New here! Stage 2 treatment advice

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Tim21spurs
Posts: 2
Joined: Tue Feb 28, 2017 7:43 pm

New here! Stage 2 treatment advice

Postby Tim21spurs » Tue Feb 28, 2017 7:48 pm

Hi to everyone. My story is about my mother. She was diagnosed with colon cancer about 1 month ago. She had a big anemia, and started making tests, until a colonoscopy discover the tumour.

It was located in ascending colon, and she went into surgery, with aproximately 20 cm of the bowel resected. The analysis of the cancer revealed that it was T3N0M0, and none of the considered high-risk factors like obstruction, perforation, vessels invasion... were present. So, she was diagnosed as stage IIa with low risk factors. The only bad prognosis factor was a preoperative CEA level of aproximately 11 (it go down in postoperative analysis, with a value of 1,5).

Past week we met the oncologist, and she told us that FOLFOX is the recommended treatment for my mum stage. I was suprised, since I have searched for many information about CRC stages, and I thought that for this case, no chemo or just 5-FU or Xeloda was recommended. We had talked with my mum on affording a treatment with just Xeloda, but adding oxaliplatin to the treatment is scary due to its hard side effects.

What treatment do you think that is the most used for T3N0M0 with low risk factors? We would like to avoid oxaliplatin if possible, but, of course, we want the best treatment to prevent cancer re-coming in the future.

Thanks a lot to everyone for the help, and forgive me for bad english. I am not a native speaker, but i am learning.

DarknessEmbraced
Posts: 3816
Joined: Sat Nov 01, 2014 4:54 pm
Facebook Username: Riann Fletcher
Location: New Brunswick, Canada

Re: New here! Stage 2 treatment advice

Postby DarknessEmbraced » Tue Feb 28, 2017 11:37 pm

I'm sorry for your mother's diagnosis!*hugs* I was diagnosed as stage 2a T3N0M0 at 36 in 2014. My tumor was at the junction of my sigmoid and rectum. I had half of my rectum and half of my sigmoid removed. Chemo wasn't recommended and I have been in remission since surgery. My CEA has always been below 1 even before surgery. They also check my Ca 125 which was high but which went back to normal.
Diagnosed 10/28/14, age 36
Colon Resection 11/20/14, LAR (no illeo)
Stage 2a colon cancer, T3NOMO
Lymph-vascular invasion undetermined
0/22 lymph nodes
No chemo, no radiation
Clear Colonoscopy 04/29/15
NED 10/20/15
Ischemic Colitis 01/21/16
NED 11/10/16
CT Scan moved up due to high CEA 08/21/17
NED 09/25/17
NED 12/21/18
Clear colonoscopy 09/23/19
Clear 5 year scans 11/21/19- Considered cured! :)

Thetoad
Posts: 165
Joined: Mon Nov 23, 2015 2:46 am
Location: New Zealand

Re: New here! Stage 2 treatment advice

Postby Thetoad » Wed Mar 01, 2017 12:55 am

Hi. Another T3N0M0 here. Extended right hemicolectomy 39 months ago. Everything ok since and no chemo offered. There was underlying perforation well away from the tumour and the tumour caused a blockage. CEA staying between 1 and 1.5 usually and tested 6 monthly. You will find this forum very useful. Best wishes...
Emergency extended rt hemi November 2013.
Complete blockage, small perforation.
Stage 2a.
T3N0M0
22 Lymph nodes clear.
No bag.

Yearly appts appts and 6 monthly CEA tests.
Incisional hernia repair, mesh Nov. 2014.
Cellulitus
CEA 1.4 on 28/7/17
27/5/17. Gallbladder removed, open.
Good consultation Feb. 2017
CEA 1.7 on 16/11/17 colonoscopy ok Jan. 2018 :)
Nurse pleased, March 2018. CEA 1.8. One more CEA test and hopefully last appt in November, 2018.
Prostate cancer, Gleason 7 (3+4) Sept. '18.

Beckster
Posts: 438
Joined: Thu Jan 12, 2017 3:01 pm
Location: New Jersey

Re: New here! Stage 2 treatment advice

Postby Beckster » Wed Mar 01, 2017 5:07 am

Welcome... I had the same surgery and am also 2A. If you look at my signature, you will see the details. Because of my 2 high risk factors (LVI and grade), I was recommended chemo. I started with Oxi and Xeloda, but had a reaction to the OXI. I am now on only Xeloda, which is doable... 8 cycles of 2 weeks on and one week off. There has to be a reason for the chemo. Did you ask the oncologist? My CEA was 1.9 before surgery. What is her postoperative CEA?

