Avastin or no Avastin?

[plastikos]

Hi again. I noticed a lot of folks here got chemo (FOLFOX or FOLFIRI) plus Avastin after a liver resection for liver mets. I just had a liver recurrence which was resected with clean margins and now histopath-wise and scan-wise it seems all macroscopic disease is gone. My onc plans to start FOLFIRI. He says that there is no evidence that Avastin has any benefit in adjuvant treatment for completely resected disease. I have also read the same. I know that for stage IV patients with resectable disease the treatments can be very nuanced (observation without chemo, chemo with or without biologicals etc). Just wondering what were the circumstances in your cases when you received Avastin? Were you being treated as resected disease (adjuvant "mop up" chemo) or as mCRC?

[dudette]

I read in a 2013 medication report from my health insurer that Bevacizumab (Avastin) was found to have a negative effect on overall survival when used as adjuvant therapy.

BUTT I haven't read the study itself - so not sure whether this statement is open for interpretation.

Here are the details for the study:

de Gramont A, Van Cutsem E, Schmoll HJ, Tabernero J, Clarke S, Moore MJ, Cunningham D, Cartwright TH, Hecht JR, Rivera F, Im SA, Bodoky G, Salazar R, Maindrault-Goebel F, Shacham-Shmueli E, Bajetta E, Makrutzki M, Shang A, André T, Hoff PM (2012): Bevacizumab plus oxaliplatin-based chemotherapy as adjuvant treatment for colon cancer (AVANT): a phase 3 randomised controlled trial. Lancet Oncol; 13 (12): 1225-33.

However, I find that particularly in cancer research you always have a yay and nay side. Does my head in when I try to make a decision

[plastikos]

I read in a 2013 medication report from my health insurer that Bevacizumab (Avastin) was found to have a negative effect on overall survival when used as adjuvant therapy.

BUTT I haven't read the study itself - so not sure whether this statement is open for interpretation.

Here are the details for the study:

de Gramont A, Van Cutsem E, Schmoll HJ, Tabernero J, Clarke S, Moore MJ, Cunningham D, Cartwright TH, Hecht JR, Rivera F, Im SA, Bodoky G, Salazar R, Maindrault-Goebel F, Shacham-Shmueli E, Bajetta E, Makrutzki M, Shang A, André T, Hoff PM (2012): Bevacizumab plus oxaliplatin-based chemotherapy as adjuvant treatment for colon cancer (AVANT): a phase 3 randomised controlled trial. Lancet Oncol; 13 (12): 1225-33.

However, I find that particularly in cancer research you always have a yay and nay side. Does my head in when I try to make a decision

Yes I think I have encountered this study as well. Kind of confusing (and frustrating) that something with benefit at a more advanced stage of disease would have no benefit at a slightly earlier stage. Especially if you are inclined to just throw everything but the kitchen sink at it.

[midlifemom]

I did folfox as adjuvant after colon resection.
Three months later mets showed in the liver.
Did liver resection and HAI pump insertion.
Before starting folfiri for the liver adjuvant, ct showed affected lymph nodes.
Folfiri had no affect on nodes.
Then, got mets to the lungs, while still on folfiri.
That's when avastin started.
After 3 avastin trmts, ct showed no change.
Going for another ct in a few weeks - hoping for shrinkage.
If not, don't know what to do.

[chrisin]

If not, don't know what to do.

Kras g12s and g13d benefit from anti egfr agents (only with folfiri).

[LeonW]

I read in a 2013 medication report . . that Bevacizumab (Avastin) was found to have a negative effect on overall survival when used as adjuvant therapy.

the report says this more cautious, I think. It says

Overall survival data suggest a potential detrimental effect with bevacizumab plus oxaliplatin-based adjuvant therapy in these patients. On the basis of these and other data, we do not recommend the use of bevacizumab in the adjuvant treatment of patients with curatively resected stage III colon cancer.

Not a "no", just a "not recommended".

