Rectal cancer (Stage 3A) diagnosed late June 2017

[retiredteacher]

Good luck Mike - sure things will go well - so great to see you finally at this stage!
Terri

[Caat55]

Hi, I am age 44, diagnosed with Stage 3A T1N1 low rectal cancer early June 2018. Done with LAR surgery on 28 Jun. On illeostomy. Started Folfox on 25 July.

Oncologist and radio therapist recommended 4 months chemo followed by 2 months radio.

Surgeon is confident that the surgery was done clean and complete.

I am torn between full 6 months chemo or chemo plus radio bearing in mind that radio may cause long term side effects such as poorer bowel functions.

Weighing against risk of local recurrence between 5 to 7% without radio and 3 to 4% with radio.

Hello,
We have all probably struggled with that decision. In my case the chemo and radiation came prior to surgery, shrunk tumor to virtually nothing but scar tissue. Yes, there is damage from radiation. The sequence of your treatment is so different from mine, where do you live? Have you had a second opinion just to help with decision making?
S

[Hocks]

Thanks. I am from Singapore.

[NHMike]

Hi, I am age 44, diagnosed with Stage 3A T1N1 low rectal cancer early June 2018. Done with LAR surgery on 28 Jun. On illeostomy. Started Folfox on 25 July.

Oncologist and radio therapist recommended 4 months chemo followed by 2 months radio.

Surgeon is confident that the surgery was done clean and complete.

I am torn between full 6 months chemo or chemo plus radio bearing in mind that radio may cause long term side effects such as poorer bowel functions.

Weighing against risk of local recurrence between 5 to 7% without radio and 3 to 4% with radio.

I'm a bit surprised with doing radiation after surgery and chemo - I've never seen that order before - and I thought that the radiation was there to shrink the tumor. In your case, the tumor is already gone. Maybe the radiation does some other things too?

It sounds like you have 3.5 months to decide on what you want to do. Less time on chemo would probably mean less neuropathy weighed against any undesired damage from the radiation. As far as I can tell, I didn't have any further damage from radiation but I'll find out soon when I get the reversal done. I'm not sure if you're male or female but females have more organs that can be damaged by radiation. I think that I'd ask the oncologist the pros and cons of the two approaches and then look at the research and decide. Or, if I had complete trust in the oncologist, then I might just go with their recommendation.

But it's ultimately your decision.

[NHMike]

Thanks. I am from Singapore.

My wife is Singaporean and she was there for a few months earlier this year.

The document on recommended CRC treatment in Singapore is at http://www.annals.edu.sg/pdf/44VolNo10O ... 10p379.pdf (I do not know if there is a newer version of this). They basically took the US (NCCN), European and UK treatment approaches but they recommend the NCCN guidelines overall. Neo-Adjuvant (Pre-surgical) chemo and radiation are recommended for Stage 3 and riskier Stage 2 patients.

Neoadjuvant/adjuvant therapy of clinical stage II (T3-4, node-negative disease with tumour penetration through the muscle wall) or stage III (node positive disease without distant metastasis) rectal cancer often includes locoregional treatment due to the relatively high risk of locoregional recurrence. A total of approximately 6 months of 5-FU-based perioperative treatment is preferred. Preoperative chemoradiotherapy showed fewer local recurrences (relative risk, 0.46; 95% CI 0.26 to 0.82; from 6% to 13%) and less acute and late toxicities.Patients, with resected stage II or III rectal cancer, who have not received preoperative radiotherapy should be offered postoperative therapy with concurrent chemoradiotherapy in addition to fluoropyrimidine-based chemotherapy. It is recommended that the total duration for perioperative therapy be approximately 6 months.

http://www.annals.edu.sg/pdf/44VolNo10O ... 10p379.pdf

In the US, the standard procedure is Neo-Adjuvant Chemo + Radiation. The Radiation is 28 days, same as the chemo. There have been clinical trials with Total Neoadjuvant Therapy (a lot of chemo and radiation up front to possibly avoid surgery). I'm not sure if this is a standard option.

It appears that you weren't offered Neo-Adjuvant Chemo/Radiation before surgery so it's offered after surgery. I actually wanted my doctors to just cut out the tumor right away but I couldn't get surgeons to do that over here without the neo-adjuvant therapy.

I would guess that there's a moderate amount of research or Big Data analysis on the Neo-Adjuvant/Surgery/Adjuvant approach in the US. It would take some digging around to see what the results of six months of chemo vs four months of chemo + two months of radiation looks like - if the data is available.

