If bowel cancer has spread to the liver
When bowel cancer spreads to the liver your treatment options will be considered by a multi-disciplinary team (MDT). If you are referred for liver treatment, your MDT is likely to include:
- hepato-biliary surgeons: surgeons who specialise in operations on the liver
- hepato-biliary clinical nurse specialists: nurses who have specialised skills in caring for patients with liver cancer and/or liver disease.
- hepatologists: doctors who specialise in diagnosing and treating liver disease
- hepato-biliary nurse specialists: nurses who have specialised skills in caring for patients with liver cancer and/or liver disease.
- specialist diagnostic radiologists: doctors who use X-rays and scanners to locate and measure the extent of a cancer.
- medical oncologists: doctors who are skilled in treating patients with chemotherapy and biological therapies.
Chemotherapy uses drugs to kill cancer cells. Your healthcare team may offer you chemotherapy to shrink the cancer. You may have one chemotherapy drug or a combination of two or three drugs. If your cancer comes back after treatment, you may be able to have chemotherapy again.
If you have been diagnosed with advanced (metastatic) bowel cancer, your specialist may offer you a biomarker test. This looks for changes (mutations) in a group of genes, called RAS genes. If the cancer has a normal RAS gene, it’s known as RAS wild type. If it’s abnormal, it is called a ‘mutated’ RAS gene.
Cancer cells are collected during endoscopy or surgery and are usually stored in a laboratory. If you can’t have biomarker testing straight away, you may be able to have it in the future.
Your cancer specialist can use the results of biomarker testing to see which treatments may work and which ones are unlikely to work for you. This is called personalised medicine, because your treatment is being tailored to the genetic make-up of your cancer. For example, if you have a mutated RAS gene, you will not benefit from two biological therapies, called Cetuximab and Panitumumab.
Biomarker testing is not offered to everyone and we are campaigning for this to change. If you have been diagnosed with advanced bowel cancer, ask your specialist if you can be tested.
Biological therapies are also called targeted therapies. They help your body control the way cancer cells grow. You may have them as a drip into a vein or you may take them as tablets, depending on which drug you’re having.
Biological therapies may be used together with chemotherapy to treat bowel cancer that has spread to other parts of the body.
Some examples of biological therapies include the following drugs:
- Cetuximab (Erbitux®)
- Panitumumab (Vectibix®)
- Bevacizumab (Avastin®)
- Aflibercept (Zaltrap®)
- Regorafenib (Stivarga®)
Cetuximab and Panitumimab work by blocking messages that tell cancer cells to grow. They won’t work if your cancer cells have a change (mutation) in a group of genes known as RAS genes.
Bevacizumab, Aflibercept and Regorafenib interfere with the way cancers grow their own blood supply.
Access to biological therapies
Cetuximab and Panitumumab are available to patients with a normal RAS gene (known as RAS wildtype), but the doctors will need to look at what other treatments you’ve had. If you’ve had more than one type of chemotherapy already, your doctor might need to make a special request for you to have this treatment.
In Scotland, you can have Aflibercept together with FOLFIRI chemotherapy (irinotecan, 5-fluorouracil and folinic acid) as a second line treatment if you have already had oxaliplatin.
You may have surgery to remove cancer that has spread to your liver, depending on the number of tumours, their location and size. Your liver is able to re-grow, even after large parts are removed.
You may have chemotherapy before liver surgery to shrink the cancer and make it easier and safer to remove.
A specialist liver surgeon will do the operation. Your healthcare team will refer you to a liver surgery centre, which may be at a different hospital.
If your cancer comes back after surgery, you may be able to have another operation or one of the other treatments for advanced bowel cancer.
Cancer Research UK has more information on surgery for bowel cancer that has spread to the liver.
Your healthcare team may offer you ablation to treat bowel cancer that has spread to the liver. Whether you can have this treatment depends on how many tumours you have, where in the liver they are and their size.
