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Learning about
ColorectalCancer
A Personalized TreatmentGuide for Patients
Colorectal CancerAssociation of Canada
AvastinisatrademarkofGenentech,Inc.,Usedunderlicence.CamptosarisaregisteredtrademarkYakultHonshaCompany,Ltd.Eloxatinisaregisteredtrademarksanofi-aventisCanadaInc.Erbituxisatrademark(TM)ofImCloneLLC.VectibixisaregisteredtrademarkofAmgenManufacturing,Limited,asubsidiaryofAmgenInc.XelodaisaregisteredtrademarkofF.Hoffmann-LaRocheAG,usedunderlicense.
DISCLAIMER:Whileeveryefforthasbeenmadetoensureaccuracyinthisbookletastocurrentmedicalpractice inCanada,itcannotbefullycomprehensive.Individualneedsvaryandthebookletshouldnotbe usedasasubstituteforpropermedicalcare.
PublishedbyMultimed Incorporated.Copyright2011.AllRightsReserved.66MartinStreetMilton,ONL9T2R2Telephone:905875-2456Fax:905875-2864www .multi-med .com
ACKNOWLEDGEMENT:Fundingforthisguidewasgenerouslyprovidedthrough anunrestrictededucationalgrantfromSanofiCanadaInc.
Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Knowing the Facts: Colorectal Cancer Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3What is Colorectal Cancer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Stages and Grades of Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4What are the Treatment Options? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 •Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 •RadiationTherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 •Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 •TargetedTherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 BiomarkerTesting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 •HIPECtherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Personalized Treatment SectionIntroduction: Combinations of chemotherapy and/or targeted therapy . . . . . . . . . . . . . . . . . . . . . . . . 13 •5-FU/Leucovorin/Oxaliplatin(FOLFOX-4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 •Modified5-FU/Leucovorin/Oxaliplatin(modFOLFOX-6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 •5-FU/Leucovorin/Oxaliplatin(FOLFOX-6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 •5-FU/Leucovorin/Oxaliplatin+Bevacizumab(FOLFOX(any)+Bevacizumab) . . . . . . . . . . . . . . . . . . . . 20 •5-FU/Leucovorin/Oxaliplatin+Cetuximab(FOLFOX(any)+Cetuximab) . . . . . . . . . . . . . . . . . . . . . . . . 22 •5-FU/Irinotecan/Leucovorin(FOLFIRI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 •5-FU/Irinotecan/Leucovorin+Bevacizumab(FOLFIRI+Bevacizumab) . . . . . . . . . . . . . . . . . . . . . . . . . 26 •5-FU/Irinotecan/Leucovorin+Cetuximab(FOLFIRI+Cetuximab) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 •Fluorouracil(5-FU)+Leucovorin(orfolinicacid)(5-FU/LV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 •Capecitabine(CAPECITABINE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 •Capecitabine/Oxaliplatin(CAPOX/XELOX) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 •Capecitabine/Oxaliplatin+Bevacizumab(CAPOX/XELOX+Bevacizumab) . . . . . . . . . . . . . . . . . . . . . . 36 •Irinotecan/Oxaliplatine(IROX) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 •Irinotecan+Cetuximab(IRINOTECAN+Cetuximab) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 •Cetuximab(CETUXIMAB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 •Panitumumab(PANITUMUMAB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 •Capecitabine+Bevacizumab(CAPECITABINE+Bevacizumab) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 •5-FU/Leucovorin/Irinotecan/Oxaliplatin(FOLFOXIRI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 •5-FU/Leucovorin/Irinotecan/Oxaliplatin+Bevacizumab(FOLFOXIRI+Bevacizumab) . . . . . . . . . . . . . . 50 •Irinotecan/Capecitabine/Oxaliplatin(IXO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Managing Side Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Colorectal Cancer Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Canadian Resources for Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66Ongoing Research and the Future of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Where to Find Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Colorectal CancerAssociation of Canada
1
Colorectal CancerAssociation of Canada
3
Knowing the Facts: Colorectal Cancer Statistics
CRCisthesecondleadingcauseofdeathfromcancerinCanadainbothmenandwomen combined.CRChasasignificantimpactondeathformenandwomencombined.Thisyear anestimated22,200CanadianswillbediagnosedwithCRCand8,900willdiefromit. MorethanhalfofallnewcasesofCRCwillbediagnosedinpeople70yearsofageand older.Itisestimatedthat:1-3
•9,700womenwillbediagnosedwithCRCand3,900willdieofit•12,500menwillbediagnosedwithCRCand5,000willdieofit•Onaverage,426CanadianswillbediagnosedwithCRCeveryweek•Onaverage,171CanadianswilldieofCRCeveryweek
WhatarethechancesofgettingordyingfromCRC?1-3
•Inmen:1in14isexpectedtodevelopCRCduringtheirlifetimeand1in27willdieofit•Inwomen:1in15isexpectedtodevelopCRCduringtheirlifetimeand1in31willdieofit•Overall,colorectal canceristhesecond-leadingcauseofcancerdeathinCanada•DeathfromCRCcontinuestodeclineinbothmenandwomendue
toimprovementsintreatments,especiallychemotherapy.Screening forCRCcanlowertheriskofgettingitanddyingfromit
What is Colorectal Cancer?
Cancersthatstartinthecellsthatlinetheinsideofthecolon(thelongest partofthelargeintestine)andrectum(thelastfewinchesofthelarge intestinebeforetheanus)arecalledcolorectalcancers(CRCs).Thecolon andrectumformthelargeintestine(largebowel),whichisthelastportion ofthedigestivesystem.Thedigestivesystem,whichismadeupofthe esophagus,stomach,smallandlargeintestines,extractsandprocesses nutrients(vitamins,minerals,carbohydrates,fatsandproteins)from foodandhelpspasswastematerialoutofthebody.2,4
TheimportantnewsaboutCRCisthatitusuallystartsfroma pre-cancerousgrowthcalledapolypandgrowsslowly,usually inapredictableway.Itthereforecanbepreventablewithscreening, andwhendiagnosedatanearlystage,itisoftencurable.2
Learning About Colorectal Cancer: A Personalized Treatment Guide for Patients
Introduction
WelcometoLearning About Colorectal Cancer – A Personalized Treatment Guide for Patients.
Thegoalofthisguideishelpyoulearnaboutcolorectal cancer (CRC),diagnosis, treatmentsoptionsavailabletoyou,strategiestohelpyoumanagethediseasewhilemaintainingyourwell-being,andwheretofindsupportinyourarea.
Colour-coded,Personalized Treatment Sectioncontainsinformationondifferent combinationsofchemotherapyand/ortargeted therapyusedtotreatCRC.Theguide alsodiscussescurrentresearchandlooksatfuturetherapiesinCRC .
Foryourconvenience,youcanfindaGlossaryattheendofthisbooklet,tohelpyou betterunderstandthemedicalterminologyusedinCRC.Thewordsintheguidemarked initalicscanbefoundintheGlossary .
Thecontentsofthisguidehavebeenindependentlyreviewedandapprovedbythe appropriatemedicallyqualifiedexperts.
Screening for
CRC can reduce
both occurrence
and death.
2
CRC grows in a
predictable way, and
when diagnosed at
an early stage, it is
often curable.2
Colorectal CancerAssociation of Canada
5
Stages and Grades of Colorectal Cancer
OnceaCRCdiagnosisismade,thecancerisusuallydescribedbyastageandgrade.
CRCstagingdescribesthesizeofthetumour,howfarithasgrownintothecolonorrectumwall,andwhetherthecancerhasspreadtolymph nodesorotherplacesinthebodypasttheplacewhereitfirstbegantogrow.CRCisdescribedbythefollowing5stages:1-2,4-5
Stage Description
0 Theabnormalcellsarefoundonlyintheinnermostlayer(mucosa)ofthecolonorrectum.Theseabnormalcellsmaybecomecancerousandspread.Stage0CRCisalsocalledcarcinoma in situ .
