Chemo before or after surgery?

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RachelSonenblum
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Joined: Tue Jun 12, 2018 12:26 pm
Facebook Username: Rachel.sonenblum

Chemo before or after surgery?

Postby RachelSonenblum » Tue Jun 12, 2018 12:51 pm

Hi all. This is my first post on this page. My 49 year old mom was just diagnosed with stage 3 rectal cancer (type 3B). We are trying to figure out which treatment plan to follow. The first opinion: 5-6 weeks radiation with chemo pill, wait 8 weeks, first surgery with a colostomy bag, 6 months of chemotherapy, 2nd surgery to reverse bag (hopefully). The second opinion: 4 months chemotherapy, wait 2-3 weeks, 5-6 weeks radiation with chemo pill, surgery/surgeries at the end. Does anyone have any advice or experience with these protocols for rectal cancer? The more help the better! Thank you for reading!
Daughter of mom age 49: T3B rectal cancer, stage 3
5/20 ER visit for bleeding
5/23 colonoscopy
5/24 PET
5/25 rectal protocol MRI
6/1 and 6/4 two different tumor board opinions
Waiting to start treatment

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CRguy
Posts: 9511
Joined: Sun Feb 10, 2008 6:00 pm

Re: Chemo before or after surgery?

Postby CRguy » Tue Jun 12, 2018 10:01 pm

Welcome to our little corner of helping and healing !
JMO :
I had the first option you posted for a rectosigmoid primary tumor :
The first opinion: 5-6 weeks radiation with chemo pill, wait 8 weeks, first surgery with a colostomy bag, 6 months of chemotherapy, 2nd surgery to reverse bag (hopefully).
that was in spring 2007
I am still here .....JMO

BUTT your Mom's Docs are really the ones to make the call for HER situation.
What I did when I got 2 opinions which differed ... get a third
BUTT please note that things have changed since my primary treatments in 2007 and ...
I know a lotta folks here have had option #2 as well

Cheers and best wishes
CRguy
Caregiver x 3
Stage IV A rectal cancer/lung met
11 Year survivor
my life is an ongoing totally randomized UNcontrolled experiment with N=1 !
Review of my Journey so far

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O Stoma Mia
Posts: 1322
Joined: Sat Jun 22, 2013 6:29 am
Location: Indonesian Archipelago

Re: Chemo before or after surgery?

Postby O Stoma Mia » Tue Jun 12, 2018 11:01 pm

You might want to look at the treatment protocol that member basil followed. It was somewhat similar to your second option, but his post surgery adjuvant chemo phase was eventually cancelled because his response to the pre-surgery chemotherapy was so good. The advantage of this approach was that he avoided the chemo/radiation phase completely.

You can look at basil's posts here. He was Stage III, T3N1M0:
http://coloncancersupport.colonclub.com/search.php?author_id=106499&sr=posts

You can send a private message (PM) to basil once you have been promoted to a higher level than Newly Registered User. You have to post a few more valid messages to the board before they will promote you to a higher level giving you PM privileges. The link to eventually send a PM to basil is here:

http://coloncancersupport.colonclub.com/ucp.php?i=pm&mode=compose&u=106499

Basil's signature is here:
    SIGNATURE
    40 y/o male, kids 6&9
    Dx 3/16/17, rectal cancer S3,t3,n1,m0
    PROSPECT trial (FOLFOX in lieu of chemorad)
    FOLFOX 4/5/17 - 6/26/17
    LAR 7/31/17, temp ileo
    pathological complete response
    Adjuvant chemo cancelled (IDEA Study)
    Ileo reversed 9/25/17
    NED

hawkowl
Posts: 98
Joined: Sun Dec 14, 2014 5:29 am
Location: MN/FL

Re: Chemo before or after surgery?

Postby hawkowl » Wed Jun 13, 2018 12:51 am

I did option 2: 8 cycles of FOLFOX, 3 weeks off, and then 28 days of chemoradiation. I had a complete response and was offered watch and wait instead of surgery, but I elected to follow through with the surgery. That was more than 3 years ago and I am still NED and have zero regrets. I had some significant iliac adenopathy and it made a lot of sense to treat any possible distant micrometasteses first with systemic chemo. I would do the same protocol again without hesitation
Dx 12/2014 T3N2MX (iliac nodes) low rectal
12/2014-4/2015: FOLFOX (8 cycles)
4/2015-6/2015: 28 cycles of chemoradiation with xeloda
8/2015: Robotic APR with iliac node dissection; path showed ypT0,ypN0 (complete pathological response).
11/2015 scans clear, CEA 2.1
11/2015 parastomal hernia repair
3/2016 CEA 1.7
10/2017 CEA remains in normal range (1.4), scans stable.
6/2018 CEA still normal.

