Hand Foot Syndrome

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zephyr
Posts: 363
Joined: Thu Aug 18, 2016 7:31 am

Re: Hand Foot Syndrome

Postby zephyr » Fri Aug 30, 2019 7:09 pm

TinaFish wrote:
zephyr wrote:Henna will do the trick. Please feel free to PM me if you want directions.


Really? But then my hands will be discolored by the henna, right?


Yes ... but your hand-foot will likely be gone. It might take more than one application depending on the severity.
Nov-2009 Early stage CRC, routine colonoscopy
2010-2014 F/U colonoscopies, all clear
Jun-2016 CRC during F/U colonoscopy, surgery, Stage 4, KRAS, MSS
Aug-2016-May-2018 Folfox, 5FU, Folfiri & Avastin
Aug/Sep-2018 YAG laser surgeries (Germany), 11 nodules removed
Nov-2018 clean CT scan
Mar-2019 New lung nodules
Apr-2019 Dec-2020 Xeloda/Avastin, SBRT, cont. Xeloda/Avastin
Mar-2021 Forfiri/Avastin
Mar-2022 Ablation & Thoracotomy
Feb-2023 Folfiri & Avastin
Nov-2023 Xeloda & Avastin

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

Re: Hand Foot Syndrome

Postby Rock_Robster » Fri Aug 30, 2019 7:59 pm

MeAndMine wrote:My oncologist just said to use lotion like normal & recommended two different brands. He said there are two that he likes. One is Udder Cream. I googled it & realized I had seen it before in the store. It's a white container with black spots like a dairy cow. It's called Udderly Smooth hand cream.

This is definitely a good option if you don’t want/need a medicated cream. The other cream I really like is MooGoo - I used it during radiation rather than for hand/foot, but apparently it’s good for both. They have a light version, and a thicker one (marketed for eczema/psoriasis) that could be good overnight.

Good luck
Rob
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

TinaFish
Posts: 178
Joined: Sun Jul 21, 2019 10:11 am

Re: Hand Foot Syndrome

Postby TinaFish » Fri Aug 30, 2019 8:45 pm

Thanks, all! Skin darkening from Xeloda, huh? Would it be stupid to try to scrub it off? It looks like thick, dead skin!

Zephyr, will henna get rid of what I have, too?

I managed to get a way better pic of my hand - you can really see how the knuckles got thick dark skin! It looks like elephant skin! And this literally happened overnight!

I really hope this doesn't happen to peoples' faces!!

Please see this better pic:

https://ibb.co/34s8Lbj

And here's what my knuckles look like when I make a fist:

https://ibb.co/QQvDJZV
F 45, single mother to son, 7 and daughter, 3
DX: stage 4 Rectal Cancer June 2019
Tumor Location: ? cm above anal verge
Tumor type: Adenocarcinoma
Tumor size: 5 cm
Tumor grade: ?
TNM code: ?
Stage : Stage IV-B
# of cancerous lymph nodes: ?
Mets: Numerous mets to liver, lungs
CEA: 22 in July; 11 as of August 15, 7 as of Sept 20
MSI status: MSS
KRAS/BRAF status: KRAS mutation
surgery: TBD
Ostomy surgery: TBD
Radiation therapy: TBD
Chemotherapy : CAPEOX+Avastin, 6 cycles, with CT scans after 3rd and 6th cycle.

NHMike
Posts: 2555
Joined: Fri Jul 21, 2017 3:43 am

Re: Hand Foot Syndrome

Postby NHMike » Fri Aug 30, 2019 8:53 pm

TinaFish wrote:Thanks, all! Skin darkening from Xeloda, huh? Would it be stupid to try to scrub it off? It looks like thick, dead skin!

Zephyr, will henna get rid of what I have, too?

I managed to get a way better pic of my hand - you can really see how the knuckles got thick dark skin! It looks like elephant skin! And this literally happened overnight!

I really hope this doesn't happen to peoples' faces!!

