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Postoperative Chemotherapy for Advanced Rectal Cancer

Panelists: John L. Marshall, MD, Georgetown University; Bert H. ONeil, MD, Indiana University School of Medicine; Marwan Fakih, MD, City of Hope Comprehensive Care Center; Gabriela Chiorean, MD, University of Washington School of Medicine; Wells A. Messersmith, MD, FACP, University of Colorado Cancer Center
Published: Wednesday, Aug 22, 2018



Transcript: 

John L. Marshall, MD: Gabby and Bert, I want you to help because our audience is general oncologists. We get in the weeds of all this stuff, and I still see, routinely, patients getting traditional chemotherapy/RT [radiation therapy], surgery, and then 6 months of adjuvant FOLFOX in the rectal cancer space because there’s something magical about that. And I think the defense of that position is they don’t want to undertreat. They don’t want to be wrong because this is curative therapy, and they’d rather err on the side of too much than not enough. Are we at a point with sort of cumulative evidence there that you don’t need to give 6 months afterward? And is oxaliplatin critical for all patients? What’s your take on that? Can we give them permission to back off a little bit?

Gabriela Chiorean, MD: First of all, I think that from what I’ve seen and also according to the national clinical trials, if patients receive neoadjuvant chemoradiation—the standard had been more like 4 months of adjuvant chemotherapy—we don’t need the 6 months like we do in colorectal cancer with FOLFOX. So I think that the 6 months might be a little too much chemotherapy. And second of all, again, we do not know who the patients are who really need that adjuvant chemotherapy in the first place. Because there are many patients who have T3 N0 cancers, and at the time of surgery, they don’t have any node-positive disease. They are stable or downstaged. Do we even need to give any chemotherapy to those patients? What about the pathological CRs? So I think, for the most part, 4 months of chemotherapy in the adjuvant setting is more like the standard. And third, we really truly don’t know who should get maybe more aggressive chemotherapy, maybe a FOLFOXIRI-type chemotherapy for more aggressive tumors. Who are the patients who don’t need it at all? I think that’s really a big question.

John L. Marshall, MD: Bert, I’d love to hear your thoughts on this, and you also kind of hear, “Well, they were young, they had a good performance status, so I gave them more chemotherapy,” sort of justifying being meaner to younger people. What’s your take on this sort of standard postoperative algorithm that I’m pretty sure you’re seeing, too, on a referral pattern?

Bert H. O’Neil, MD: Yes. Well, I would say a mix. I see a mix of people who come in who have had 4 months and 6 months. I give 4 months, as has been the case in the studies. But the reality is that it’s not a well-studied area. I think, unfortunately, it’s still, for many patients with rectal cancer, uncertain whether they should get any postoperative chemotherapy at all, and that makes giving people clear recommendations difficult. I think in that case, if you feel it’s important to give chemotherapy, 4 months is enough. If they’re higher risk, I think ADORE suggests FOLFOX is a good idea. If they’re lower risk, I think it doesn’t harm people to give 4 months of capecitabine, and it probably doesn’t harm them any more to give 6 months of capecitabine.

Wells A. Messersmith, MD, FACP: I’ll tell you something I don’t like to see. There are patients who have long-lasting neuropathy after 6 months of treatment for either colon or rectal cancer, but especially in rectal, where you know those last 2 months, there’s not really much guidance on that. And then when the neuropathy is ignored and these younger patients with long-lasting neuropathy have trouble working or doing the things that they enjoy, that’s something I really hate to see. So I think following the neuropathy carefully. Because if anything, it’s a fairly marginal benefit, so why make them disabled.

John L. Marshall, MD: So giving it all beforehand, before surgery, takes care of that because by the time you’re done with surgery, it moves on. So I get that. I get how that’s a nice, neat package and easy, and it’s less gray afterward and all that.

Transcript Edited for Clarity

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Transcript: 

John L. Marshall, MD: Gabby and Bert, I want you to help because our audience is general oncologists. We get in the weeds of all this stuff, and I still see, routinely, patients getting traditional chemotherapy/RT [radiation therapy], surgery, and then 6 months of adjuvant FOLFOX in the rectal cancer space because there’s something magical about that. And I think the defense of that position is they don’t want to undertreat. They don’t want to be wrong because this is curative therapy, and they’d rather err on the side of too much than not enough. Are we at a point with sort of cumulative evidence there that you don’t need to give 6 months afterward? And is oxaliplatin critical for all patients? What’s your take on that? Can we give them permission to back off a little bit?

Gabriela Chiorean, MD: First of all, I think that from what I’ve seen and also according to the national clinical trials, if patients receive neoadjuvant chemoradiation—the standard had been more like 4 months of adjuvant chemotherapy—we don’t need the 6 months like we do in colorectal cancer with FOLFOX. So I think that the 6 months might be a little too much chemotherapy. And second of all, again, we do not know who the patients are who really need that adjuvant chemotherapy in the first place. Because there are many patients who have T3 N0 cancers, and at the time of surgery, they don’t have any node-positive disease. They are stable or downstaged. Do we even need to give any chemotherapy to those patients? What about the pathological CRs? So I think, for the most part, 4 months of chemotherapy in the adjuvant setting is more like the standard. And third, we really truly don’t know who should get maybe more aggressive chemotherapy, maybe a FOLFOXIRI-type chemotherapy for more aggressive tumors. Who are the patients who don’t need it at all? I think that’s really a big question.

John L. Marshall, MD: Bert, I’d love to hear your thoughts on this, and you also kind of hear, “Well, they were young, they had a good performance status, so I gave them more chemotherapy,” sort of justifying being meaner to younger people. What’s your take on this sort of standard postoperative algorithm that I’m pretty sure you’re seeing, too, on a referral pattern?

Bert H. O’Neil, MD: Yes. Well, I would say a mix. I see a mix of people who come in who have had 4 months and 6 months. I give 4 months, as has been the case in the studies. But the reality is that it’s not a well-studied area. I think, unfortunately, it’s still, for many patients with rectal cancer, uncertain whether they should get any postoperative chemotherapy at all, and that makes giving people clear recommendations difficult. I think in that case, if you feel it’s important to give chemotherapy, 4 months is enough. If they’re higher risk, I think ADORE suggests FOLFOX is a good idea. If they’re lower risk, I think it doesn’t harm people to give 4 months of capecitabine, and it probably doesn’t harm them any more to give 6 months of capecitabine.

Wells A. Messersmith, MD, FACP: I’ll tell you something I don’t like to see. There are patients who have long-lasting neuropathy after 6 months of treatment for either colon or rectal cancer, but especially in rectal, where you know those last 2 months, there’s not really much guidance on that. And then when the neuropathy is ignored and these younger patients with long-lasting neuropathy have trouble working or doing the things that they enjoy, that’s something I really hate to see. So I think following the neuropathy carefully. Because if anything, it’s a fairly marginal benefit, so why make them disabled.

John L. Marshall, MD: So giving it all beforehand, before surgery, takes care of that because by the time you’re done with surgery, it moves on. So I get that. I get how that’s a nice, neat package and easy, and it’s less gray afterward and all that.

Transcript Edited for Clarity
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