Totally disabled due to oxaliplatin induced neuropathy and dysautonomia

NHMike
Posts: 1354
Joined: Fri Jul 21, 2017 3:43 am

Re: Chemo before or after surgery?

Postby NHMike » Wed Jun 13, 2018 9:20 am

I am going through option 1; last of Adjuvant Chemo today and reversal in the future.

The second option is newer and the idea is a study that indicated that 16% doing Total Neo-Adjuvant Therapy (chemo + chemo/Rad up front) don't need surgery. So the order is changed potentially saving the patient surgery and recovery time. That also means that the patient gets to keep their body parts if they don't need surgery. I lost my rectum so I will have to deal with that going forward.
6/23/17: ER rectal bleeding; Colonoscopy
7/13: Stage 3B rectal. T3N1bM0. 5.2 x 4.5 x 4.3 cm. Lymphs: 6 x 4 mm, 8 x 6, 5 x 5
7/31-9/8: Xeloda 3,400 mg/day+radiation
7/5: CEA 2.7; 8/16: 1.9; 9/8: 1.8; 11/30: 0.6; 12/20 1.4; 1/10 1.8; 1/31 2.2; 2/28 2.6; 4/10 2.8
MSS, KRAS G12D
10/6: 2.7 x 2.2 x 1.6 cm (-90%). Lymphs: 3 x 3 mm (-62.5%), 4 x 3 (-75%), 5 x 3 (-40%). 5.1 CM from AV
10/30: LAR, Temp Ileostomy, Path Complete Response
12/20: Started CapeOx

Caat55
Posts: 392
Joined: Sat Dec 23, 2017 6:01 pm

Re: Chemo before or after surgery?

Postby Caat55 » Wed Jun 13, 2018 9:54 am

I agree with suggestions for third opinion but treatment option two sounds great. I am doing option One, no walk in the park and like NHMike will have to deal with issues with lose of rectum when treatment is over.
Best of luck and prayers for mom.
S
55 y.o. Female
Dx 9/26/17 RC Stage 3
Completed 33 rad. tx, xeolda 12/8/17
MRI and PET 1/18 sign. regression
Surgery 1/31/18 Ileostomy, clean margins, no lymph node involved
Port 3/1/2018
Oxaliplatin and Xeloda start 3/22/18

hawkowl
Posts: 98
Joined: Sun Dec 14, 2014 5:29 am
Location: MN/FL

Re: Chemo before or after surgery?

Postby hawkowl » Wed Jun 13, 2018 1:02 pm

Option 2 is not only done to reduce the chance of needing surgery...there is also a hypothetical long term survival advantage to treating the micrometasteses first (and not waiting 4-6 months to do this as would be required in option 1)

I lost my entire rectum and have a permanent colostomy but it doesn't really limit me or affect my quality of life at all.
Dx 12/2014 T3N2MX (iliac nodes) low rectal
12/2014-4/2015: FOLFOX (8 cycles)
4/2015-6/2015: 28 cycles of chemoradiation with xeloda
8/2015: Robotic APR with iliac node dissection; path showed ypT0,ypN0 (complete pathological response).
11/2015 scans clear, CEA 2.1
11/2015 parastomal hernia repair
3/2016 CEA 1.7
10/2017 CEA remains in normal range (1.4), scans stable.
6/2018 CEA still normal.

Totally disabled due to oxaliplatin induced neuropathy and dysautonomia

NHMike
Posts: 1354
Joined: Fri Jul 21, 2017 3:43 am

Re: Chemo before or after surgery?

Postby NHMike » Wed Jun 13, 2018 1:16 pm

hawkowl wrote:Option 2 is not only done to reduce the chance of needing surgery...there is also a hypothetical long term survival advantage to treating the micrometasteses first (and not waiting 4-6 months to do this as would be required in option 1)


I didn't know about the second part. I'll keep it mind and will probably eventually read about it in a paper.
6/23/17: ER rectal bleeding; Colonoscopy
7/13: Stage 3B rectal. T3N1bM0. 5.2 x 4.5 x 4.3 cm. Lymphs: 6 x 4 mm, 8 x 6, 5 x 5
7/31-9/8: Xeloda 3,400 mg/day+radiation
7/5: CEA 2.7; 8/16: 1.9; 9/8: 1.8; 11/30: 0.6; 12/20 1.4; 1/10 1.8; 1/31 2.2; 2/28 2.6; 4/10 2.8
MSS, KRAS G12D
10/6: 2.7 x 2.2 x 1.6 cm (-90%). Lymphs: 3 x 3 mm (-62.5%), 4 x 3 (-75%), 5 x 3 (-40%). 5.1 CM from AV
10/30: LAR, Temp Ileostomy, Path Complete Response
12/20: Started CapeOx

hawkowl
Posts: 98
Joined: Sun Dec 14, 2014 5:29 am
Location: MN/FL

Re: Chemo before or after surgery?