Please see this better pic:

https://ibb.co/34s8Lbj

And here's what my knuckles look like when I make a fist:

https://ibb.co/QQvDJZV


My characterization of Hands/Feet is the feeling of arthritis. You may be too young to have experienced arthritis but I've had it in my knees in the past. It's kind of a fuzzy feeling - that you don't feel things as well as normal. Sometimes your fingers are a touch less responsive to doing what you tell them to.
6/17: ER rectal bleeding; Colonoscopy
7/17: 3B rectal. T3N1bM0. 5.2 4.5 4.3 cm. Lymphs: 6 x 4 mm, 8 x 6, 5 x 5
7/17-9/17: Xeloda radiation
7/5: CEA 2.7; 8/16: 1.9; 11/30: 0.6; 12/20 1.4; 1/10 1.8; 1/31 2.2; 2/28 2.6; 4/10 2.8; 5/1 2.8; 5/29 3.2; 7/13 4.5; 8/9 2.8, 2/12 1.2
MSS, KRAS G12D
10/17: 2.7 2.2 1.6 cm (-90%). Lymphs: 3 x 3 mm (-62.5%), 4 x 3 (-75%), 5 x 3 (-40%). 5.1 CM from AV
10/17: LAR, Temp Ileostomy, Path Complete Response
CapeOx (8) 12/17-6/18
7/18: Reversal, Port Removal
2/19: Clean CT

TinaFish
Posts: 178
Joined: Sun Jul 21, 2019 10:11 am

Re: Hand Foot Syndrome

Postby TinaFish » Fri Aug 30, 2019 9:06 pm

NHMike wrote:
TinaFish wrote:Thanks, all! Skin darkening from Xeloda, huh? Would it be stupid to try to scrub it off? It looks like thick, dead skin!

Zephyr, will henna get rid of what I have, too?

I managed to get a way better pic of my hand - you can really see how the knuckles got thick dark skin! It looks like elephant skin! And this literally happened overnight!

I really hope this doesn't happen to peoples' faces!!

Please see this better pic:

https://ibb.co/34s8Lbj

And here's what my knuckles look like when I make a fist:

https://ibb.co/QQvDJZV


My characterization of Hands/Feet is the feeling of arthritis. You may be too young to have experienced arthritis but I've had it in my knees in the past. It's kind of a fuzzy feeling - that you don't feel things as well as normal. Sometimes your fingers are a touch less responsive to doing what you tell them to.


OK, interesting. I've never experienced these arthritis symptoms, so I guess I don't have hand/foot syndrome?

I'm also reading that darker-skinned (non-Caucasian) people are the ones who get the skin darkening. Is this other peoples' experience? I'm exactly half German and half Lebanese, although my Lebanese father is extremely fair for a Lebanese.. if you saw him, you might think he was Italian, at the darkest. I have brown eyes and naturally brown hair, but my skin has always been extremely fair, and I always need a couple of sunburns before I can tan. I would never consider myself a "dark" person. This is very weird.

And would urea cream or henna help the skin darkening? Honestly, I am a bit vain, but it looks much worse in photos. I can totally live with this if it doesn't get any worse. But I am worried it will get worse... and appear on my face.
Last edited by TinaFish on Fri Aug 30, 2019 9:09 pm, edited 1 time in total.
F 45, single mother to son, 7 and daughter, 3
DX: stage 4 Rectal Cancer June 2019
Tumor Location: ? cm above anal verge
Tumor type: Adenocarcinoma
Tumor size: 5 cm
Tumor grade: ?
TNM code: ?
Stage : Stage IV-B
# of cancerous lymph nodes: ?
Mets: Numerous mets to liver, lungs
CEA: 22 in July; 11 as of August 15, 7 as of Sept 20
MSI status: MSS
KRAS/BRAF status: KRAS mutation
surgery: TBD
Ostomy surgery: TBD
Radiation therapy: TBD
Chemotherapy : CAPEOX+Avastin, 6 cycles, with CT scans after 3rd and 6th cycle.

NHMike
Posts: 2555
Joined: Fri Jul 21, 2017 3:43 am

Re: Hand Foot Syndrome

Postby NHMike » Fri Aug 30, 2019 9:09 pm

TinaFish wrote:
NHMike wrote:OK, interesting. I've never experienced these arthritis symptoms, so I guess I don't have hand/foot syndrome?

