I'm very interested in this topic due to my current situation and looking for a little help:
I did 4/8 Tx of FOLFOX (1 w/o oxaliplatin) under a TNT approach for Stage III lower/mid rectal tumor (5 cm), bailed out (with support of 2/3 of my team) to chemorad with an estimated 60-75% response. I had suffered several serious side effects, including massive UE-DVT, arrhythmias (determined after lots of monitoring & testing to be likely benign), neutropenia, low platelets, elevated liver enzymes (e.g., ALT 7x normal)), hospitalized 3 times, etc.. Did 33 Tx IMRT, 60 Gy, concurrent Capecitabine (Xeloda). Added two weeks of Capecitabine before and after the radiation treatments (so 4 extra weeks of 5-FU). Rectal exam at 5 weeks after CRT revealed no evidence of any remaining tumor in the rectum. Will be scanned in mid-April. I will pursue a watch & wait strategy if examination at the end of the interval confirms a cCR.
My dilemma is the following: My team (or at least 2/3 of it), who are fantastic and whom I love, has recommended I try to do the remaining 4 FOLFOX Tx in the interval before assessment and surgery, if necessary. I originally agreed to this, but my blood counts have remained somewhat low after 5 weeks post CRT (most around the bottom of the normal range), and appear to be increasing slowly. I considered it, agreed, but now have delayed due to concerns about heading back into active chemo with the coronavirus pandemic just ramping up. I could try CSF, but of course I would still be immunocompromised for at least some periods and want to avoid that right now.
For now I don't think this picture is too bad, but I don't think I want to skip the remaining 4 Tx entirely if I can help it, and I suspect pandemic conditions may be worse in a month or so when I am assessed and confronted with what may be a more final decision on additional chemo (my understanding is that chemo in the interval is still uncommon, though a promising treatment, but I fear that 3.5/4 cycles of FOLFOX + an extra month of Capecitabine would generally be regarded as undertreatment). Though I have seen that some approaches drop the adjuvant chemo entirely after the achievement of a cCR even without the 4-6 cycles of neoadjuvant treatment I got (4+ a month of Xeloda).
Can anyone provide links to literature on the current thinking on the value of, say, 4 vs. 6 vs. 8 chemo cycles (particularly FOLFOX)? I think the extra Capecitabine probably adds the equivalent of a cycle or two to the picture, but it's very hard for me to balance risk right now, and this is a piece where I just can't find the relevant data/studies (that are referred to in this thread). Thanks for any information/links anyone can provide -- I'm a voracious consumer of the stuff, but I just can't locate good material on this particular subject. Thanks!
7/19: Rectal cancer: Initially staged as IIIA, T2N1M0
Initially approx 4.25 cm, low/mid rectum, mod. well diff. adenocarcinoma
8/22 -10/14 4 rounds FOLFOX neoadjuvant, 3 w/Oxiplatin (lots of side effects/reduced size est. 70-75%)
Switched to neoadjuvant chemorad in 11/19 (Xeloda and approx. IMRT, 60 Gy, 33 fractions)
Trying to achieve cCR.