You will find a lot of help on this forum. Good luck and if you have any other questions, please contact me

Beckster
57/F
DX:(CC) 10/19/16
11/4/16- Lap right hemi(cecum)
CEA- Pre Op (1.9), Pre Chemo (2.5)
Type: Adenocarcinoma
Tumor size:3.5 cm x 2.5 x 0.7 cm
Grade: G3
TNM: T3N0M0/IIA
LN: 0/24
LVI present
Surgical margins: clear
MSS
12/27/2016 - Capeox, anaphylactic
1/2/17 to 6/9/17- Xeloda
6/17,12/17,6/18,12/18,6/19,12/19,12/20,12/21 CT Scan NED :D
CEA- 6/17- 3.6, 9/17- 2.8 12/17-2.8, 3/18-3.1, 6/18-3.0, 9/18 2.8, 12/18 2.5 3/19 3.1 6/19 3.1 9/19 2.6 12/19 2.8 6/20 3.0 12/20 2.7 6/21 2.9,[color=#000000]12/21 2.7[/color]
Clear Colonoscopy 10/17, 11/19,11/21 :D

User avatar
Maia
Posts: 2443
Joined: Fri Aug 24, 2012 8:00 am

Re: New here! Stage 2 treatment advice

Postby Maia » Wed Mar 01, 2017 5:52 am

Xeloda monotherapy is usual but there is no reason (other than preference in USA) to no use Folfiri instead of Folfox. Results in first line at practically equivalent, side effects are different. Irinotecan (the compound in the combo, instead of oxaliplatin) might cause diarrhea and hair thinning or loss, but they are transient effects (neuropathy --nerve damage-- from oxaliplatin might be permanent) and manageable (diarrhea) with dose reduction, with little lost of effectivity (specially, for a stage II-III).
You have also a couple of clinical trials with immuotherapies instead of chemo, to prevent recurrence; they are just that --trials-- and you'd have to see if she qualifies and if location is logistically possible.

Deb m
Posts: 558
Joined: Tue Jan 14, 2014 10:08 am

Re: New here! Stage 2 treatment advice

Postby Deb m » Wed Mar 01, 2017 9:46 am

You didn't mention how many lymph nodes were removed. If they removed less than 12, then perhaps that's the reason why they are advising chemo. My husband was a stage II also, but had two high risk features, lymphovascular invasion and micro perforation of the colon wall. He did 12 round of folfox and everything turned out well. NED for over 6 years now. Also, you didn't mention whether your cell type was high grade or low grade, well differentiated or poor. I believe if it's high grade or poorly differentiated, that's also a high risk feature. Wishing you the best,

deb m

Tim21spurs
Posts: 2
Joined: Tue Feb 28, 2017 7:43 pm

Re: New here! Stage 2 treatment advice

Postby Tim21spurs » Wed Mar 01, 2017 10:35 am

Thanks to everyone for you answers. I will give you all the data now:

- My mother is 67 years old. She is quite healthy. Former smoker (after surgery :lol: ). The recovery of the colon resection has been really good, she is doing practically complete normal life after 5 weeks.

Related to the cancer:

- No bowel perforation
- 13 Lymph nodes examined, and all of them were clean
- No bowel obstruction
- The cells were moderately differenciated, grade 2, so, as far as I know, it isn't a risk factor
- No lymphovascular vessels invaded
- Related to microsatellites,they didn't detected MLH-1 expression, so, the diagnosis was MSI. But we don't know until now if it is MSI-H or MSI-L

So, the only "risk factor" is the preoperative CEA level, aproximately 11. 20 days after surgery, CEA level go down to a level of 1.5.
Considering the "good" prognosis of my mother case, I was surpised when the oncologist recommended FOLFOX just for the preoperative CEA level. As far as I know, preoperative CEA level could be related with a little poor prognosis. But I havent find any study in which FOLFOX worked better than just Xeloda, just considering preoperative CEA level. And I don't see any article in which CEA level could be a risk factor at the same level of previously mentioned factors (perforation, obstruction, grade...etc)
We are trying to avoid oxaliplatin, due to neuropathy side effect. But, on the other side, we don't want to fight with the oncologist, altough we don't agree with the proposed treatment. So, according to my mother case, what do you think we should do? We can also ask for a second opinion in another hospital.

