Rectal Cancer: Habr-Gama Watch and Wait Strategy to Avoid Surgery

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MegTayMcc
Posts: 13
Joined: Wed Dec 28, 2016 10:27 pm

Re: Rectal Cancer: Habr-Gama Watch and Wait Strategy to Avoid Surgery

Postby MegTayMcc » Sat May 06, 2017 5:49 pm

mozart13 wrote:SMH Toronto, storry about W&W apptoach:
Some patients have such a dramatic response to chemotherapy and radiation that there is no detectable tumour at the time of surgery, said Dr. Fahima Dossa, the study’s lead author and a surgical resident at St. Michael’s Hospital. These patients, termed complete responders, have excellent survival and low rates of cancer recurrence, which raises questions about whether they benefit from surgery, said Dr. Dossa.
Link:
http://stmichaelshospital.com/media/det ... ign=buffer


Interesting article! I'm being treated by Dr. Nancy Baxter at SMH, senior author of the attached study. I was the perfect candidate for watch and wait, as her and the team were confident I had complete response. Dr Baxter weighed many options with me, but I decided to go ahead with APR surgery, and a permanent colostomy. If I was older, my children were grown I would have absolutely went with w&w approach. Dr Baxter performed my surgery In January this year and all pathology came back clear. Still, knowing what I do now, I'm happy I'm not living everyday with a worry in my heart. My colostomy has been a breeze, I can't believe the tears I shed over the thought of it. No, it's not ideal, but it could be a lifesaver.
32/wife/mom/CAN
Rectal IIb - 08/16
ChemoRad - 09/16-11/16
APR - 01/17
Complete Pathological Response
Folfox 03/17 - 07/17
NED

mozart13
Posts: 73
Joined: Fri Dec 09, 2016 7:38 pm
Location: Toronto

Re: Rectal Cancer: Habr-Gama Watch and Wait Strategy to Avoid Surgery

Postby mozart13 » Tue May 09, 2017 2:41 pm

Meg, It wasnt an easy dessiccion, the week that I had to make it, my stress level went to the roof, but than it came to me , why am I stresing myself, should be the opposite, was lucky , cancer is no longer detectablle.
I took that week off just to concentrate on that, my surgeon mention to me , that I might have hard time living with it. My kids are big, so no burden in that way, still consider myself young, I am very active, skiing, swimming, biking, just couldnt bring myself to struggle with surgicall issuess , specially since I was given that chance.
My rationale, related to my case, 25% of people have complete clinical response, as per one study when people are given 3 rounds of folfox, after inital chemo/rad, that number goes to 50%, since I am in first 25%, the extra chemo should be able to kill any remaining microcells, if any left, on plus side I am athe peak of the radiation therapy as per charts, and folfox is much stronger than just xeloda given with radiation.
Of course will be on strict follow up schedule, as reassurance.

Good luck to all of us!
55 year, male, never been seek in my life.
Diagnosed with T1,T2 N0 M0 rectal cancer, tumor 4.5cm,
Stage 1
CEA 2.0
Discovered by pure lack, after taking baby ASA, had blood in stool.
25 sessions of Xeloda 1750 twice a day and Radiation 50 gy finished end of January 2017
Tumor erased, CCR, negative mri, ct, scope, just scar left, no evidence of cancer
W&W approach 8)
April 2017, folfox 8 rounds plus 2 rounds of xeloda
Sept.2017 CT , MRI negative

mozart13
Posts: 73
Joined: Fri Dec 09, 2016 7:38 pm
Location: Toronto

Re: Rectal Cancer: Habr-Gama Watch and Wait Strategy to Avoid Surgery

Postby mozart13 » Tue May 16, 2017 10:30 pm

Folfox, on my thrid one, my lab results are not very encoruging, WBC down, platlets down , liver functions in the sky, kidney function are good, I think nettle tea took care of that.
My oncologist is very aggressive, what I like, so we decided to proceed further.
Gonna give myself 3 injections this weekend of Glastofil, to boost bone marrow, to inrease platlets.
Not sure what to do about high Liver results, any body , any idea of good tea to flush it?
Thx!
55 year, male, never been seek in my life.
Diagnosed with T1,T2 N0 M0 rectal cancer, tumor 4.5cm,
Stage 1
CEA 2.0
Discovered by pure lack, after taking baby ASA, had blood in stool.
25 sessions of Xeloda 1750 twice a day and Radiation 50 gy finished end of January 2017
Tumor erased, CCR, negative mri, ct, scope, just scar left, no evidence of cancer
W&W approach 8)
April 2017, folfox 8 rounds plus 2 rounds of xeloda
Sept.2017 CT , MRI negative

