I'm Back……Questions re Treatment Advances in Last 6 Years

[Surroundedbylove]

Hello all,

I know it has been a long time. Things are pretty well on my front although I do have some significant post chemotherapy permanent side effects but all in all, things are fine. I'm back because my SIL was just diagnosed with rectal cancer. Don't have clinical staging yet though - will have more details later in the week.

My questions are what treatment protocol changes have been made - if any - in the last 6 years? Still 5FU or Xeloda during chemoradiation? Still most people don't get oxaliplatin during neoadjuvant treatment (I did, but I recognize that was unusual and very aggressive treatment). Still 6 weeks of chemorad, then wait a couple of months for surgery?

Any tumor type testing done? Any other pretreatment tests done (I know of the test for 5FU negative reaction).

Thanks all.

SBL

[CRguy]

Good to see you posting again my friend, sorry about the reason though.
Sending your SIL best wishes.

As you know I was in the same "vintage" you refer to, with Xeloda neoadjuvant chemorad then a wait for TME resection for a rectal primary tumor (2007) ....
Hmmm guess that is a tad more than 6 years

I think we have had more FOLFOX / XELOX neoadjuvant chemos than in my day, but a lot depends upon actual staging and "local" preferences it seems.

I am sure some of the other folks will chime in here to say "HI" to you and offer some insight.

In Harmony
Always on the Journey
CRguy

[Krim4fun]

Hi-

As you can see from my signature not much has changed since your treatment. I was diagnosed a little over a year ago with stage III rectal cancer. I had 6 weeks of chemoradiation which amounted to 3 sessions of 5FU which included a 4 hour infusion with a 48 hour take home pump. Followed by surgery about 2 months later to remove the tumor. About 6-8 weeks after surgery I had my adjuvant chemo of oxilpatain & Xeloda. I only had about 4 month of adjuvant chemo, my oncologist said that this is becoming the standard practice for rectal cancer stating that the chemo done prior to surgery kind of counts as "time already served". So as I said, pretty much no real changes from 6 years ago...

Good luck to your SIL

KIM

[weisssoccermom]

Hey there SBL.....it's been a long time. Sorry to hear about your SIL and I don't know what I can add as my treatment plan was 'different' and was longer ago than yours. However, I recently read an article or two where some oncs are trying out (and it was with rectal cancer) utilizing some chemo after neoadjuvant chemoradiation but before surgery and then adjusting the amount of adjuvant chemo afterwards. It reminds me of the then 'out of the box' thinking that my onc did. I remember the article said that by utilizing this method, more patients came out of surgery with complete and total responses as compared to with neoadjuvant chemorad only. I don't know if this is in the 'clinical trial' setting or what but, it may be worth having her talk with her onc about it.

[BrownBagger]

Welcome back, SBL. Sorry to hear about your sister in law.

[SkiFletch]

Hey SBL, so sorry you need to come back here. Not a whole lot has changed early on for rectal as you've noted. Maybe the only thing is that it's become standard practice to wait AT LEAST 8 weeks post chemo/rad for surgery. Some docs prefer 10 or more.

[rp1954]

Lots of discussions with cimetidine, celecoxib, PSK, aspirin and vitamin D3 as adjuncts.

I always grind my teeth over the inadequate baseline blood testing we had available after dx, before initial surgery, despite a number of repeated inquiries. Trashed by low information "standards" again. Also a graded CA19-9 tissue stain, is highly useful for cimetidine treatments for transitional serum values in the 2 to 35 range.

Since then, we get a broad baseline of blood tests before surgery, retest the high cancer markers after surgery, ca 1-2 monthly. In addition to our basic CEA, CA19-9, LDH, GGTP, ESR, we added CA125, CA72-4, AFP markers plus CRP, vitamin D3, fibrinogen and quantitative d-dimer into the presurgeries/recur baseline, which could be crucial information if higher range. Maintenance of the extra tests costs us a little more, ca $1000 a year but probably saves us more on scans. My special snowflake is worth it anyway, and hasn't melted, in part because of the extra tests.

[Surroundedbylove]

Thank you all for the welcome back and the cares for my SIL. Ski Fletch - good to hear the surgeons are waiting for the surgery. I pushed for the 10 weeks with my surgeon after showing him the study that showed improvement if waiting 10 weeks rather than 6-8 (he previously liked to wait . Glad to hear standards are catching up to what I pushed for 6 years ago!

Weissersoccermon - so far the ERUS is showing T3 and no local nodes. 15 cm up - at rectosigmoid junction. That's still LAR territory isn't it rather than what your surgery was - or would your surgery type be on the table to discuss (and therefore learn about)?

