The Colon Club

Hello, my husband was diagnosed with CRC a moth ago. He had a large mass in the cecum (7 x 7.5 cm), so he had a right colectomy procedure. Based on pathology, the tumor was T3N0 (19 nodes removed). The cells were well differentiated (Low Grade). Further pathology tests, however, were confusing and we are not sure what we should do.
The MSI test indicated "MSI Stable (also known as MSS)" but his Oncotype DX score was 17, which only indicated 3% improvement in survival with chemotherapy. I requested CEA assay prior to surgery, but our surgeon didn't order it. We had it done only after the surgery (it was 1.0). My husband is also slightly anemic (prior surgery and even after) with platelet number >400. The CT scan indicated a 1.3 cm low-attenuation lesion in the posterior segment right hepatic lobe as indeterminate. The doctor ordered MRI with and without contrast to further investigate.
So here is what I struggle with: MSS shows lower survival and worse prognosis, but the Oncotype test had a low score. If the lesion is not a tumor, he should be ok, but on cancer.org they say that patients with MSS and early stage CRC should be given a more aggressive treatment. Is anybody experiencing the same dilemma between chemo or not? What should we do? My husband is 42 years old and we have 2 small children that need him very much. Thank you.

I wasn't familiar with the Oncotype DX service but it appears to use Genomic and Immunohistochemistry testing to make a recommendation on post-surgical chemo. From your information, T3N0, the staging would be IIA and that's the gray area for oncologists. If the staging was III, then you'd do the post-surgical chemo.

Disclaimer: I'm not a doctor nor an expert but I've done some reading and my son works in cancer pathology.

I would guess that the survival rate for IIA would already be quite good so a small improvement with chemotherapy may indicate that it could be skipped or the patient could be placed in a wait and watch mode (someone here has that status I think).

From memory: MSI refers to vertical copy errors. There are mechanism to repair these errors but they are controlled by four genes which are routinely tested in CRC cancer via genomic testing or immunohistochemistry testing. Presence of MSI high may mean that the person has Lynch Syndrome which can be treated with drugs like Keytruda. MSI-high isn't very common but can result in CRC in relatively young adults.

I'm unclear about this piece: "but on cancer.org they say that patients with MSS and early stage CRC should be given a more aggressive treatment." Could you provide a link to the cancer.org page that states this as I'd like to see the context.

My husband age 57 has an almost identical diagnosis to yours we are waiting on the Oncox type test you mentioned to decide if chemo is warranted . He did not have anything show up in his ct prior to surgery and his CEAwas <2
I am unsure how to post the information on the bottom of the screen where the timeline and diagnosis go. He is anxious about doing chemo if not really warranted .

Ampes wrote:I am unsure how to post the information on the bottom of the screen where the timeline and diagnosis go. He is anxious about doing chemo if not really warranted .

Username Pulldown in upper right, select User Control Panel, Profile tab, then Edit Signature.

Danka wrote:Hello, my husband was diagnosed with CRC a moth ago. He had a large mass in the cecum (7 x 7.5 cm), so he had a right colectomy procedure. Based on pathology, the tumor was T3N0 (19 nodes removed). The cells were well differentiated (Low Grade). Further pathology tests, however, were confusing and we are not sure what we should do.
The MSI test indicated "MSI Stable (also known as MSS)" but his Oncotype DX score was 17, which only indicated 3% improvement in survival with chemotherapy. I requested CEA assay prior to surgery, but our surgeon didn't order it. We had it done only after the surgery (it was 1.0). My husband is also slightly anemic (prior surgery and even after) with platelet number >400. The CT scan indicated a 1.3 cm low-attenuation lesion in the posterior segment right hepatic lobe as indeterminate. The doctor ordered MRI with and without contrast to further investigate.
So here is what I struggle with: MSS shows lower survival and worse prognosis, but the Oncotype test had a low score. If the lesion is not a tumor, he should be ok, but on cancer.org they say that patients with MSS and early stage CRC should be given a more aggressive treatment. Is anybody experiencing the same dilemma between chemo or not? What should we do? My husband is 42 years old and we have 2 small children that need him very much. Thank you.

Welcome... I am also a T3N0M0 stage IIA. I also had a mass in the cecum and MSS. I did not do the Oncotype, but I trusted my oncologist. Therefore, I did 6 months of Xeloda (oral form of 5/FU) and do not regret it. I wanted any extra boost...Stage IIA has a good prognosis. The main reason I did Chemo was because of my age.

NHMike wrote:... I'm unclear about this piece: "but on cancer.org they say that patients with MSS and early stage CRC should be given a more aggressive treatment." Could you provide a link to the cancer.org page that states this as I'd like to see the context.

