Hi Punky, indeed it is a challenge! I have had 3 opinions and 3 different approaches for RC treatments - all variants on what you described above. It seems to mainly depend on: a) the beliefs/conventions of the oncologist and country/hospital in question, and b) the strategy being pursued.
In my case we are going for 4 rounds FOLFOX, then liver resection, long-course chemorad (2x25 Gy with 5FU), rectal resection, then 5 rounds FOLFOX (presuming all goes well). This is because my liver is (very fortunately) resectable now, so the goal of neo-adjuvant chemo is not so much to achieve major shrinkage but to provide some protection against further metastasis during the surgical period. The goal of chemorad before the rectal resection is to sterilise the surgical area from rogue malignant cells, and shrink the tumour as much as possible to give the best surgical margins. It’s worth noting that there is a synergistic effect between the 5FU and radiation - the concurrent chemo I understand is to make the tumour cells more sensitive to the radiation and increase the response.
I got the sense if significant lesion shrinkage was required for liver resectability I would be doing more rounds of chemo up-front, likely with Avastin added.
In Europe, they suggested short-course chemorad first, then surgeries, then adjuvant chemo. In the US they seem to favour more rounds of FOLFOX (ie 12), and both US and Australia seem to favour long-course radiation. Some go for surgery first with more adjuvant chemo (perhaps MSKCC, depending on staging?).
It is indeed very frustrating that there is no definitive standard approach, but as you say at the same time it means there are no “wrong” answers - just tradeoffs between different valid approaches. The main thing I would want to uunderstand is the rationale as to *why* they are suggesting a certain approach. In my sense I could “buy in” to the strategy being applied, and it seems to be fairly consistent with the research.
Best of luck, let me know if I can be of any more help.
Last edited by Rock_Robster
on Fri Nov 30, 2018 8:38 pm, edited 1 time in total.
Male 36 years; Melbourne, Australia
10/2018 Dx: rectal cancer, 3.5 cm adenocarcinoma, 10 cm from verge. Well/mod diff (G1-2). T3bN1bM1a.
3 regional lymph nodes involved and 4 mets to liver, surgical margins clear.
Mutation in NRAS (G13R; exon 2, codon 13). MSS; MMR-proficient. Lynch likely negative.
11/19/18 - started FOLFOX