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Forum Name: Colon and Rectal Cancers

Question: Questions about my treatment plan for Colorectal cancer


 Lindseysmommy - Wed Jan 07, 2009 11:30 am

HI, I am 42 y/o female with rectal bleeding, so colonoscopy done and 3 cm sessile appearing polyp found in rectosigmoid junction approx 15 cm from anal verge. Appeared benign. Biopsies showed high grade dysplasia. Referred to major hospital for endoscopic removal. After removal, was determined to be a pedunculated T1 tubulovillous lesion with grade 3 cells. All scans/bloodwork for metastatic disease negative. Genetic testing negative, Also no family hx. Was referred for LAR. Pathology post surgery: no residual carcinoma identified. There is a nodule (1.0 cm in greatest dimension) of epiploic fat showing fat necrosis, hemosiderin deposit and foreign body giant cell reaction. A single of 26 lymph nodes is positive for metastatic disease, with no evidence of extranodal extension. The colorectal surgeon told me i had stage 3 disease and gave me approx 40-60% survival odds.

I was referred for 4-6 months of FOLFOX/chemoradiation.

Back home i did my own research and found out i was actually stage IIIa and it appeared my odds were much better than what she had given me, and the oncologists have given me odds in the 90's. Do you agree with this? I am concerned about the grade 3 of 4. I always thought Grade 3 was poorly differentiated, yet my pathology on 2 different forms says the moderately differentiated grade 3 of 4. Is this a mistake or does that hospital maybe have a different grading system?
My other questions are the following: How do you know how much chemo is enough? I am confused because other people i talk to are getting such different regimens. For myself, my plan is for 2 cycles chemo, 6 weeks chemoradiation, and then 6 more cycles FOLFOX. I am currently undergoing cycle 2 of the 6 having completed radiation. I know others have received the radiation plus 12 cycles of FULFOX. Is this "enough" for me?
I am also concerned about the leucovorin shortage as my chemo center does not have it. I received one cycle without it already and at the same time had a 30% reduction in the 5FU/Oxaliplatin because of how my blood counts had been. With the last treatment i got Fusilev. Is this a good enough equivalent or should i be asking to switch to Xeloda? Also when on radiation, i did not get the continous 5FU, i got it only M-F for 4 of the 6 weeks, and now with the cycle of the missed leucovorin, I am wondering if i should do "make up" chemo? According to a calculator on the sloan kettering website chemo only gives me a 1% benefit..so wondering if i should even be doing it at all.. it is all so confusing. I apologize i know this got long,, but i really want to do everything i can to beat this cancer and these things are really bothering me, and i hope you will kindly answer my questions. Thank you so much.
 Dr. Tamer Fouad - Tue Jan 13, 2009 8:57 am

User avatar Hello,

It is very hard to give you a prognostic assessment over the internet. It does seem that you are stage IIIa and the presence of only one lymph node in 26 is reassuring of course.

I think your doctor knows what he is doing. Yes, the leucovorin alternative is fine. I am not sure about the benefit of adding leucovorin to 5FU in adjuvant chemoradiotherapy. So missing a dose should not be a problem.

FOLFOX after chemoradiotherapy is recommended by one of the most important guidelines in the US (NCCN). However, there are some reports of increased blood toxicity - meaning decreased white blood cells, decreased hemoglobin and platelet counts.

There are concerns about the variable bioavailability of Xeloda and for this reason it seems sensible to use the IV regimen (5FU).

I hope this is useful.
 Lindseysmommy - Fri Jan 16, 2009 11:40 am

Thank you so much for your response. I did go over and look at the guidelines from the NCCN, but I am still unable to find how doctors determine how much chemo to give in the event of someone who has had radiation. It just says FOLFOX every 2 weeks..it does not say for how many cycles. If the recommendations for me were to have 4-6 months of systemic chemotherapy in addition to the radiation..how does the doctor determine whether it should be 8 cycles or 12 cycles? Are there recommendations posted somewhere on this? Thank you
 Dr. Tamer Fouad - Sat Jan 17, 2009 9:25 am

User avatar Hi,
Thank you for your question.
I think there may be a little confusion with the number of cycles here which may make things a little easier.

Each cycle of FOLFOX is broken down in two D1 and D15, meaning: what you call 12 'cycles' is actually 6 cycles and what you call 8 'cycles' is actually 4.

We traditionally stick to 6 cycles (12 sessions) for most chemotherapy regimens. Some patients at low risk can be given 4 cycles. Notice as well that this is usually related to the chemoradiotherapy regimen that you are taking. Chemoradiotherapy is delivered in many different ways and there is no 'standard' protocol.

I hope this helps.
 Lindseysmommy - Sun Jan 18, 2009 1:01 am

yes my oncologist referred to the 'cycles' the same way as you. I guess i am just going to have to trust her judgement then as there does not seem to be a particular standard protocol in my case. I was told that i was considered at 'low risk', so i assume that must be the reason for the 4-6 month recommendation.. i just hope we do the right thing... again thanks for your responses. I appreciate it!!
 Dr.M.Aroon kamath - Wed Oct 14, 2009 8:27 pm

User avatar Hi Lindseysmommy,
Questions about staging of cancers and therapy could be at times, very confusing to even medical personnel. This is partly due to the various staging systems and treatment modalities(which are constantly changing!).
Institutions tend to follow their own protocols as well. Dr.Tamer Fouad has tried his best to clarify & answer your queries.
Colonic cancers are staged according to the TNM staging system or at times the well known Duke's staging system.
6th & 7th editions of AJCC staging system have included the "T' Category(tumor) into the stage III (IIIA,IIIB,IIIC) - this in effect, has brought some aspect of Duke's into TNM .
I am just trying to explain why & how it ends up being confusing.These changes are on-going and are primarily meant to improve the management & improve outcomes - but confusion is bound to be an inevitable side effect!!
Good luck!

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