mozart13
Posts: 73
Joined: Fri Dec 09, 2016 7:38 pm
Location: Toronto

Re: Rectal Cancer: Habr-Gama Watch and Wait Strategy to Avoid Surgery

Postby mozart13 » Thu Jun 29, 2017 8:49 am

Just finishing my 5th round, after one week delay, developed grade 2 oxilaplatin side effects, dose dropped, symptoms are going away, my lab results are back to normal, receving 4 injections of Gastrofil to boost bone marrow production, overall dose reduction helped.

Here is interesting link about cCR and pCR, where nodal involvment predicts distal methasasis, if its less than 1 cm is not considered cancerogen :

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4663384/

Another interesting link from Memorial Sloan Hospital :

https://www.healio.com/hematology-oncol ... id-surgery

Some interesting cases from Australia:

https://hssaustralia.com.au/wp-content/ ... r-talk.pdf
55 year, male, never been seek in my life.
Diagnosed with T1,T2 N0 M0 rectal cancer, tumor 4.5cm,
Stage 1
CEA 2.0
Discovered by pure lack, after taking baby ASA, had blood in stool.
25 sessions of Xeloda 1750 twice a day and Radiation 50 gy finished end of January 2017
Tumor erased, CCR, negative mri, ct, scope, just scar left, no evidence of cancer
W&W approach 8)
April 2017, folfox 8 rounds plus 2 rounds of xeloda
Sept.2017 CT , MRI negative

mozart13
Posts: 73
Joined: Fri Dec 09, 2016 7:38 pm
Location: Toronto

Re: Rectal Cancer: Habr-Gama Watch and Wait Strategy to Avoid Surgery

Postby mozart13 » Thu Jun 29, 2017 9:54 pm

Oxilaplatin
Here is the interesting link about oxilaplatin, side effects, dose, grading:

https://cancercare.on.ca/CCO_DrugFormul ... xaliplatin
55 year, male, never been seek in my life.
Diagnosed with T1,T2 N0 M0 rectal cancer, tumor 4.5cm,
Stage 1
CEA 2.0
Discovered by pure lack, after taking baby ASA, had blood in stool.
25 sessions of Xeloda 1750 twice a day and Radiation 50 gy finished end of January 2017
Tumor erased, CCR, negative mri, ct, scope, just scar left, no evidence of cancer
W&W approach 8)
April 2017, folfox 8 rounds plus 2 rounds of xeloda
Sept.2017 CT , MRI negative

Big Jay
Posts: 14
Joined: Fri Jun 17, 2016 5:41 pm
Location: Baltimore, MD

Re: Rectal Cancer: Habr-Gama Watch and Wait Strategy to Avoid Surgery

Postby Big Jay » Fri Jun 30, 2017 7:10 am

Here's a rather reassuring article from the May of this year posted in Lancet:

http://thelancet.com/journals/langas/article/PIIS2468-1253(17)30074-2/fulltext

"Most patients treated by watch-and-wait avoid radical surgery and of those who have regrowth almost all have salvage therapy. Although we detected no significant differences in non-regrowth cancer recurrence or overall survival in patients treated with watch-and-wait versus surgery, few patients have been studied and more prospective studies are needed to confirm long-term safety."
DX at 45yo 6/9/16, 2.4cm tumor, 9cm from Anal Verge, 6/27/16
Clinical staging IIIC, CEA 3.1 7/1/16
30x Chemorad 8/5/16 - 9/16/16
CT/MRI/Scope = NED! AKA:CCR 11/1/16... Rolling the dice on Watch & Wait
8/7/17 9mo NED

