Question for those who have undergone radiation for rectal cancer

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weisssoccermom
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Question for those who have undergone radiation for rectal cancer

Postby weisssoccermom » Wed Apr 20, 2022 9:37 pm

I know that things have changed since I was diagnosed and underwent my treatment. Right now, I have a friend who was recently diagnosed with rectal cancer. His protocol includes 4 rounds of XELOX prior to radiation and then (I assume) 28 - 30 days of radiation. When I was in treatment, they didn't do chemo first...we started with radiation. So obviously protocols have changed somewhat. My question for those who underwent radiation for rectal cancer, what type of chemo did you have during your radiation? I was on Xeloda (back then there was no generic capecitabine) but at a lower dose than the dosage without radiation. Did you have Xeloda/Capecitabine during radiation at the same dosage before or after (surgery). How many of you also had OXI during radiation? He's asking me all sorts of questions and while much has remained the same....a lot of the treatment protocol has been tweaked/modified. He's really having a hard time on his CAPEOX (XELOX) protocol right now and I'm pretty certain he will have radiation WITH the Xeloda(Capecitabine) but I don't know about the oxi.

Please share your experiences so I can give him a better idea of what to expect. IF you had OXI during radiation, how often was that? When I was in treatment, it (IMO the correct decision) was thought that radiation/Xeloda was tough enough....not warranted to add the OXI. Any information you can give me would be greatly appreciated.

Thanks
Jaynee
Dx 6/22/2006 IIA rectal cancer
6 wks rad/Xeloda -finished 9/06
1st attempt transanal excision 11/06
11/17/06 XELOX 1 cycle
5 months Xeloda only Dec '06 - April '07
10+ blood clots, 1 DVT 1/07
transanal excision 4/20/07 path-NO CANCER CELLS!
NED now and forever!
Perform random acts of kindness

roadrunner
Posts: 240
Joined: Sun Jan 12, 2020 8:46 pm

Re: Question for those who have undergone radiation for rectal cancer

Postby roadrunner » Wed Apr 20, 2022 10:58 pm

Mine was just like yours. Never heard of Oxaliplatin during radiation.
7/19: Rectal cancer: Staged as IIIA, T2N1M0
approx 4.25 cm, low/mid rectum, mod. well diff.
8/22 -10/14 4 rounds FOLFOX neoadjuvant, 3 w/Oxiplatin (side effects/reduced size est. 70-75%)
neoadjuvant chemorad 11/19
4 rounds of FOLFOX July-August 2020
ncCR found 10/20; biopsies negative
TAE 11/20, tumor cells removed, lung nodules orig id’d 6/20 stable Nov 2020
Chest CT 3/30/21 small growth in 2 nodules (3 and 5mm)
VATS 12/8/21 sub-pleural met 7mm.
SBRT for remaining nodule 1/22
CT 3/22: Clear

MadMed
Posts: 123
Joined: Sun May 02, 2021 5:52 pm
Location: Massachusetts

Re: Question for those who have undergone radiation for rectal cancer

Postby MadMed » Wed Apr 20, 2022 11:30 pm

I had radiation last October, it was the regular Xeloda/Capecitabine week days with radiation. 28 days. That being said, i did have 4 months of chemo before radiation (TNT) and that did include oxi..ugh!
If your friend is getting XELOX during rad, that's a really old protocol.I think they used to do that back in the early 2000s.

I can't imagine getting oxi twice, during chemo and the CRT!
52M DX: RC lower rectum, guessing now 2cm from AV 4/27/2021
T3N0M0 adenocarcinoma with signet ring cell features
Tumor size 30mm
Tumor grade: G3
Baseline CEA 1.0
MSI status: MSS pMMR
Started Folfox 5/12/2021
Switched to FOLFIRINOX from session 2. 8 rounds total.
CT+MRI tumor contained shrunk 80%, no spread to other organs.
CRT started xeloda + 28 days Radiation 9/27-11/04
NED as of 4/06 CT/MRI/sigmoidoscopy
On W&W 04/06/2022

prayingforccr
Posts: 317
Joined: Sun Jun 28, 2020 4:44 pm

Re: Question for those who have undergone radiation for rectal cancer

Postby prayingforccr » Wed Apr 20, 2022 11:49 pm

Did radiation with capecitabine and peposertib (clinical trial drug)

Waited six weeks.

8 cycles folfox.

