'It’s Not What Happens, It’s How You React'
- Chris Kowalski, 37, was diagnosed with stage 4 colon cancer after experiencing unusual fatigue; the news reshaped life for him and his wife, Erin, as they raised two young children.
- Stage 4 colon cancer can vary widely in how far it spreads, making treatment highly individualized; experts emphasize the importance of determining the right sequence of chemotherapy and surgery.
- “A stage 4 can be one tiny spot on the liver, or it could be 100 spots throughout the abdomen, and obviously those patients are going to be treated differently,” explains Dr. Daniel Labow at Mount Sinai Health System.
- “If a tumor is very large, chemotherapy can sometimes shrink it enough to make surgery safer and more effective. We also consider chemotherapy first in the small number of cases where the cancer has already spread beyond the colon,” medical oncologist Dr. Paul Oberstein explains.
- Chris began immediate chemotherapy—15 rounds over several months—while navigating the emotional weight of his diagnosis as Erin prepared to give birth to their son. The couple was surprised by the diagnosis since Chris was just 37.
- The American Cancer Society notes that colon cancer is typically diagnosed around age 68 in men and 72 in women, yet the National Cancer Institute reports a steady rise in cases among adults under 50 since the 1990s.
- “It is likely a combination of factors, including diet and genetics as well as access to care and some environmental factors,” Colorectal Surgeon and Surgical Oncologist Dr. Heather Yeo, on the early onset of cancer in younger adults.
When he brought his concerns to his doctor, he was advised to undergo a colonoscopy. The test revealed stage 4 colon cancer, a diagnosis that instantly reshaped the future the couple had imagined.
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“Effective chemotherapy and effective surgery are both important for the best possible outcome, and part of the job is figuring out which one should come first.”
WATCH: Not All Metastatic Colon Cancer Patients Are the Same
For Chris, the timing of his diagnosis was especially overwhelming. Erin was expecting to give birth to their son soon, and he worried about whether he would be able to support her postpartum, care for their toddler daughter, or continue the physical activities that had always grounded him.
“I’m not going to be able to help our newborn baby… When you get a phone call as I did, you think about everything—the whole scope of your life—, and there was so much unknown,” he said.
Soon after his diagnosis, Chris’s doctor told him he needed to begin chemotherapy right away. Erin admits she was “terrified” when she learned he would undergo 15 rounds of treatment, administered every two weeks. Once chemotherapy was completed, his care team would determine whether surgery would also be necessary.
Chemo for Colon Cancer
“There are two main situations where we use chemotherapy before surgery,” explains Dr. Paul Oberstein, a medical oncologist specializing in gastrointestinal cancers.
“If a tumor is very large, chemotherapy can sometimes shrink it enough to make surgery safer and more effective. We also consider chemotherapy first in the small number of cases where the cancer has already spread beyond the colon.”
Chemotherapy is a well‑established and extensively studied treatment for colorectal cancer, and it has been shown to improve survival. The standard regimen is called FOLFOX, though doctors may add medications such as irinotecan (FOLFIRI) or cetuximab depending on how the tumor responds and the specific characteristics of each patient’s cancer. We’ll explore these options in more detail later.
WATCH: Chemotherapy Before Colon Cancer Surgery
In some situations, surgery isn’t possible because not all tumors can be removed. When that happens, the focus of treatment shifts to controlling the disease—slowing or stopping its growth, preventing further spread, and reducing symptoms.
“The reality for most people with metastatic colon cancer is that surgery isn’t an option, meaning the cancer can’t be completely removed,” Dr. Oberstein says.
He notes that patients with inoperable metastatic disease will live with their cancer long‑term. “Our role is to partner with them—using chemotherapy or other emerging treatments—to keep the cancer controlled for as long as possible while minimizing side effects. For many, that means moving through a series of treatments over time.”
Refusing to Be Defined By a Diagnosis
When Chris was diagnosed, he made a deliberate choice—not only to fight his cancer, but to stay fully present in every part of his life. He continued showing up for his family, kept working, and remained physically active.
“Since that day, I haven’t taken a single day off from work or from being a husband or a dad,” Chris said. “And I think I’ve been a good support for my team at work.”