Postby hawkowl » Wed Jun 13, 2018 1:32 pm

NHMike wrote: I didn't know about the second part. I'll keep it mind and will probably eventually read about it in a paper.


When I was first diagnosed in 2014 there were some preliminary data from the PROSPECT trial that showed (if I remember correctly) an 85% disease free survival at 4(?) years with neoadjuvant FOLFOX. In the prospect trial those who respond well to the FOLFOX don't receive chemoradiation.

There is also the total neoadjuvant optopn where everyone gets FOLFOX (for 6-8 cycles) followed be chemoradiation.

My initial plan was to avoid chemoradiation but I chickened out even though I responded well to FOLFOX. And then I planned to do watch and wait after the radiation but I chickened out again. It will be interesting to see the actual 5 and 10 year data when they are published
Dx 12/2014 T3N2MX (iliac nodes) low rectal
12/2014-4/2015: FOLFOX (8 cycles)
4/2015-6/2015: 28 cycles of chemoradiation with xeloda
8/2015: Robotic APR with iliac node dissection; path showed ypT0,ypN0 (complete pathological response).
11/2015 scans clear, CEA 2.1
11/2015 parastomal hernia repair
3/2016 CEA 1.7
10/2017 CEA remains in normal range (1.4), scans stable.
6/2018 CEA still normal.

Totally disabled due to oxaliplatin induced neuropathy and dysautonomia

NHMike
Posts: 1354
Joined: Fri Jul 21, 2017 3:43 am

Re: Chemo before or after surgery?

Postby NHMike » Wed Jun 13, 2018 2:27 pm

I think that I had a big benefit from the radiation. My tumor was large (> 100 cm^3) and I credit the radiation for causing the large amount of shedding and reducing the size by 90%. It was also very uncomfortable. Of course I didn't have a good idea about what the Xeloda did or the radiation in relation to the tumor - I just wanted it out of there. It must be tough for the oncologists to decide and I guess that's why they pass the decision to the patient.
6/23/17: ER rectal bleeding; Colonoscopy
7/13: Stage 3B rectal. T3N1bM0. 5.2 x 4.5 x 4.3 cm. Lymphs: 6 x 4 mm, 8 x 6, 5 x 5
7/31-9/8: Xeloda 3,400 mg/day+radiation
7/5: CEA 2.7; 8/16: 1.9; 9/8: 1.8; 11/30: 0.6; 12/20 1.4; 1/10 1.8; 1/31 2.2; 2/28 2.6; 4/10 2.8
MSS, KRAS G12D
10/6: 2.7 x 2.2 x 1.6 cm (-90%). Lymphs: 3 x 3 mm (-62.5%), 4 x 3 (-75%), 5 x 3 (-40%). 5.1 CM from AV
10/30: LAR, Temp Ileostomy, Path Complete Response
12/20: Started CapeOx

RachelSonenblum
Posts: 2
Joined: Tue Jun 12, 2018 12:26 pm
Facebook Username: Rachel.sonenblum

Re: Chemo before or after surgery?

Postby RachelSonenblum » Wed Jun 13, 2018 5:02 pm

Thank you all so much for your inputs! It is so nice to get some inside information and support. We spent all day at the UM cancer center and finally reached a conclusion for a treatment plan. I think we will go with 4 months chemo, one month break, 5-6 weeks radiation with chemo pill, one month break, followed by surgeries at the end. This is apparently the “newer” way to do it and seems to be the way to go. I am sure that I will have a million questions in the near future and it is really comforting to know that this is a place I can ask them. Sending my best wishes to you all.
Daughter of mom age 49: T3B rectal cancer, stage 3
5/20 ER visit for bleeding
5/23 colonoscopy
5/24 PET
5/25 rectal protocol MRI
6/1 and 6/4 two different tumor board opinions
Waiting to start treatment

hawkowl
Posts: 98
Joined: Sun Dec 14, 2014 5:29 am
Location: MN/FL

Re: Chemo before or after surgery?

Postby hawkowl » Thu Jun 14, 2018 11:56 pm

It is always good to come up with a treatment plan! I hope that all goes well :-)
Dx 12/2014 T3N2MX (iliac nodes) low rectal
12/2014-4/2015: FOLFOX (8 cycles)
4/2015-6/2015: 28 cycles of chemoradiation with xeloda
8/2015: Robotic APR with iliac node dissection; path showed ypT0,ypN0 (complete pathological response).
11/2015 scans clear, CEA 2.1
11/2015 parastomal hernia repair
3/2016 CEA 1.7
10/2017 CEA remains in normal range (1.4), scans stable.
6/2018 CEA still normal.

Totally disabled due to oxaliplatin induced neuropathy and dysautonomia


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