I Thetumour(cancer)hasgrownintotheinnerwallofthecolonorrectum,buthasnotgrownthroughthewall.
II Thetumour(cancer)hasgrownmoredeeplyintoorthroughthewallcolonorrectum,andmayinvadenearbytissuesbuthasnotspreadtothelymph nodes .
III Cancerinvolvesthenearbylymph nodes,butnottootherpartsofthebody.
IV Cancerhasspreadtootherpartsofthebody,suchastheliverorlungs.
4
Cancerthathasbeentreatedandhascomebackafteraperiodoftimewhenthecancercouldnotbedetectediscalledrecurrence.Thecancermaycomebackinthecolonorrectum,orinanotherpartofthebody.1-2,4-5
Inadditiontothecancerstage,itisalsousefultodeterminethegradeofthecancer,whichisdonebyexaminingabiopsysamplefromthetumourunderamicroscope.Examininghowthecancer cellslookandbehaveincomparisontonormalcellswillhelpdeterminethegradeofthecancer,andenableyourdoctortoestimatehowquicklythecancermaybegrowing.CRChasthreegrades:1-2,4-5
Grade Description
1 (Low) Cancerisslowgrowing,alsoreferredtoaswelldifferentiated
2 (Moderate) Cancerisintermediategrowing,alsoknownasintermediatedifferentiation
3 (High) Cancerisfastergrowing,alsoreferredtoaspoorlydifferentiated
What are the Treatment Options?
Yourtreatmentwilldependonyourgeneralhealthaswellasthetype,stageandgradeofthecancer.ForCRC,yourtreatmentmayincludeacombinationofsurgery, radiation therapy, chemotherapyandtargeted therapy . Workingtogetherwithyourhealthcareteam,youwilldecidewhattreatmentswillbebestforyou.Youmaybeinvitedtotakepartinaclinical trialtotestnewertreatmentoptionsorcombinations.1-2
AvailabletreatmentsforCRCaredescribedbelow.
Treatment option: Surgery
SurgeryisthemaintreatmentforCRC.Surgeryisusedtocurethecancerintheearlystagesbycompletelyremovingthetumourandtissuesaffectedbyit.It’soccasionallypossiblethatsurgerymayalsobeofferedtopeoplewhosetumourshavereturnedinthepelvisorspreadtotheliverorthelungs.Forpeoplewithdiseasethatcannotberemovedintotal,surgerymaybeofferedtohelprelievethesymptomsofcancer .1-2
Thesizeofthetumouranditslocation(whereitisintheintestine)willdeterminewhichsurgeryisrightforyou.1-2
Differentsurgicalproceduresareusedtoremovetumoursdependingontheirsize,location,howfartheyhavegrownintothewallofthecolonorrectum,andtheamountofcolonorrectumthatneedstoberemoved.Forremovalofsmallearlycancerssuchascancerouspolyps,atube(orscope)isinsertedthroughtherectum,whileforlargertumoursremovalofthepartoftheintestinecontainingthecancerisusuallynecessary.Ifapartoftheintestineisremoved,theremaininghealthypartsoftheintestinearesewntogether.Ifthiscan’tbedoneimmediately,atemporarycolostomymaybeperformedwhereanopeningwillbemadeintheabdomenandthecolonwillbepulledthroughthisopeningtotheoutsideofthebody.Thiswillhelpthebodypassthewastedirectlyfromthecolonthroughtheopeningintheskinandintoabag,whichcanbeemptiedregularly.Becauseeverypatientisdifferent,forsomeacolostomymaybepermanentwhileforothersitmayonlybeneededuntil
Treatment for
CRC will primarily
depend on its
stage. Knowing
the stage and
grade of the cancer
can help you and
your healthcare
team decide which
treatment is best
for you.1-2, 3-5
Source of illustration: C3Life.com, a website supported by Hollister Incorporated
radiationoncologistcandeliverhighdosesofthecancer-killingradiationmoresafelyforrectalcancers eitherbeforeoraftersurgery.Itisfollowingthedetailedpathologyanalysisofrectalcancersthatadecisionabouttheneedforradiationisusuallyreached.1-2
Possiblesideeffectsthatmaybeexperiencedafterradiationtreatmentincludefeelingofbeingmoretired thanusual,occasionaldiarrhea,andperhapschangestotheskinsuchasrednessortendernessinthearea ofthebodywherethetreatmentwasapplied.Thesesideeffectsaretemporaryandwillusuallygoaway whenthetreatmentperiodisoverandthenormalcellshavehadthechancetorepairthemselvesandusuallywithin1-2weeks.1-2
Treatment option: Chemotherapy
Commonly,drugs(medications)areusuallyusedtotreatthedifferentstagesofCRC . Chemotherapyisthe useofanticancermedications,alsocalledchemotherapy drugs,thataretypicallygivenbyinjectionintoavein byintravenousorIV infusion,orsometimesaspills,todestroycancer cells .1-2,4-5
Whilechemotherapydrugsworktodestroycancer cellsandhelppreventcancer cellsfromgrowingandspreading,theyalsocandamagehealthycells,andmaycausesideeffects.However,damagetohealthy cellsistemporaryandtheywillrepairthemselvesafterthetreatmentstops.1-2,4-5
Someofthesideeffectsthatmaybeexperiencedincludenausea,vomiting,stomatitisormucositis(soreness inthemouth),lossofappetite,tiredness,alopecia(hairloss),diarrhea,neurotoxicity,anincreasedriskofinfection,andbleeding.Yourhealthcareteamwillcarefullymonitoranysideeffectsandprovidemedications thatareeffectiveinreducingthesymptoms.1-2,4-5
Chemotherapytreatmentmaybegivenbeforeoraftersurgeryorboth.Differenttypesofchemotherapy (neoadjuvant, adjuvant,andpalliative)aredescribedinthetablebelow:1-2,4-5
Timing of chemotherapy treatment Purpose
Beforesurgery
Neoadjuvant chemotherapy / chemoradiation therapy
Givenbeforesurgery(preoperative)todecreasetumour sizeandcontrollocalspreadChemoradiation therapyischemotherapycombinedwithradiation therapytoshrinkarectaltumour
Aftersurgery
Adjuvant chemotherapy Givenaftersurgery(post-surgical)todestroyanymicroscopiccancercellsleftbehindandthereforehelptoreducetheriskofthecancercomingback
Palliative chemotherapy GiventohelpslowdownandcontrolthecancerwhenthecancerhasspreadtodistantorgansThegoalistocontrolsymptomsandextendlifebutultimately,thecancerisnotcurable
Colorectal CancerAssociation of Canada
7
therectumhealsandafterabout2-3monthsthecolostomycanberemoved(orreversed).Thehealthcareprofessionalteamwillteachthepatienthowtomanageacolostomy,whichwillallowthepatienttocontinuetoparticipateineverydayactivities.1-2
ForsomepatientswithCRCthathasspreadinalimitedwaytoanareasuchastheliver,specializedsurgerycalledpartial liver resection for colorectal liver metastasis,maybeanoptiontoremovelivermetastasesiftheyaresmallorfewinnumber.1-2
Upto30percentofpeoplemaybecuredifmetastasesinthelivercanbecompletelyremoved (orresected).6
Treatment option: Radiation therapy
