Rock_Robster wrote:I just finished long-course chemoradiation treatment prior to surgery on my primary rectal tumour, and I now have a 7 week break. I had previously discussed with my onc doing an additional 2 cycles of FOLFOX during this time, but he has now recommended deferring it until after the surgery in light of some mild but persistent peripheral neuropathy from my neoadjuvant chemo.
I am both relieved and stressed by this. It feels like a long time off chemo (last FOLFOX was before my liver resection in March), and aside from the neuropathy I feel fit and well enough to handle it. But as he said, permanent nerve damage is no fun. I asked if I could just do 5-FU and he said if I were to do that then I might as well just stay on the Xeloda (from the chemoradiation), but the benefit would be largely psychological. I’ve tolerated the Xeloda ok, but of course if there’s no material survival benefit then it would be unnecessary treatment.
Dionca wrote:I'm confused - why would continuing with the xeloda be just considered to be of "psychological benefit". It's chemo, not carrot juice.
The oncologist appears to be speaking in a broad statistical sense for Folfox, that there may be almost no additional benefit for incremental treatments without additional insights or identifiable risk factors
. We accepted CA199(+CSLEX1) stained tissue as a known metastatic risk factor.
*Each* heavy chemo treatment has some risk, some kinds cumulative or more than others, some risks related to staff alertness and readiness. Witness the patients here who experienced allergic or anaphalactic reactions, organ injury, or even died, during or soon after, a chemo treatment. Just a week ago, at an informal lunch at a friend's house, between cancer patients for other cancers, right out of the blue: "My brother with CRC died on his fourth chemo" (from chemo). BAM. So patients walk a fine line, Benefit and Risk, dr selection and mental preparations.
One of oncology's stage 2-3 treatment conclusions that I respect is that chemo intensity
is more important than chemo duration
, at least for less metastatic molecular biology. That is, perhaps crudely expressed as "burning out" (somewhat resistant) residual cancer cells. This observation starts back years ago with some mild 5FU trials up to two years long not having survival advantage over 1 year of treatment, or where Folfox might gain a few percent survival at 2-5 years post tx, after 6 months treatment, finally down to as low as three months tx, depending on risk factors.
However, for someone who is mCRC, stage 4, has especially metastatic molecular biology (e.g. CA199+ CSLEX1+ tissue), and/or tests with circulating tumor cells, some kind of effective
maintenance chemo certainly has an appeal. We pushed for both
maintenance intensity and
duration yet less side effects.
So as far as I can see, I have 3 options:
1. Kick, scream and beg to do the FOLFOX now, and take what the neuropathy brings,
2. Wait the 7 weeks but do ‘maintenance’ Xeloda to keep myself sane, or
3. Take the 7 weeks to focus on eating well, fitness, supplementation (I have an integrative oncology person too); then go hard for surgery and adjuvant chemo
However, even extra days of additional Xeloda in excess can rapidly deteriorate a patient's bloodwork, with special respect for the prior radiation. Various papers indicate some patients benefit from maintenance chemo with milder components e.g. celecoxib, aspirin, cimetidine, PSK, especially when targeted by companion markers. Likewise, a common observation here is that specialized nutrition can greatly improve patients' side effect profile if well done. Some papers indicate improvements in chemo performance are possible this way, too.
So we chose to combine choices 2 and 3 in a run up to surgery, daily oral chemo intensified by nutraceuticals and mild drugs with a minimal side effect footprint. This is where I would be most diligent, consult around, and demand more with integrative oncology results. With multiple opinions, the goal is to achieve maximum "intensity", beat on personal targets or cancer pathways, dramatically improve physical condition in the run up to surgery, to the surgeon's specifications
(for us, this included PT/INR and PTT levels). I don't have background chemo information on liver surgery, with big potential bleed issues. I will note that the potential chemo exclusion period for my wife's non liver surgery
could have been 6, 4, 3, 2, or 0 weeks before/after surgery, depending on the global medical source and treatment approach. In reality, after checking and careful tx construction, we phased some things down/out the last week or days before surgery, when she was doing very well.
A lot depends on how much skill and experience you can rapidly bring into focus on your biology with your consults, and then execute on.