Recurrence Rates W/ and W/O Chemo

My wife was diagnosed with stage II rectal cancer (T3, N0, M0) in Feb.of this year. She has already undergone surgery to remove the tumor and has undergone adjuvant radiation and oral chemo. 

We are now considering whether she should continue with i.v. chemo (port and pump) - whether the decrease in recurrence rates will be enough to offset the additional pain and suffering involved.

Her oncologist put recurrence rates with nothing except surgery at 40% and with everything (radiation, oral and i.v chemo) at 20%. He also said that "if you only choose one or the other, radiation is the most important part" and so we assume that she would only see less than a 10% improvement in the odds if she continued with the i.v. treatments. But we really would like to find some reliable statistics.

Can anyone help?

On 6/29/2009 sajbs1 wrote:

My wife was diagnosed with stage II rectal cancer (T3, N0, M0) in Feb.of this year. She has already undergone surgery to remove the tumor and has undergone adjuvant radiation and oral chemo. 

We are now considering whether she should continue with i.v. chemo (port and pump) - whether the decrease in recurrence rates will be enough to offset the additional pain and suffering involved.

Her oncologist put recurrence rates with nothing except surgery at 40% and with everything (radiation, oral and i.v chemo) at 20%. He also said that "if you only choose one or the other, radiation is the most important part" and so we assume that she would only see less than a 10% improvement in the odds if she continued with the i.v. treatments. But we really would like to find some reliable statistics.

Can anyone help?

 

I'm not sure where your onc is getting his figures from.  It is true that rectal cancer has a higher LOCAL recurrence rate than colon cancer.  In addtion, it is also true that neoadjuvant chemoradiation offers better statistical (by a few percentage points) advantage over adjuvant chemoradiation.  Which brings me to the question.  Why with a T3 tumor (this should have been clinically staged prior to surgery) didn't your onc recommend chemoradiation prior to surgery??

As to the other points in your post.  Those statistics that your onc quoted are from a long time ago and are no longer accurate with the newer techniques in surgery.  The TME (total mesorectal excision) has drastically improved the odds in patients.  Again,  however, I wonder why chemoradiation was not done first to shrink the tumor and to help with local control.

Unless you have some negative prognostic factors, such as: mucinous or signet cell adenocarcinoma, poorly differentiated tumor, vascular invasion, etc. I would recommend adjuvant chemo HOWEVER, there is no need to do the full blown chemo with a stage IIA with no negative prognositic factors.  Furthermore, the pump/port is also not necessary.  The oral chemo, Xeloda, has been proven to be just as effective and most studies actually show it to be significantly MORE effective than 5FU.leucovorin via infusion.  The addition of oxi to the protocol is not warranted (again assuming no negative prognositic factors) for stage IIA patients as it only adds 1 -2 percent to an already high (85-88% NOT the figures he gave you) statistical survival benefit.  Remember that oxi also has long term and even permanent side effects and the patient needs to weigh the risks of side effects against the potential benefit it might give him/her.

The choice is up to you.  Personally I had the following protocol with a stage IIA (there was some discrepancy as to whether or not my tumor truly was a T3 or a T2 on the clinical ERUS exam) rectal cancer diagnosis.  5-6 weeks of chemoradiation with Xeloda (tried the pump for one week and got off of that thing soooo quickly!), 5 more months of Xeloda only, full thickness transanal excision.  I was diagnosed in 6/06, had my surgery in 4/07 and am still NED.

Remember that this is YOUR decision not the oncs.  The decision to follow up with more chemo does not have to follow his plan either.  If you want more chemo and you feel that you can tolerate Xeloda, insist that you be given that instead of the infused 5FU/leucovorin.  There is no reason why you shouldn't take it but be prepared for some potential arguments.  Although I would like to say it doesn't happen, oncs are more apt to want to Rx the infusion vs oral simply for monetary reasons.  Sometime go to the colonclub.com and read what others have said on this issue. 

