Patients With Stage IV Colon Cancer Still Have Many Options

Hearing that you or someone you know has been diagnosed with stage IV colon cancer can feel like a huge weight being placed on your shoulders. It’s natural to have many fears and worries—and a lot of questions. So, let’s unpack what exactly stage IV colon cancer is and what that diagnosis might mean.

What does stage IV mean?

When diagnosing colon cancer, your doctor will use the results of the diagnostic tests to stage your cancer. The goals of staging are to determine as accurately as possible:

• How far has cancer spread from where it began in the colon or rectum

• How much cancer there is in your body

The answers to these questions can be pretty complex, requiring a variety of diagnostic tests and procedures. Depending on all the information available, cancer will be categorized as stages I, II, III, or IV.  The least advanced cancers are stage I, and the most advanced, widespread cancers are stage IV.

A letter is also added to each of those stages to give more information about how the cancer is progressing: IVA, IVB, or IVC.

Colon cancer is categorized as stage IV by looking at three broad aspects of the disease: the tumor (T), the involvement of the lymph nodes (N) to which cancer typically spreads first, and its metastasis (M). M is the spread of cancer to other organs or areas of the body. In colorectal cancer, metastases most often spread to the liver and lungs.

The tumor (T)

What is the extent or size of the tumor? Specifically, doctors consider how far it has penetrated the wall of the colon or rectum. This area has layers from the inner lining to the thin, outermost layers of connective tissue over the colon (but not the rectum).

In stage IV, the focus is somewhat less on the original tumor and its growth because that characterized earlier stages.

The lymph nodes (N)

What is the extent of cancer's spread from the walls of the colon or rectum to nearby nodes of the body's lymphatic system? This is important because similar to your circulatory system, lymph nodes are found throughout your body. One way that cancer spreads is by latching onto your lymph nodes and hitching a ride to other areas.

As with the tumor (T) stage, in stage IV, the focus has shifted away from the lymph nodes because that characterized earlier stages.

Metastasis (M)

Has colorectal cancer spread to distant lymph nodes and other organs such as the liver and lungs? This question is the main focus and defining characteristic of stage IV. It’s also why this stage is the most difficult to treat. Your doctor will break it down even further:

In stage 4A, colorectal cancer has spread to one distant organ such as the liver or lungs or distant lymph nodes. It has not spread to distant parts of the lining of the abdominal cavity.

In stage 4B, colorectal cancer has spread to more than one distant organ or distant set of lymph nodes, but still not distant parts of the lining of the abdominal cavity.

In stage 4C, cancer has spread to distant parts of the lining of the abdominal cavity and may or may not have spread to other distant organs or lymph nodes.

Of course, how precise your doctor can be when assigning these stages depends upon how much information is available. Overall, the most accurate and reliable way to do this is by removing tissue from the body (AKA surgical staging).

The five-year survival rate for stage IV colon cancer

Cancer may continue to progress and spread despite the best treatments in the earlier stages or because the cancer was discovered late. On average, regular screenings can detect colorectal cancer two or more years earlier than when you may notice symptoms.

Some 22% of colorectal cancers¹ are stage IV or metastatic. That’s why it’s so important to get routine screenings after age 50, rather than waiting and watching for symptoms of colorectal cancer.

Unfortunately, at stage IV, the prospects are the lowest for successful treatment of any kind and for a patient's long-term survival. However, keep in mind that every cancer patient is unique—for example, the overall state of health, motivation to recover, and genetic makeup—so statistics on survival are averages based on the past.

Rates for colon and rectal cancer

You may hear your doctor talk about a “five-year survival rate.” Essentially, this number asks, “From the time of diagnosis of particular cancer at a particular stage, what percentage of patients are still alive five years later?”

The five-year survival rate for those diagnosed with stage IV colon cancer is about 15%. The five-year survival rate for those diagnosed with stage IV rectal cancer is 16%.

Note that these percentages apply to prospects for five-year survival at the time a stage of colorectal cancer is diagnosed. From that point, some patients may respond better to treatment, receive better social support, or be more proactive in their treatment (e.g., healthy lifestyle changes, getting regular exercise). Therefore, a given patient's prospects of five-year survival may improve or worsen after the diagnosis.

