Stage IV Colorectal Cancer: Monitoring and Treatment Insights

Stage III colorectal cancer with metastasis to the lungs is classified as Stage IV?

Hello Doctor:
1.
I was diagnosed with stage III cancer in 1998.
After surgery, my CEA level was 0.19, consistently ranging from 0.16 to 0.19.
After undergoing 12 sessions of chemotherapy over six months, I only had blood tests and chemotherapy during this period without any X-rays or CT scans.
When I inquired with my doctor about the need for imaging tests, the doctor stated that my CEA levels were normal and that they were not necessary.
Therefore, at the end of February 1999, the doctor said I could switch to a monitoring approach.
2.
After five months (June 1999), during a follow-up visit that included X-rays and blood tests, the doctor found multiple spots on the X-ray of my chest (both lungs) and requested another blood draw.
I expressed my concern about having just had a blood draw the day before, to which the doctor replied that it was to check the CA 19-9 level.
3.
In July 1999, it was confirmed that the cancer had metastasized to the lungs, resulting in stage IV cancer.
I underwent chemotherapy combined with targeted therapy (out-of-pocket) and took chemotherapy pills for four cycles over three months, after which my CA 19-9 level dropped to 86.
The doctor mentioned that the treatment was unexpectedly effective and suggested switching to first-line chemotherapy drugs covered by insurance, along with targeted therapy (out-of-pocket) and chemotherapy pills.
After another four cycles over three months, the doctor still noted that the treatment was unexpectedly effective and there was no deterioration, so I could not apply for second-line targeted therapy covered by insurance.
The doctor recommended that we pause chemotherapy and monitor for three months.
I have the following questions:
1.
Why is my CEA level normal (0.19) while my CA 19-9 level is 126.5? Should I change my follow-up to focus on the CA 19-9 level?
2.
If I am only monitoring, is there a possibility that during my follow-up in three months, the doctor will inform me of further metastasis? Should I continue chemotherapy (all out-of-pocket)?
3.
I have heard that after lung metastasis, it is easy for cancer to spread to the brain.
What is the typical timeframe for this?
4.
What symptoms might appear before metastasis to the brain? (I want to be vigilant and prepared in advance.) Thank you.

Fen, 40~49 year old female. Ask Date: 2011/03/04

Dr. Chen Sirong reply Oncology

1.
(Why) It may not be possible to explain why some tumors have elevated CA19-9 levels, some have elevated CEA levels, some have both elevated, and some have neither.
Monitoring can involve testing just one marker or both.

2.
There is certainly a chance of metastasis within three months of monitoring.
If your physical condition can tolerate second-line chemotherapy and your financial situation allows for out-of-pocket expenses for second-line treatment, continuing chemotherapy is one option; observation is also a viable option.

3.
Primary lung cancer is more likely to metastasize to the brain.
According to statistics from the United States, 15% of cancer patients will experience brain metastasis.
According to the Japanese Ministry of Health, out of an average of 320,000 cancer-related deaths per year, over 50,000 cases will have metastasized to the brain.
Anatomical case studies indicate that as many as 30% of cancer patients may have brain metastasis.
While there are no definitive statistics in Taiwan, the expected probability of brain metastasis should not be far off.
The cancers that primarily metastasize to the brain include lung cancer (approximately 50%), breast cancer (about 10%), kidney cancer (around 5%), colorectal cancer (about 5%), and gastric cancer (approximately 5%).
It is currently estimated that there are nearly 10,000 cases of brain metastasis in Taiwan each year.
The likelihood may not be as high as you think; it is difficult to predict the timing, and it is possible that there may be no metastasis to the brain at all.

4.
If there are persistent headaches or accompanying neurological symptoms such as limb weakness, vomiting/nausea, or visual disturbances, one should suspect the possibility of brain metastasis.
If necessary, a CT scan or MRI of the brain should be performed.
Patients with brain tumors or brain metastasis are at high risk for seizures.

5.
I would like to introduce you to Dr.
Chen Jun-yi's website: http://cancerfree.medicalmap.tw/, which contains a wealth of information for reference.
Thank you for your letter.

Sincerely,
Dr.
Chen Si-rong

Reply Date: 2011/03/04

More Info

Understanding Stage IV Colorectal Cancer: Monitoring and Treatment Insights
Stage IV colorectal cancer (CRC) is a critical condition characterized by the spread of cancer to distant organs, such as the liver or lungs. The management of this stage involves a combination of chemotherapy, targeted therapy, and careful monitoring of tumor markers like CEA (Carcinoembryonic Antigen) and CA19-9. Your situation highlights several important aspects of monitoring and treatment in advanced colorectal cancer.

1. Understanding CEA and CA19-9 Levels:
CEA is a tumor marker often used to monitor colorectal cancer. A normal CEA level (like your 0.19) can indicate that there is no active disease or that the cancer is well-controlled. However, CA19-9 is another marker that can be elevated in various conditions, including pancreatic and biliary cancers, and is not specific to colorectal cancer. Your CA19-9 level of 126.5 suggests that there may be some underlying process that warrants further investigation. It is essential to discuss with your oncologist whether to prioritize monitoring CA19-9 levels moving forward, especially if they are more indicative of your current condition.

2. Monitoring and Follow-Up:
The decision to switch to a monitoring phase after achieving a stable condition is common in oncology. However, it is crucial to maintain regular follow-ups, including imaging studies like CT scans or MRIs, even if your tumor markers are stable. The concern about potential metastasis, especially to the lungs and possibly the brain, is valid. While your current treatment has been effective, the risk of progression remains, and regular imaging can help catch any changes early.

3. Risk of Brain Metastasis:
The timeline for metastasis to the brain after lung involvement can vary significantly among patients. Some may experience brain metastases within months, while others may not see this progression for years. Factors influencing this include the biology of the tumor, the effectiveness of systemic therapy, and individual patient factors. It is essential to remain vigilant for neurological symptoms, which may indicate brain involvement.

4. Symptoms of Brain Metastasis:
Common symptoms of brain metastasis can include headaches, seizures, changes in vision, cognitive changes, and motor deficits. If you notice any new neurological symptoms, it is crucial to report them to your healthcare provider immediately. Early detection can lead to timely interventions, which may include radiation therapy or other treatments.

5. Treatment Decisions:
The decision to continue or pause chemotherapy should be made collaboratively with your oncologist, considering your overall health, side effects, and quality of life. If your current regimen is effective and well-tolerated, it may be beneficial to continue. However, if there are concerns about the potential for further metastasis, discussing the possibility of resuming treatment sooner rather than later may be prudent.

In conclusion, managing Stage IV colorectal cancer requires a multifaceted approach that includes regular monitoring of tumor markers, imaging studies, and open communication with your healthcare team. It is essential to remain proactive about your health, report any new symptoms, and engage in discussions about the best monitoring and treatment strategies tailored to your individual situation. Your oncologist is your best resource for navigating these complex decisions, and staying informed will empower you to take an active role in your care.

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