[justin case]

I'm about 2 1/2 years out. I had 3 rounds of folfox, before chemorad, and did folfox as my gift for the 6 weeks of radiation, totaling 9 before surgery. (I was only stage 2). after surgery, I did 12 rounds of 5FU weekly by bolus, 6weeks, 2 week break, 6 final weeks and done. I had the bag for 3 weeks, as me and it could not find a happy place, and my surgeon didn't want me to die before he got paid.
Regards,
Michael

[weisssoccermom]

SBL - 15 cm up is too far up for the 'traditional' transanal excision surgery BUT...not too far up IF TEM (not to be confused with TME) is available. TEM stands for transanal endoscopic microsurgery. It's expensive equipment, has a tedious learning curve and therefore isn't readily available at all centers. IF she lives in an area where it is available it might be worth looking into. Is she in this area? I can only tell you that 8 years ago, the closest place that did the TEM surgery was in Portland (and, btw, the surgeon there is the pioneer in it). Superior to the type of surgery that I had, simply because the doctor has a much better visual of the area.

[nkoske]

My tumor was about 15cm up. I did Chemo(xeloda)/Rad(IMRT) for 25 days. Then a Laparoscopic LAR. The Surgeon was able to plug me back together and was happy with the connection so no temp ileo. My Onc gave me credit for the chemo during chemo/rad so I only had to do 6 rounds of XelOx (Xeloda + Oxaliplatin normal course is 8 cycles).

There are studies out there that say adding Oxali to Chemo/rad doesn't help.

Another recent study said, "Adjuvant fluorouracil-based chemotherapy after preoperative radiotherapy (with or without chemotherapy) does not affect disease-free survival or overall survival. Our trial does not support the current practice of adjuvant chemotherapy after preoperative radiotherapy with or without chemotherapy. New treatment strategies incorporating neoadjuvant chemotherapy are required."
http://www.ncbi.nlm.nih.gov/pubmed/24440473
The one caveat seems to be that the adjuvant chemo administered was just 5-FU not 5-FU w/ Oxali (which is standard these days), which could make a difference.

[justin case]

My tumor was about 15cm up. I did Chemo(xeloda)/Rad(IMRT) for 25 days. Then a Laparoscopic LAR. The Surgeon was able to plug me back together and was happy with the connection so no temp ileo. My Onc gave me credit for the chemo during chemo/rad so I only had to do 6 rounds of XelOx (Xeloda + Oxaliplatin normal course is 8 cycles).

There are studies out there that say adding Oxali to Chemo/rad doesn't help.

Another recent study said, "Adjuvant fluorouracil-based chemotherapy after preoperative radiotherapy (with or without chemotherapy) does not affect disease-free survival or overall survival. Our trial does not support the current practice of adjuvant chemotherapy after preoperative radiotherapy with or without chemotherapy. New treatment strategies incorporating neoadjuvant chemotherapy are required."
http://www.ncbi.nlm.nih.gov/pubmed/24440473
The one caveat seems to be that the adjuvant chemo administered was just 5-FU not 5-FU w/ Oxali (which is standard these days), which could make a difference.

When one has 2 tumors, one in the rectum, and 1 in the sigmoid colon, as only the rectum can be radiated, combining oxi with radiation can, and did treat both tumors before surgery. As there were clear margins, and no intravenous infiltration, I have been NED for over 2 3/4 years. Perhaps oxi had nothing to do with it, butt I wouldn't have done anything differently. After 9 rounds of Folfox, 5FU was a walk in the park, and I probably didn't need that.
Michael

[nkoske]

My tumor was about 15cm up. I did Chemo(xeloda)/Rad(IMRT) for 25 days. Then a Laparoscopic LAR. The Surgeon was able to plug me back together and was happy with the connection so no temp ileo. My Onc gave me credit for the chemo during chemo/rad so I only had to do 6 rounds of XelOx (Xeloda + Oxaliplatin normal course is 8 cycles).

There are studies out there that say adding Oxali to Chemo/rad doesn't help.

Another recent study said, "Adjuvant fluorouracil-based chemotherapy after preoperative radiotherapy (with or without chemotherapy) does not affect disease-free survival or overall survival. Our trial does not support the current practice of adjuvant chemotherapy after preoperative radiotherapy with or without chemotherapy. New treatment strategies incorporating neoadjuvant chemotherapy are required."
http://www.ncbi.nlm.nih.gov/pubmed/24440473
The one caveat seems to be that the adjuvant chemo administered was just 5-FU not 5-FU w/ Oxali (which is standard these days), which could make a difference.

When one has 2 tumors, one in the rectum, and 1 in the sigmoid colon, as only the rectum can be radiated, combining oxi with radiation can, and did treat both tumors before surgery. As there were clear margins, and no intravenous infiltration, I have been NED for over 2 3/4 years. Perhaps oxi had nothing to do with it, butt I wouldn't have done anything differently. After 9 rounds of Folfox, 5FU was a walk in the park, and I probably didn't need that.
Michael

There's exceptions to every rule...doesn't change the results of studies though.

Having synchronous tumors I would think puts you in a different program. Makes sense to me to go with an aggressive chemo while frying one tumor but not another. Don't want floaters sloughing off the tumor not getting cooked and setting up shop somewhere new.