mozart13
Posts: 73
Joined: Fri Dec 09, 2016 7:38 pm
Location: Toronto

Re: Rectal Cancer: Habr-Gama Watch and Wait Strategy to Avoid Surgery

Postby mozart13 » Sat Jul 01, 2017 8:34 pm

This post is re: how many folfox treatments are enough to have disease free survival, study that I found is more relevant to post-op treatment, and is for stage 3, but I suppose principals could be applied non operative group.
It shows that one needs to get at least 7,8 rounds of folfox:
https://www.ncbi.nlm.nih.gov/pmc/articl ... po=27.5000
55 year, male, never been seek in my life.
Diagnosed with T1,T2 N0 M0 rectal cancer, tumor 4.5cm,
Stage 1
CEA 2.0
Discovered by pure lack, after taking baby ASA, had blood in stool.
25 sessions of Xeloda 1750 twice a day and Radiation 50 gy finished end of January 2017
Tumor erased, CCR, negative mri, ct, scope, just scar left, no evidence of cancer
W&W approach 8)
April 2017, folfox 8 rounds plus 2 rounds of xeloda
Sept.2017 CT , MRI negative

User avatar
CRguy
Posts: 9168
Joined: Sun Feb 10, 2008 6:00 pm

Re: Rectal Cancer: Habr-Gama Watch and Wait Strategy to Avoid Surgery

Postby CRguy » Sat Jul 01, 2017 11:11 pm

While I would love to jump up and give HI fives to less FOLFOX for anyone !!!!! :shock:
( I did 12 cycles for a met ) the discussions ARE in very specific terms for stages and in consideration of OTHER complicating factors.

Is a Lynch stage 3 Dx referable to KRAS wild ? .. or mutant ?
Is MSS stage 3 referable to MSI-high ?
I think the reason you found more reference for post-op IS because the standard with higher stages / grades has always been SURGERY !

but I suppose principals could be applied non operative group.

I would NOT extrapolate from SURGICAL groups to non surgical ... that is where the NEW paradigm is wanting to evaluate the
"watch and wait" ... NOT where they have defined they HAVE vetted it as alternate standard of care.

JMO

I had the full meal deal with neo-adjuvant chemoradiation ( which ultimately revealed as pCR ... NOT cCR ... pCR which IS the gold standard ! )
and had post-op adjuvant chemo. Was NED for 3 years with vigilant follow up ... and wait for it ....
was Dx with a single confirmed CRC lung met.

How many cycles of FOLFOX ?
the discussions started at "10 as good as 12 ?"
went to "is 8 as good as 12 ?"
now down to " 6 may be as good in certain situations."

BUTT .. as you have so astutely noted are ALL after complete surgical resections.

There IS a new paradigm for SOME CRC patients wherein, the wait and see MAY be as beneficial as the full meal deal I had.

Personally IF I could have avoided a whole shitload of issues by not having a resection, believe me I would have.

BUTT until the evidence is overwhelmingly in FAVOR of watch and wait ... I would remain optimistically skeptical, if not
skeptically optimistic ....

I believe that for certain situations it may be a huge benefit

I do NOT believe that there is enough evidence to suggest this is a go to for ALL patients in any particular stage / grade / group,
and I have seen no evidence that the watch and waiters have defined exactly WHO would benefit ... BEFORE making that possibly life altering decision ... and who would be ultimately compromised IF they did follow it.
again ... JMO ... BUTT I've BTDT

Cheers
CR
Caregiver x 3
Stage IV A rectal cancer/lung met
10 Year survivor
my life is an ongoing NONrandomized UNcontrolled experiment with N=1 !
Review of my Journey so far

prs
Posts: 103
Joined: Sat Dec 12, 2015 7:09 pm
Location: Central California

Re: Rectal Cancer: Habr-Gama Watch and Wait Strategy to Avoid Surgery

Postby prs » Sun Jul 02, 2017 5:02 pm

I was offered treatment of 8 three week cycles of Xelox or 12 two week cycles of Folfox, and I chose the Xelox. I believe the Oxaliplatin dose for Xelox is 50% bigger than the dose for Folfox because it has to last three weeks instead of the two weeks for Folfox. I ended up having only the first six of the eight Oxi infusions because my blood counts dropped too low, and stayed low. However I did complete all eight cycles of Xeloda. My oncologist later said he thought 80% of the benefit came from the Xeloda.

It may be worth pointing out that my oncologist set my initial Xeloda dose at 1,500 mg twice/day and dropped it to 1,000 mg twice per day for the fourth cycle onwards because of side effects. I later learned on this forum that this dose was much lower than the manufacturers recommended dose. I did ask my Dr why this was and was told it was because they had found thru experience this dose was the limit that most people could tolerate, and it was better to keep the dose tolerable rather than keep having to delay or abandon treatment because of side effects.

