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What is metastatic colon cancer (MCC)? Colon cancer, like other cancers, happens when normal colon cells become abnormal and grow out of control. This growth forms tumors and may spread outside of the colon. Colon cancer is called metastatic when the tumor has grown into nearby areas, or when it has spread to the lymph nodes or bones. The most common form of colon cancer is called colon adenocarcinoma. Common chemotherapy regimens are known by their abbreviations—FOLFOX, FOLFIRI, and CapeOX (see Table 1). Once colon cancer becomes metastatic, chemotherapy can help shrink tumors or slow their growth, but it is unlikely to kill all the cancer cells. In addition to attacking cancer cells chemotherapy medications also damage healthy cells, which can cause many side effects. How is MCC treated? What is targeted therapy? Colon cancer can be treated with a combination of surgery, radiation, and/or medication. Surgery is used to remove the cancer from the colon. Medication may be used when: surgery is not an option; to shrink tumors before surgery; if surgery cannot remove all of the cancer; or if the cancer has spread. Medication options include chemotherapy and targeted therapy. Targeted therapy focuses on unique features of specific cancer cells—such as blocking proteins needed by certain tumors to grow. Medications for targeted therapy may be used alone, or in combination with chemotherapy treatment. What is chemotherapy? Chemotherapy can stop the abnormal growth of cancer cells. Treatment usually consists of several medications taken together (a “regimen”), though single medications are sometimes used. Chemotherapy medications for MCC include 5-FU, irinotecan, oxaliplatin, and capecitabine (Xeloda®). Targeted therapies for MCC include bevacizumab (Avastin®) and ziv-aflibercept (Zaltrap®), which block formation of new blood vessels in tumors; cetuximab (Erbitux®) and panitumumab (Vectibix®), which block “epidermal growth factor receptor” (EGFR) on cells with too much EGFR protein; and regorafenib (Stivarga®), which blocks a protein that helps cancer cells multiply and survive. Continued Table 1. Medication Options for Metastatic Colon Cancer Medication PA? Route Frequency Cost a Effectiveness Evidence Improves overall Fair survival by several months Chemotherapy Regimens b IV Every 2 weeks $1,200 FOLFIRI c IV Every 2 weeks $500 CapeOX d IV + oral Every 3 weeks $3,200 capecitabine (Xeloda®) Oral Twice daily $2,900 FOLFOX Preferred Targeted Therapy Preferred bevacizumab (Avastin®) IV Every 2 weeks cetuximab (Erbitux®) IV Every week IV Every 2 weeks panitumumab Nonpreferred (Vectibix®) regorafenib (Stivarga®) Oral Once daily ziv-aflibercept (Zaltrap®) IV Every 2 weeks $5,100 Improves overall $10,200 survival by a couple months $8,700 compared to $9,700 chemotherapy alone $10,700 Poor Fair Poor Poor Poor Approximate cost estimates based on a 30-day supply. Actual prices may vary depending on your pharmacy and amount or strength of medication dispensed. b 5-FU + leucovorin + oxaliplatin. c 5-FU + leucovorin + irinotecan. d Xeloda + oxaliplatin. PA = requires Prior Authorization. a Revised Sept. 2014 © 2014 OmedaRx Are there differences in side effects from MCC treatments? Common side effects from chemotherapy include low blood counts, feeling tired, nausea, and hair loss. Other serious side effects are possible and vary between medications. Targeted therapies usually have fewer side effects than chemotherapy. Common side effects include skin changes, nausea, feeling tired, and diarrhea. Other serious side effects (bleeding problems, blood pressure changes, liver changes, and intestinal perforation) are possible and vary between medications. How well do these treatments work? The choice of therapy and medication to treat MCC is often patient-specific. Different combinations may be used over the course of treatment. Both chemotherapy and targeted therapy can help shrink tumor size, reduce pain, and also possibly prolong survival for some patients. There is no specific medication, therapy, or treatment regimen proven to cure MCC, however. Ziv-aflibercept (Zaltrap) is recommended for use in combination with FOLFIRI for MCC patients previously treated with chemotherapy regimens containing oxaliplatin. It is unknown whether ziv-aflibercept (Zaltrap) is effective in patients who have not taken oxaliplatin. The Bottom Line Medication options for treatment of metastatic colon cancer (MCC) include chemotherapy, targeted therapy, or a combination of the two. The type of therapy or medication used to treat MCC usually differs depending on the patient and stage of their disease. Some medications used in MCC are recommended only for patients who meet certain treatment criteria. Although effectiveness, safety, and cost of medications vary, none are proven to cure MCC. Why do some MCC medications require prior authorization? Prior authorization helps ensure cancer medications are used for treatment situations where they are proven to be safest and most effective: Bevacizumab (Avastin) is only recommended for MCC when used in combination with a chemotherapy regimen containing 5-FU. It is unknown how effective bevacizumab (Avastin) is when used without 5-FU. Cetuximab (Erbitux) is only recommended for MCC patients with no mutations in a gene named “KRAS.” Studies show cetuximab (Erbitux) is not effective in patients with KRAS mutations (tests are available to check for these mutations). Regorafenib (Stivarga) has been studied only in MCC cases previously treated with a number of other regimens, and is recommended exclusively for patients who have tried several different medications. Note: Since many medication options are available, our physicians and pharmacists developed this ConsumerRx to provide you with information about the available alternatives, as well as potential advantages and lack of advantages of the various products. This medication summary was developed based upon an evaluation of information from the US Food and Drug Administration (FDA), scientific studies, and input from practicing doctors and specialists. Revised Sept. 2014 © 2014 OmedaRx