Primary tumor destroyed……now mets to lungs

Nasty, nasty, nasty proctitis and stricture.
11/19: colonoscopy
12/19: diagnosed with stage 3 rectal cancer 6+cm tumor
1-3/20: 20 sessions of radiation, mon-fri capecetibine+clinical trial drug m3814
7/20: 8 treatmentsFOLFOX
11/20: Primary tumor had complete response. Possible tumor deposits on latest mri. Biopsy negative for cancer.
5/21: Multiple lung nodules (3-6mm) on ct scan
10/21: md anderson gives me 1 year without treatment/3 years with folfiri/avastin (refused)
3/22 No growth in nodules 6 months…..most showing cavitation.

jsbsf
Posts: 92
Joined: Sat Aug 24, 2019 6:01 am
Location: San Francisco

Re: Question for those who have undergone radiation for rectal cancer

Postby jsbsf » Thu Apr 21, 2022 8:34 am

DH was diagnosed with stage 4 low rectal 8/2019. He was treated with 12 rounds of FOLFOX from 9/2019 to 6/2020, the last 3 had slightly reduced oxi. He has no permanent side effects. They postponed one for a week during covid.

His rectal area was treated with 5 days of high dose ERBT 500 cGy/ day for a total 2500 cGy. The logic was that his immune system could handle it as he’d held up very well through chemo. The final chemo infusion (graduation) was 6/2/2020 and the radiation was at the end of July 2020.

He has been NED (conservatively) since 10/2020. He’s currently having that verified with an ultrasound and biopsies, and we’ll have more conclusive evidence next week.
DH 61
2019 4A t3 n2 m1a
8/23 C-scopy, 5+cm mass. CEA:4.1
8/26 CT ~1cm lvr met?
9/6 PET: lvr spot
9/16 MSS. MRI: 2 live mets: 2.7 & 7mm
9/23 Port
9/30 Start FOLFOX 1-6
10/4 Lg lvr met ~3.7cm (raised concern), pri tmr stable.
CEA: 10/13,12.5;10/27-12/8 btw 4.7 & 3.1
11/5 both lvr mets ~ 2/3 smaller.
12/17 PET: sm lvr met gone, remaining tmrs @10% of orig sz & actvty
Chemo break
2020
MWA 2/5, Lap resection 2/11
CEA: 3/1-5/31 btw 2.1&2.9
3/2 start FOLFOX 7-12
7/23-29 rad
10/2/2020 NED/W&W

Claudine
Posts: 680
Joined: Tue Mar 12, 2019 2:41 pm
Location: Montana

Re: Question for those who have undergone radiation for rectal cancer

Postby Claudine » Thu Apr 21, 2022 4:29 pm

My husband was supposed to get 5 weeks of EBRT radiation with Xeloda concurrently, but since the MRI showed a T1/2 tumor instead of the expected T3, neoadjuvant treatment was cancelled. He's really suffered from oxaliplatin in the past (has permanent neuropathy from it) and developed tumors while on it, so that would not have been part of the treatment.
Wife of Dx 04/18 (51 yo). MSS, KRAS G12A, no primary
Lytic met L4 vertebrae, EBRT 04/18, SBRT 02/19
Resect small intestine 05/18 (no cancer - Crohn's)
Failed adjuvant Xelox ; Folfiri + Avastin 03/19 to 01/20
6.7 cm left adrenal mass 03/19, successful resection 02/20
Multiple small lung nodules (03/19) now gone/calcified
L3-L4-L5 fusion surgery and partial corpectomy 05/20
CEA since 03/19: high 81.1, low 3.2, now 66
MRI 2/11/22: rectal adenocarcinoma pT3 pN0 stage 2A
LAR surgery April 11

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beach sunrise
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Re: Question for those who have undergone radiation for rectal cancer

Postby beach sunrise » Thu Apr 21, 2022 5:01 pm

I had 31 rad treatments along with 5FU pump.
Someone I know up in a North West state had 30 rad treatments. Half way thru they added 4 FOLFOX treatments, then surgery. Adjuvent chemo was 4 FOLFOX infusions with the 5FU pump after each infusion for 42 hrs.
8/19 RC CEA 82.6 T3N0M0
Neoadj 5FU/rad 6 wk
High dose IVC 1 1/2 wks before surgery. Continue still twice a week
Surg 1/20 APR - margins T4bN1a IIIC G2 MSI- 1/20 LN+ LVI+ PNI-
pre cea 24/post 5.9
FOLFOX
7 rds 6-10 CEA 11.4 No more
7/20 CEA 11.1, 8.8
8/20 CEA 7.8
9/20 CEA 8.8, 9, 8.6
10/20 CEA 8.1
11/20 CEA 8's
12/20 CEA 8's & 9's
ADAPT+++ TM drug
MHL1+
PMS2+
MSH2+
MSH6+
POLD1 , KRAS Q61H
Chem-sens test NCI "Test failed, neo adj CR worked. Not enough ca cells to test"