So mozart13, I get the impression you are thinking of cutting back on your number of cycles, but perhaps it might be better to get the dose reduced to something you can tolerate, and do the full number of cycles?
Peter, age 65 at dx
DX 4 cm x 4 cm very low rectal adenocarcinoma into the sphincters 01/15
Stage III T3 N1 M0 with two suspicious lymph nodes
26 sessions IMRT radiation with 1,000 mg Xeloda twice per day 03/15 to 04/15
Complete clincal response to the chemoradiation...the tumor shrank completely away 06/15 :D
No surgery...Habr-Gama watch and wait protocol instead
Xelox chemotherapy 07/15-12/15
MRI and rectal exam every three months starting 07/15
MRI and rectal exam every six months starting 07/17
NED

mozart13
Posts: 73
Joined: Fri Dec 09, 2016 7:38 pm
Location: Toronto

Re: Rectal Cancer: Habr-Gama Watch and Wait Strategy to Avoid Surgery

Postby mozart13 » Mon Jul 03, 2017 11:29 am

You are right on the money prs, I am thinking about cutting number of cycles, alerady have numbness in feet, mouth, finger tips, numbness is not going away, seem to be there all the time after 3 doses of oxilaplatin. Blood work is in boots, so far 2 doses of folfox had to be posponed by one week, last dose of oxilaplatin was dropped to 65%, I get 4 doses of gastrofil injections , will be interesting to see blood work next week.
I think my oncologist will try to get at least 8 doses of folfox than switch to xeloda.
Thx for support, will try to stay on the target.
55 year, male, never been seek in my life.
Diagnosed with T1,T2 N0 M0 rectal cancer, tumor 4.5cm,
Stage 1
CEA 2.0
Discovered by pure lack, after taking baby ASA, had blood in stool.
25 sessions of Xeloda 1750 twice a day and Radiation 50 gy finished end of January 2017
Tumor erased, CCR, negative mri, ct, scope, just scar left, no evidence of cancer
W&W approach 8)
April 2017, folfox 8 rounds plus 2 rounds of xeloda
Sept.2017 CT , MRI negative

mozart13
Posts: 73
Joined: Fri Dec 09, 2016 7:38 pm
Location: Toronto

Re: Rectal Cancer: Habr-Gama Watch and Wait Strategy to Avoid Surgery

Postby mozart13 » Mon Jul 03, 2017 2:56 pm

Just to add to previous post, my oncologist is counting those 25 days of xeloda back in Jan. as 2 rounds of folfox, thats why only 10 rounds of folfox scheduled.
Radiation peak was somwhere around when I started folfox, that probablly plays role as well.
55 year, male, never been seek in my life.
Diagnosed with T1,T2 N0 M0 rectal cancer, tumor 4.5cm,
Stage 1
CEA 2.0
Discovered by pure lack, after taking baby ASA, had blood in stool.
25 sessions of Xeloda 1750 twice a day and Radiation 50 gy finished end of January 2017
Tumor erased, CCR, negative mri, ct, scope, just scar left, no evidence of cancer
W&W approach 8)
April 2017, folfox 8 rounds plus 2 rounds of xeloda
Sept.2017 CT , MRI negative

prs
Posts: 103
Joined: Sat Dec 12, 2015 7:09 pm
Location: Central California

Re: Rectal Cancer: Habr-Gama Watch and Wait Strategy to Avoid Surgery

Postby prs » Tue Jul 04, 2017 11:48 am

My oncologist didn't count the five weeks of xeloda during radiation, so my chemo treatment plan was for the full six months!!!

I know I was tempted to call it quits about four months into chemo because it seemed like the side effects were cumulative and things got worse after each cycle but, in retrospect, I'm glad I didn't. If I'd had a recurrence I'd always be kicking myself for not hanging in there for those last few weeks of torture.

