How I treat stage II colon cancer patients

Abstract

Stage II colon cancer (CC) is probably one of the best prognosis gastrointestinal tumors seen in our consultations, but often takes a lot of time for physicians to determine appropriate treatment because of the limited benefit of adjuvant chemotherapy (CT) in these patients, together with the limited evidence in this situation. How to choose the best treatment for each individual patient is thus dependent on molecular (microsatellite instability/microsatellite stability status) and clinico-pathological features relevant enough to classify these tumors into low-, intermediate- and high-risk stage II disease and to choose an appropriate attitude for each of these subgroups. In practice, the first step in treatment decision making must be to assess the patient's status and comorbidities to see if the patient is eligible for an adjuvant treatment. Then, as fluoropyrimidines (FPs) are the corner stone of CC adjuvant treatment, screening for dihydropyrimidine dehydrogenase deficiency is mandatory in western countries. Finally, depending on the patient's characteristics and tumor risk stage, the strategy may be surveillance, adjuvant FP alone or oxaliplatin-based adjuvant CT. In the near future, new tools such as Immunoscore® (HalioDx; Luminy Biotech Enterprises, Marseille Cedex, France) and circulating tumor DNA may help to identify more precisely patients with minimal residual disease for more personalized adjuvant treatment approaches.

Keywords: colon cancer; early colon cancer; stage II disease.

Figure 1

Treatment algorithm in stage II colon cancer (CC). CAPOX, capecitabine and oxaliplatin; CEA, carcinoembryonic antigen; CT, chemotherapy; MSI, microsatellite instability; MSS, microsatellite stability. ^aIf partial but not complete DPYD deficiency, with uracilemia >16 ng/ml, discuss each patient case individually depending on the benefit/risk balance for adjuvant fluoropyrimidine.