I'm also reading that darker-skinned (non-Caucasian) people are the ones who get the skin darkening. Is this other peoples' experience? I'm exactly half German and half Lebanese, although my Lebanese father is extremely fair for a Lebanese.. if you saw him, you might think he was Italian, at the darkest. I have brown eyes and naturally brown hair, but my skin has always been extremely fair, and I always need a couple of sunburns before I can tan. I would never consider myself a "dark" person. This is very weird.


I got Hand/Foot in Adjuvant Chemo. I didn't get it during Neo-Adjuvant and I think that's because the dose was lower and I only took Xeloda during the week. WIth Adjuvant, I took it 14 days in a row, so things built up, then declined on the week off. But eventually, it didn't go away on the rest week.

I'm light-skinned Chinese and I had the darkening on the backs of my hands and the tops of my feet.
6/17: ER rectal bleeding; Colonoscopy
7/17: 3B rectal. T3N1bM0. 5.2 4.5 4.3 cm. Lymphs: 6 x 4 mm, 8 x 6, 5 x 5
7/17-9/17: Xeloda radiation
7/5: CEA 2.7; 8/16: 1.9; 11/30: 0.6; 12/20 1.4; 1/10 1.8; 1/31 2.2; 2/28 2.6; 4/10 2.8; 5/1 2.8; 5/29 3.2; 7/13 4.5; 8/9 2.8, 2/12 1.2
MSS, KRAS G12D
10/17: 2.7 2.2 1.6 cm (-90%). Lymphs: 3 x 3 mm (-62.5%), 4 x 3 (-75%), 5 x 3 (-40%). 5.1 CM from AV
10/17: LAR, Temp Ileostomy, Path Complete Response
CapeOx (8) 12/17-6/18
7/18: Reversal, Port Removal
2/19: Clean CT

TinaFish
Posts: 178
Joined: Sun Jul 21, 2019 10:11 am

Re: Hand Foot Syndrome

Postby TinaFish » Fri Aug 30, 2019 9:16 pm

NHMike wrote:
I got Hand/Foot in Adjuvant Chemo. I didn't get it during Neo-Adjuvant and I think that's because the dose was lower and I only took Xeloda during the week. WIth Adjuvant, I took it 14 days in a row, so things built up, then declined on the week off. But eventually, it didn't go away on the rest week.

I'm light-skinned Chinese and I had the darkening on the backs of my hands and the tops of my feet.


Thank you for that info, Mike. Sorry, adjuvant means post-surgery, right? I think? So right now, I'm on neo-adjuvant Xeloda (pre-surgery). But I'm doing the 2 weeks on, one week off program.

AAAAAND I just started my Xeloda again today. I was off of it for a whole week until today. Shouldn't this dark skin have improved during my off week? It doesn't look any different than when I first noticed it a week ago.

And while we're on the topic of skin, let me tell you something very weird: for the past couple of years, I have had two patches of eczema - one on each knee. It just looked like dry skin, and only itched a little bit, on occasion. If I really wanted to hide it, like if I was wearing an outfit that showed my legs, then some Vaseline would do the trick. But after starting chemo, the eczema has been totally gone! Is that normal? Chemo gets rid of eczema?
Last edited by TinaFish on Fri Aug 30, 2019 9:23 pm, edited 1 time in total.
F 45, single mother to son, 7 and daughter, 3
DX: stage 4 Rectal Cancer June 2019
Tumor Location: ? cm above anal verge
Tumor type: Adenocarcinoma
Tumor size: 5 cm
Tumor grade: ?
TNM code: ?
Stage : Stage IV-B
# of cancerous lymph nodes: ?
Mets: Numerous mets to liver, lungs
CEA: 22 in July; 11 as of August 15, 7 as of Sept 20
MSI status: MSS
KRAS/BRAF status: KRAS mutation
surgery: TBD
Ostomy surgery: TBD
Radiation therapy: TBD
Chemotherapy : CAPEOX+Avastin, 6 cycles, with CT scans after 3rd and 6th cycle.