Again, thanks to everyone!

Deb m
Posts: 558
Joined: Tue Jan 14, 2014 10:08 am

Re: New here! Stage 2 treatment advice

Postby Deb m » Wed Mar 01, 2017 11:34 am

At this point, if I were you, I would probably be looking for a second opinion.

Once again wishing you the best.

deb m

Beckster
Posts: 438
Joined: Thu Jan 12, 2017 3:01 pm
Location: New Jersey

Re: New here! Stage 2 treatment advice

Postby Beckster » Wed Mar 01, 2017 11:55 am

Tim21spurs wrote:Thanks to everyone for you answers. I will give you all the data now:

- My mother is 67 years old. She is quite healthy. Former smoker (after surgery :lol: ). The recovery of the colon resection has been really good, she is doing practically complete normal life after 5 weeks.

Related to the cancer:

- No bowel perforation
- 13 Lymph nodes examined, and all of them were clean
- No bowel obstruction
- The cells were moderately differenciated, grade 2, so, as far as I know, it isn't a risk factor
- No lymphovascular vessels invaded
- Related to microsatellites,they didn't detected MLH-1 expression, so, the diagnosis was MSI. But we don't know until now if it is MSI-H or MSI-L

So, the only "risk factor" is the preoperative CEA level, aproximately 11. 20 days after surgery, CEA level go down to a level of 1.5.
Considering the "good" prognosis of my mother case, I was surpised when the oncologist recommended FOLFOX just for the preoperative CEA level. As far as I know, preoperative CEA level could be related with a little poor prognosis. But I havent find any study in which FOLFOX worked better than just Xeloda, just considering preoperative CEA level. And I don't see any article in which CEA level could be a risk factor at the same level of previously mentioned factors (perforation, obstruction, grade...etc)
We are trying to avoid oxaliplatin, due to neuropathy side effect. But, on the other side, we don't want to fight with the oncologist, altough we don't agree with the proposed treatment. So, according to my mother case, what do you think we should do? We can also ask for a second opinion in another hospital.

Again, thanks to everyone!


If it were me, I would get a second opinion from a large cancer center like MD Anderson. My oncologist told me, when I could not take the oxi, that Xeloda alone would be fine. He said that normally they give oxi to more advance stages. I go to MD Anderson and my oncologist listens to me and told me that he works for me. Be an advocate...they work for you!
57/F
DX:(CC) 10/19/16
11/4/16- Lap right hemi(cecum)
CEA- Pre Op (1.9), Pre Chemo (2.5)
Type: Adenocarcinoma
Tumor size:3.5 cm x 2.5 x 0.7 cm
Grade: G3
TNM: T3N0M0/IIA
LN: 0/24
LVI present
Surgical margins: clear
MSS
12/27/2016 - Capeox, anaphylactic
1/2/17 to 6/9/17- Xeloda
6/17,12/17,6/18,12/18,6/19,12/19,12/20,12/21 CT Scan NED :D
CEA- 6/17- 3.6, 9/17- 2.8 12/17-2.8, 3/18-3.1, 6/18-3.0, 9/18 2.8, 12/18 2.5 3/19 3.1 6/19 3.1 9/19 2.6 12/19 2.8 6/20 3.0 12/20 2.7 6/21 2.9,[color=#000000]12/21 2.7[/color]
Clear Colonoscopy 10/17, 11/19,11/21 :D

peanut_8
Posts: 2340
Joined: Sun May 25, 2014 1:31 pm

Re: New here! Stage 2 treatment advice

Postby peanut_8 » Wed Mar 01, 2017 1:13 pm

Hi Tim,
Sorry to hear about your Mom's diagnosis.

A few questions for you. Is your Mom being treated in the US? Seems like treatment recommendations vary from country to country, and stage 2 is a controversial topic.

Does the treatment center do the FOLFOX infusions themselves? Unfortunately some places might recommend a more aggressive treatment approach such as FOLFOX, for economic reasons. Since the oxaliplatin in FOLFOX can only be administered by infusion, that becomes an income producing factor for the treatment center.