Therearetwotypesofradiation therapythatcanbeused:external beam radiation therapyand,occasionally,brachytherapy.Inexternalbeamradiation,thebeamofradiationisaimeddirectlyatthetumour.Inbrachytherapy,radioactivematerialisplacedinsidethetumour,makingitpossibletotreatthecancerinaveryfocusedmanner.1-2,7-11
Duringradiation therapy(alsocalledradiotherapy),highdosesofaspecialtypeofenergy(radiation)areaimedattheareawherethecancerisgrowing,destroyingcellsandmakingitimpossibleforthemtogrowanddivide.Whileradiation therapydestroyscancercells,whichgrowuncontrollably,italsocandamagehealthycellsnearby.Thegoodnewsisthathealthycellsareabletorepairthemselvesafterthetherapyiscomplete.1-2,7-11
Radiochemotherapy(alsocalledchemoradiation)ischemotherapy(typically5-FUorcapecitabine)combinedwithradiation therapy.Itisusedbeforerectalcancersurgerytoimprovethechancesofbettertumourcontrol,andreducelocalrecurrences(cancerfromcomingback).1-2,7-11
WhileradiochemotherapyisastandardofcareinCanada,notallpatientswithrectalcancerareconsideredcandidatesforthistreatmentbeforesurgery.Forexample,patientswhoareatriskofseveresideeffectsfromthecombinedtherapywhichmightpreventsuccessfulsurgery,aregenerallyexcluded,andgivenradiationalone,aseitherstandardfractionationorshorter-courseradiotherapy .10
TworadiotherapyoptionsareavailableinCanada:short-course(25Gygiveninfivefractions)andlong-course(45Gygivenin25fractions).8,12-13Bothshort-courseradiationalone(25Gyinfivefractions)andlong-courseradiation therapycombinedwithchemotherapy(45–50Gyin25–28fractions)havebeenshowntobeeffectiveindecreasinglocalrecurrenceriskforrectalcancer .14
Radiation therapyisrarelyusedforcoloncancerbecausethecolonisquitemobileandcancers,evenwhenonthesurface,tendtopushawayfromnearbystructuresandthelocalriskofcontaminationbythecancerislow.Thesmallintestineisalsonearbyanditfurtherlimitsthetypesofradiationdosagethatmightbenecessary.1-2
However,theoppositeistruefortherectum,wherelocalspreadcanreadilycontaminatethesidewallofthepelvis.Inaddition,thesmallintestineisatasafedistance.Thismeansthatthe
6
Chemotherapy
Forprimarycoloncancer
Forpeopleathighriskforrecurrence(stage3andhigh-riskstage2coloncancer)
Themostcommonchemotherapycombinationusedasadjuvant therapyisFOLFOX: LV(folinicacid)(Leucovorin®),fluorouracil(5-FU,Adrucil®),oxaliplatin(Eloxatin®)givenintravenouslyeverytwoweeksforaplannedtotalof12treatments
ForpeoplewhoarenotabletotoleratetheFOLFOXtreatmentregimen
Oralcapecitabine(Xeloda®)(thisis5-FUinpillform,whichistakentwicedailyfor2ofevery 3weeks,foraplannedtotalof24weeks.
ForadvancedormetastaticCRC
Themostcommonchemotherapycombinationsusedtotreatadvancedormetastatic CRC
1.FOLFOX:LV(folinicacid)(Leucovorin®),fluorouracil(5-FU,Adrucil®),oxaliplatin (Eloxatin®)+/-BEV
2.FOLFIRI:LV(folinicacid)(Leucovorin®),fluorouracil(5-FU,Adrucil®),irinotecan (Camptosar®,CPT-11);+/-BEV
3 . Capecitabine(Xeloda®)takeninsteadof 5-FUcombinationtreatments+/-BEV
Forpeopleafterpreviouschemotherapy treatmentshavefailed
Cetuximab(Erbitux®),typeoftargeted therapy,maybetakenalone,orincombinationwithirinotecan,forthetreatmentofnon-mutated (wild type) KRAS metastatic CRC.
Secondorthirdtreatmentchoiceforpeopleforwhomfirstchoicetreatmentoptionsdidnotwork
Panitumumab(Vectibix®),typeoftargeted therapy inthesameclassascetuximab,alsousedforthetreatmentofpatientswithnon-mutatedKRAS aftertreatmentscontainingfluoropyrimidines,oxaliplatinoririnotecanhavefailed.
Allavailablechemotherapytherapieseitheraloneorincombinationforthetreatmentofdifferentstages ofCRCaredescribedinthePersonalized Treatment Sectionofthisguide.
Colorectal CancerAssociation of Canada
9
Ifsurgicalremovalofthelivermetastasesissuccessful,additionalchemotherapyisusuallyrecommendedaftersurgery(alsosometimesreferredtoas‘pseudo’-adjuvant chemotherapy).1-2.4-5
Insomecases,chemotherapymayberecommendedbeforesurgerytotheliver,ifthecancer isonlyconfinedtotheliver.Thisapproachmaybeusedtohelpapersonwhoisaborderlinecandidateforsurgery,becauseofthesizeorlocationoftheliver metastases,tohavesuccessfulsurgeryaftertheCRC metastaseshavebeenreducedinsizebythechemotherapy .15,16
Thetypesofchemotherapydrugs,andcertainlythedosesandschedulesvaryforeachpatient,andthetreatmentplanwilldependonyouruniquesituation.1-2,4-5
Descriptionofallavailablechemotherapyand/ortargeted therapycombinationsforthetreatmentofdifferentstagesofCRCaredescribedinthePersonalized Treatment Sectionofthisguide.
ThemostcommonlyusedchemotherapydrugstotreatCRCarefluorouracil (5-FU)andleucovorin (LVorfolinicacid),whichisaddedtoincreasetheeffectivenessof5-FU. 5-FUhasbeenusedformanyyearsanditseffectivenessisproven.OtherdrugsusedtotreatCRCincludeoxaliplatin, irinotecan, capecitabine(thisis5-FUinpillform),bevacizumab(BEV),cetuximab,andpanitumumab.Otherthancapecitabine,whichisapillandistakenbymouth,allotherchemotherapydrugsaregivenintoavein(intravenouslyorIV)throughapump.Theregimeninvolvingcontinuousintravenous infusion,requiresthatpatientshaveacentralvenous(intoavein)accesscathetereitherwitha“port-a-cath”whichisavascularaccessdevicesurgicallyimplantedunderneaththeskinandconnectedtooneofthelargebloodvesselsinthechest,oraperipherallyinsertedcentralcatheter(PICC)whichisinsertedthroughaveininthearm.The5-FU infusionisthendeliveredthroughaportablechemotherapypumpathome(referredtoasahomeinfusion pump).Thispumpisverysmall,anditfitsintoapackthatcanbewornaroundthewaist.1-2,4-5,15
Chemotherapydrugsinterferewiththeabilityoffastgrowingcells(likecancer cells)todivideormultiply.Becausemostofbody’snormalcellsofanadultarenotactivelygrowing,theyarelessaffectedbychemotherapy,exceptforthoseofbonemarrow(wherethebloodcellsaremade),thehair,andtheliningofthedigestivetract.Effectsofchemotherapyontheseandothernormaltissuescancausesideeffectssuchasnausea,hairloss,andtiredness.1-2,4-5
Thereareseveralchoicesofchemotherapyforbothprimaryandadvancedormetastatic CRC,whicharedecideduponindiscussionmainlywithyourmedicaloncologist,andtailoredspecificallytoyoursituation.1-2,4-5
8
As with all
chemotherapy
treatments you
may experience
side effects.