Here is a 2010 page from cancer.org that discusses some of these issues:
.
https://csn.cancer.org/node/186070

Danka wrote:... Is anybody experiencing the same dilemma between chemo or not? What should we do? ....

Your DH had a right-side tumor in the cecum. Statistically speaking, right-sided cancers have a poorer prognosis than cancers on the other side. This is something you might want to keep in mind as you decide what to do about chemo. However, this area, too, is a bit confusing and needs more clarification. These results are based on patients diagnosed at all stages, not just Stage II, so they are not directly relevant to your situation. However, it seems that right-sided tumors are biologically different from left-sided tumors, so there may be a need to look for more details about the genetic profile of your DH's tumor.

https://www.medscape.com/viewarticle/863537

Did the path report any high risk features (e.g. lymphovascular invasion, etc., also listed in NCCN)?

I am same stage, MSS, no high risk features, Oncotype score 7, but left sided mass. I had three Oncs give me three opinions, and all basically let me choose. I opted for adjuvant chemo with Xeloda monotherapy. I'm in the thick of it, on day 11 of cycle 4 out of 8. Get as many opinions as you need to feel comfortable with your choice. There is not a clear path based on evidence.

The 3-4% benefit was worth it to me. I say this as I punch out these words with a stylus because I've got cotton gloves over my Udderly Smooth-lathered hands. The redness and peeling and everything else... I'm okay with if it means cure.

My husband also had a tumor in his cecum and had most of his ascending colon removed. He was MSS stable and his cells were moderately differentiated. His, however was a t4 so chemo was highly advised for him. We would of done the chemo even if he were a t3. The reason why the prognosis for rt sided tumors is worse is because they are found much later because you usually don't have many symptoms like blood in the stool ect. till it's already advanced. Because yours is a stage ll, you really can't say that your prognosis is worse just because it's on the rt. side.

debm

Most right sided is not found until later stage. Poor prognosis is not true for localized stage 1 and 2. See below for the article

https://bmccancer.biomedcentral.com/art ... 016-2412-0

As the article states, "This population-based analysis on stage I - III colon cancer provides evidence that the prognosis of localized right-sided colon cancer is better compared to left-sided colon cancer. This questions the paradigm from previous research claiming a worse survival in right-sided colon cancer patients."

In addition, another article states "Stage II right-sided cancers had lower mortality than left-sided cancers (HR, 0.92; 95% CI, 0.87 to 0.97; P = .001)"

http://ascopubs.org/doi/full/10.1200/jco.2011.36.4414

I have been researching this for the past year....as you can see in my signature, I am right sided, cecum.

The biggest issue is the liver feature, if it is not cancerous then he is stage 2 and M0.

If it is detected as cancerous he is M1, an early stage 4a but with some good, potentially curative options at this moment. He is assumed M0 without additional clear, direct findings.

Where I have a lot of technical dissatisfaction with NCCN is for patients who belatedly turned out to be stage 4 or mCRC, at the divergence between US practices and easy risk factors described in the literature. In some places, CEA and CA19-9 are done before and after surgery.

Some authors have demonstrated that the statistical CRC cutoff for a single CA19-9 test (before diagnosis and surgery) should be 25-27 units, not 34 - 40 units, as typically used in pancreatic cancer diagnostics. Very low 25 hydroxy vitamin D levels are a risk factor as are platelets over 400, high LDH, ESR and AFP. These are cheap, common blood panels; prices can vary greatly with how you order. We've used hsCRP to monitor transient even silent inflammations that can distort markers greatly.

In any case, for us, we've found (paying for and) serially monitoring these extra blood panels very enlightening and allow us to change my wife's immunochemo in real time to beat ominous marker levels down as well as more closely monitor than is possible with scans alone. I would be bitter if we had followed NCCN's knuckle dragging there and gotten torpedoed with "too late" diagnoses. Also we better know what formula works at the personalized level.

What would I do in your situation? If no chemo, I'd definitely get extra blood data every 5-6 weeks for 6-12 months, where NCCN now admits 2 month intervals might be better than 3 months. Chemo for stage 2 can have several options, from 3-6 months xeloda with or without nutritional and immune support, to folfox. Some patients overcome Xeloda's side effects with diet, supplements and IV vitamin C.

Although we buy an oral chemo not approved in the US instead of xeloda, we've seen that high dose supplements, IV C, and off label drugs can intensify 5FU based oral chemo while suppressing its side effects and living well.

Personally since there is only 3% increased survival I would not sign up for chemo with all the possible side effect., but that certainly has to be a personal/family decision. My oncologist recommended against chemo because of my microsatellte instabily. 4 years NED!