NHMike
Posts: 2555
Joined: Fri Jul 21, 2017 3:43 am

Re: Hand Foot Syndrome

Postby NHMike » Fri Aug 30, 2019 9:22 pm

TinaFish wrote:
NHMike wrote:
I got Hand/Foot in Adjuvant Chemo. I didn't get it during Neo-Adjuvant and I think that's because the dose was lower and I only took Xeloda during the week. WIth Adjuvant, I took it 14 days in a row, so things built up, then declined on the week off. But eventually, it didn't go away on the rest week.

I'm light-skinned Chinese and I had the darkening on the backs of my hands and the tops of my feet.


Thank you for that info, Mike. Sorry, adjuvant means post-surgery, right? I think? So right now, I'm on neo-adjuvant Xeloda (pre-surgery). But I'm doing the 2 weeks on, one week off program.

AAAAAND I just started my Xeloda again today. I was off of it for a whole week until today. Shouldn't this dark skin have improved during my off week? It doesn't look any different than when I first noticed it a week ago.


I've never heard of two weeks on/one week off on neo-adjuvant before. Must be something that came out of the TNT trials or something. I did not pay that much attention to the darkening skin because I had much bigger problems with the Oxaliplatin. The skin coloring issue went away a few months after the end of treatment.
6/17: ER rectal bleeding; Colonoscopy
7/17: 3B rectal. T3N1bM0. 5.2 4.5 4.3 cm. Lymphs: 6 x 4 mm, 8 x 6, 5 x 5
7/17-9/17: Xeloda radiation
7/5: CEA 2.7; 8/16: 1.9; 11/30: 0.6; 12/20 1.4; 1/10 1.8; 1/31 2.2; 2/28 2.6; 4/10 2.8; 5/1 2.8; 5/29 3.2; 7/13 4.5; 8/9 2.8, 2/12 1.2
MSS, KRAS G12D
10/17: 2.7 2.2 1.6 cm (-90%). Lymphs: 3 x 3 mm (-62.5%), 4 x 3 (-75%), 5 x 3 (-40%). 5.1 CM from AV
10/17: LAR, Temp Ileostomy, Path Complete Response
CapeOx (8) 12/17-6/18
7/18: Reversal, Port Removal
2/19: Clean CT

TinaFish
Posts: 178
Joined: Sun Jul 21, 2019 10:11 am

Re: Hand Foot Syndrome

Postby TinaFish » Fri Aug 30, 2019 9:25 pm

Yeah, oxaliplatin is a bitch.

I'm surprised that the two weeks on, one week off for neo-adjuvant isn't standard! What was your neo-adjuvant protocol, Mike?
F 45, single mother to son, 7 and daughter, 3
DX: stage 4 Rectal Cancer June 2019
Tumor Location: ? cm above anal verge
Tumor type: Adenocarcinoma
Tumor size: 5 cm
Tumor grade: ?
TNM code: ?
Stage : Stage IV-B
# of cancerous lymph nodes: ?
Mets: Numerous mets to liver, lungs
CEA: 22 in July; 11 as of August 15, 7 as of Sept 20
MSI status: MSS
KRAS/BRAF status: KRAS mutation
surgery: TBD
Ostomy surgery: TBD
Radiation therapy: TBD
Chemotherapy : CAPEOX+Avastin, 6 cycles, with CT scans after 3rd and 6th cycle.

NHMike
Posts: 2555
Joined: Fri Jul 21, 2017 3:43 am

Re: Hand Foot Syndrome

Postby NHMike » Fri Aug 30, 2019 9:39 pm

TinaFish wrote:Yeah, oxaliplatin is a bitch.

I'm surprised that the two weeks on, one week off for neo-adjuvant isn't standard! What was your neo-adjuvant protocol, Mike?


It may be standard now. There were a lot of clinical trials with TNT the past two years.