You must be a decision making partner in your care and ultimately you have the sole discretionary power to say yes or no to any decisions regarding your care.  Since it sounds like you don't have a port, I would tell the onc you want the Xeloda to avoid that minor surgery, then you can still go on with the chemo and know that you have done the 'standard of care' (FOLFOX is NOT standard of care for stage IIA with no negative prognostic factors) for your stage.

Jaynee

Thanks Jaynee for the info.

 Based on your recommendation my wife decided to go with the oral xeloda.

 We feel that this should give her good odds without the additional trauma of the i.v. chemo.

Hello...

       My husband is just finishing up his Xeloda and oxiciyplatin...its an IV treatment given every 21 days. He has done VERY WELL on the Xeloda and not so bad with the oxy....everyone IS different....BUT taking the chemo AFTER IS very important....If it wasn't for Jaynee, we would have done things SO WRONG. She helped us through a real bad time and she made a bad time ALOT easier.....you could NOT ask for a better freind.

                                            Sheila

Sheila,

Thanks.  Got to tell you Sheila is an awesome woman and a wonderful caregiver. Kudos to you Sheila for being there and remaining cool during all of this!

Glad to help.  Just be sure that whatever your wife (and you) decide you are comfortable with that decision.  Xeloda and radiation is the 'standard of care' as well as the continuous pump.  Again, however, quality of life (no pump -absolutely wonderful) is a HUGE component in any patient's decision!

Jaynee

On 6/29/2009 soccermom wrote:

 

On 6/29/2009 sajbs1 wrote:

My wife was diagnosed with stage II rectal cancer (T3, N0, M0) in Feb.of this year. She has already undergone surgery to remove the tumor and has undergone adjuvant radiation and oral chemo. 

We are now considering whether she should continue with i.v. chemo (port and pump) - whether the decrease in recurrence rates will be enough to offset the additional pain and suffering involved.

Her oncologist put recurrence rates with nothing except surgery at 40% and with everything (radiation, oral and i.v chemo) at 20%. He also said that "if you only choose one or the other, radiation is the most important part" and so we assume that she would only see less than a 10% improvement in the odds if she continued with the i.v. treatments. But we really would like to find some reliable statistics.

Can anyone help?

 

I'm not sure where your onc is getting his figures from.  It is true that rectal cancer has a higher LOCAL recurrence rate than colon cancer.  In addtion, it is also true that neoadjuvant chemoradiation offers better statistical (by a few percentage points) advantage over adjuvant chemoradiation.  Which brings me to the question.  Why with a T3 tumor (this should have been clinically staged prior to surgery) didn't your onc recommend chemoradiation prior to surgery??

As to the other points in your post.  Those statistics that your onc quoted are from a long time ago and are no longer accurate with the newer techniques in surgery.  The TME (total mesorectal excision) has drastically improved the odds in patients.  Again,  however, I wonder why chemoradiation was not done first to shrink the tumor and to help with local control.

Unless you have some negative prognostic factors, such as: mucinous or signet cell adenocarcinoma, poorly differentiated tumor, vascular invasion, etc. I would recommend adjuvant chemo HOWEVER, there is no need to do the full blown chemo with a stage IIA with no negative prognositic factors.  Furthermore, the pump/port is also not necessary.  The oral chemo, Xeloda, has been proven to be just as effective and most studies actually show it to be significantly MORE effective than 5FU.leucovorin via infusion.  The addition of oxi to the protocol is not warranted (again assuming no negative prognositic factors) for stage IIA patients as it only adds 1 -2 percent to an already high (85-88% NOT the figures he gave you) statistical survival benefit.  Remember that oxi also has long term and even permanent side effects and the patient needs to weigh the risks of side effects against the potential benefit it might give him/her.

The choice is up to you.  Personally I had the following protocol with a stage IIA (there was some discrepancy as to whether or not my tumor truly was a T3 or a T2 on the clinical ERUS exam) rectal cancer diagnosis.  5-6 weeks of chemoradiation with Xeloda (tried the pump for one week and got off of that thing soooo quickly!), 5 more months of Xeloda only, full thickness transanal excision.  I was diagnosed in 6/06, had my surgery in 4/07 and am still NED.

