Understand the Standard Playbook

The NCCN Standard of Care for Colon Cancer

The National Comprehensive Cancer Network (NCCN) publishes evidence-based guidelines that most oncologists follow to achieve No Evidence of Disease. The patient-friendly version is available at nccn.org/patients. This is the playbook your oncologist will suggest following, so it is good to know what they will propose as first and second line treatment.

Standard Workup and Diagnosis

• Colonoscopy with biopsy:Confirms the diagnosis and identifies the location and size of the tumor.
• CT scan of chest, abdomen, and pelvis:To check for metastasis to the liver, lungs, or other organs.
• MRI of the liver:Sometimes ordered if CT shows possible liver involvement, to better characterize the lesions.
• PET scan:Not routine, but sometimes used in complex or metastatic cases.
• CEA (carcinoembryonic antigen):A baseline blood test. Important for tracking treatment response later.
• Molecular profiling:MSI/MMR, RAS/RAF, HER2, and ideally a full genomic panel. This should happen at diagnosis, not after treatment starts.
• CBC, CMP, and liver function tests:Baseline blood work before treatment.

 

Standard Treatment by Stage

Stage	Standard Treatment Approach
Stage I	Surgery alone. Colectomy (removal of part of the colon) is curative in most cases.
Stage II (low risk)	Surgery. Adjuvant chemotherapy is sometimes recommended depending on risk factors.
Stage II (high risk)	Surgery followed by adjuvant chemotherapy (typically CAPOX or FOLFOX).
Stage III	Surgery followed by 6 months of adjuvant chemotherapy (FOLFOX or CAPOX).
Stage IV (metastatic)	Systemic chemotherapy with targeted therapy. Surgery may be possible if metastases are limited (especially liver).
MSI-H (any stage with metastasis)	Pembrolizumab (immunotherapy) is now a first-line option. Ask specifically about this.

Common Chemotherapy Regimens

• FOLFOX:5-fluorouracil (5-FU), leucovorin, and oxaliplatin. A standard adjuvant and metastatic regimen.
• CAPOX (XELOX):Capecitabine (oral) and oxaliplatin. An alternative to FOLFOX.
• FOLFIRI:5-FU, leucovorin, and irinotecan. Often used after FOLFOX or as first-line in metastatic disease.
• FOLFOXIRI:A more intensive three-drug regimen sometimes used in metastatic disease for patients who can tolerate it.

Targeted Therapies and Immunotherapy

• Bevacizumab (Avastin):Anti-angiogenic. Commonly added to FOLFOX or FOLFIRI in metastatic disease.
• Cetuximab or panitumumab:EGFR inhibitors. Only work in RAS/RAF wild-type (no mutation) tumors. More effective in left-sided colon cancers.
• Pembrolizumab (Keytruda):Immunotherapy approved for MSI-H or dMMR colon cancer. First-line option in metastatic MSI-H.
• Regorafenib and TAS-102 (trifluridine/tipiracil):Later-line options for metastatic disease.
• Encorafenib plus cetuximab:For BRAF V600E-mutated metastatic colon cancer. Now used in the first-line setting added to chemotherapy (FOLFOX or FOLFIRI), which improved both progression-free and overall survival versus standard chemotherapy in the BREAKWATER trial.

 

Standard care is the floor, not the ceiling. These guidelines represent what works for most people most of the time. Your molecular profile may open doors well beyond the standard path. A Data G knows to look for those doors because we deserve personalized care.