[NHMike]

I had a look around for papers on Adjuvant Radiation Therapy and found some pretty old articles/papers:

Adjuvant Radiation Therapy of Rectal Cancer, Journal of Clinical Oncology, Vol 19, No 17, September 1, 2001.
http://ascopubs.org/doi/abs/10.1200/jco ... alCode=jco

Benefits of adjuvant therapy for rectal cancer, National Cancer Institute (NCI) March 13, 1991

On March 13, 1991, the National Cancer Institute released a clinical announcement concerning the benefits of adjuvant therapy for rectal cancer. The data, which are described in the clinical announcement, state that a sequential regimen of 5-fluorouracil-based chemotherapy and radiation therapy can reduce overall tumor recurrence rates, substantially reduce local recurrence, and prolong survival in patients with resected, TNM stage II (Dukes' B) and III (Dukes' C) rectal cancer. The full text of this clinical announcement can be obtained by selecting the NEWS option in the PDQ database. Those with access to a fax machine can have the announcement faxed to them by calling on their fax machines the NCI's new service, CANCERFAX, at 1-301-402-5874 and entering ID # 400004. Patients and the public may obtain information on rectal cancer by calling NCI's Cancer Information Service at 1-800-4-CANCER.

Improving Adjuvant Therapy for Rectal Cancer by Combining Protracted-Infusion Fluorouracil with Radiation Therapy after Curative Surgery
New England Journal of Medicin, Aug 25, 1994
https://www.nejm.org/doi/full/10.1056/N ... 8253310803

The combination of radiation therapy and chemotherapy with fluorouracil plus semustine after surgery has been established as an effective approach to decreasing the risk of tumor relapse and improving survival in patients with rectal cancer who are at high risk for relapse or death. We sought to determine whether the efficacy of chemotherapy could be improved by administering fluorouracil by protracted infusion throughout the duration of radiation therapy and whether the omission of semustine would reduce the toxicity and delayed complications of chemotherapy without decreasing its antitumor efficacy.
Methods

Six hundred sixty patients with TNM stage II or III rectal cancer received intermittent bolus injections or protracted venous infusions of fluorouracil during postoperative radiation to the pelvis. They also received systemic chemotherapy with semustine plus fluorouracil or with fluorouracil alone in a higher dose, both before and after the pelvic irradiation.
Results

With a median follow-up of 46 months among surviving patients, patients who received a protracted infusion of fluorouracil had a significantly increased time to relapse (P = 0.01) and improved survival (P = 0.005). There was no evidence of a beneficial effect in the patients who received semustine plus fluorouracil.
Conclusions

A protracted infusion of fluorouracil during pelvic irradiation improved the effect of combined-treatment postoperative adjuvant therapy in patients with high-risk rectal cancer. Semustine plus fluorouracil was not more effective than a higher dose of systemic fluorouracil given alone.


Semustine was apparently one of the chemo drugs used several decades ago and it carried a Leukemia risk.

[Hocks]

Thanks. Surgeon did not recommend pre surgery chemorad as the tumour was small.

[Hocks]

Thanks Mike, I am a male 44 year old Singaporean.

[NHMike]

The other side.

They gave me too high a dosage on the anesthetic so I woke up around 1 PM. The surgery started at 7:30 AM and should have taken 90 minutes. I was quite out of it and it took a while to get to normal.

They are out of beds at the hospital so I’m in recovery until they find one. I’ve walked 1.5 miles so far so I’m not a wreck physically. There’s no place nearby to do yoga.

[heiders33]

Congrats, Mike! And way to go on the walking. That will get things going faster than anything. Sorry about the heavy anesthetic.

[NHMike]

Total of four miles after surgery. Some gas came out afterwards and some watery stools. I put on shorts with a pad to keep things from getting messy. I’m getting heparin shots every 8 hour’s.
So far one in the knee and one in the stomach.

The port remainders looks awful. But I don’t feel anything.

[Atoq]

Congratulations!

Claudia

[susie0915]

I am glad everything went well. Keep walking. Final phase of treatment finished. Be patient with the reversal, things will continue to improve.

[Shana]

Glad to hear that all went well.

Hope you're feeling better today, walking is great but don't push it either!

[NHMike]

The bowel stuff is pretty tough. A lot of messy cleaning and the skin gets raw. I went through two underwear and one pair of shorts and asked for mesh and they gave me a pair and I hope it works. The pads are lifesavers.

I need to pick up Chux, pads and wipes. It’s like having babies.

Everyone tells me that things will get better in two to six weeks. It will be quite the challenge. I’ve seen lots of others go through it though.