Risk Management & Treatment

Biomarkers, targeted and immunotherapies for colorectal cancer

This section covers the following topics:


tests

tests look at samples of blood, tumor or other tissue for changes or abnormalities caused by cancer. These tests can give doctors clues about the cancer, including:

  • how fast the cancer is growing
  • which treatments are most likely to work
  • whether or not the cancer is responding to treatment or growing
  • whether or not the cancer has come back after remission


Biomarkers for treatment selection

tests may be used to select treatments, and help patients avoid side effects from treatments that will not work for them. tests used to select a specific treatment are sometimes called "companion diagnostic tests." These tests may be done on tumor tissue or (in many cases) on blood. See our Testing section for more information. 

  • Experts recommend testing all colorectal cancers for an abnormality known as MSI-H ( high") also known as "" ( or ).
    • cancers are common in people with a  gene mutation. People with advanced or MSI-high colorectal cancer may respond well to a type of known as an immune checkpoint inhibitor
  • Experts recommend testing  colorectal cancers for the following biomarkers:
    • A specific mutation in a gene known as BRAF.  Tumors with the mutation called V600E, may respond to targeted therapies known as BRAF inhibitors
    • (also known as HER2/neu or ERBB2) is a commonly used in breast cancer to select patients who would benefit from anti-HER2 therapy (for example Herceptin (trastuzumab). In advanced colorectal cancer, tumors that test negative for RAS and BRAF mutations may be tested for . Tumors that test positive for may be treated with Herceptin or a related anti-HER2 drug, usually in combination with standard chemotherapy.
  • Additional tests that may be used in colorectal cancer:
    • A known as an NTRK fusion is rare in colorectal cancer. Advanced/metastatic colorectal cancer with an NTRK fusion may benefit from the Vitrakvi (larotrectinib).
    • Additional tumor testing may help people learn if they are eligible for certain clinical trials. 


Immunotherapies 

Immunotherapies help the body’s immune system detect and attack cancer cells.

  • Immune checkpoint inhibitors are often used to treat advanced or colorectal cancer that have MSI-H or ; usually after other treatments have been tried. The most common immune checkpoint inhibitors used for colorectal cancer are:
    • Keytruda (pembrolizumab)
    • Opdivo (nivolumab)
    • Yervoy (ipilimumab)


Targeted therapies

Several targeted therapies are used to treat advanced or colorectal cancer.  Some work best for people with or without a certain

  • Anti VEGF therapies block tumors from forming blood vessels. Anti VEGF drugs used to treat colorectal cancer include:
    • Avastin (bevacizumab) 
    • Cyramza (ramucirumab)
    • Zaltrap (ziv-aflibercept)
  • Anti EGFR therapies slow down tumor cell growth. Anti EGFR drugs used to treat colorectal cancer include:
    • Erbitux (cetuximab)
    • Vectibix (panitumumab)
  • BRAF inhibitors are oral medications that help slow down tumor growth in advanced colorectal cancers that test positive for the tumor called a BRAF V600E mutation. BRAF inhibitors are usually given in combination with other oral targeted drugs called MEK inhibitors (e.g., trametinib [Mekinist] or binimetinib [Mektovi]). BRAF inhibitors include:
    • Tafinlar (dabrafenib)
    • Braftovi (encorafenib)
  • Stivarga (regorafenib) blocks several different types of proteins in the body that tumors use to grow. Stivarga may be used to treat  colorectal cancer that has come back after treatment with other drugs. 
  • Herceptin (trastuzumab) is used to treat advanced or recurrent  colorectal cancers that do not haveBRAF, KRAS or NRAS mutation.
  • Vitrakvi (larotrectinib) is approved for treatment of advanced cancers that have worsened with other treatments. It targets a genetic change called an NTRK fusion. This type of genetic change is found in a range of cancers, including some colon cancers.

 

Table of targeted and immunotherapies for colorectal cancer

Name of drug Type of agent Cancer Indication
Keytruda (pembrolizumab) Immune checkpoint inhibitor or  unresectable colorectal cancer For first-line treatment of or unresectable colorectal cancer High (MSI-H) or  (
or  unresectable For treatment of that have progressed after treatment and for which there are no other treatment options High (MSI-H) or  (
or  unresectable For the treatment of that have progressed after treatment and for which there are no other treatment options High (TMB-H)
or unresectable colorectal cancer Cancer that has progressed following treatment with a fluoropyrimidine, oxaliplatin, and irinotecan High (MSI-H) or  (
Opdivo 
(nivolumab)
Immune checkpoint inhibitor colorectal cancer

As a single agent or in combination with Yervoy (ipilimumab) for cancer that has progressed following treatment with a fluoropyrimidine, oxaliplatin, and irinotecan