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CRguy
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Re: Question for those who have undergone radiation for rectal cancer

Postby CRguy » Fri Apr 22, 2022 4:53 pm

Hey Jaynee
just replied to your PM and have been "on the road" or would have been back here sooner too ... :oops:

JME from 2007 :
- 6 weeks neo-adjuvant chemoradiation with Xeloda ( 3600 mg/day ) oxaliplatin not offered
- surgery
- higher dose Xeloda adjuvant chemo ( 5000 mg/day ), oxaliplatin offered BUTT not taken

Get him to join the BEST forum in the world !!!!

Cheers all
CRguy
Caregiver x 4
Stage IV A rectal cancer/lung met
15 Year survivor
my life is an ongoing totally randomized UNcontrolled experiment with N=1 !
Review of my Journey so far

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Peregrine
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Re: Question for those who have undergone radiation for rectal cancer

Postby Peregrine » Sat Apr 23, 2022 6:25 am

Given the description of your friend's current regimen, it seems to me that he is being put on the new TNT (Total Neoadjuvant Therapy) regimen, whereby the first segment of TNT is chemotherapy with oxaliplatin, the second segment is chemo/radiation with reduced-dose capecitabine without oxaliplatin (i.e., capecitabine by itself as a low-dose radiation-sensitizer). This is then followed finally by surgery. According to current NCCN Rectal Guidelines, the TNT approach is highly recommended because it maximizes the chances of zapping any micro-metastases in the pelvic region before any surgery is attempted.

This option is shown as "Scenario 1-1-0" in the rectal cancer overview quoted below. This scenario is now gaining acceptance as the preferred way to approach rectal cancer treatment. There is no post-surgery adjuvant therapy under this regimen. All therapy is done before surgery. It wasn't like that 10 or 15 years ago when most of the rectal cancer patients had some sort of adjuvant therapy after surgery.

I would suggest that your friend check with his oncologist to verify what regimen he is actually on, and to verify the sequence of treatments within the regimen.

    Green Tea wrote:

    Code: Select all

    DISCLAIMER: This post concerns only M-Stage=MØ patients, that is, Stage I, Stage II, or Stage III rectal cancer patients who have no evidence of remote metastasis to the liver, lungs, peritoneum or other remote sites.

    CancerBum21 wrote:...I just feel like the process is moving so slowly! I'm try to be as proactive as I can, but the process just seems so disorganized. Is it common for it to take over a month to go from initial diagnosis to staging and treatment? It just seems like this process is taking forever. I want to take some action or at least know how bad it is...

    Welcome to the Club!

    I'm sorry to hear that things are moving so slowly. Sometimes it just takes a long time for them to get all of the relevant data together.

    First of all, the treatment for rectal cancer is somewhat different from the treatment for colon cancer because rectal cancer (nonmetastatic) usually involves three phases, not just two.

    The three phases are:
    1. Pre-surgery (also called "neoadjuvant therapy")
    2. Surgery
    3. Post-surgery (also called "adjuvant therapy")

    The difference is that for rectal cancer it is very important to reduce the size of the tumor before surgery if at all possible. Then after surgery has taken place it may be advisable to invoke one or more more treatment protocols to "mop up" any stray tumor cells or micro-metastases that may still be present.

    So, when a patient is diagnosed with rectal cancer, at least two doctors must be assigned -- a Colorectal Surgeon and a Medical Oncologist.  But there is also the possibility that a third doctor may need to be on the team -- a Radiation Oncologist -- in case it is decided that pelvic radiation is advisable either before or after surgery.  Thus, a rectal cancer treatment plan requires that all three of the above phases be addressed up front in the planning phase before the doctors can start any kind of treatment, because the doctors need to look at the big picture to assess the best way to guarantee overall treatment success while maintaining good quality of life.

    Before a treatment plan can be launched, the team must agree specifically on what (if anything) should be done in each of the three phases above. (It should be mentioned here that in some cases it is not necessary to have all three phases.  For example, a Stage I diagnosis may require only surgery and nothing more.)

