Question on adjuvant chemo sequencing

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Rock_Robster
Posts: 1027
Joined: Thu Oct 25, 2018 5:27 am
Location: Brisbane, Australia

Question on adjuvant chemo sequencing

Postby Rock_Robster » Tue Mar 19, 2019 11:56 pm

Hi all, so far my treatment is going well (successful liver resection! Am thrilled), so thought I’d turn to the experts here once again for thoughts on sequencing my next treatment steps.

I completed 6 rounds of neoadjuvant FOLFOX before my liver resection. The plan now is that I do 5 weeks chemoradiation (with Xeloda), have an 8 week break, then surgery on the primary rectal tumour (ULAR). I expressed concern about the total time off systemic chemo here, and my oncologist suggested I do 2 more rounds of FOLFOX during the 8 week radiation recovery period (still leaving a 4 week recovery before surgery). I like this idea as it greatly reduces the time off full chemo, and accelerates the overall treatment plan. My surgeon thinks it’s a good idea as well.

In total he wants me to do 12 rounds of chemo during my treatment, but only 8-9 rounds with oxaliplatin to try to avoid too much permanent neuropathy. This would only leave *maybe* one more round with oxy to be done after the rectal surgery (then 3-4 rounds of just 5FU). I am concerned based on my understanding that the point of adjuvant chemo was to ‘clean up’ any residual micro-level cells or metastases that may remain after surgery, and that this true adjuvant regime may not be sufficient for this. He was of the view that the most important thing was to get the full FOLFOX course done, minimising time off chemo, and that the trend is toward giving more chemo earlier to try to stay ahead of any spread.

Any perspectives on the above? I know I could always push to do 12 rounds with oxaliplatin (as many have), but also don’t want to risk leaving myself without any adjuvant options if toxicity gets too great.

I also realise standard protocol is to wait until after all surgeries to do adjuvant chemo, but this sounds like a potentially good optimisation - my onc is sharp (and very research-oriented) and I don’t want to miss an opportunity to get a better outcome.

Thanks for any input.
41M Australia
2018 Dx RC
G2 EMVI LVI, 4 liver mets
pT3N1aM1a Stage IVa MSS NRAS G13R
CEA 14>2>32>16>19>30>140>70
11/18 FOLFOX
3/19 Liver resection
5/19 Pelvic IMRT
7/19 ULAR
8/19 Liver met
8/19 FOLFOX, FOLFOXIRI, FOLFIRI
12/19 Liver resection
NED 2 years
11/21 Liver met, PALN, lung nodules
3/22 PVE, lymphadenectomy, liver SBRT
10/22 PALN SBRT
11/22 Liver mets, peri nodule. Xeloda+Bev
4/23 XELIRI+Bev
9/23 ATRIUM trial
12/23 Modified FOLFIRI+Bev
3/24 VAXINIA (CF33 + hNIS) trial

Punky44
Posts: 498
Joined: Mon Oct 01, 2018 4:29 pm

Re: Question on adjuvant chemo sequencing

Postby Punky44 » Wed Mar 20, 2019 12:15 am

My mom’s isn’t exactly the same but her onc team recommended 8 rounds of neoadjuvant chemo, then a short course of radiation followed immediately by surgery and then *potentially* 4 more rounds of adjuvant chemo to start within 6 weeks after surgery.

I’ve also wondered about the “when” of chemo and the “split” of chemo. I plan on asking about this at our post surgical oncology consult in April.

I guess you could look at it like doing all or most of it upfront theoretically is catching any micro mets at that time and assuming there isn’t too much downtime between that and surgery, there may not be much or any more to mop up?

They told us the reason they chose 8 upfront rounds for my mom was they didn’t want the long downtime from diagnosis > radiation > surgery > recovery to starting chemo to allow micro mets to spread. That, and they said it can be tolerated better and chances of completion are better upfront.

It’s not currently the standard of care, but remember not long ago they waited to do radiation after as well and now they’ve changed that. I have a feeling it could become a viable standard of care in the future for advanced high risk stage 3 patients.
Caregiver to my amazing mom (68 at dx)
10/1/18 DX with rectal cancer; CEA 17
T3N2M0
Total neoadjuvant therapy:
8 rounds Folfox 11/5/18 - 2/11/19
Short course radiation 3/14/19 - 3/20/19
Robotically assisted laparoscopic LAR 3/21/19
Pathology report says yT2N0M0 with 0/38 nodes
6/28/19 Reversal and port out
CEA 2.1; 1.9; 2.6; 2.8; 2.3; 2.4; 3.0; 3.4; 3.1; 3.4; 3.0; 3.1; 2.6
Latest update: 8/21/23 Clear CT with CEA 2.6!