High (MSI-H) or  (
Yervoy (ipilumumab) Immune checkpoint inhibitor colorectal cancer Combined with Opdivo (nivolumab) for cancer that has progressed following treatment with a fluoropyrimidine, oxaliplatin, and irinotecan High (MSI-H) or  (
Avastin
(bevacizumab)
Monoclonal antibody for vascular endothelial growth factor (VEGF) colorectal cancer Combined with intravenous 5-fluorouracil-based chemotherapy for first- or second-line treatment No required
colorectal cancer In combination with chemotherapy for second-line treatment in patients who have progressed on a first-line Avastin-containing regimen No required
Cyramza
(ramucirumab)
Monoclonal antibody for vascular endothelial growth factor (VEGF) colorectal cancer Combined with FOLFIRI chemotherapy, for treatment after disease progression on, or after prior therapy with bevacizumab, oxaliplatin, and a fluoropyrimidine No required
Erbitux
(cetuximab)
Monoclonal antibody for  epidermal growth factor receptor (EGFR) colorectal cancer Combined with FOLFIRI for first-line treatment, or combined with irinotecan for cancers that no longer respond to irinotecan-based chemotherapy or as a single agent in patients who have progressed after oxaliplatin- and irinotecan-based chemotherapy EGFR positive and KRAS mutation negative
Vectibix
(panitumumab)
Monoclonal antibody for  epidermal growth factor receptor (EGFR) colorectal cancer Combined with FOLFOX for first-line treatment Negative for KRAS and NRAS tumor mutations
colorectal cancer As a single therapy following disease progression after prior treatment with fluoropyrimidine, oxaliplatin, and irinotecan-containing chemotherapy Negative for KRAS and NRAS tumor mutations

 

key-facts key-facts

  • All colorectal cancers should be tested for biomarkers related to , such as  or .
  • Advanced cancers that are dMMR/MSI-high may respond well to called immune checkpoint inhibitors. 
  • Cancers in people with are often dMMR/MSI-high. 

guidelines guidelines

The National Comprehensive Cancer Network (NCCN) provides expert-developed guidelines for tumor testing for people with colorectal cancer. NCCN recommends the following for tumor testing in people with colorectal cancer:

  • All newly-diagnosed colorectal cancers should be tested for  (MSI) or  ( or ).  
    • People diagnosed with advanced MSI-H/dMMR cancers may benefit from treatment with a type of known as immune checkpoint inhibitors.
  • Depending on MMR/MSI test results, referral for genetic counseling for an inherited gene mutation associated with
  • Additional tumor tests may help determine treatment options in  colorectal cancer. This includes testing for:
    • BRAF V600E
    • KRAS
    • NRAS

updated: 12/04/2021

paying-for-service paying-for-service

Paying for testing

Insurance companies are required to cover the costs for cancer treatment. However, health plans may vary on the amount of out-of-pocket costs and coverage for specific doctors, facilities or treatments. Your doctor's office and treating hospital should disclose how much your treatment may cost you and work with your insurance company to help you plan for the cost of your care. Visit our Health Insurance Appeals page for additional information on insurance appeals. 

Medicare will cover the cost for genetic testing and testing for people who meet certain criteria. Medicare coverage varies based on the policies of Medicare in your region. Visit this site to find and contact your regional Medicare provider for more information about coverage. The Medicaid website has a link to state Medicaid programs, which list specific eligibility for each state.

Some laboratories have assistance programs that help cover the cost for tumor testing: 

Organizations that offer co-pay assistance:

Other resources:

  • The American Cancer Society provides information and resources on covering the cost of cancer care. Public assistance, such as Medicaid may be available if you are ineligible for other programs. 
  • Triage Cancer offers tools and resources to help individuals cope with the financial aspects of a cancer diagnosis.

updated: 01/22/2022

paying-for-service paying-for-service

Paying for cancer treatment

The majority of public and private health insurance plans are required to cover cancer diagnosis and treatment; copays, coinsurance and deductibles often apply. Patient costs and coverage for specific doctors, facilities or treatments may vary based on your health plan. Visit our section on Insurance and Paying for Care: Treatment  for more information, links to sample appeal letters and other resources. 

Some pharmaceutical companies have assistance programs that help cover the cost for their medications: 

Organizations that offer co-pay assistance:

Other resources:

  • The American Cancer Society provides information and resources on covering the cost of cancer care. Public assistance, such as Medicaid may be available if you are ineligible for other programs. 
  • Needy Meds: Assistance programs to help patients with cost of medications and other healthcare.
  • Triage Cancer offers tools and resources to help individuals cope with the financial aspects of a cancer diagnosis.

updated: 01/22/2022

clinical-trials clinical-trials

The following are studies enrolling people with advanced colorectal cancer.  

A number of other clinical trials for patients with colorectal cancer can be found here.

updated: 12/04/2021

Last updated January 22, 2022