    The interventions applied in the three phases above must be tailored to the specific rectal cancer diagnosis at hand, which means that the very first part of the planning sequence is to determine a detailed diagnosis as completely as possible and as early as possible. This means that a number of diagnostic tests (e.g., CT scans,  x-rays, MRIs, ultrasounds, lab tests, genetic tests, etc.) will need to be done. This may take some time, especially if the diagnosis turns out to be a difficult, complex one.

    The NCCN gives a list of about a dozen recommended items to address when finalizing a rectal cancer diagnosis. In addition, the College of American Pathologists has a list of required pathology data elements that must be captured for a complete colorectal cancer diagnosis. Altogether there are about a dozen or a dozen and a half important data items that must be captured and incorporated in the initial diagnosis.

    Eight of the most important data elements to be captured initially are:

    1.  T-stage of primary mass:   The initial T-stage of the tumor before any intervention, i.e., T1, T2, T3, T4a, or T4b  -- the degree to which the tumor has grown into or through the rectum wall.

    2. N-stage: The initial N-stage of the regional (mesorectal) lymph nodes. i.e., N0, N1a, N1b, N1c, N2a, or N2b  according to  the number of suspicious local lymph nodes appearing on the scans.

    3.Orientation of tumor within the rectum: Dorsal-wall/ventral-wall/left-wall/right-wall.

    4. Distance between the lower aspect of the tumor and the ano-rectal ring (sphincter muscle). Degree of sphincter involvement.

    5. Tumor length (mm)

    6. Radial Margin -  Amounted of cancer-free space between the tumor and other important organs/structures. The smallest distance (mm) between the tumor and the Mesorectal Fascia (MRF)

    7. MSI or dMMR status - Whether the tumor is Microsatellite-High (MSI-H), or Microsatellite-Stable (MSS)

    8. Baseline CEA - Initial CEA level prior to any treatment intervention.

    Armed with good data in the critical areas of the diagnosis, the doctors can then proceed, in a coordinated way, to plan their respective interventions.

    For most (but not all) cases, it is assumed that surgery will need to be performed at some point in time.  Given the data received from the initial diagnosis, the surgeon will determine the various approaches that could be taken to remove the tumor, and which approach would be the best one to use in this case.

    For rectal cancer, there are a number of surgical possibilities, including AR (anterior resection) LAR (low anterior resection), ULAR (ultra low anterior resection), APR (abdomino-perineal resection), PE (pelvic extenteration), TE (trans-anal excision), TME (total mesorectal excision) TAMIS (trans anal minimally invasive surgery), TEM  (trans-anal endoscopic microsurgery), ESD (endoscopic submucosal dissection), TASER (trans anal submucosal endoscopic resection). The surgeon must determine the best approach to take given the constraints and circumstances.  In addition, the surgeon must assess whether a temporary ileostomy or a permanent colostomy will be required. And in some cases the surgeon may recommend an additional J-pouch surgery

    The type of surgery envisioned may then dictate what kind of pre-surgery treatment would be required, such as TNT (total neoadjuvant therapy), LCCRT (long course chemo-radiation therapy), SCRT (short course radiation therapy), NCT (neoadjuvant chemotherapy) --  or possibly no pre-surgery treatment at all. If radiation is deemed necessary then a Radiation Oncologist must be added to the team.

    For the post-surgery phase -- which is normally a phase of fixed length (usually from 4 to 8 months) -- there are about half a dozen options commonly available, such as FOLFOX, XELOX(CAPOX), 5FU/Leucovorin, FOLFIRI, FOLFIRINOX,  Xeloda monotherapy, or LCCRT (long course chemo/radiation therapy). These chemo options are standard, traditional cytotoxic chemo regimens. Note: For M0-staged patients, targeted therapies and immunotherapies are not on the NCCN recommended list; those therapies are reserved for Stage IV patients.

    After the team has determined the best overall treatment plan, then the patient will be informed about the specific interventions that are planned (if any) for each of the three phases.

    Since there are 3 possible phases and each of the three phases could theoretically have or not have a treatment intervention, there will be 8 possible scenarios. 