He draws strength from lessons he learned watching both of his parents face cancer. His father was diagnosed with lymphoma, and his mother battled breast cancer. “My dad taught me that it’s not what happens to you—it’s how you react to it,” he said.
That mindset carried him into a commitment he made long before his own diagnosis: running a marathon in honor of a friend’s late mother. Even as he began biweekly chemotherapy, Chris refused to back out.
“I didn’t know how I’d feel on chemo,” he explained. “But as I started treatments every two weeks, I realized I was feeling okay. Being active is something I love, and I’d promised to run this race for my buddy’s mom. I wanted to keep that commitment. So I trained, did the best I could, ran the race—and I’m still running.”
For many people, staying active or continuing to work can be a powerful way to hold onto normalcy during treatment, as long as they’re physically and emotionally able.
“We always encourage people to keep working if they can,” says licensed clinical social worker Sarah Stapleton. “It helps create a sense of normalcy. If you’re able to work, you stay busy—and you’re not constantly worrying about how treatment is going.”
People Under 50 Diagnosed With Cancer
One aspect of Chris’ experience with advanced colon cancer that stunned the couple was that he could have gotten it in the first place, given his age.
“We had not heard that early-onset colon cancer has been increasing in young adults under age 50,” Erin said.
The average age at which people are diagnosed with colon cancer is 68 for men and 72 for women, according to the American Cancer Society.
However, the National Cancer Institute reports that since the 1990s, colorectal cancer cases have been rising among adults younger than 50. Research published in CA: A Cancer Journal for Clinicians found that cases in people younger than 55 “increased from 11% in 1995 to 20% in 2019.”
WATCH: Debunking misconceptions about colon cancer.
“We know rates are increasing in young people, but it’s alarming to see how rapidly the whole patient population is shifting younger, despite shrinking numbers in the overall population,” cancer epidemiologist and lead study author Rebecca Siegel said.
Researchers are still trying to determine why younger people are being diagnosed in more significant numbers. Some experts point to risk factors, which include obesity, physical inactivity, and smoking, as a possible explanation for the increase.
“We don’t know for sure why we are seeing earlier onset and death from colon cancer,” Colorectal Surgeon and Surgical Oncologist Dr. Heather Yeo told SurvivorNet.
“It is likely a combination of factors, including diet and genetics as well as access to care and some environmental factors,” Dr. Yeo added.
Coping With an Advanced Colon Cancer Diagnosis
“The first-line (initial treatment) chemotherapy for metastatic colon cancer, if they’ve not seen any other chemotherapy before, is the standard FOLFOX,” Dr. Yeo explained to SurvivorNet.
“Most colon cancers do respond to FOLFOX. If you respond really well, then we keep you on that until you stop responding really well. But if after a few cycles your disease has progressed, that’s when we think about adding additional chemotherapies,” Dr. Yeo continued.
WATCH: Managing Metastatic Colon Cancer
The cancer starts when abnormal lumps called polyps grow in the colon or rectum. If you don’t have these polyps removed, they can sometimes change into cancer. It takes up to 10 years for a colon polyp to become a full-blown cancer, according to SurvivorNet experts.
“When we see a polyp, we actually physically take the polyp out through the colonoscope,” Dr. Zuri Murrell, a colorectal cancer surgeon and Director of the Cedars-Sinai Colorectal Cancer Center, explained.
WATCH: When to get a colonoscopy
Most colon cancers can be prevented if people are regularly screened. The screening usually involves a colonoscopy, in which a long, thin tube attached to a camera examines the colon and rectum. If no polyps are discovered, the following screening won’t be needed for about ten years.
What Treatment Options Exist for Colon Cancer?
“There are a lot of advances being made in colorectal cancer,” Dr. Yeo previously told SurvivorNet.
Colon cancer treatment is more targeted, meaning doctors often test for specific changes or genetic mutations that cause cancer growth.
Biomarkers are key to tailoring specific treatments. Biomarkers are molecular patterns becoming more commonly used in colon cancer diagnosis, prognosis, and management. According to the National Cancer Institute, a biomarker is “a biological molecule found in blood, other body fluids, or tissues that is a sign of a normal or abnormal process, or a condition or disease,” such as cancer.