You may have ablation if:
- You can’t have surgery
- There are any small areas of cancer left after surgery
- Your cancer has come back after surgery
Treatment involves placing one or more needles into the affected parts of the liver. The doctor uses an ultrasound or CT scan to guide the needle into the tumour. Ablation works by heating the tumour and a surrounding area of normal liver tissue to destroy the cancer cells. Various devices can be used including radiofrequency and microwave energy.
NanoKnife (Irreversible electroporation)
Irreversible electroporation (also known as NanoKnife) is a new type of ablation treatment which involves placing thin needles around the tumour using ultrasound or CT scan under general anaesthetic. High frequency electrical currents are then passed between the needles causing damage and death of cancer cells. One of the advantages of this technique is the limited damage to the healthy surrounding tissues. This allows the treatment of tumours which are close to vital structures such as blood vessels. At the moment there isn’t much evidence about how well Nanoknife works compared to other available treatments. Irreversible electroporation is not currently available in all areas of the UK through the NHS and can sometimes only be received as part of a clinical trial.
Stereotactic ablative radiotherapy (SABR) / Cyberknife
Stereotactic ablative radiotherapy (SABR) is an alternative option for treating liver metastases. It’s sometimes referred to as Stereotactic Body Radiotherapy (SBRT) or CyberKnife. It is currently only available in a few specialist hospitals. SABR may be used if surgery and ablation treatment is not possible. Your suitability for SABR treatment depends on the number, size and location of the tumours in the liver and will be decided by a specialist team. SABR may be funded on the NHS if you meet a number of specific eligibility criteria.
SABR is given using a radiotherapy machine known as a Linear Accelerator. It may also be given using a robotic radiotherapy machine called a CyberKnife. You may need to have small metallic markers inserted into your liver under the guidance of a CT scan as preparation for the treatment. Stereotactic radiotherapy uses lots of small radiation beams directed from many angles that overlap at the tumour. This gives a very high dose of radiotherapy to the cancer while limiting damage to the surrounding healthy tissue, reducing the risk of side effects. The radiation is delivered in a very precise way. SABR is usually given in a few daily treatments (generally three to five), as an outpatient. Research has shown that for suitable patients, SABR is very effective and has a low chance of serious side effects.
Macmillan Cancer Support has more information on stereotactic radiotherapy.
Selective internal radiotherapy (SIRT)
SIRT is a fairly new treatment and is only available in a small number of hospitals. It isn’t routinely available on the NHS. You may be able to have SIRT as part of a clinical trial or if your specialist liver team think you will benefit from it. The treatment isn’t suitable for everyone. You will need to meet certain treatment criteria, you must be fit enough for the treatment and your liver must be working well.
Treatment involves inserting a very fine tube, which passes into the major blood vessel (artery) that leads to the liver. The doctor injects tiny radioactive beads into the tube, which block the tiny blood vessels that feed the cancer cells and release a high dose of radiation into the tumour.
You may have SIRT on its own or together with chemotherapy. If you have chemotherapy, you will take a break from it while you have SIRT. There isn’t much evidence to show how well SIRT works in people who haven’t had chemotherapy. If you have had chemotherapy, SIRT can keep the cancer under control for longer than if you had no treatment. But more research needs to be done before we can say whether it improves quality of life or increases survival.
Before you have your treatment, your doctor will check the blood supply to your liver to make sure the beads won’t travel to other parts of the body. You will only be able to have the treatment if this procedure shows it is safe to go ahead.
National Institute for Health and Care Excellence (NICE) produces guidance on SIRT to treat cancer that has spread to the liver.
Chemoembolization with Irinotecan-loaded beads (DEBIRI TACE)
In some patients whose bowel cancer has spread to the liver, a treatment called DEBIRI TACE could be an option. This involves inserting very small beads loaded with a high dose of the chemotherapy drug Irinotecan. The beads are used to deliver the drug and stop the blood supply to the cancer cells, which can shrink the cancer or stop it from growing. The main benefit of this treatment is that it just works in the liver, reducing the chance of complications elsewhere in the body. You might have the treatment on its own or in combination with other treatments.
Updated August 2018. Due for review March 2019