim of the trial is to find out whether it is better to remove the original bowel cancer before having chemotherapy. Or whether it is better to wait to see if the cancer causes symptoms before removing it.

New operations for cancer spread to the liver

You may hear your doctor call cancer that has spread to the liver 'secondary cancer' or liver secondaries. There are specialised surgical treatments for liver secondaries, such as radiofrequency ablation and cryotherapy.

Surgeons have developed a new type of surgery for people with liver tumours in parts of the liver that are usually too dangerous or difficult to operate on. One example is when a tumour is very close to major liver blood vessels. This type of surgery is very new and experimental. Doctors only use it if a patient would die if they did not have it because there is a risk of dying from the surgery itself. The operation involves removing the liver from the body, cutting away the diseased tissue, and then putting back the healthy liver tissue. Doctors call this ex vivo hepatic resection and reimplantation for liver cancer.

The National Institute for Health and Clinical Evidence (NICE) has guidelines about ex vivo hepatic resection and reimplantation surgery. You can read their report on the NICE website. They say that there is limited evidence for the safety of this type of operation, and it is not clear how well it works. But it may be helpful for some people with liver cancer. People having the surgery must have full information about the possible risks and benefits.

You can find out more about surgery trials for bowel cancer on our clinical trials database. Go to the advanced trials search and choose 'bowel' from the dropdown menu of cancer types and 'surgery' from the list of treatment types. If you want to see all the trials, tick the boxes for closed trials and trial results.

Some specialists see their patients regularly after treatment has finished, but some do not. Follow up varies a lot between different hospitals and doctors are not sure what is best. Seeing patients more often and having certain tests may help the doctors to diagnose bowel cancer that has come back (recurred) more quickly. But having regular tests can be stressful for patients. 

Currently there is limited evidence that diagnosing a recurrence of bowel cancer earlier will improve survival rates. The FACS trial is trying to find the best way to follow up patients after treatment for bowel cancer.

Bowel cancer is sometimes diagnosed when it causes a blockage in the bowel, which makes you feel very unwell. In this situation you would usually have emergency surgery to relieve the blockage and allow your bowel to start working again. Doctors often treat bowel cancer with surgery. But emergency surgery is more difficult than surgery that is planned. There is a higher risk of complications and it is more likely that you will need to have a colostomy (a stoma).

In the CReST trial the researchers want to see if it is possible to delay surgery by putting a tube called a stent into the bowel to relieve the blockage (endoluminal stenting). The stent opens up the bowel so that the waste from food you have digested can pass through. You may be able to join this trial if you have a suspected bowel cancer that is causing a blockage on the left hand side of your bowel.

Doctors want to find out if stenting before you have an operation can

• Reduce the complications of surgery
• Reduce the number of people who need a stoma
• Help people to live longer

Biological therapies are treatments that use natural body substances or change the ways that cells signal to each other to grow. There is detailed information about biological therapies in our cancer treatment section. You can find out more about biological therapy trials for bowel cancer on our clinical trials database. Go to the advanced trials search and choose 'bowel cancer' from the dropdown menu of cancer types and 'biological therapy' from the list of treatment types. If you want to see all the trials, tick the boxes for closed trials and trial results.

Current research for bowel cancer is looking at

• Cetuximab (Erbitux)
• Bevacizumab (Avastin)
• Panitumumab (Vectibix)
• Pazopanib
• Cediranib (AZD2171) and AZD6244
• Bortezomib (Velcade) and an anti epilepsy drug
• ZD4054
• RO5083945
• Using antibodies to target other treatment

Cetuximab (Erbitux)

Cetuximab (Erbitux) is a biological therapy that blocks a growth factor called epidermal growth factor (EGF). Some bowel cancer cells have EGF receptors. When triggered, the EGF receptors tell the cell to grow and divide into more cells. So, cetuximab is a growth factor blocker. You can find information about cetuximab as a treatment for bowel cancer on the biological therapies for bowel cancer page. 

We know from trials that having cetuximab with chemotherapy makes chemotherapy work better. So researchers are looking at the best way of combining cetuximab with chemotherapy. You can find trials looking at cetuximab for bowel cancer on our clinical trials database. Choose 'bowel cancer' from the dropdown list of cancer types and type 'cetuximab' into the search box. We have described some of these trials briefly below. 

The COIN-B trial is looking at standard chemotherapy with cetuximab. Doctors want to see if it helps as a first treatment for people with bowel cancer that has spread. The aim of this trial is to find out if it is best to have cetuximab continuously, or to have it in 12 week courses with breaks in between. 

The E-SCOUT trial is looking at combining cetuximab with the chemotherapy drugs irinotecan, oxaliplatin and Tegafur with uracil (UFT). This trial is for people who haven't yet had chemotherapy for bowel cancer that has spread locally or to other parts of the body.

The New EPOC trial is looking at cetuximab for bowel cancer that has spread to the liver but can be removed. Everyone on this trial has chemotherapy for 12 weeks. They have oxaliplatin and either fluorouracil with folinic acid, or capecitabine. Then they have the cancer removed from the liver and then another 12 weeks of chemotherapy. Some people have cetuximab with their chemo and the rest don't. This is to see if cetuximab and chemotherapy work better together than chemotherapy on its own.

Bevacizumab (Avastin)

Bevacizumab (Avastin) is a biological therapy licensed in the UK to treat advanced bowel cancer. Avastin blocks a growth factor protein called VEGF. VEGF triggers blood vessels to grow. This is called angiogenesis. All cancers need to grow their own blood supply. Avastin stops tumours from making blood vessels.

In December 2010, the National Institute for Health and Clinical Excellence (NICE) said that bevacizumab with chemotherapy should not be available as a treatment in the NHS for people with advanced bowel cancer. They made this recommendation because they said that it did not give enough benefit to patients for its very high cost. Research is continuing into bevacizumab, to try to find ways of improving the results of this treatment.  

