The first 60 days: Colorectal cancer
The cancer where screening works best and where immunotherapy can make some tumours disappear entirely, yet most metastatic disease still depends on chemotherapy. Below, week by week, is what OnCo's record of Colorectal cancer says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
Weeks 1 to 2
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
From the recorded treatment journey
- Colonoscopy with biopsy, CT of chest, abdomen and pelvis, CEA blood test; MMR/MSI testing on the tumour.
Biomarkers your report may list
RAS (KRAS/NRAS)BRAF V600EMSI/dMMRHER2NTRKsidednessctDNA MRDRAS (KRAS and NRAS exons 2-4) for anti-EGFR eligibilityMMR/MSI status (universal testing at diagnosis)HER2 amplification (IHC/ISH or NGS)Primary tumour sidednessNTRK fusions (rare)POLE/POLD1 (ultramutated, IO-responsive)ctDNA MRD after surgery (Signatera, Guardant Reveal)CEA (monitoring)UGT1A1*28 (irinotecan dosing) and DPYD (fluoropyrimidine toxicity)Germline testing for Lynch when dMMR or young onset
Ask which of these were tested and what the results were; see the report reader for what each value means.
Tests and imaging linked to this cancer
CEA surveillance after colorectal cancer surgeryColorectal cancer screening (colonoscopy, FIT, stool DNA, blood)Companion diagnosticsComprehensive genomic profilingDPYD genotyping and DPD phenotyping before fluoropyrimidinesEndoscopic ultrasound and EBUS systemsGermline (hereditary) testingHistopathology & immunohistochemistry
How it is staged
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- PathologistNamed in the standard of care for: Screening, Stage II-III, Screening (average risk, age 45-75), Stage I-II colon and 1 more.
- RadiologistNamed in the standard of care for: Screening (average risk, age 45-75).
- SurgeonNamed in the standard of care for: Stage II-III, Stage I-II colon, Stage III colon, pMMR, Stage III colon, dMMR and 3 more.
- Medical oncologistNamed in the standard of care for: Screening, Stage II-III, Metastatic, MSS, Metastatic, dMMR and 14 more.
- Clinical oncologist (radiotherapy)Named in the standard of care for: Locally advanced rectal, pMMR, Locally advanced rectal, dMMR, Oligometastatic liver or lung disease.
- Palliative and supportive care teamNamed in the standard of care for: Stage II-III.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
Colonoscopy, FIT, Cologuard, Shield blood test from age 45.
Colonoscopy every 10 years, annual FIT, multitarget stool DNA every 3 years, CT colonography, or the Shield blood test every 3 years; start at 45 (USPSTF 2021). Lynch carriers: colonoscopy every 1-2 years from age 20-25.
Surgery; adjuvant chemotherapy guided by risk and (in trials) ctDNA; exercise programme.
Surgical resection; observation for stage I and low-risk stage II. High-risk stage II (T4, obstruction, <12 nodes, LVI): consider 3-6 months fluoropyrimidine ± oxaliplatin; ctDNA-negative patients can safely omit (DYNAMIC). dMMR stage II derives no benefit from 5-FU alone.
Resection then adjuvant CAPOX for 3 months (T1-3 N1, low risk) or FOLFOX/CAPOX for 6 months (T4 or N2), per IDEA.
Resection then FOLFOX + atezolizumab for 12 months (ATOMIC, 3-year DFS 86% vs 77%). Neoadjuvant nivolumab + ipilimumab (NICHE-2) is an alternative under evaluation.
Total neoadjuvant therapy: short-course radiation or long-course chemoradiation plus FOLFOX/CAPOX, then TME surgery or watch-and-wait for clinical complete response (OPRA). Non-operative management for select cCR.
Dostarlimab monotherapy for 6 months with organ preservation (MSK cohort 100% cCR; AZUR-1 registrational, PDUFA February 2027). Chemoradiation and surgery reserved for non-responders.
Doublet/triplet chemotherapy + biologic by genotype; targeted combinations for BRAF, KRAS G12C, HER2.
Checkpoint inhibitors; organ preservation in rectal cancer.
- 11.Metastatic, dMMR/MSI-high, first lineNCCN category Category 1 (pembrolizumab, nivolumab + ipilimumab), ESMO-MCBS 4 (pembrolizumab)
Pembrolizumab (KEYNOTE-177) or nivolumab + ipilimumab (CheckMate 8HW, PFS 54 months); nivolumab monotherapy alternative. Chemotherapy reserved for IO-refractory disease.
FOLFOX or FOLFIRI + panitumumab or cetuximab (PARADIGM OS 37.9 months); bevacizumab if anti-EGFR contraindicated. Maintenance fluoropyrimidine ± biologic after induction.