Because everyone
responds to
treatment
differently, your
side effects
may be different
as well. Talk to
your healthcare
team to learn ways
to manage these
side effects.1-2,4-5
Panitumumab (Vectibix®)
Panitumumab(Vectibix®),likecetuximab,alsotargetstheEGFR . Panitumumabisusuallyusedformetastatic CRC,afterotherdrugshavebeentriedanddidnotwork.Alsolikecetuximab,panitumumabiseffectiveonlyfortumoursthatdonothaveaspecificmutationintheKRAS gene.Formoreinformationontestingforbiomarkers,seesectiononBiomarker Testingofthisguide.15,20
Biomarker Testing
CRCisoneofthemostcommonlydiagnosedcancers.Recentscientificadvancesinhowitistreatedhavedramaticallyimprovedsurvival.OnesuchadvanceisabetterunderstandingofgenescalledKRASandBRAFwhichledresearcherstodevelopa waytopersonalizetreatmentforsomepatientswithmetastatic CRC .21
KRASandBRAFarebiomarkers,alsocalledmolecularmarkers,whicharebiologicalmoleculesfoundinblood,otherbodyfluids,ortissuesthatisasignofanormalorabnormalprocess,orofaconditionordisease.Atestforaparticularbiomarker,calledbiomarker testing,maybeusedtoseehowwellthebodyrespondstoatreatmentfor adiseaseorcondition.4
Biomarker testingisaformofpersonalizedapproachwhichistheoppositeofa“onesizefitsall”approachashasbeenusedbeforethediscoveryofbiomarkers.Withthe“onesizefitsall”approach,allpatientswiththesametypeandstageofCRCgotthesametreatment.However,thediscoveryofbiomarkerschangedthat,andnowresearchersknowthatnotwopatients’tumoursareexactlyalike.Knowingtheinformationaboutyourtumourcanhelpdoctorsdecidewhichtreatmentismorelikelytoworkthananother.21
KRAS and BRAF mutations
ResearchersfoundthatKRAS geneismutated(orchanged)inabout40%ofpeoplewithCRC.Theother60%ofpeoplewithCRChaveanon-mutated(alsocalledwild-type)KRAS gene.Abiomarkertest,alsoknownasKRAS mutationanalysis,or“KRAStesting”,whichisdoneonsampletissuefromtumoursremovedduringsurgery,cantellifthetumourhasthismutation .21
Itisrecommendedthatallpatientswithmetastatic CRCgettestedfortheKRAS mutation.IfKRAS mutationisfound,thenpatientsshouldnotbetreatedwithcetuximab (Erbitux®)orpanitumumab(Vectibix®).ThesedrugsdonotworkintumoursthathavetheKRAS mutation.However,notallpeoplewiththenon-mutated(alsocalledwild-type)KRAS tumoursrespondwelltotreatmentwithcetuximaborpanitumumabeither.Othertumourmarkersmaybepresentthancangiveadditionalinformationastowhattreatmentswillworkbestforthesepatients,buttheresearchinthisareaisstillongoing.21,22-23
Colorectal CancerAssociation of Canada
11
Treatment option: Targeted therapy
Targeted therapyisanothertreatmentoptionavailabletohelptreatCRC . Targeted therapy drugsaredesignedtofindandattackspecificcancer cellswhiletryingnottoharmnormalcells . Monoclonal antibody therapyisatypeoftargeted therapyusedtotreatCRC.Thistypeoftherapyusesantibodiesmadeinthelaboratoryfromasingletypeofimmune system cell.Theseantibodiescanfindsubstancesoncancercellsornormalsubstancesthatmayhelpcancercellsgrow,sticktothesesubstancesanddestroythecancer cells,blocktheirgrowth,orstopthemfromspreading.1-2,4-5
Themostcommonlyavailabletargeted therapydrugoptionsincludebevacizumab(Avastin®),cetuximab(Erbitux®),andpanitumumab(Vectibix®),allofwhicharemonoclonal antibodies .17,19,20
Bevacizumab (Avastin®)
Bevacizumab(Avastin®)isoneofthetargeted therapydrugsusedforthetreatmentofmetastatic cancer ofthecolonandrectum.Bevacizumabtargetsthevascular endothelial growth factor (VEGF),whichisoneofthemainproteins(substances)madebycellsusedtohelpbuildbloodvesselsthatmakesmalltumourtogrowlarger.VEGFisimportantinthedevelopmentofabloodsupplyinagrowingtumourasthisbloodsupplyisessentialforthetumourtogrowandspread.BevacizumabworksbyattachingtoVEGFandstoppingbloodvesselsfromreachingatumour . Withoutbloodsupply,thetumourdies.Bevacizumabalsoimproveshowchemotherapydrugsworkbyhelpingcarrythesedrugsdirectlytothetumour . Bevacizumabisgenerallygivenincombinationwithotherdrugs,suchas5-FU, oxaliplatin, irinotecanandcapecitabine .17,18
Cetuximab (Erbitux®)
Cetuximab(Erbitux®)worksbytargetingaproteincalledtheepidermal growth factor receptor (EGFR)onthecancer cell . EGFRisfoundinabout80percentofCRCs.EGFRhelpscancer cells growandsurvivebytransmittingsignalstothesecells . Cetuximabattachestothesereceptors,whichcutsoffthissignaltransmissiontocancer cellsandcausesthesecellstodie.Cetuximab hasalsobeenshowntoworkevenifEGFRisnotfoundinanindividualtumour . Cetuximabdoesnotworkforallpatients.TheeffectivenessofcetuximabtreatmentwilldependonwhetherornotthetumourhasamutationintheKRAS gene.IfthetumourhastheKRAS mutation, cetuximabisnoteffective,butifthetumourdoesnothavetheKRAS mutation,cetuximabmaybeeffective.Cetuximabisactivewhengivenaloneorincombinationwithotherdrugs,likeirinotecan .2,15,19Formoreinformationontestingforbiomarkers,seesectiononBiomarker Testingofthisguide.
10
Description of
all available
chemotherapy
combinations with
bevacizumab,
cetuximab and
panitumumab for
the treatment of
different stages
of CRC are
described in the
Personalized
Treatment Section
of this guide
Talk to your doctor
about biomarker
testing to find a
treatment that is
right for you.
.
Talk to your
doctor about
biomarker
testing to find
a treatment
that is right
for you.
Personalized Treatment Section
Introduction: Combinations of chemotherapy and/or targeted therapy
Personalized Treatment Sectionofthisguidedescribesallavailablechemotherapyand/ortargeted therapyoptions,aloneorincombination,totreatCRC.Thissectionisdesignedtohelppatientstogo directlytospecificinformationrelatingtochemotherapyand/ortargeted therapycombinationrelatedto theirtreatment.Tohelpyounavigatethroughthissection,everydrugcombinationhasadifferentcolour, sothatyoucaneasilyfindthesectionofinterest,andreferbacktoit,justbylookingforthespecific colouronthetab.
Thefollowingchemotherapyand/ortargeted therapycombinationsaredescribedinthissection:
FOLFOX-4 CAPOX/XELOX modFOLFOX-6 CAPOX/XELOX+Bevacizumab FOLFOX-6 IROX FOLFOX(any)+Bevacizumab IRINOTECAN+Cetuximab FOLFOX(any)+Cetuximab CETUXIMAB FOLFIRI PANITUMUMAB FOLFIRI+Bevacizumab CAPECITABINE+Bevacizumab FOLFIRI+Cetuximab FOLFOXIRI 5-FU/LV FOLFOXIRI+Bevacizumab CAPECITABINE IXO
The side effects of combinations of chemotherapy and/or targeted therapy used to treat of CRC depend on the type, combination, and schedule of drugs used.
