Treatment and Pre-meds

Question 1

Tumors in upper 1/3 of rectum

Answer 1

Treat as colon cancer

Question 2

Tumers in lower 2/3 of rectum

Answer 2

Treat as rectal cancer- radiation is adjuvant therapy and palliative therapy.

Question 3

Stage 0-1

Answer 3

Surgery

Question 4

Stage 2

Answer 4

Surgery +/- adjuvant therapy (high-risk Duke Grade 3)

Question 5

Stage 3

Answer 5

Surgery + adjuvant therapy

Question 6

Stage 4

Answer 6

Chemotherapy +/- surgery

Question 7

Adjuvant therapy

Answer 7

FOLFOX X 6 months= 5-FU, Leucovorin, Oxaliplatin
5-FU
Oxaliplatin: peripheral neuropathy is dose limiting and cold-induced–> avoid cold drinks and ice cream for 5 days. Can cause laryngeal spasm- cover up when going outdoors. Not renally toxic like cisplatin. Neutropenia (acute), peripheral neuropathy (cumulative), nausea and vomiting, mucositis, diarrhea, cold induced neuropathy/dysesthesias.
Give dexamethasone, granisetron, and aprepitant.
5-FU: Diarrhea, mucositis, myelosuppression, nausea and vomiting, HFS
Severe diarrhea: Loperamide 4 mg now, 2 mg q2hrs until diarrhea free for 12 hours.

Question 8

First line chemotherapy for metastatic disease

Answer 8

FOLFOX/FOLFIRI/XELOX + mab.

Question 9

Second line chemotherapy for metastatic disease

Answer 9

All regimens include 5-FU. Add another agent not previously given (OX or IRI). Consider giving mab or aflibercept.

Question 10

Third line chemotherapy for metastatic disease

Answer 10

Cetuximab or panitumumab +/- ironotecan OR regorafanib

Question 11

Cetuximab and panitumumab

Answer 11

EGFR mabs
Can only be used in WT KRAS.
Skin rash, hypersensitivity reaction, electrolyte imbalance, diarrhea, mucositis, ILD (rare).
Infusion related reactions requiring discontinuation with cetuximab.
Give 50-100 mg doxycyline PO BID.

Question 12

Bevacizumab and Aflibercept

Answer 12

VEGF inhibitors

HTN, proteinuria, wound dehiscence, arterial thrombosis, hemorrhage

Question 13

Regorafenib

Answer 13

VEGF TKI

Fatigue, hoarseness, HFS, HTN, diarrhea, rash, mucositis

Question 14

Capecitabine

Answer 14

HFS and hyperbilirubinemia seen, don’t really see it with continuous infusion 5-FU.