Your Mom should be able to determine the best course of treatment for her with the facts at hand. How risk averse is she? I've seen figures anywhere from 1-5% where oxaliplatin increases your survival odds. Probably, really something like 3% better odds. At least in my opinion, that was not sufficient enough to get the oxi. My oncologist originally suggested FOLFOX, and I countered with Xeloda (pil,l so no infusion). He said that was a perfectly acceptable solution. He did mention that for RC, it is not Standard of Care in the US, IMO covering his butt for potential lawsuit issues.

If your Mom's current oncologist isn't receptive to Xeloda instead of FOLFOX, you probably should get a second opinion.

Best Wishes,
peanut
female, diagnosed Jan 14, RC stage 2a, age 56
MSS
April 14, 28 chemo/rad with Xeloda
June 14 adjuvant Xeloda 6 rounds
currently NED

daisydaisy
Posts: 71
Joined: Wed Dec 11, 2013 12:19 pm

Re: New here! Stage 2 treatment advice

Postby daisydaisy » Wed Mar 01, 2017 3:07 pm

Hi, I've noticed that the tumor was MSI - from what I know, 5-FU or Xeloda (and 5-FU is a part of Folfox regimen) is useless for MSI tumors. Good thing is that msi-tumors are considered as having better prognosis. Please confirm with your oncologist or get a second opinion, because your mother might be exposed to absolutely unnecessary chemo. I think you can even google papers about this. Otherwise, oral chemo - xeloda - is usually handled well. best of luck to your mother!

Deb m
Posts: 558
Joined: Tue Jan 14, 2014 10:08 am

Re: New here! Stage 2 treatment advice

Postby Deb m » Thu Mar 02, 2017 9:11 am

If possible, I also think MDA in Houston Texas would be a great place for a second opinion. My husband had all his care and follow ups there and we were very happy with the care. I know not everybody can do this because of financial reasons. We were very blessed at the time and were able. I pray that your able to obtain a second opinion from a major cancer center.

deb m

User avatar
Maia
Posts: 2443
Joined: Fri Aug 24, 2012 8:00 am

Re: New here! Stage 2 treatment advice

Postby Maia » Thu Mar 02, 2017 2:20 pm

daisydaisy wrote:Hi, I've noticed that the tumor was MSI - from what I know, 5-FU or Xeloda (and 5-FU is a part of Folfox regimen) is useless for MSI tumors. Good thing is that msi-tumors are considered as having better prognosis. Please confirm with your oncologist or get a second opinion, because your mother might be exposed to absolutely unnecessary chemo. I think you can even google papers about this. Otherwise, oral chemo - xeloda - is usually handled well. best of luck to your mother!


Yes. The NCCN Guidelines state that "Stage II MSI-H patients may have a good prognosis and do not benefit from 5-FU adjuvant therapy. (50)"

50. J Clin Oncol. 2010 Jul 10;28(20):3219-26. doi: 10.1200/JCO.2009.27.1825. Epub 2010 May 24.
Defective mismatch repair as a predictive marker for lack of efficacy of fluorouracil-based adjuvant therapy in colon cancer. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2903323/


Adjuvant Chemotherapy for Resectable Colon Cancer

Patients with stage I disease and patients with MSI-high [MSIH],
low-risk stage II disease do not require any adjuvant therapy.

PRINCIPLES OF RISK ASSESSMENT FOR STAGE II DISEASE

• Patient/physician discussion regarding the potential risks of therapy compared to potential benefits, including prognosis. This should include discussion of evidence supporting treatment, assumptions of benefit from indirect evidence, morbidity associated with treatment, high-risk characteristics, and patient preferences.
• When determining if adjuvant therapy should be administered, the following should be taken into consideration:
Number of lymph nodes analyzed after surgery (<12)
Poor prognostic features (eg, poorly differentiated histology [exclusive of those that are MSI-H]; lymphatic/vascular invasion; bowel
obstruction; PNI; localized perforation; close, indeterminate, or positive margins)
Assessment of other comorbidities and anticipated life expectancy.
• The benefit of adjuvant chemotherapy does not improve survival by more than 5%.
• Microsatellite Instability (MSI) or Mismatch Repair (MMR) Testing: Universal MMR* or MSI* testing is recommended in all patients with a personal history of colon or rectal cancer.

https://www.nccn.org/professionals/phys ... s.asp#site
Stage II MSI-H patients may have a good prognosis and do not benefit from 5-FU adjuvant therapy.