My neo-adjuvant was Chemo + Radiation for 28 days M-F and weekends off.
6/17: ER rectal bleeding; Colonoscopy
7/17: 3B rectal. T3N1bM0. 5.2 4.5 4.3 cm. Lymphs: 6 x 4 mm, 8 x 6, 5 x 5
7/17-9/17: Xeloda radiation
7/5: CEA 2.7; 8/16: 1.9; 11/30: 0.6; 12/20 1.4; 1/10 1.8; 1/31 2.2; 2/28 2.6; 4/10 2.8; 5/1 2.8; 5/29 3.2; 7/13 4.5; 8/9 2.8, 2/12 1.2
MSS, KRAS G12D
10/17: 2.7 2.2 1.6 cm (-90%). Lymphs: 3 x 3 mm (-62.5%), 4 x 3 (-75%), 5 x 3 (-40%). 5.1 CM from AV
10/17: LAR, Temp Ileostomy, Path Complete Response
CapeOx (8) 12/17-6/18
7/18: Reversal, Port Removal
2/19: Clean CT

TinaFish
Posts: 178
Joined: Sun Jul 21, 2019 10:11 am

Re: Hand Foot Syndrome

Postby TinaFish » Sat Aug 31, 2019 10:13 pm

Well, I did some reading, and it said that hand-foot syndrome is brought on by the capillaries in the hands and feet leaking out some of the chemo medicine. The chemo medicine is so destructive to the skin, and evidently the capillaries in the hands and feet have a tendency to leak moreso than the capillaries elsewhere on the body.

So if the skin is so harmed by the chemo meds, then how does it even help the situation when you keep the skin moisturized? I think you'd literally be moisturizing dead skin. Maybe that helps it to slough off faster, but I can't see how it could cure or prevent the blisters and swelling.
F 45, single mother to son, 7 and daughter, 3
DX: stage 4 Rectal Cancer June 2019
Tumor Location: ? cm above anal verge
Tumor type: Adenocarcinoma
Tumor size: 5 cm
Tumor grade: ?
TNM code: ?
Stage : Stage IV-B
# of cancerous lymph nodes: ?
Mets: Numerous mets to liver, lungs
CEA: 22 in July; 11 as of August 15, 7 as of Sept 20
MSI status: MSS
KRAS/BRAF status: KRAS mutation
surgery: TBD
Ostomy surgery: TBD
Radiation therapy: TBD
Chemotherapy : CAPEOX+Avastin, 6 cycles, with CT scans after 3rd and 6th cycle.

TinaFish
Posts: 178
Joined: Sun Jul 21, 2019 10:11 am

Re: Hand Foot Syndrome

Postby TinaFish » Sat Aug 31, 2019 10:22 pm

Beckster wrote:
TinaFish wrote:Bumping, sorry. Please see the pics in my previous reply?? I'd really like some feedback


To me, it looks like darkening of your skin from Xeloda...here is a picture of the bottom of my foot after the 3rd cycle

https://ibb.co/vsWjS70


Beckster, is that just discoloration? Because it looks like a painful blister. And that's the area of your foot that bears your weight when you stand/walk, so all the more reason for me to think it's a blister. How did this resolve itself? Did it get worse than what the photo shows, before it got better? I'm asking because today, I started feeling some tenderness on the balls of my feet too. I've been trying to stay off my feet as much as possible.
F 45, single mother to son, 7 and daughter, 3
DX: stage 4 Rectal Cancer June 2019
Tumor Location: ? cm above anal verge
Tumor type: Adenocarcinoma
Tumor size: 5 cm
Tumor grade: ?
TNM code: ?
Stage : Stage IV-B
# of cancerous lymph nodes: ?
Mets: Numerous mets to liver, lungs
CEA: 22 in July; 11 as of August 15, 7 as of Sept 20
MSI status: MSS
KRAS/BRAF status: KRAS mutation
surgery: TBD
Ostomy surgery: TBD
Radiation therapy: TBD
Chemotherapy : CAPEOX+Avastin, 6 cycles, with CT scans after 3rd and 6th cycle.

Beckster
Posts: 438
Joined: Thu Jan 12, 2017 3:01 pm
Location: New Jersey

Re: Hand Foot Syndrome

Postby Beckster » Sun Sep 01, 2019 5:50 am

TinaFish wrote:
Beckster wrote:
TinaFish wrote:Bumping, sorry. Please see the pics in my previous reply?? I'd really like some feedback


To me, it looks like darkening of your skin from Xeloda...here is a picture of the bottom of my foot after the 3rd cycle

https://ibb.co/vsWjS70


Beckster, is that just discoloration? Because it looks like a painful blister. And that's the area of your foot that bears your weight when you stand/walk, so all the more reason for me to think it's a blister. How did this resolve itself? Did it get worse than what the photo shows, before it got better? I'm asking because today, I started feeling some tenderness on the balls of my feet too. I've been trying to stay off my feet as much as possible.