Colorectal CancerAssociation of Canada
13
WhiletheabsenceofamutationintheKRAS genecanpredictthatapatientwillrespondtotreatmentwithcetuximaborpanitumumab,notallpatientswithnon-mutated(alsocalledwild-type)KRASrespondtotreatmentwiththesedrugs.Approximately5%to9%ofCRCshaveamutationinanothergenecalledBRAF .22-23
BRAF genemakesaproteincalledBRAF,whichisinvolvedinsendingsignalstocells,promotingcellgrowth.Thisgenemaybemutated(changed)inmanytypesofcancer,whichcausesachangeintheBRAF protein.Thiscanincreasethegrowthandspread(metastasis)ofcancer cells .4
PatientwhosetumourshaveBRAF mutations,alsomaynotrespondtotreatmentwithcetuximab orpanitumumab . BRAFtestingcanbeconsideredbutisnotyetrecommendedasastandardtestinallpatientswithCRC .22-23
Treatment option: HiPEC therapy
Hyperthermic Intraperitoneal ChemotherapyorHiPECisahighlyspecializedsurgicaltreatmentoptionusedforselectedpatientswhosecancershavespreadtotheliningsurfacesoftheperitoneal(abdominal)cavity(andnowhereelse),andareotherwisedifficulttotreatwithotheravailabletreatments.“Intraperitoneal”meansthatthetreatmentisdeliveredtotheabdominal cavity,and“hyperthermicchemotherapy”meansthatthesolutioncontainingchemotherapyisheatedtoatemperaturethatishigherthannormalbodytemperature.24
BeforereceivingHiPEC,thesurgeonwillremoveallvisibletumoursthatcanberemovedthroughouttheperitonealcavity.Afterthesurgery,whilestillintheoperatingroom,thesurgeonwillgivethepatientHiPECtreatment.DuringtheHiPECprocedure,thesurgeonwillcontinuouslyapplyaheatedsolutioncontainingachemotherapydrugthroughouttheperitonealcavity,foramaximumoftwohours(usually30minutesto90minutesdependingofwhichdrugsareused).TheHiPECprocedureisdesignedtohelpdestroyanycancercellsthatmaybeleftafterthesurgery.24
Thisprocedurealsoimprovesdrugabsorptionandeffectwithminimalexposuretotherestofthebody,whichhelpsavoidtheusualsideeffectsofchemotherapy . Oxaliplatinandmitomycin-C aresomeofthedrugsthatcanbeusedHiPEC therapy . HiPECsurgeryshouldonlybedoneincentresspecializedinperformingsuchproceduresandpatientsmustbecarefullyreviewedbyamultidisciplinaryteambeforeHiPECcanbeconsidered.24
12
Because drugs,
doses and
schedules may
vary from person
to person, your
doctor will decide
on the treatment
plan that is best
suited for you.
The side effects
will be different
depending on the
type of therapy.
Talk to your
healthcare
professionals
if you have any
questions or
concerns about
your treatments.
FOLFOX-4 treatment schedule27,28
FOLFOX-4 combination Treatment Schedule
Day 1 Oxaliplatin + LV:IV infusionover2hours followedby
5-FU:IV bolus followedby
5-FU:continuousIV infusionover22hours
Onceevery2weeksfor 12cyclesinadjuvantsetting.
Inthemetastaticsetting,thescheduledependsontheresponseortolerancetothetherapy .Day 2 LV:IV infusionover2hours
followedby5-FU:IV bolus followedby
5-FU:continuousIV infusionover22hours
What are the possible side effects?27-31
• Alopecia • Anemia • Diarrhea• Hepatotoxicity• Hypersensitivity • Nausea/vomiting• Neurotoxicity/neuropathy• Neutropenia • Stomatitis/mucositis• Thrombocytopenia
Please see the Glossary for definition of side effects appearing in italics. To help you manage your side effects, please see Managing Side Effects section.
Talk to your healthcare professional if you have these symptoms. This is not a complete list of side effects. If you have any unexpected effects while taking FOLFOX-4, contact your healthcare professional.
15
FOLF
OX
-4
5-FU/Leucovorin/Oxaliplatin (FOLFOX-4)
What is it?
FOLFOX-4isoneofseveralchemotherapycombinationsthatinclude5-fluorouracil (5-FU),leucovorin(LVorfolinicacid),andoxaliplatin.FOLFOXtreatmentschedulediffersindosingandadministrationscheduleofeachdrugandincludeFOLFOX-4,FOLFOX-6,modifiedFOLFOX-6(mFOLFOX-6),orothers.25-26
What is it used for?
Oxaliplatinplus5-FUandLV chemotherapycombinationorFOLFOX-4isusedisusedfortheadjuvanttreatmentofpatientswithstageIIorIIIcoloncanceraftertheyhaveundergoneasurgerytoremovethetumour,andformetastatic CRC .27
How is it given?
TheFOLFOX-4isgivenintoavein(intravenouslyorIV).27
How often is it given?
FOLFOX-4combinationisgivenevery2weeks.Everypatientisdifferent;yourdoctorwilldeterminewhatdoseisrightforyou.27
14
modFOLFOX-6 treatment schedule30
modFOLFOX-6 combination Treatment Schedule
Day 1 Oxaliplatin + LV:IV infusionover2hours followedby
5-FU:IV bolus followedby
5-FU:continuousIV infusionover22hours
Onceevery2weeksfor 12cyclesinadjuvantsetting.
Inthemetastaticsetting,thescheduledependsontheresponseortolerancetothetherapy .Day 2 5-FU:continuousIV infusionover24hours
What are the possible side effects?27-31
• Alopecia • Anemia • Diarrhea• Hepatotoxicity• Hypersensitivity • Nausea/vomiting• Neurotoxicity/neuropathy• Neutropenia • Stomatitis/mucositis• Thrombocytopenia
Please see the Glossary for definition of side effects appearing in italics. To help you manage your side effects, please see Managing Side Effects section.
Talk to your healthcare professional if you have these symptoms. This is not a complete list of side effects. If you have any unexpected effects while taking modFOLFOX-6, contact your healthcare professional.
17
mo
dFO
LFO
X-6
Modified 5-FU/Leucovorin/ Oxaliplatin (modFOLFOX-6)
What is it?
modFOLFOX-6isoneofseveralchemotherapycombinationsthatinclude5-fluorouracil (5-FU), leucovorin(LVorfolinicacid),andoxaliplatin.FOLFOXtreatmentscheduledifferindosingandadministrationscheduleofeachdrugandincludeFOLFOX-4,FOLFOX-6,modifiedFOLFOX-6(modFOLFOX-6),orothers.25-26
What is it used for?
Oxaliplatinplus5-FUandLV chemotherapycombinationormodFOLFOX-6isusedforthe adjuvanttreatmentofpatientswithstageIIorIIIcoloncanceraftertheyhaveundergone asurgerytoremovethetumour,andformetastatic CRC .29-30
How is it given?
ThemodFOLFOX-6isgivenintoavein(intravenouslyorIV).29-30
How often is it given?
modFOLFOX-6combinationisgivenonceevery2weeks.Everypatientisdifferent;yourdoctorwilldeterminewhatdoseisrightforyou.29-30
16
FOLFOX-6 treatment schedule31
FOLFOX-6 combination Treatment Schedule
Day 1 Oxaliplatin + LV:IV infusionover2hours followedby
5-FU:IV bolus followedby
5-FU:continuousIV infusionover22hours
Onceevery2weeks
Day 2 5-FU:continuousIV infusionover24hours
What are the possible side effects?27-31
• Alopecia • Anemia • Diarrhea• Hepatotoxicity• Hypersensitivity • Nausea/vomiting• Neurotoxicity/neuropathy• Neutropenia • Stomatitis/mucositis• Thrombocytopenia
Please see the Glossary for definition of side effects appearing in italics. To help you manage your side effects, please see Managing Side Effects section.
Talk to your healthcare professional if you have these symptoms. This is not a complete list of side effects. If you have any unexpected effects while taking FOLFOX-6, contact your healthcare professional.
19
FOLF
OX
-6
5-FU/Leucovorin/Oxaliplatin (FOLFOX-6)
What is it?
FOLFOX-6isoneofseveralchemotherapycombinationsthatinclude5-fluorouracil (5-FU), leucovorin(LVorfolinicacid),andoxaliplatin.FOLFOXtreatmentscheduledifferindosing andadministrationscheduleofeachdrugandincludeFOLFOX-4,FOLFOX-6,modified FOLFOX-6(modFOLFOX6),orothers.25-26
What is it used for?
Oxaliplatinplus5-FUandLV chemotherapycombinationorFOLFOX-6isusedtotreatpeople withmetastatic CRC .31
How is it given?
TheFOLFOX-6isgivenintoavein(intravenouslyorIV).31
How often is it given?
FOLFOX-6isgivenevery2weeksincombination.Everypatientisdifferent;yourdoctorwilldeterminewhatdoseisrightforyou.31
18
FOLFOX (any) + bevacizumab treatment schedule32-33
FOLFOX (any) + bevacizumab combination Treatment Schedule
Day 1 BevacizumabBEV:IV infusionover30-90minutesfollowedby
FOLFOXOxaliplatin:IV infusionover2hoursLV:IV infusionover2hours followedby
5-FU:IV bolus followedby continuousinfusionover22hours
Onceevery2weeks
Day 2* 5-FU:continuousIV infusionover22hours
*TreatmentonDay2willvarydependingontheFOLFOXcombination.