I think your Dr reducing your oxi dose was a great idea, I wish mine had done that, he had no problem cutting back the xeloda, but the oxi was never discussed. FWIW it took about a year but the neuropathy in my feet has completely gone away.
Peter, age 65 at dx
DX 4 cm x 4 cm very low rectal adenocarcinoma into the sphincters 01/15
Stage III T3 N1 M0 with two suspicious lymph nodes
26 sessions IMRT radiation with 1,000 mg Xeloda twice per day 03/15 to 04/15
Complete clincal response to the chemoradiation...the tumor shrank completely away 06/15 :D
No surgery...Habr-Gama watch and wait protocol instead
Xelox chemotherapy 07/15-12/15
MRI and rectal exam every three months starting 07/15
MRI and rectal exam every six months starting 07/17
NED

mozart13
Posts: 73
Joined: Fri Dec 09, 2016 7:38 pm
Location: Toronto

Re: Rectal Cancer: Habr-Gama Watch and Wait Strategy to Avoid Surgery

Postby mozart13 » Tue Jul 04, 2017 12:55 pm

Thx prs, I am gonna stick with the plan as well!
:D
55 year, male, never been seek in my life.
Diagnosed with T1,T2 N0 M0 rectal cancer, tumor 4.5cm,
Stage 1
CEA 2.0
Discovered by pure lack, after taking baby ASA, had blood in stool.
25 sessions of Xeloda 1750 twice a day and Radiation 50 gy finished end of January 2017
Tumor erased, CCR, negative mri, ct, scope, just scar left, no evidence of cancer
W&W approach 8)
April 2017, folfox 8 rounds plus 2 rounds of xeloda
Sept.2017 CT , MRI negative

Foreveryoung
Posts: 7
Joined: Thu Jun 22, 2017 9:39 am

Re: Rectal Cancer: Habr-Gama Watch and Wait Strategy to Avoid Surgery

Postby Foreveryoung » Thu Jul 13, 2017 4:12 pm

prs wrote:My surgeon indicated there were very strict guidelines for admission to their Watch and Wait program. I believe this paper by Dr Habr-Gama outlines the guidelines, sorry this link only gives the abstract unless you pay: http://www.hemonc.theclinics.com/article/S0889-8588(14)00125-7/abstract

Also, of course, the "Watch" part of the strategy is very important so if there is a recurrence it's caught before it spreads. The Kaiser "Watch" procedures are:

1. Six months of folfox or xelox chemotherapy to kill any remaining cancer cells. I was encouraged to start chemo without delay.

2. A CEA, a rectal exam, a flex sig, and a special pelvic MRI every three months for the first two years, and then every six months for the following three years.

3. An annual colonoscopy.

4. An annual CT scan of chest, abdomen, and pelvis.

The special pelvic MRI was developed at Kaiser and scans the rectum in much greater detail than a standard abdominal MRI. The results of the scan are determined by a designated radiologist.

Yes, the three month follow ups are a pain but I understand the need for them, and know if I don't the alternative could be much worse. So far I've been very lucky, if I'd been diagnosed just a year earlier this program would not have been available.


Hi Peter - I just signed up and do not have the ability to send PM. But I was hoping to contact you offline since I too have RC that's low. Is there anyway for us to connect?
33 y/o M DX June 2017
RC lower

mozart13
Posts: 73
Joined: Fri Dec 09, 2016 7:38 pm
Location: Toronto

Re: Rectal Cancer: Habr-Gama Watch and Wait Strategy to Avoid Surgery

Postby mozart13 » Mon Jul 17, 2017 7:27 pm

Folfox and chemoradiation combined deliverd 40% response, pCR and cCR combined:
From Memorial Sloan-Katterin cancer center

"Of the 28 patients who received all 8 cycles of FOLFOX, 8 experienced a pathCR (29%) and 3 a CCR (11%). No serious adverse events occurred that required a delay in treatment during FOLFOX or chemoradiation. FOLFOX and chemoradiation before planned TME results in tumor regression, a high rate of delivery of planned therapy, and a substantial rate of pathCRs, and offers a good platform for nonoperative management in select patients."

http://www.jnccn.org/content/12/4/513.a ... _TrendMD_1
55 year, male, never been seek in my life.
Diagnosed with T1,T2 N0 M0 rectal cancer, tumor 4.5cm,
Stage 1
CEA 2.0
Discovered by pure lack, after taking baby ASA, had blood in stool.
25 sessions of Xeloda 1750 twice a day and Radiation 50 gy finished end of January 2017
Tumor erased, CCR, negative mri, ct, scope, just scar left, no evidence of cancer
W&W approach 8)
April 2017, folfox 8 rounds plus 2 rounds of xeloda
Sept.2017 CT , MRI negative


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