FOLFOX, FOLFIRI, or FOLFOXIRI + bevacizumab; anti-EGFR contraindicated. KRAS G12D and other alleles: RAS(ON) inhibitors in trials.
First line: encorafenib + cetuximab + mFOLFOX6 or FOLFIRI (BREAKWATER, OS 30.3 vs 15.1 months). Later line: encorafenib + cetuximab (BEACON).
Sotorasib + panitumumab (CodeBreaK 300) or adagrasib + cetuximab after chemotherapy; first-line trials ongoing.
Tucatinib + trastuzumab (MOUNTAINEER) or trastuzumab deruxtecan 5.4 mg/kg (DESTINY-CRC02) after chemotherapy; MOUNTAINEER-03 tests first-line use.
Resection, thermal ablation, or SBRT with curative intent after multidisciplinary review; perioperative chemotherapy; 5-year survival 30-50% after complete resection of liver metastases.
Trifluridine/tipiracil + bevacizumab (SUNLIGHT, OS 10.8 months), then fruquintinib (FRESCO-2) or regorafenib; NTRK inhibitor if fusion; clinical trials.
Decision points in the recorded journey, Stage III colon
- Low-risk (T1-3 N1) or high-risk (T4 or N2) stage III?
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example RAS, BRAF V600E, MSI/dMMR, HER2, NTRK), and what were the results?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Recognised subtypes for this cancer include Chromosomal instability / APC-KRAS-TP53 pathway, Mismatch-repair deficient / MSI-high, Lynch syndrome.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
Screening
- For my situation (screening), which of the standard options do you recommend and why?Guideline options include: Colonoscopy, FIT, Cologuard, Shield blood test from age 45.
- Am I a candidate for Shield, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Stage II-III
- For my situation (stage ii-iii), which of the standard options do you recommend and why?Guideline options include: Surgery; adjuvant chemotherapy guided by risk and (in trials) ctDNA; exercise programme.
- Am I a candidate for Signatera, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of DYNAMIC apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Metastatic, MSS
- For my situation (metastatic, mss), which of the standard options do you recommend and why?Guideline options include: Doublet/triplet chemotherapy + biologic by genotype; targeted combinations for BRAF, KRAS G12C, HER2.
- Am I a candidate for Encorafenib, Sotorasib, Adagrasib or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Metastatic, dMMR
- For my situation (metastatic, dmmr), which of the standard options do you recommend and why?Guideline options include: Checkpoint inhibitors; organ preservation in rectal cancer.
- Am I a candidate for Pembrolizumab, Nivolumab, Dostarlimab, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Screening (average risk, age 45-75)
- For my situation (screening (average risk, age 45-75)), which of the standard options do you recommend and why?Guideline options include: Colonoscopy every 10 years, annual FIT, multitarget stool DNA every 3 years, CT colonography, or the Shield blood test every 3 years; start at 45 (USPSTF 2021). Lynch carriers: colonoscopy every 1-2 years from age 20-25.
- Am I a candidate for Shield, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Stage I-II colon
- For my situation (stage i-ii colon), which of the standard options do you recommend and why?Guideline options include: Surgical resection; observation for stage I and low-risk stage II. High-risk stage II (T4, obstruction, <12 nodes, LVI): consider 3-6 months fluoropyrimidine ± oxaliplatin; ctDNA-negative patients can safely omit (DYNAMIC). dMMR stage II derives no benefit from 5-FU alone.
- Am I a candidate for CAPOX (capecitabine, oxaliplatin), and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of DYNAMIC apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Stage III colon, pMMR
- For my situation (stage iii colon, pmmr), which of the standard options do you recommend and why?Guideline options include: Resection then adjuvant CAPOX for 3 months (T1-3 N1, low risk) or FOLFOX/CAPOX for 6 months (T4 or N2), per IDEA.
- Am I a candidate for FOLFOX (5-FU, leucovorin, oxaliplatin), CAPOX (capecitabine, oxaliplatin), and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Stage III colon, dMMR
- For my situation (stage iii colon, dmmr), which of the standard options do you recommend and why?Guideline options include: Resection then FOLFOX + atezolizumab for 12 months (ATOMIC, 3-year DFS 86% vs 77%). Neoadjuvant nivolumab + ipilimumab (NICHE-2) is an alternative under evaluation.
- Am I a candidate for Atezolizumab, FOLFOX (5-FU, leucovorin, oxaliplatin), and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of ATOMIC (Alliance A021502) and NICHE-2 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Locally advanced rectal, pMMR
- For my situation (locally advanced rectal, pmmr), which of the standard options do you recommend and why?Guideline options include: Total neoadjuvant therapy: short-course radiation or long-course chemoradiation plus FOLFOX/CAPOX, then TME surgery or watch-and-wait for clinical complete response (OPRA). Non-operative management for select cCR.