Besides, some members of my onc team studied the effectiveness of adding Avastin to primary chemotherapy back in 2008 and found that "the addition of bevacizumab to primary chemotherapy could increase the rate of pathological Complete Response (pCR) in liver metastatic CRC patients and may help to improve survival rates in patients with initially unresectable liver disease". They found that pCR is achieved in 4% of all resected patients (29 of 767 patients). They added that another study (by Adam et al.) found that the pCR of liver metastases was associated with a 5-year overall survival of 76%

Butt, as usual, these are just statistics. For any of us, any treatment either works or doesn't. Also, all the above is for primary treatment, not for recurrences. And only for patients with initially unresectable liver mets.

As one of the very very lucky ones with pCR after initially unresectable liver mets, I believe that the Xelox + Avastin may well have mopped up all my visible and stray cancer cells. Hence my believe that there is alot of benefit in chemo if you can manage the many vicious side effects.

[arizona mom]

Hi,

I have been told that avastin works by cutting blood supply to tumors, so you only use it when there are known tumors to shrink. The theory is that it doesn't have any affect on the floating micro cancer cells which is what you are targeting in adjuvant therapy.

I received avastin for 2 or 3 of the four treatments I had before my colon/liver surgery. Obviously that it when I had active disease in both my liver and colon. I have not been on it since because all other chemo has been adjuvant.

[JDinNC]

I had my colon and lung resection then folfox with avastin. I had no ideal about any of this stuff and just did what my oncologist gave me. I later research the purpose of avastin and learned it's used to prevent the growth of new tumors. My thoughts were.... avastin stopped the growth of new blood vessels which is needed to grow new tumors. My understanding that the only way cancer can grow is by way of new blood vessels. So if there were micro cancer cells still floating around after my resection and if there's weren't any new blood vessels then these cells would die. I know there are always other factors in the development of cancer/ recurrences but it's this one I'm focusing on.

Jan

[plastikos]

I had my colon and lung resection then folfox with avastin. I had no ideal about any of this stuff and just did what my oncologist gave me. I later research the purpose of avastin and learned it's used to prevent the growth of new tumors. My thoughts were.... avastin stopped the growth of new blood vessels which is needed to grow new tumors. My understanding that the only way cancer can grow is by way of new blood vessels. So if there were micro cancer cells still floating around after my resection and if there's weren't any new blood vessels then these cells would die. I know there are always other factors in the development of cancer/ recurrences but it's this one I'm focusing on.

Jan

So I am guessing all your visible tumors were resected yet you were still given Avastin? Or was it given because you had lung mets? Like I said it seems the treatments at this point can be very nuanced. I wouldnt mind if my onc just adds Avastin to my regimen. Alas he is adamant that it has no additional benefit in my case. And I cant just "request" to be given the drug.

[rp1954]

When we worried about VEGF-A, we worked on histamine levels, which is the VEGF-A trigger. We attacked inflammation, histamine and histamine production. Starting with IV vitamin C, which helps prevent HIF-1a formation (watching for LDH improvement) which communicates through histamine production, IV vit C reduces CRP, and causes neutralization of the histamine molecule. Even thinking to spend $15-$30,000 a month on -iri-BV, we'd sure get our money's worth by avoiding unnecessary VEGF-A.

One of our mCRC friends, occasionally on this board, added IV vit C, K3, half dose celebrex to Xeliri+BV, when she almost quit Folfiri after 1.5 yrs. Her quality of life much improved, and she was able to handle Xeliri/Folfiri for ~3 years more, where her CEA always jumped hard and fast if she went off chemo for any reason. I suspect the Xeliri etc eventually wore her blood values down, when she stopped chemo.

[AnonSurvivor]

A few thoughts:

1. Avastin is VERY expensive, at least it was in 2013, when I was taking it. As I recall, it was $20,000 per cycle.

2. I strongly suspect that Avastin aggravates certain undesirable side effects of Fluorouracil,in particular painful bowel movements.

3. At diagnosis I had a single liver met, which was resected, and had 20 cycles of avastin (with Folfox and -oxali after 12) thereafter. I have been NED since surgery in October 2012.

[jortego128]

Avastin is still extremely expensive. Its about $16,500 per infusion on the itemized bill sent to the insurance. The remaining FOLFOX and anti-nausia meds add about $4,000 for a total of $20,500 every infusion.