The BOXER trial recently looked at giving bevacizumab with oxaliplatin and capecitabine to people whose bowel cancer had spread to the liver but nowhere else in the body. It found that adding bevacizumab to chemotherapy was safe and worked well. It shrank the cancers more than chemotherapy alone and allowed more people to have surgery. 

A large study called QUASAR 2 is looking at whether adding bevacizumab to capecitabine chemotherapy after surgery for early stage cancer (adjuvant treatment) helps people to live longer. 

Panitumumab (Vectibix)

Panitumumab (also known as Vectibix) is another type of monoclonal antibody. It has been approved in Europe for treating people with bowel cancer that has spread and standard chemotherapy has not worked. As with cetuximab, to have panitumumab, your bowel cancer cells must have EGF receptors.

The Scottish Medicines Consortium (SMC) and the All Wales Medicines Strategy Group (AWMSG) do not recommend panitumumab for people with bowel cancer that has spread. Panitumumab is currently being assessed by the National Institute for Health and Clinical Excellence (NICE).

The PICCOLO trial is looking at how well panitumumab works as a treatment for bowel cancer that has come back. People on this trial had a standard course of irinotecan, or irinotecan with panitumumab, or irinotecan with ciclosporin. Ciclosporin is not an anticancer drug, but doctors think it might reduce the side effects of irinotecan. Early results of the PICCOLO trial were presented at a major conference in 2011. They showed that adding panitumumab to irinotecan didn't help people to live longer than irinotecan alone. But we are waiting for further results from this trial. 

Doctors are also trying panitumumab as part of the FOxTROT trial. There is information about this above, in the chemotherapy before surgery for bowel cancer section.

Pazopanib

Pazopanib (Votrient) is a new type of growth factor blocker (tyrosine kinase inhibitor). You take it as a tablet. The aim of the treatment is to stop tumour cells growing their own blood vessels. Doctors have tested it as a treatment for several other cancer types and it is now also in early stage clinical trials for advanced bowel cancer.

Cediranib (AZD2171) and AZD6244

The DREAM study is looking at adding a growth blocker (tyrosine kinase inhibitor) to the standard treatment of chemotherapy and radiotherapy. This trial is for people who have cancer that started in the back passage (rectum) and has grown into surrounding body tissue. The study is looking at two different tyrosine kinase inhibitors – cediranib (AZD2171) and AZD6244. Some people have cediranib and some people have AZD6244. The trial aims to find the highest dose of each drug that people can have safely at the same time as chemoradiotherapy for rectal cancer. The researchers also want to find out how the drugs affect cancer growth.

Bortezomib (Velcade) and an anti epilepsy drug

A phase 2 study is looking at whether bortezomib and an epilepsy drug could be a treatment for bowel cancer. Bortezomib (Velcade) is a type of biological therapy called a proteasome inhibitor. It blocks cancer cells from breaking down proteins that the cell doesn't need so the cell dies. Researchers know that the anti epilepsy drug sodium valproate blocks enzymes called histone deacetylases, which cells need to grow and divide. Early research using drugs of this type for cancer has shown promising results. This study is to find out how small doses of bortezomib (Velcade) and sodium valproate work in people with bowel cancer. 

ZD4054

A trial called FOLFERA is testing chemotherapy with a new drug called ZD4054 for bowel cancer that has spread. Doctors usually treat advanced bowel cancer with chemotherapy. One combination of drugs they use is irinotecan, fluorouracil (5FU) and folinic acid, known as FOLFIRI. The aim of this trial is to find out how well the combination of ZD4054 and FOLFIRI works for people with bowel cancer that has spread.

RO5083945

Researchers have developed a new type of monoclonal antibody called RO5083945. They are looking at whether it can help people who have already had chemotherapy for bowel cancer that has spread. A trial is giving RO5083945 alongside FOLFIRI chemotherapy and comparing this treatment with FOLFIRI and another monoclonal antibody called cetuximab. The researchers hope that RO5083945 may be able to stop or slow down the growth of bowel cancer cells. And it may also help the immune system to attack cancer cells.

Using antibodies to target other treatments

Scientists can attach cancer drugs or radioactive atoms to monoclonal antibodies. The antibodies then carry these treatments straight to the cancer cells to kill them. The researchers hope that this targeted treatment will work better than regular chemotherapy or radiotherapy. The treatment may also mean that other healthy cells in your body don't get damaged, so there could be fewer side effects.

Resveratrol is a type of chemical called an antioxidant. It occurs naturally in some foods, such as grapes and peanuts. Antioxidants can stop genes inside cells becoming damaged, and may help to prevent cancer. In the laboratory resveratrol has been shown to help kill bowel cancer cells. Doctors want to find out more about what happens to resveratrol in the body after it is eaten or drunk. 

There is a small study looking at resveratrol and the effects it might have on bowel cancer cells in the body. People on this trial took resveratrol for 8 days before their operation to remove bowel cancer. Then the tumour cells were examined in the laboratory. This study is no longer recruiting patients and we are waiting for the results.

A study is looking at symptoms that could be caused by cancer coming back after treatment. After treatment for cancer of the breast, lung, prostate or bowel, you have follow up appointments with your specialist doctor. But after a few years, if you stay well, these appointments may stop. You then have to to see your GP if you have any new symptoms or are worried about anything.

Researchers looked back at the medical notes of people who went to their GP with symptoms some time after cancer treatment. They looked at people whose cancer came back as well as people whose symptoms were caused by something else. The trial aims to find common symptoms of cancer recurrence to help doctors spot the signs that cancer may have come back. The trial has now closed and we are waiting for the results.