Green Tea wrote:
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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")
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)
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.
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