Me: 34, first colonoscopy 11/16/18—normal! Come back in 5 years.

Rock_Robster
Posts: 1027
Joined: Thu Oct 25, 2018 5:27 am
Location: Brisbane, Australia

Re: Question on adjuvant chemo sequencing

Postby Rock_Robster » Wed Mar 20, 2019 12:42 am

Punky44 wrote:I guess you could look at it like doing all or most of it upfront theoretically is catching any micro mets at that time and assuming there isn’t too much downtime between that and surgery, there may not be much or any more to mop up.

Thanks Punky, really helpful to hear your experience and thoughts.

The above was sort of my logic too - if the cells are there then they’re there, and the earlier you can hit them the better. Unless of course the surgery itself seeded additional micro-mets or cellular spread, in which case more chemo post-surgery could be important. Hopefully not such an issue if surgery is done correctly, I guess!

I’ve looked a bit into surgery-induced metastasis and though this is a credible concern, it seems to be more about the surgery creating a metastasis-conducive environment (immunosuppression, inflammation, pro-angiogenesis, coagulopathy etc.) than the surgery itself creating a whole bunch of new cellular spread that would require mopping up (though remains possible).
41M Australia
2018 Dx RC
G2 EMVI LVI, 4 liver mets
pT3N1aM1a Stage IVa MSS NRAS G13R
CEA 14>2>32>16>19>30>140>70
11/18 FOLFOX
3/19 Liver resection
5/19 Pelvic IMRT
7/19 ULAR
8/19 Liver met
8/19 FOLFOX, FOLFOXIRI, FOLFIRI
12/19 Liver resection
NED 2 years
11/21 Liver met, PALN, lung nodules
3/22 PVE, lymphadenectomy, liver SBRT
10/22 PALN SBRT
11/22 Liver mets, peri nodule. Xeloda+Bev
4/23 XELIRI+Bev
9/23 ATRIUM trial
12/23 Modified FOLFIRI+Bev
3/24 VAXINIA (CF33 + hNIS) trial

Punky44
Posts: 498
Joined: Mon Oct 01, 2018 4:29 pm

Re: Question on adjuvant chemo sequencing

Postby Punky44 » Wed Mar 20, 2019 12:57 am

Very interesting research. Another thought/question I had is Stage 1 and some Stage 2 cancers don’t get chemo after they are surgically removed so why not the concern with “surgery causes mets” in those patients?
Caregiver to my amazing mom (68 at dx)
10/1/18 DX with rectal cancer; CEA 17
T3N2M0
Total neoadjuvant therapy:
8 rounds Folfox 11/5/18 - 2/11/19
Short course radiation 3/14/19 - 3/20/19
Robotically assisted laparoscopic LAR 3/21/19
Pathology report says yT2N0M0 with 0/38 nodes
6/28/19 Reversal and port out
CEA 2.1; 1.9; 2.6; 2.8; 2.3; 2.4; 3.0; 3.4; 3.1; 3.4; 3.0; 3.1; 2.6
Latest update: 8/21/23 Clear CT with CEA 2.6!

Me: 34, first colonoscopy 11/16/18—normal! Come back in 5 years.

Rock_Robster
Posts: 1027
Joined: Thu Oct 25, 2018 5:27 am
Location: Brisbane, Australia

Re: Question on adjuvant chemo sequencing

Postby Rock_Robster » Wed Mar 20, 2019 1:06 am

Punky44 wrote:Very interesting research. Another thought/question I had is Stage 1 and some Stage 2 cancers don’t get chemo after they are surgically removed so why not the concern with “surgery causes mets” in those patients?

Very good question!

I guess you could argue that stage I/II tumours are node-negative and some of the metastatic pathways (eg EMVI+, LVI+) are less likely to be present (meaning low chance of tumour cells outside of the primary), but it still doesn’t address the issue of surgery creating a metastasis-promoting environment, or surgery seeding spread if not executed carefully.
41M Australia
2018 Dx RC
G2 EMVI LVI, 4 liver mets
pT3N1aM1a Stage IVa MSS NRAS G13R
CEA 14>2>32>16>19>30>140>70
11/18 FOLFOX
3/19 Liver resection
5/19 Pelvic IMRT
7/19 ULAR
8/19 Liver met
8/19 FOLFOX, FOLFOXIRI, FOLFIRI
12/19 Liver resection
NED 2 years
11/21 Liver met, PALN, lung nodules
3/22 PVE, lymphadenectomy, liver SBRT
10/22 PALN SBRT
11/22 Liver mets, peri nodule. Xeloda+Bev
4/23 XELIRI+Bev
9/23 ATRIUM trial
12/23 Modified FOLFIRI+Bev
3/24 VAXINIA (CF33 + hNIS) trial


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