The Colon Club

Just curious if anyone has any insight into the splitting of rounds of Folfox one should receive as part of treatment for rectal cancer.

While the standard of care is chemo-rad, surgery, chemo, my mom’s oncs in Iowa City and Mayo are taking a neoadjuvant chemo approach with her treatment, starting her off with 8 rounds of Folfox.

Originally, we assumed 8 would be sufficient because the long-course radiation includes chemo that from my understanding is basically equivalent to the remaining 4 rounds in a sense.

However, Mayo said she is a candidate for short course radiation that does not include chemo since it’s only a 5 day deal. It was mentioned that 4 rounds of Folfox would likely follow as a result after surgery.

I am curious if there is any data on if it matters if these 12 rounds are not done concurrently. I have seen a few of the signatures of folks here who did short course radiation and they seem to have had 4 neoadjuvant rounds followed by 8 adjuvant rounds, so obviously other people have had their rounds split up, although the quantity of the split is reversed.

Side note—I don’t know whether to feel good or bad about the fact that there are so many variations of care for rectal cancer. It’s like in a way you are happy it can be customized to your situation but in another way you feel immense pressure to pick the best path to NED.

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.

Thanks so much for replying with such a helpful response! My mom’s onc is thinking just like yours—“providing protection against possible mets”during the surgical period—both times we’ve gone to the infusions and explain we are Stage 3 but doing this upfront we get the comment “wow that’s an aggressive approach”. But we are all for being aggressive!

Best of luck to you with your plan and please keep us in your prayers!