Bowel Cancer Awareness Month: Let's shine a light on colorectal cancer

Bowel cancer in a few figures

Bowel cancer, also called colorectal cancer, includes cancers of the colon and rectum. Between 60 and 80% of colorectal cancers develop from benign tumours: polyps or adenomas. There are 4 stages of severity of these cancers, ranging from superficial damage to the gastrointestinal wall to metastasis, where the cancer spreads to other organs in the body. It is a cancer that is very prevalent throughout the world with risk factors such as excess weight/obesity, diet rich in red or processed meat and low in fibre, physical inactivity, alcohol or tobacco consumption.

In the UK, the following trends have been observed: 

• Mortality rates are in decline: Over the past ten years, bowel cancer mortality rates have decreased by more than a tenth (12%) and are estimated to fall by 23% between 2014 and 2035. It is the third most common cause of cancer death in both women and men.
• Incidence rates have declined in men and remained stable in females since the 1990s: it is the 4th most common cancer in the UK and the third most common for both men and women.
• Survival rate is improving and has more than doubled in the last 40 years: almost 8 in 10 people (73.3%) survive their disease for one year or more and almost 6 in 10 (58.4%) survive for five years or more.

Screening is one of the factors that have made it possible to reduce the mortality rate of this cancer by detecting the disease at an early stage, thereby enabling patients to be treated more quickly. It is offered to all men and women aged 60 to 74 and is conducted by testing for blood in the stool. This screening should be done every two years.

Treatments have also reduced patient mortality and increased life expectancy. 

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Bowel cancer treatments

Treatment is adapted to each patient and care is multidisciplinary. 

Surgery

Surgery is very often used in the case of colorectal cancers. It consists of removing the part of the colon or rectum affected by the tumour. It can be done by making an incision in the abdominal wall to operate.

Another technique, laparoscopic surgery or minimally invasive surgery (MIS), is also possible and consists of introducing a miniature camera and surgical instruments through small incisions. As this technique is less invasive, it reduces hospitalisation time, complications and improves patients' quality of life.

Chemotherapy

Chemotherapy can be prescribed alone or after surgery. Many compounds are on the market but fluorouracil (5-FU) remains the preferred option for bowel cancer. To improve its efficacy, irinotecan (CAMPTO®) or oxaliplatin can be administered in parallel. Another drug exists, capecitabine (XELODA®), which is given in tablet form. New drugs are still being developed to treat colorectal cancer.

For bowel cancer that has metastasised, chemotherapy is systematically prescribed. It can be given before the first surgical operation in order to make the operation easier or instead of surgery when the latter is not possible.

Pembrolizumab, a new treatment for certain types of bowel cancer

On 28 January 2021, the European Medicines Agency (EMA) gave a positive opinion for the use of KEYTRUDA® (pembrolizumab) for certain types of bowel cancer. 

Keytruda® is a drug used to treat various cancers: melanoma, non-small cell lung cancer, kidney cancer and squamous cell carcinoma of the head and neck, for example. It is a monoclonal antibody that is administered by infusion. 

Indications for using Keytruda® in cases of bowel cancer: 

• It is a first-line monotherapy in microsatellite instable (MSI-H) metastatic bowel cancer or mismatch repair deficient (MMR deficient) metastatic bowel cancer in adults.

These two forms of cancer represent 5% of metastatic colorectal cancers. 

A phase 3 study ( a study on a large number of patients) called Keynote-177 compared the efficacy of pembrolizumab with first-line chemotherapy. The study showed significant improvement of progression-free bowel cancer survival of 16.5 months in the pembrolizumab group, versus 8.2 months in the chemotherapy group. This represents a 40% reduction in progression risk with pembrolizumab.

The tolerability profile was also more favourable on pembrolizumab, with 22% of serious adverse events (grade 3 or 4) compared to 66% on chemotherapy.

The Keynote-177 study also studied the quality of life of patients on pembrolizumab compared with that of patients undergoing first-line chemotherapy. The assessment was carried out using two scales that measure quality of life. It was shown that the quality of life was improved and that the delay before quality of life deteriorated was longer.

Keytruda® is currently under appraisal by the National Institute for Health and Care Excellence to extend its marketing authorisation to cover treatment for colorectal cancer.

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