Remember that this is YOUR decision not the oncs.  The decision to follow up with more chemo does not have to follow his plan either.  If you want more chemo and you feel that you can tolerate Xeloda, insist that you be given that instead of the infused 5FU/leucovorin.  There is no reason why you shouldn't take it but be prepared for some potential arguments.  Although I would like to say it doesn't happen, oncs are more apt to want to Rx the infusion vs oral simply for monetary reasons.  Sometime go to the colonclub.com and read what others have said on this issue. 

You must be a decision making partner in your care and ultimately you have the sole discretionary power to say yes or no to any decisions regarding your care.  Since it sounds like you don't have a port, I would tell the onc you want the Xeloda to avoid that minor surgery, then you can still go on with the chemo and know that you have done the 'standard of care' (FOLFOX is NOT standard of care for stage IIA with no negative prognostic factors) for your stage.

Jaynee

My doc here in Louisiana very much promoted the iv

chemo method. I stood my ground and insisted or oral

Xeloda. Not the docs are telling me that after surgery I will

need a port for chemo iv. Can't I take oral meds again?

I was diagnosed with stage II rectal cancer on July 24, 2009. I am not undergoing chemo(Xeloda, oral) and radiation 5 days per week. My surgery is scheduled for

the first week in Nov, 2009 at MD Anderson in Houston,Tx.

By all means you can and if you want, should request the oral chemo again.  There are some reasons why an onc would insist on using the infused 5FU  - one would be the cost if you didn't have insurance but in your case, since you were already on it, that doesn't seem to be an issue.  Secondly, if an onc feels that a patient would be non-compliant that also would be an issue, but again, since you took it prior to surgery and I assume without incidence that would not be an issue for you.  Finally and unfortunately, the issue of control and cost comes into play with way too many oncs.  As I stated earlier, EVERY study has proven Xeloda to be just as effective as infused 5FU and most studies actually show a significant improvement with the oral.  Stand your ground on that one if it is what you want.  HOWEVER, the onc still will want the port if he/she is planning on administering oxaliplatin.  Your veins, regardless of the oral or infused chemotherapy become difficult to access due to the toxic effects that chemo has on them (veins).   As a stage IIA rectal cancer patient, IF you have no negative prognostic factors, the addition of oxi is going to have to be YOUR decision.  For this stage and criteria, it only adds a very miniscule advantage (studies put it at ~2-3% max) than not adding it BUT the risk of permanent or long term neuropathy is quite high.  This is a personal decision and one that only YOU can make.  The studies just don't bear out the benefit of oxi - particularly for stage IIA (stage IIB is a different story) but many oncs will pull out all the big guns.  If your onc is planning on using the oxi, he will want the port placed.  You may try and insist on having this done with a PICC line or even try the oxi with an IV but chances are as time goes by, finding a vein and being able to access it consistently will become harder and harder.

Jaynee

Thank you so much for the advice. Unfortunately, most of the information

that one receives about cancer, drugs, and side effects are answered by

other cancer survivors. The docs do not seem to want to give out a lot of

info, either because they do not want us to know or maybe that aren't

sure of the answers.

I am on Xeloda, 3000 mg. per day with daily radiation. This treatment is

pre-surgery. My operation is scheduled for early November. And of course

chemo and rad post surgery.

I am having so issues with chemo brain. Again, the info I received about

it was because of my research. My docs never warned me about this side

effect. I thought I was losing it. Glad to know that its the drugs.

I don't know when your radiation began but I certainly hope that the rad oncs were honest with you about all of the potential side effects and told you things to do/not to do to avoid or minimize them.  If not, send me a PM if you need any other advice.

Jaynee

They told me the only thing I needed to be concerned about was redness

at the target sight and some diaharea. The also said I may experience

some fatigue. Is there more? Also, I have noticed joint pain in my jaw and

forearms, is this another side effect?