- Am I a candidate for FOLFOX (5-FU, leucovorin, oxaliplatin), and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Locally advanced rectal, dMMR
- For my situation (locally advanced rectal, dmmr), which of the standard options do you recommend and why?Guideline options include: Dostarlimab monotherapy for 6 months with organ preservation (MSK cohort 100% cCR; AZUR-1 registrational, PDUFA February 2027). Chemoradiation and surgery reserved for non-responders.
- Am I a candidate for Dostarlimab, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of AZUR-1 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Metastatic, dMMR/MSI-high, first line
- For my situation (metastatic, dmmr/msi-high, first line), which of the standard options do you recommend and why?Guideline options include: Pembrolizumab (KEYNOTE-177) or nivolumab + ipilimumab (CheckMate 8HW, PFS 54 months); nivolumab monotherapy alternative. Chemotherapy reserved for IO-refractory disease.
- Am I a candidate for Pembrolizumab, Nivolumab, Ipilimumab, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of KEYNOTE-177 and CheckMate 8HW apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Metastatic, RAS/BRAF wild-type, left-sided
- For my situation (metastatic, ras/braf wild-type, left-sided), which of the standard options do you recommend and why?Guideline options include: FOLFOX or FOLFIRI + panitumumab or cetuximab (PARADIGM OS 37.9 months); bevacizumab if anti-EGFR contraindicated. Maintenance fluoropyrimidine ± biologic after induction.
- Am I a candidate for Panitumumab, Cetuximab, FOLFOX (5-FU, leucovorin, oxaliplatin) or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of PARADIGM and CRYSTAL & FIRE-3 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Metastatic, RAS-mutant or right-sided (non-G12C)
- For my situation (metastatic, ras-mutant or right-sided (non-g12c)), which of the standard options do you recommend and why?Guideline options include: FOLFOX, FOLFIRI, or FOLFOXIRI + bevacizumab; anti-EGFR contraindicated. KRAS G12D and other alleles: RAS(ON) inhibitors in trials.
- Am I a candidate for Bevacizumab, FOLFOX (5-FU, leucovorin, oxaliplatin), FOLFIRI (5-FU, leucovorin, irinotecan) or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Metastatic, BRAF V600E
- For my situation (metastatic, braf v600e), which of the standard options do you recommend and why?Guideline options include: First line: encorafenib + cetuximab + mFOLFOX6 or FOLFIRI (BREAKWATER, OS 30.3 vs 15.1 months). Later line: encorafenib + cetuximab (BEACON).
- Am I a candidate for Encorafenib, Cetuximab, FOLFOX (5-FU, leucovorin, oxaliplatin) or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of BREAKWATER apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Metastatic, KRAS G12C
- For my situation (metastatic, kras g12c), which of the standard options do you recommend and why?Guideline options include: Sotorasib + panitumumab (CodeBreaK 300) or adagrasib + cetuximab after chemotherapy; first-line trials ongoing.
- Am I a candidate for Sotorasib, Adagrasib, Panitumumab or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of CodeBreaK 300 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Metastatic, HER2-amplified, RAS wild-type
- For my situation (metastatic, her2-amplified, ras wild-type), which of the standard options do you recommend and why?Guideline options include: Tucatinib + trastuzumab (MOUNTAINEER) or trastuzumab deruxtecan 5.4 mg/kg (DESTINY-CRC02) after chemotherapy; MOUNTAINEER-03 tests first-line use.
- Am I a candidate for Tucatinib, Trastuzumab, Trastuzumab deruxtecan, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of MOUNTAINEER & MOUNTAINEER-03 and DESTINY-CRC02 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Metastatic, refractory (third line and beyond)
- For my situation (metastatic, refractory (third line and beyond)), which of the standard options do you recommend and why?Guideline options include: Trifluridine/tipiracil + bevacizumab (SUNLIGHT, OS 10.8 months), then fruquintinib (FRESCO-2) or regorafenib; NTRK inhibitor if fusion; clinical trials.
- Am I a candidate for Trifluridine/tipiracil, Fruquintinib, Regorafenib or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of SUNLIGHT and FRESCO-2 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Oligometastatic liver or lung disease
- For my situation (oligometastatic liver or lung disease), which of the standard options do you recommend and why?Guideline options include: Resection, thermal ablation, or SBRT with curative intent after multidisciplinary review; perioperative chemotherapy; 5-year survival 30-50% after complete resection of liver metastases.
Any stage
- Are there clinical trials I could join, for example of Daraxonrasib, Autogene cevumeran, Signatera, PF-08634404?Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Supportive care improves quality of life and helps patients complete treatment.