Thetoad
Posts: 165
Joined: Mon Nov 23, 2015 2:46 am
Location: New Zealand

Re: New here! Stage 2 treatment adv

Postby Thetoad » Thu Mar 02, 2017 7:06 pm

Hello again. I sometimes wonder why I wasn't offered some form of chemo. Mainly because there were two risk factors - a small perforation and the tumour caused an obstruction. My consultant said it was not offered because the perforation was well away from the tumour and the stage was 2a, so the colon wall had not been penetrated. No spreading. Sounds logical I guess, but I still wonder. It's coming up to 40 months since surgery and all ok, so my survival chances are hopefully improving. I'd like to believe that those two risk factors were a potential problem at the time of surgery only, so can now be discounted. I seem to be the only person who questions them during appointments, but that's how I am.
Best wishes to you all.
Emergency extended rt hemi November 2013.
Complete blockage, small perforation.
Stage 2a.
T3N0M0
22 Lymph nodes clear.
No bag.

Yearly appts appts and 6 monthly CEA tests.
Incisional hernia repair, mesh Nov. 2014.
Cellulitus
CEA 1.4 on 28/7/17
27/5/17. Gallbladder removed, open.
Good consultation Feb. 2017
CEA 1.7 on 16/11/17 colonoscopy ok Jan. 2018 :)
Nurse pleased, March 2018. CEA 1.8. One more CEA test and hopefully last appt in November, 2018.
Prostate cancer, Gleason 7 (3+4) Sept. '18.

PainInTheAss
Posts: 673
Joined: Tue Jul 02, 2013 3:08 am

Re: New here! Stage 2 treatment advice

Postby PainInTheAss » Mon Mar 06, 2017 7:18 am

peanut_8 wrote:Hi Tim,
Sorry to hear about your Mom's diagnosis.

A few questions for you. Is your Mom being treated in the US? Seems like treatment recommendations vary from country to country, and stage 2 is a controversial topic.

Does the treatment center do the FOLFOX infusions themselves? Unfortunately some places might recommend a more aggressive treatment approach such as FOLFOX, for economic reasons. Since the oxaliplatin in FOLFOX can only be administered by infusion, that becomes an income producing factor for the treatment center.

Your Mom should be able to determine the best course of treatment for her with the facts at hand. How risk averse is she? I've seen figures anywhere from 1-5% where oxaliplatin increases your survival odds. Probably, really something like 3% better odds. At least in my opinion, that was not sufficient enough to get the oxi. My oncologist originally suggested FOLFOX, and I countered with Xeloda (pil,l so no infusion). He said that was a perfectly acceptable solution. He did mention that for RC, it is not Standard of Care in the US, IMO covering his butt for potential lawsuit issues.

If your Mom's current oncologist isn't receptive to Xeloda instead of FOLFOX, you probably should get a second opinion.

Best Wishes,
peanut


Bear in mind that the difference in odds has everything to do with the stage. This is something many miss on this topic. For a IIIc, adding oxi makes a huge difference adding something like 15% to the 12% of 5FU so 27% combined to boost the no chemo of 33% to 60% chance of being NED at 5 years. Huge difference and well worth the risk of neuropathy. From what I remember, the oxi only adds 1% to a IIa which is why they don't recommend it. Because the risk of permanent grade 3 neuropathy is also 1%, the extra 1% gained doesnt seem to be worth the risk. But that does NOT mean it only adds 1% to other stages. Many people learn the stats for their own stage and think it applies to all. Just want to state that for other stages who haven't started chemo yet and are hoping to drop the oxi (like I did until my Onc pulled out the charts and graphs and explained all this to me). The only situation where it may be justified for other stages is if you had a complete pathological response.
47yo single mom of 4 (24, 21, 18, 16) at Dx
6/13 - RC T4b IIIc 5LNs on PET CEA 5.4
8/13 - Finish chemorad
10/13 - APR/hyst+ovaries/perm colostomy 2/12 nodes+
6/14 - Finish Xelox 6 rds
1/15 - CT clear CEA 0.2
10/15 - CT/MRI clear CEA 0.7
4/16 - CT clear
10/16 - CT/MRI clear CEA 0.6
5/17 - PET clear? Follow up MRI to verify inflammation


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