“In colon cancer, we’re starting to look more and more at people’s biomarkers, so we’re starting to take the cancers, sequence them, understand where the different mutations are to figure out whether or not someone has a normal gene here or an abnormal gene,” Dr. Yeo explained.
“Those are the areas that people want to be able to target a little bit more. We’re getting close to more of what we would call precision medicine, meaning we can start looking at people’s genetic mutations and think about how they might respond to different drugs.”
There are different types of biomarkers, including DNA, proteins, and genetic mutations found in blood, tumor tissue, or other body fluids. The biomarkers most commonly used in colon cancer management are:
- Genetic mutations within the tumor, such as MMR/MSI, KRAS, BRAF, and HER2
- Bloodstream carcinoembryonic antigen (CEA)
CEA is a protein produced by most tumor cells (but not all) and can be picked up in the bloodstream. High CEA levels do not establish a colon cancer diagnosis. However, higher CEA levels correlate with a worse prognosis and potential metastasis. Carcinoembryonic antigen is important for post-treatment follow-up to ensure the cancer hasn’t returned. Be sure to check with your doctor before treatment starts to ensure a CEA blood sample has been obtained.
More on Treating Colon Cancer
Surgery and chemotherapy are common approaches to colorectal cancer.
Some examples of Food and Drug Administration (FDA) approved chemotherapy drug treatments include:
- FOLFOX: leucovorin, 5-FU, and oxaliplatin (Eloxatin)
- FOLFIRI: leucovorin, 5-FU, and irinotecan (Camptosar)
- CAPEOX or CAPOX: capecitabine (Xeloda) and oxaliplatin
- FOLFOXIRI: leucovorin, 5-FU, oxaliplatin, and irinotecan
- Trifluridine and tipiracil (Lonsurf)
WATCH: Understanding Your Options with Metastatic Colon Cancer
Among metastatic colon cancer patients, multiple treatment options exist, including surgical and non-surgical options.
One treatment option includes an oral treatment called Fruquintinib, which is a targeted therapy for adults who have metastatic colorectal cancer and have tried other treatments. Results from a trial published last year showed the drug improved overall survival and progression-free survival, which measures the amount of time before the cancer returns or spreads. It works by blocking the growth of blood vessels, which increases tumor growth.
Once you get to the metastatic setting, many patients “just run out of options,” Jennifer Elliott, head of solid tumors at Takeda, explained to SurvivorNet at the ASCO Annual Meeting. So it was critically important for Takeda to do this deal to in-license fruquintinib. We hope to give patients another option.”
Fruquintinib has been approved in China since 2018 and was originally developed by the Chinese biopharmaceutical company HUTCHMED. Takeda Oncology acquired the exclusive worldwide license for the drug outside of mainland China, Hong Kong, and Macau in January 2023.
More on Colon Cancer
Colon cancer is very treatable and curable if caught early. Colon cancer screenings can involve at-home tests such as Cologuard, but a colonoscopy is more effective, according to SurvivorNet experts.
The cancer starts when abnormal lumps called polyps grow in the colon or rectum. It takes up to 10 years for a colon polyp to become full-blown cancer, according to SurvivorNet experts.
The American Gastrointestinal Association lowered the recommended initial age for colorectal screening from 50 to 45. However, experts recommend screening earlier for some people who may be at an increased risk of developing colon cancer, such as those with a family history of the disease.
WATCH: Debunking misconceptions about colon cancer.
The most poignant signature of colon cancer includes a change in bowel habits. This may include constipation or diarrhea due to changes in the size or shape of bowel movements. A change in stool color, particularly black or tarry stools, can indicate bleeding from a tumor that lies deep in the colon.
Other symptoms can be harder to pinpoint, such as abdominal pain and unintentional weight loss. Finally, some tumors bleed a small amount over a long period of time, resulting in anemia (low red blood cell count) that is picked up on blood work.
Questions to Ask Your Doctor
If you are facing a colon cancer diagnosis, here are some questions you may ask your doctor.
- What are my treatment options based on my diagnosis?
- If I’m worried about managing the costs of cancer care, who can help me?
- What support services are available to me? To my family?
- Could this treatment affect my sex life? If so, how and for how long?
- What are the risks and possible side effects of treatment?
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