- I read that “MSS metastatic disease is immunotherapy-resistant”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “Early-onset CRC causes unknown”. How does that affect my plan?Open problems are where trials and second opinions matter most.
Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.
- A Clinical Study of Calderasib (MK-1084) With Targeted Therapy and Chemotherapy in People With Colorectal Cancer (MK-1084-012/KANDLELIT-012)Phase 3 · recruiting · NCT06997497A Phase 3, Randomized, Open-label, Multicenter Clinical Study to Evaluate the Safety and Efficacy of MK-1084, Cetuximab, and mFOLFOX6 Versus mFOLFOX6 With or Without Bevacizumab as First-line Treatment of Participants With KRAS G12C-mutant, Locally Advanced Unresectable or Metastatic Colorectal Cancer (KANDLELIT-012)
- A Clinical Study of SHR-A1811 in Combination With Chemotherapy and Bevacizumab Versus Standard Therapy as First-Line Treatment for Advanced ColorectalPhase 3 · recruiting · NCT07676162A Randomized, Open-label, Controlled, Multicenter Phase III Clinical Study of SHR-A1811 in Combination With mFOLFOX6 (-1) and Bevacizumab Versus mFOLFOX6 in Combination With Bevacizumab as First-line Treatment for Advanced Colorectal Cancer.
- A Clinical Trial Evaluating the Efficacy and Safety of IBI310 in Combination With Sintilimab, for Neoadjuvant Treatment of MSI-H/dMMR Resectable Colon CancerPhase 3 · active · NCT05890742A Phase 1b/3 Clinical Trial Evaluating the Efficacy and Safety of IBI310 in Combination With Sintilimab, for Neoadjuvant Treatment of Microsatellite Instability-high or Mismatch Repair-deficient, Resectable Colon Cancer
- A Phase Ib/III Study of Suvemcitug Plus FTD/TPI in Participants With Refractory Metastatic Colorectal CancerPhase 3 · recruiting · NCT07361003A Phase Ib/III Study of Suvemcitug Plus Trifluridine/Tipiracil Tablets (FTD/TPI) Versus Placebo Plus Trifluridine/Tipiracil Tablets in Participants With Refractory Metastatic Colorectal Cancer
- A Randomized, Double-blind, Placebo-controlled, Parallel-group, Comparative, Phase III Study to Evaluate the Efficacy and Safety of Nuvastatic® 300mg Capsule in Reducing Cancer-Tumor in Patients With Metastatic Colorectal Cancer Receiving Standard Chemotherapy.Phase 3 · recruiting · NCT07669454A Randomized, Double-blind, Placebo-controlled, Parallel-group, Comparative, Phase III Study to Evaluate the Efficacy and Safety of Nuvastatic® 300mg Capsule in Reducing Cancer-Tumor in Patients With Metastatic Colorectal Cancer Receiving Standard Chemotherapy.
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Colorectal cancer: the full pageThe cancer where screening works best and where immunotherapy can make some tumours disappear entirely, yet most metastatic disease still depends on chemotherapy.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment journey: Stage III colonSurgery to remove the tumour and its nodes, then three or six months of chemotherapy depending on risk, and five years of follow-up with blood tests, scans and a colonoscopy.
- Guidelines comparedNCCN, ESMO and NICE side by side for this cancer.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
Words this page and the cancer page use
- Faecal immunochemical test (FIT): A stool test for hidden blood, done at home every year.
- Total neoadjuvant therapy (TNT, rectal cancer): Giving all the chemotherapy and radiotherapy for rectal cancer before surgery rather than splitting it around the operation.
- Sidedness (left vs right colon): Where in the colon a tumour starts changes its biology and which drugs work.
- Abdominoperineal resection: Removing the rectum and anus together, leaving a permanent colostomy.
- Colonoscopy: Examining the whole large bowel with a flexible camera; polyps found on the way are removed (polypectomy), which prevents most bowel cancers.
- Consensus molecular subtypes (CMS1-4): The consensus molecular subtypes are four gene-expression groups of bowel cancer: immune (CMS1), canonical (CMS2), metabolic (CMS3), and mesenchymal (CMS4), with different prognoses.
- Total mesorectal excision (TME): The standard rectal cancer operation: the rectum is removed together with its surrounding fatty envelope (the mesorectum) in one intact package, which is where local recurrences used to come from.
- Glycaemic index and glycaemic load: How fast a food raises blood sugar (index) and how much, given the portion (load).
- Microsatellite-stable (MSS) / mismatch-repair proficient (pMMR): The 'normal' result on the mismatch-repair test: the tumour has intact DNA spell-checking and few mutations.
- Colectomy: Removing the part of the colon containing the cancer along with its blood supply and lymph nodes, then joining the ends.
Every term links to the glossary.