Colorectal cancer: Recent advances in management and treatment

Table 1 Immune checkpoint inhibitors approved by the Food and Drug Administration for the treatment of colorectal cancer

Trade name	Generic name	Strategy	Date of FDA approval	Type of cancer	Local/metastatic
Jemperli	Dostarlimab	PD-1 inhibitor	January 2023	dMMR/MSI-H	Local
Yervoy	Ipilimumab	CTLA-4 inhibitor	July 2018	dMMR/MSI-H	Metastatic
Opdivo	Nivolumab	PD-1 inhibitor	July 2017	dMMR/MSI-H	Metastatic
Keytruda	Pembrolizumab	PD-1 inhibitor	June 2020 (first-line treatment)	dMMR/MSI-H	Metastatic
			May 2017 (second-line treatment)

CTLA-4: Cytotoxic T-lymphocyte associated protein 4; dMMR: Deficient mismatch repair; FDA: Food and Drug Administration; MSI-H: High microsatellite instability; PD-1: Programmed death 1.

Table 2 Different treatment options for colorectal cancer

Treatment	Modalities	Uses	Advantages	Disadvantages
Surgery	Laparoscopic surgery	Can be used in all stages of colon and rectal cancer	Laparoscopic surgery is safe and effective for CRC	Decreased survival with laparoscopic surgery in certain subgroups
			Laparoscopic surgery carries significantly lower costs than open surgery and a decreased risk of surgical site infection
	Robotic surgery		Robotic surgery offers improved dexterity, precision, stereoscopic vision, and more precise lymph node dissection and intracorporeal anastomoses	Robotic surgery requires longer operating times, higher costs, and a steeper learning curve
			Robotic-assisted colectomy may lead to better long-term survival for patients with stage I-III colon cancer
	Navigation surgery		Navigation surgery allows for real-time visualization of blood flow in the colon and rectum	Transanal total mesorectal excision involves a non-standardized operative technique, risk of contamination of the surrounding space and the peritoneal cavity with bacteria or malignant cells, risk of urethral injury, anastomotic leaks, bowel injuries, urinary dysfunction, and bleeding
			Navigation surgery is useful for lymph node mapping
Radiation therapy	Image-guided radiation therapy	Mainly used in stages III and IV colon and rectal cancers	Neoadjuvant-Shrink tumors to facilitate easier surgical removal (mainly for rectal cancer)	Causes skin irritation (redness, blistering, peeling)
	Intensity-modulated radiation therapy		Adjuvant-Cancer cell eradication to reduce recurrence risk	Gastrointestinal complications (nausea, diarrhea, painful bowel movements, blood in stool)
	Stereotactic body radiation therapy		Non-surgical candidates-Control cancer and alleviate symptoms in patients not fit for surgery	Bowel incontinence
	Adaptive radiation therapy		Can be used to prevent or relieve symptoms such as pain from advanced colorectal cancer. It may also treat metastatic areas like the lungs or bones, shrinking tumors temporarily, but not likely curing the cancer	Bladder irritation (frequency, burning, pain, hematuria)
	Nanoparticle-mediated radiation therapy			Fatigue
	Proton beam therapy			Sexual adverse events (erection issues, vaginal irritation)
	Heavy ion therapy			Tissue damage (scarring, fibrosis, adhesions)
Chemotherapy	Alkylating agents	Used in stage II, III and IV in colorectal cancer	Wide range of use	Common toxicity to cancer and normal cells
	Antimetabolites		May stop or slow cancer growth	Several side effects
	Antimicrotubular agents		Variety of available agents	Decreased immunity by harming to immune cells
	Antibiotics		Can be used as a combination therapy	Individual variations
	Miscellaneous			Needs frequent monitoring and hospital visits
Targeted therapy	Targeting EGFR pathway	Used in stage IV colon and rectal cancers	Can be used when chemotherapy fails	Expensive drugs
	Targeting VEGF/VEGFR pathway		Synergy with chemotherapy: Improved survival compared to chemotherapy alone	Genetic testing often needed: Drugs do not work on all patients
	Targeting BRAF		Targeted mechanism of action: Fewer side effects compared to chemotherapy	Limited long-term clinical experience
	Targeting HER2			Side effects include hypertension, skin rashes, cardiotoxicity, and diarrhea
Immunotherapy	Immune checkpoint inhibitors	Can be used in stage II, III and IV in colorectal cancer	Potential to treat many cancer types	Dependent on immune status of patient
	Adoptive cell therapy		May be nonspecific to cancer type	Several side effects
	Vaccines		May provide lifelong protection from cancer	Possible resistance
				Possible adverse immunological events

CRC: Colorectal cancer; EGFR: Epidermal growth factor receptor; HER2: Human epidermal growth factor receptor-2; VEGF: Vascular endothelial growth factor.