nova17 wrote:...The plan now is daily Xeloda because it worked well with the primary. Obviously the more heavy hitting chemo regimens are still options but the onc wants to start with this and see where it goes. He wasn’t even adamant about starting chemo immediately due to the slow growth. Is only daily Xeloda for this situation appropriate? Or is this strategy too relaxed?
Green Tea wrote:nova17 wrote:...The plan now is daily Xeloda because it worked well with the primary. Obviously the more heavy hitting chemo regimens are still options but the onc wants to start with this and see where it goes. He wasn’t even adamant about starting chemo immediately due to the slow growth. Is only daily Xeloda for this situation appropriate? Or is this strategy too relaxed?
Hello Nova17 and welcome to the Forum.
I'm sorry to hear about your father. This is really disappointing news, given that your father has done so well up to now.
I did some checking on the NCCN 2021 Rectal Cancer Guidelines for first-line treatment of recurrent CRC, and this is what I found in the guidelines:
There are two first-line treatment tracks for mCRC listed in Section on page 41 . The first track is called, "Patients with advanced or metastatic CRC who are appropriate candidates for intensive therapy " and the second track is called "Patients with advanced or metastatic CRC who are not appropriate candidates for intensive therapy ".
The first track is the one that lists the "heavy hitting" regimens like FOLFOX+Avastin(bevacizumab), FOLFOXIRI, etc. Almost all of the regimens in this track are combination regimens that usually contain powerful drugs like Eloxatin(oxaliplatin), or Avastin(bevacizumab), or targeted therapy drugs like Erbitux(cetuximab) or Vectabix(panitumumab) etc. This track doesn't have any recommended single-drug regimens like 'Xeloda monotherapy', except for several new immunotherapy options like Keytruda.
The second track has a number of options, including the one that your oncologist is recommending (Xeloda monotherapy), as well as several other single-drug regimens, including immunotherapy options, and a few combination regimens, too. This is a track of "softer" chemo options that might be called something like "chemo light".
So it looks like the oncologist has decided that your father falls in the second category, but I'm not sure why. It suggests that your oncologist considers your father to be a "Patient who is an inappropiate candidate for intensive therapy."
The second track obviously exists because there are indeed some patients who either cannot tolerate the stronger regimens or who don't need such strong regimens to control their situation.
I would suggest that your father have another discussion with the oncologist to ask for further clarification on the matter. The oncologist may be able to specify exactly what constraints make the second track the preferable one at this time.
It should be mentioned that if your father's tumor was tested for micro satellite instability (MSI) just after surgery and if the tumor was classified as MSI-High, then he would qualify now for a powerful first-line mCRC immunotherapy option like Keytruda(pembrolizumab). You might want to ask the oncologist if the resected tumor could be retrieved from storage and tested now for MSI if it has not yet been tested.
It would also help if you could get clarification on exactly where the troublesome nodules are located, because it might make a difference for the long-term treatment strategy.
catstaff wrote:My husband has lingering neuropathy from folfox but is on folfiri+bev right now. Folfiri should not cause or exacerbate neuropathy. Are there perhaps other health issues? So far DH is tolerating folfiri much better than folfox, though he hasn't had that many rounds yet.
nova17 wrote:... Also if anyone who’s knowledgeable about PET scans has any insight on my last post I would greatly appreciate any input! I find it odd that the impression just says “continued attention on CT follow up recommended” and makes no indication that this is definitely a recurrence. Do scan impressions usually leave that decision to the oncologist?
Green Tea wrote:nova17 wrote:... Also if anyone who’s knowledgeable about PET scans has any insight on my last post I would greatly appreciate any input! I find it odd that the impression just says “continued attention on CT follow up recommended” and makes no indication that this is definitely a recurrence. Do scan impressions usually leave that decision to the oncologist?
In my experience, it has been the radiologist who made the decision. In your case, I think the problem is that the spots are too small for the radiologist to make a determination at this time. He/she needs a larger, more detailed image in order to look at the detail, such as the shape, symmetry of the spot and also to be able to use the software tools that come with the scanner to estimate the spot's density, homogeneity, etc. When the spots are too small all they can really say is that they have noticed something abnormal that is unlike the adjacent tissue, but they cannot recognize any of the standard features that would allow its identity to be verified. In such a case, the radiologist's default response is just to alert the doctor to the fact that something unusual has been seen but that it cannot be characterized until, or if, it increases in size so that they can see more detail. So they just remind the doctor that he/she should submit a requisition for a new scan later on when the spots might become larger and more visible.
Right now it impossible for the radiologist to distinguish between benign granulomas and malignant metastases because they would all look the same at this level of definition.
nova17 wrote:... I just wondered why no judgment call was made yet on the PET even after interval growth was observed on the previous CT. I also just noticed that the top of the PET report says “enlarging lung nodule seen on previous CT scan”, which implies that only a single nodule definitely grew?
jts wrote:Last year I had a PET/CT that discovered a 5-6 mm lung met. It was actually the CT part of the scan that discovered it, because it did not show up on the PET. Going back to my old scans, the radiologist could show it was growing steadily for about 9 months, but had never been formally noted. There was some disagreement about whether to "wait and see what it does" because it didn't show decisive activity on the PET, or take it out right away. Luckily I was able to have it removed, and it turned out to be a met after all. Also luckily, almost a year later my lungs are still clear.
In my case they did not do chemo first, because when they discovered the met, I had just finished with adjuvant FOLFOX. The met had been growing the whole time. There was no point in doing more of that.
Your oncologist's plan, assuming it is most likely disease and making a plan that hopefully gets your dad clean lungs, makes sense to me. I would still be eager to talk to a surgeon to get some idea if the collection of nodes will be operable. Maybe your oncologist already talked about it, or had some feedback from their tumor conference.
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