What are the possible side effects?32-33
• Abdominal abscess• Alopecia • Anemia • Arterial thromboembolism• Diarrhea• Gastrointestinal perforation• Hepatotoxicity• Hypersensitivity • Hypertension • Nausea/vomiting• Neurotoxicity/neuropathy• Neutropenia • Proteinuria• Stomatitis/mucositis• Thrombocytopenia • Woundhealingcomplications
Please see the Glossary for definition of side effects appearing in italics. To help you manage your side effects, please see Managing Side Effects section.
Talk to your healthcare professional if you have these symptoms. This is not a complete list of side effects. If you have any unexpected effects while taking FOLFOX (any) + bevacizumab, contact your healthcare professional.
21
FOLF
OX
(an
y) +
Bev
aciz
umab
5-FU/Leucovorin/Oxaliplatin + Bevacizumab (FOLFOX (any) + Bevacizumab)
What is it?
FOLFOXisoneofseveralchemotherapycombinationsthatinclude5-fluorouracil (5-FU), leucovorin(LVorfolinicacid),andoxaliplatin.FOLFOXtreatmentscheduledifferindosingandadministrationscheduleofeachdrugandincludeFOLFOX-4,FOLFOX-6,modifiedFOLFOX-6(modFOLFOX6),orothers.Bevacizumab (BEV)canbeaddedtoanyFOLFOXcombination.25-26
WhenaddedtoFOLFOX(any),BEVincreasesthechancesthatthetumourwillrespondtotreatmentandprolongssurvivalcomparedwithtreatmentwithoutbevacizumab . BEVtogetherwithFOLFOXisrecommendedinmostcasesasaofthefirst-lineorsecond-linetreatmentofmetastatic CRC .15
What is it used for?
Oxaliplatinplus5-FUandLV chemotherapyorFOLFOX(any)incombinationwithBEVisused asfirst-lineorsecond-linetreatmentinpeoplewithmetastatic CRC .32
How is it given?
TheFOLFOX(any)+BEVcombinationisgivenintoavein(intravenouslyorIV).32
How often is it given?
FOLFOX(any)+BEVcombinationisgivenevery2weeks.Everypatientisdifferent;your doctorwilldeterminewhatdoseisrightforyou.32-33
20
FOLFOX (any) + cetuximab treatment schedule34
FOLFOX (any) + cetuximab combination Treatment Schedule
Day 1 Cetuximab:IV infusionover2hoursfortheinitialdose.Afterthat,weeklydosesaregivenover1hour followedafter1hourbyFOLFOX
FOLFOXOxaliplatin + LV:IV infusionover2hours followedby
5-FU:IV bolus followedby
5-FU:continuousIV infusionover22hours
Onceevery2weeks
Day 2* 5-FU:continuousIV infusionover22hours
*TreatmentonDay2willvarydependingontheFOLFOXcombination.
What are the possible side effects?34
• Alopecia • Anemia • Diarrhea• Hepatotoxicity• Hypersensitivity • Infusion reactions• Nausea/vomiting• Neurotoxicity/neuropathy• Neutropenia • Skinreactions(rash,acne,itching,nailchanges,andinfusion-relatedreactions)• Stomatitis/mucositis• Thrombocytopenia
Please see the Glossary for definition of side effects appearing in italics. To help you manage your side effects, please see Managing Side Effects section.
Talk to your healthcare professional if you have these symptoms. This is not a complete list of side effects. If you have any unexpected effects while taking FOLFOX (any) + cetuximab, contact your healthcare professional.
23
FOLF
OX
(an
y) +
Cet
uxim
ab
5-FU/Leucovorin/Oxaliplatin + Cetuximab (FOLFOX (any) + Cetuximab)
What is it?
FOLFOXisoneofseveralchemotherapycombinationsthatinclude5-fluorouracil (5-FU),leucovorin(LVorfolinicacid),andoxaliplatin.FOLFOXtreatmentscheduledifferindosing andadministrationscheduleofeachdrugandincludeFOLFOX-4,FOLFOX-6,modified FOLFOX-6(modFOLFOX6),orothers.CetuximabcanbeaddedtoanyFOLFOXcombination.25-26
What is it used for?
FOLFOX(any)+cetuximabcombinationisusedtotreatpatientswithEGFR-expressing metastatic CRCwhosetumourshavewild-type(non-mutated)KRAS gene .34
How is it given?
FOLFOX(any)+cetuximabcombinationisgivenintoavein(intravenouslyorIV).34
How often is it given?
FOLFOX(any)+cetuximabcombinationisgivenevery2weeks.Everypatientisdifferent; yourdoctorwilldeterminewhatdoseisrightforyou.34
22
FOLFIRI treatment schedule31
FOLFIRI combination Treatment Schedule
Day 1 LV:IV infusionover2hoursIrinotecan:IV infusionover90minutes followedby
5-FU:IV bolus followedby
5-FU:continuousIV infusionover22hours
Onceevery2weeks
Day 2 5-FU:continuousIV infusionover24hours
What are the possible side effects?31
• Alopecia• Anemia • Diarrhea• Hypersensitivity• Nausea/vomiting• Neutropenia • Stomatitis/mucositis • Thrombocytopenia
Please see the Glossary for definition of side effects appearing in italics. To help you manage your side effects, please see Managing Side Effects section.
Talk to your healthcare professional if you have these symptoms. This is not a complete list of side effects. If you have any unexpected effects while taking FOLFIRI, contact your healthcare professional.
25
FOLF
IRI
5-FU/Irinotecan/Leucovorin (FOLFIRI)
What is it?
FOLFIRIisacombinationtherapyconsistingof5-fluorouracil (5-FU),irinotecan,andleucovorin (LVorfolinicacid).25-26
What is it used for?
Irinotecanplus5-FUandLVcombinationchemotherapyregimensorFOLFIRImaybeconsideredforthetreatmentofadvancedormetastatic CRC .31
How is it given?
FOLFIRIisgivenintoavein(intravenouslyorIV).31
How often is it given?
FOLFIRIisgiveneverytwoweeks.31
24
FOLFIRI + bevacizumab treatment schedule35
FOLFIRI + bevacizumab combination Treatment Schedule
Day 1 Bevacizumab BEV:IV infusionover90minutes followedbyFOLFIRI
FOLFIRI Irinotecan:IV infusionover90minutesLV:IV infusionover90minutes followedby
5-FU:IV bolus followedby
5-FU:continuousIV infusionover22hours
Onceevery2weeks
Day 2 5-FU:continuousIV infusionover24hours
What are the possible side effects?35
• Abdominal abscess• Alopecia• Anemia • Arterial thromboembolism• Diarrhea• Gastrointestinal perforation • Hypersensitivity• Hypertension• Nausea/vomiting• Neutropenia • Stomatitis/mucositis • Thrombocytopenia • Woundhealingcomplications
Please see the Glossary for definition of side effects appearing in italics. To help you manage your side effects, please see Managing Side Effects section.
Talk to your healthcare professional if you have these symptoms. This is not a complete list of side effects. If you have any unexpected effects while taking FOLFIRI + bevacizumab, contact your healthcare professional.
27
FOLF
IRI +
Bev
aciz
umab
5-FU/Irinotecan/Leucovorin + Bevacizumab (FOLFIRI + Bevacizumab)
What is it?
FOLFIRI+bevacizumabisacombinationtherapyconsistingof5-fluorouracil (5-FU),irinotecan,leucovorin(LVorfolinicacid),andbevacizumab (BEV) .25-26
What is it used for?
FOLFIRI+BEVcombinationisusedforthetreatmentofadvancedormetastatic CRC .35
How is it given?
FOLFIRI+BEVaregivenintoavein(intravenouslyorIV).35
How often is it given?