    The most common of these scenarios are the following:

    Scenario 1-1-1 : neoadjuvant therapy > surgery > adjuvant ("mop-up") therapy
    Scenario 1-1-0 : TNT > surgery > (post-surgery observation only)
    Scenario 1-0-0 :  Habr-Gama protocol to avoid surgery *** > (post treatment Wait & Watch)
    Scenario 0-1-1 :  Emergency surgery > adjuvant ("mop-up") therapy
    Scenario 0-1-0 :  Surgery only (for Stage 1 and some Stage 2A patients)

    *** Scenario 1-0-0 is when it is desired to eliminate surgery itself by imposing a powerful neoadjuvant chemotherapy regimen up-front designed to achieve complete clinical response ( cCR ) by obliterating the tumor and nearby lymph nodes. This approach is called the Habr-Gama protocol for avoiding surgery, otherwise known as Watch and Wait (W&W)

prayingforccr
Posts: 317
Joined: Sun Jun 28, 2020 4:44 pm

Re: Question for those who have undergone radiation for rectal cancer

Postby prayingforccr » Sat Apr 23, 2022 6:45 am

11/19: colonoscopy
12/19: diagnosed with stage 3 rectal cancer 6+cm tumor
1-3/20: 20 sessions of radiation, mon-fri capecetibine+clinical trial drug m3814
7/20: 8 treatmentsFOLFOX
11/20: Primary tumor had complete response. Possible tumor deposits on latest mri. Biopsy negative for cancer.
5/21: Multiple lung nodules (3-6mm) on ct scan
10/21: md anderson gives me 1 year without treatment/3 years with folfiri/avastin (refused)
3/22 No growth in nodules 6 months…..most showing cavitation.

Rock_Robster
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Location: Brisbane, Australia

Re: Question for those who have undergone radiation for rectal cancer

Postby Rock_Robster » Sat Apr 23, 2022 7:46 pm

Peregrine wrote:Given the description of your friend's current regimen, it seems to me that he is being put on the new TNT (Total Neoadjuvant Therapy) regimen, whereby the first segment of TNT is chemotherapy with oxaliplatin, the second segment is chemo/radiation with reduced-dose capecitabine without oxaliplatin (i.e., capecitabine by itself as a low-dose radiation-sensitizer). This is then followed finally by surgery.


This (TNT) is exactly what I did too and it worked well (complete metabolic response). They drop the oxaliplatin and reduce the capecitabine dose during radiation, due to cumulative toxicity risk. I have never known anyone to do FOLFOX/FOLFIRI during radiation. There are some experimental ‘sandwich’ protocols being used, but this is very theoretical. Some centres may also offer 2 cycles of FOLFOX during the 8-10 week pre-surgery period after long-course radiation (mine did but for some reason I didn’t do it; bizarrely I can’t remember why).

Good luck,
Rob
40M Australia
2018 Dx RC, 12cm high
Mod diff, EMVI, LVI. 4 liver mets
pT3N1aM1a Stage IVa. MSS NRAS G13R
CEA: Nov-18= 14; then ~2. Nov-21: 5.4
11/18 FOLFOX x6
3/19 Liver resection
5/19 25x pelvic IMRT radiation
7/19 ULAR & ileo, 1/27 LN
8/19 Liver lesion
8/19 FOLFOX, FOLFOXIRI, FOLFIRI x7
12/19 Liver resection
NED
2/20 Ileo reversed
11/21 Liver met & celiac node; 2-3 tiny lung things, indeterminate
12/21 PVE
3/22 Nodal spread & 3 liver lesions. Lymphadenectomy
4/22 Liver SBRT x 5

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Rob in PA
Posts: 2017
Joined: Wed Dec 09, 2009 9:16 pm
Location: Pennsylvania

Re: Question for those who have undergone radiation for rectal cancer

Postby Rob in PA » Mon Apr 25, 2022 7:16 am

I did neoadjuvant Xelox (ugh) with radiation prior to surgery. I had good response and they were able to cut it out without much trouble due to it having shrunk up a good bit. The thing i thought was weird is that the chemo was a pill regimen at home.

Best of luck to your friend,

Rob in PA
dx 11/07 crc IIIb @ 39
Xelox/Rad/ temp colostomy
LAR/J-pouch/ temp ileo
Folfox-8
Failed reversal
2/09 liver mets; liver resect/ileo reversal
Folfiri/Avastin - 12
2/11 5 lung mets
Folfiri/Avastin 2011
SBRT 3/12
Lung met 5/13/ said NO to more chemo
SBRT 8/13
2 lung mets 5/14, VATS 8/14, NED


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