Age and the survival rate

The age² of a patient diagnosed with metastatic colorectal cancer can affect survival. Both the younger and older age groups tend to have a poorer overall survival rate and cancer-free survival. They are being studied as possible high-risk populations.

Survival rate without treatment

What about patients with stage IV colon cancer who don't receive treatment? Given the extreme difficulty of treating stage IV effectively, this is a valid question. Relatively new treatments³ available today have been shown to increase the relative survival rate for both stage III and the length of life of stage IV patients.

Stage IV colon cancer patients who survive

Long-term survival and even cancer survival of stage IV colon cancer patients are statistically uncommon but not impossible⁴. ”Stage IV colon cancer isn't always terminal," says hematologist-oncologist Ranju Gupta, M.D. "A proportion of patients, especially those with limited liver disease, do very well and can be potentially cured."

However, this kind of "cure" requires multiple surgeries and other treatments that, by stage IV, relatively few patients are strong enough to survive.

Stage IV colon cancer treatment

Staging colorectal cancer is important because cancers at different stages have proven responsive to different treatments. By stage IV, depending upon individual factors and the patient's preference, colon cancer treatment is often limited to trying to slow the spread of cancer and keep the patient as comfortable as possible (palliative care).

Home support can affect survival

Stage IV colon cancer can be extremely painful and difficult. Patients⁵ may experience abdominal pain (cramping) and bloat. Constipation and diarrhea are also common with long, thin stools. There is also general fatigue and weakness, and often weight loss.

This means that patients require a lot of support at home. The extent of that support⁶, and emotional atmosphere, may even affect how long they survive. The patient's attitude toward the disease and initiative in self-care can also affect their quality of life and possibly survival.

Some risks of final aggressive treatment

One major influence on long-term survival in palliative care is how the patient was impacted by the last stages of aggressive treatment of cancer. For that reason, the choice to be treated in stage IV and for how long is personal and important.

New treatments for colorectal cancer are being sought, and new possibilities are being identified and tested. Individual, personalized care can help a stage IV patient make the best choices for final treatments so that damage to the body from chemotherapy and radiotherapy does not reduce the survival rate in palliative care.

Chemotherapy versus radiation

In stages III and IV of colorectal cancer, chemotherapy is essential. It is far more common than surgery or radiation therapy, but it is primarily palliative at this stage.

Different chemotherapy medications are used. Some are oral (capecitabine), and some are intravenous (fluorouracil), but all have essentially the same effects. Also, some are used as first-line therapy (the initial treatment), and if the disease does not respond, others as second-line therapy.

Like chemotherapy, radiotherapy has special uses in stage IV. It is sometimes used with rectal tumors (more accessible to radiation than the bowels, which also are highly sensitive to radiation). The goal of radiation therapy with the rectum may be to downsize the tumor in preparation for surgery and reduce the recurrence rate after treatment.

Treatments during palliative care

When a patient's colorectal cancer is incurable, treatments may continue to relieve symptoms or complications during palliative care.

For example, surgery may remove some cancer tissue, bypass the worst affected parts of the colon, or place stents. Other surgical goals may be to reduce bleeding from the tumor, reduce abdominal pain, or remove an obstruction from the colon.

As with many disorders, genetics plays a role in the prognosis for a patient with stage IV colon cancer. Fewer than 600 genes are linked to colorectal cancer outcomes. When expressed (active), some of these genes are unfavorable to outcomes, while others are associated with better survival (an example⁷ is thought to be RNA-binding protein 3 RBM3).

The lowdown

The hard news is that stage IV colon cancer is the most difficult for patients to survive, with only 15% of those diagnosed alive five years later. Yet, this does not mean treatments don't exist; there are many different treatments, and they are constantly improving, particularly with the help of clinical trials.

Some stage IV patients survive longer and are even cured. The main focus of this stage is palliative care, which may slow cancer and keep patients as comfortable as possible.

At this stage, support from family, friends, and the community can make the greatest difference.