FOLFIRI+BEVcombinationisgiveneverytwoweeks.35
26
FOLFIRI + cetuximab treatment schedule36
FOLFIRI + cetuximab combination Treatment Schedule
Day 1 Cetuximab:IV infusionover2hoursinitially, thenweeklyover1hour followedafteronehourbyFOLFIRI
Onceevery1or2weeks
Day 1 FOLFIRI Irinotecan:IV infusionover30-90minutes followedby
LV:IV infusionover2hours followedby
5-FU:IV bolus followedby
5-FU:continuousIV infusionover22hours
Day 2 5-FU:continuousIV infusionover24hours
What are the possible side effects?36
• Alopecia• Anemia • Diarrhea• Hypersensitivity• Infusion reactions• Nausea/vomiting• Neutropenia • Stomatitis/mucositis • Skinreactions(rash,acne,itching,nailchanges,andinfusion-relatedreactions)• Thrombocytopenia
Please see the Glossary for definition of side effects appearing in italics. To help you manage your side effects, please see Managing Side Effects section.
Talk to your healthcare professional if you have these symptoms. This is not a complete list of side effects. If you have any unexpected effects while taking FOLFIRI + cetuximab, contact your healthcare professional.
29
FOLF
IRI +
Cet
uxim
ab
5-FU/Irinotecan/Leucovorin + Cetuximab (FOLFIRI + Cetuximab)
What is it?
FOLFIRI+cetuximabisacombinationtherapyconsistingof5-fluorouracil (5-FU),irinotecan,leucovorin(LVorfolinicacid),andcetuximab .25-26
What is it used for?
Forpatientswithwild-type(non-mutated)KRAS gene,cetuximabisaddedtotheFOLFIRIcombinationtotreatadvancedormetastatic CRC .36
How is it given?
FOLFIRI+cetuximabcombinationisgivenintoavein(intravenouslyorIV).36
How often is it given?
FOLFIRI+cetuximabcombinationisgivenevery2weeks.36
28
5-FU/LV treatment schedule27,37
5-FU/LV combination Treatment Schedule
Day 1 LV:IV infusionover2hours followedby
5-FU:IV bolus followedby
5-FU:continuousIV infusionover22hours
Onceevery2weeksfor12cyclesinadjuvantsetting.
Inthemetastaticsetting,thescheduledependsontheresponseortolerancetothetherapy .Day 2 LV:IV infusionover2hours
followedby5-FU:IV bolus followedby
5-FU:continuousIV infusionover22hours
What are the possible side effects?37
• Alopecia• Anemia• Diarrhea• Nausea/vomiting• Neutropenia• Stomatitis/mucositis• Thrombocytopenia
Please see the Glossary for definition of side effects appearing in italics. To help you manage your side effects, please see Managing Side Effects section.
Talk to your healthcare professional if you have these symptoms. This is not a complete list of side effects. If you have any unexpected effects while taking 5-FU/LV, contact your healthcare professional.
31
5-FU
/LV
Fluorouracil (5-FU) + Leucovorin (or folinic acid) (5-FU/LV)
What is it?
5-FU/LVisachemotherapycombinationoffluorouracil (5-FU)andleucovorin (LVorfolinicacid).25-26
What is it used for?
ForpatientswhocannottolerateanaggressivechemotherapyregimenFOLFOX,XELOX, orFOLFIRIduetotheirage,physicalcondition,orothermedicalproblems,thereis anotheralternative.15
5-FU/LV chemotherapycombinationisalesstoxicalternative,whichisusedasadjuvant treatmentforpeoplewithstageIIorIIIcoloncanceraftertheyhaveundergoneasurgery toremovethetumour.Itisalsousedinthetreatmentofadvancedormetastatic CRC .27,37
How is it given?
5-FU/LVisgivenintoavein(intravenouslyorIV).27,37
How often is it given?
5-FU/LVcombinationisgivenonceevery2weeks.Everypatientisdifferent;yourdoctor willdeterminewhatdoseisrightforyou.27,37
30
Capecitabine treatment schedule39
Capecitabine Treatment Schedule
Day 1-14 Capecitabine:Tabletstakentwiceaday(morningandeveningdoses)for14dayswithin30minutesaftertheendofameal(breakfastanddinner)
Takenin21daycycles-takecapecitabinefor14daysandthenstoptakingitfor7days,thenstartagain
What are the possible side effects?38-39
• Anemia• Diarrhea• Hand-and-foot syndrome• Nausea/vomiting• Neutropenia • Stomatitis/mucositis• Thrombocytopenia
Please see the Glossary for definition of side effects appearing in italics. To help you manage your side effects, please see Managing Side Effects section.
Talk to your healthcare professional if you have these symptoms. This is not a complete list of side effects. If you have any unexpected effects while taking capecitabine, contact your healthcare professional.
33
CAPE
CITA
BIN
E
Capecitabine (CAPECITABINE)
What is it?
ForpatientswhocannottolerateanaggressivechemotherapyregimenFOLFOX,XELOX, orFOLFIRIduetotheirage,physicalcondition,orothermedicalproblems,thereisanotheralternative,capecitabinealone.Capecitabineworksalmostaswellasanintravenous 5-fluorouracil (5-FU)plusleucovorin(LVorfolinicacid).25-26,38
Capecitabinebelongstoafamilyofmedicationscalledthefluoropyrimidines(medicationsthatinterferewiththegrowthofcellsthatrapidlydivideinthebody,includingcancer cells).Capecitabineisaninactivesubstanceonitsown.Whencapecitabineistaken,itischangedinthebody,mostlywithinthetumour(cancer cells),tobecomethecommonlyusedcancer medicationcalled5-FU.Insomepatients5-FUwillkillcancer cellsanddecreasethesize ofthetumour .15,38
What is it used for?
CapecitabineisusedasadjuvanttreatmentforpeoplewithstageIIorIIIcoloncancerafter theyhaveundergoneasurgerytoremovethetumour.Itisalsousedinthetreatmentofadvancedormetastatic CRC.38,39
How is it given?
Capecitabineisavailableastabletsthataretakenbymouth,andswallowedwholewithwater.Yourdoctorwillcalculatethedoseforyou.Youmayneedtotakeacombinationof150mgand500mgtablets.Togettherightdoseitisveryimportantthatyouidentifythetabletscorrectlyeachtimeyoutakecapecitabine.Takingthewrongtabletscouldresultinanoverdose(too muchmedication)orunderdose(toolittlemedication).38
How often is it given?
Capecitabinetabletsaretakentwiceadayfor14days.38,39
32
CAPOX/XELOX treatment schedule40
CAPOX/XELOX combination Treatment Schedule
Day 1 Oxaliplatin:IV infusionover2hours Onceevery3weeks
Day 1-14 Capecitabine:Tabletstakentwiceaday(morningandeveningdoses)for14dayswithin30minutesaftertheendofameal(breakfastanddinner)
What are the possible side effects?40
• Alopecia• Anemia• Diarrhea• Hand-and-foot syndrome• Hepatotoxicity • Nausea/vomiting• Neurotoxicity/neuropathy• Neutropenia • Stomatitis/mucositis• Thrombocytopenia
Please see the Glossary for definition of side effects appearing in italics. To help you manage your side effects, please see Managing Side Effects section.
Talk to your healthcare professional if you have these symptoms. This is not a complete list of side effects. If you have any unexpected effects while taking CAPOX/XELOX, contact your healthcare professional.
35
CAPO
X/X
ELO
X
Capecitabine/Oxaliplatin (CAPOX/XELOX)
What is it?
CAPOX/XELOXisacombinationoftwoanticancerdrugs:capecitabineandoxaliplatin .25-26
What is it used for?
CAPOX/XELOXisusedinadjuvanttreatmentofadvancedormetastatic CRCthathasspreadoutsideofthecolonand/orrectum.40
How is it given?
CAPOX/XELOXcombinationisgivenasanintravenous infusionofanoxaliplatinfollowed bycapecitabinetabletstakenbymouth.40
How often is it given?
