The cytotoxic effect of the natural porphyrin precursor 5-aminolevulinic acid (ALA) exposed to high energy shock waves (HESW) was investigated in vitro on DHD/K12/TRb rat colon cancer cells and in vivo on a syngeneic colon cancer model. In vitro, viable cell growth was determined by trypan blue exclusion assay and cell death was investigated by flow cytometry. ALA (50 µg/ml) and HESW (E1, EFD = 0.22 mJ/mm², 1000 shots or E2, EFD = 0.88 mJ/mm², 500 shots) showed a significant reduction of cancer cell proliferation at day 3 compared to cells exposed to ALA (p < 0.01) or HESW (p < 0.001) alone. An enhancement of necrotic and apoptotic cells was observed after combined treatment at day 1 with ALA and HESW E1 (a 3.1 and 6.4 fold increase vs ALA alone) or E2 (a 3.4 and 5.3 fold increase vs ALA alone). In vivo, apoptosis detection was carried out by TUNEL assay, the pro-apoptotic gene Bad and Bcl-2 mRNA expression was evaluated by quantitative SYBR Green real time RT-PCR and cleavage of poly(ADP-ribose)-polymerase (PARP) was investigated by Western Blotting. An enhancement of apoptosis was observed in tumour tissues after the combined treatment at day 1 with ALA (375 mg/kg i.v.) and HESW (E2) compared to that of ALA exposure alone with improved apoptotic index (a 2.0 fold increase), Bad enhanced mRNA expression (p < 0.01), Bcl-2 decreased mRNA expression (p < 0.05) and increased PARP cleavage. The interaction between HESW and ALA is then effective in inducing apoptosis on a syngeneic colon cancer model.