It was discoloration....in fact, as time progressed, the discoloration spread. The tips of my fingers also turned darker. I lived in sketchers and continued to walk even though the bottom of my feet were sore. As soon as he adjusted my dosage, the soreness was less intense. The good news is that when I finished the chemo, my feet went back to normal. It took about 4-6 months for the discoloration to go away.
57/F
DX:(CC) 10/19/16
11/4/16- Lap right hemi(cecum)
CEA- Pre Op (1.9), Pre Chemo (2.5)
Type: Adenocarcinoma
Tumor size:3.5 cm x 2.5 x 0.7 cm
Grade: G3
TNM: T3N0M0/IIA
LN: 0/24
LVI present
Surgical margins: clear
MSS
12/27/2016 - Capeox, anaphylactic
1/2/17 to 6/9/17- Xeloda
6/17,12/17,6/18,12/18,6/19,12/19,12/20,12/21 CT Scan NED :D
CEA- 6/17- 3.6, 9/17- 2.8 12/17-2.8, 3/18-3.1, 6/18-3.0, 9/18 2.8, 12/18 2.5 3/19 3.1 6/19 3.1 9/19 2.6 12/19 2.8 6/20 3.0 12/20 2.7 6/21 2.9,[color=#000000]12/21 2.7[/color]
Clear Colonoscopy 10/17, 11/19,11/21 :D

TinaFish
Posts: 178
Joined: Sun Jul 21, 2019 10:11 am

Re: Hand Foot Syndrome

Postby TinaFish » Sun Sep 01, 2019 7:54 pm

So here's some crazy info:

I already mentioned that I'm on the toilet a million times a day. I noticed today that when I sit on the toilet, I have a tendency to fold my arms a certain way, with the elbow of my left arm sitting on top of, and pushing into, my right hand! I swear, when I do this, the skin on my right hand's knuckles gets bunched up, and that little "smear" area near my wrist is an area that receives pressure too!

Isn't this super weird? I'm sure it's related to the capecitabene, I mean, this crazy s*** wouldn't be happening otherwise, but has anyone heard of skin being effected like this because it gets pushed into a wrinkled position, or because it gets pushed on excessively? I think this is so weird.
F 45, single mother to son, 7 and daughter, 3
DX: stage 4 Rectal Cancer June 2019
Tumor Location: ? cm above anal verge
Tumor type: Adenocarcinoma
Tumor size: 5 cm
Tumor grade: ?
TNM code: ?
Stage : Stage IV-B
# of cancerous lymph nodes: ?
Mets: Numerous mets to liver, lungs
CEA: 22 in July; 11 as of August 15, 7 as of Sept 20
MSI status: MSS
KRAS/BRAF status: KRAS mutation
surgery: TBD
Ostomy surgery: TBD
Radiation therapy: TBD
Chemotherapy : CAPEOX+Avastin, 6 cycles, with CT scans after 3rd and 6th cycle.

MeAndMine
Posts: 149
Joined: Mon Aug 05, 2019 2:40 pm

Re: Hand Foot Syndrome

Postby MeAndMine » Wed Sep 18, 2019 4:22 pm

I just started my Xeloda again today.

How are you doing Tina? I hope your treatment is getting easier and you're handling it well.
F 56 non-smoker
8/5/2019 - Colonoscopy - 4-5 cm rectal mass, 2-3 cm proximal to anal verge and 6mm polyp
8/13/2019 - CT - No mets
8/19/2019 - Rectum: Adenocarcinoma arising from tubulovillous adenoma. Descending colon: tubular adenoma
8/23/2019 First visit with surgeon
8/26/2019 First visit with oncologist
8/26/2019 MRI
CEA 8/19/19=3.9, 8/26/19=7.1
9/6/2019 - T3N2a
9/11/2019 - Radiation begins - 5.5 weeks along with oral capecitabine


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