Capecitabinetabletsaretakentwiceaday,andoxaliplatinisinfusedonceevery3weeks.40
34
CAPOX/XELOX + bevacizumab treatment schedule41
CAPOX/XELOX + bevacizumab combination Treatment Schedule
Day 1 Oxaliplatin:IV infusionover2hoursBEV:IV infusionover90minutesthefirsttime,and30or60minutesafterthesecondorthirdtime
Onceevery3weeks
Capecitabineistakenin21daycycles-takecapecitabinefor 14daysandthenstoptakingitfor7days,thenstartagain
Day 1-14 Capecitabine:Tabletstakentwiceaday(morningandeveningdoses)for14dayswithin30minutesaftertheendofameal(breakfastanddinner)
What are the possible side effects?42
• Abdominal abscess • Alopecia• Anemia• Arterial thromboembolism• Diarrhea• Gastrointestinal perforation• Hand-and-foot syndrome• Hepatotoxicity • Hypertension • Nausea/vomiting• Neurotoxicity/neuropathy• Neutropenia • Stomatitis/mucositis• Thrombocytopenia• Woundhealingcomplications
Please see the Glossary for definition of side effects appearing in italics. To help you manage your side effects, please see Managing Side Effects section.
Talk to your healthcare professional if you have these symptoms. This is not a complete list of side effects. If you have any unexpected effects while taking CAPOX/XELOX + bevacizumab, contact your healthcare professional.
37
CAPO
X/X
ELO
X +
Bev
aciz
umab
Capecitabine/Oxaliplatin + Bevacizumab (CAPOX/XELOX + Bevacizumab)
What is it?
CAPOX/XELOX+Bevacizumabisachemotherapycombinationofcapecitabine,oxaliplatin andbevacizumab (BEV) .25-26
What is it used for?
CAPOX/XELOX+BEVcombinationisusedforadvancedormetastatic CRCthathasspreadoutsideofthecolonand/orrectum.41
How is it given?
OxaliplatinandBEVaregivenintoavein(intravenouslyorIV).Capecitabineisatablet andistakenbymouth.41
How often is it given?
Capecitabinetabletsaretakentwiceaday,andoxaliplatinandBEVaregivenonceevery 3weeksintoaveinbyintravenous infusion .41
36
IROX treatment schedule43
IROX combination Treatment Schedule
Day 1 Oxaliplatin + irinotecan:IV bolus infusion Onceevery3weeks
What are the possible side effects?43
• Diarrhea• Nausea/vomiting• Neurotoxicity/neuropathy• Neutropenia
Please see the Glossary for definition of side effects appearing in italics. To help you manage your side effects, please see Managing Side Effects section.
Talk to your healthcare professional if you have these symptoms. This is not a complete list of side effects. If you have any unexpected effects while taking IROX, contact your healthcare professional.
39
IRO
X
Irinotecan/Oxaliplatin (IROX)
What is it?
IROXisachemotherapycombinationconsistingoftwodrugs,irinotecanandoxaliplatin .25-26
What is it used for?
IROXisusedtotreatadvancedormetastatic CRCinpatientswhocannotuse5-fluoropyrimidine therapysuchas5-FUorcapecitabine .43
How is it given?
IROXisgivenintoavein(intravenouslyorIV).43
How often is it given?
IROXisgivenonceevery3weeks.43
38
Irinotecan + Cetuximab treatment schedule19,44,45
Irinotecan + cetuximab combination Treatment Schedule
Day 1 Cetuximab:IV infusionover2hours followedby
Irinotecan:IV infusionover60-90minutes
Cetuximab:Onceeveryweek
Irinotecan:Onceevery2weeks
Ifyoureceiveirinotecanwithcetuximabinthesameweek,irinotecanwillbegivenaftertheendofthecetuximab infusion .
What are the possible side effects?19,44
• Anemia• Diarrhea• Hypersensitivity • Infusionreactions• Nausea/vomiting• Neutropenia• Skinreactions(rash,acne,itching,nailchanges,andinfusion-relatedreactions)• Stomatitis/mucositis• Thrombocytopenia
Please see the Glossary for definition of side effects appearing in italics. To help you manage your side effects, please see Managing Side Effects section.
Talk to your healthcare professional if you have these symptoms. This is not a complete list of side effects. If you have any unexpected effects while taking Irinotecan + cetuximab, contact your healthcare professional.
41
IRIN
OTE
CAN
+ C
etux
imab
Irinotecan + Cetuximab (IRINOTECAN + Cetuximab)
What is it?
Irinotecan + cetuximabisachemotherapycombinationconsistingoftwoanticancerdrugs,irinotecanandcetuximab .25-26
What is it used for?
Thiscombinationisusedforthetreatmentofnon-mutatedKRAS metastatic CRCin patientswhohavebeenresistanttootherchemotherapyregimenscontaining5-FU, irinotecanoroxaliplatin .19
How is it given?
Irinotecan + cetuximabaregivenintoavein(intravenouslyorIV).19
How often is it given?
Irinotecan + cetuximabaregivenonceeveryweek.19,44
40
Cetuximab treatment schedule19
Cetuximab Treatment Schedule
Day 1 Cetuximab:IV infusionover2hours Onceeveryweek
What are the possible side effects?19
• Diarrhea• Hypersensitivity• Infusion reactions• Skinreactions(rash,acne,itching,nailchanges,andinfusion-relatedreactions)
Please see the Glossary for definition of side effects appearing in italics. To help you manage your side effects, please see Managing Side Effects section.
Talk to your healthcare professional if you have these symptoms. This is not a complete list of side effects. If you have any unexpected effects while taking cetuximab, contact your healthcare professional.
43
CETU
XIM
AB
Cetuximab (CETUXIMAB)
What is it?
Cetuximabisamonoclonal antibodythatspecificallyrecognizesandbindstotheepidermal growth factor receptor (EGFR)foundonthesurfaceofcertaintumour cells .19
What is it used for?
CetuximabisusedtotreatEGFR-expressingmetastatic CRCwithnon-mutated(wild-type) KRASafterfailureofchemotherapyregimenscontainingfluoropyrimidine, oxaliplatin, andirinotecan .19
What does it do?
Cetuximabbindstotheepidermal growth factor receptor (EGFR)foundonthesurfaceof certaintumour cells,andasaresultofthisbinding,thetumour cellcannolongerreceive themessagesitneedsforgrowth,progressionandmetastasis .19
How is it given?
Cetuximabisgivenintoavein(intravenouslyorIV).19
How often is it given?
Cetuximabaloneisgivenonceaweek.19
42
Panitumumab treatment schedule20
Panitumumab Treatment Schedule
Day 1 Panitumumab:IV infusionover1hour Onceevery2weeks
What are the possible side effects?20
• Anemia• Diarrhea• Hypersensitivity• Skinrash
Please see the Glossary for definition of side effects appearing in italics. To help you manage your side effects, please see Managing Side Effects section.
Talk to your healthcare professional if you have these symptoms. This is not a complete list of side effects. If you have any unexpected effects while taking panitumumab, contact your healthcare professional.
45
PAN
ITU
MU
MA
B
Panitumumab (PANITUMUMAB)
What is it?
Panitumumabisamonoclonal antibodythatrecognizesandattachestoCRC cellsthat expressepidermal growth factor receptor (EGFR) .20
What is it used for?
PanitumumabisusedtotreatEGFR-expressingmetastatic CRCwithnon-mutated(wild-type)KRASafterfailureofchemotherapyregimenscontainingfluoropyrimidine, oxaliplatin, andirinotecan .20
What does it do?
PanitumumabrecognizesandattachestoCRC cellsthatexpressEGFR,preventing thecancer cellsfromgrowinganddividing.20
How is it given?
Panitumumabisgivenintoavein(intravenouslyorIV).20
How often is it given?
Panitumumabisgivenonceeverytwoweeks.20
44
Capecitabine + bevacizumab treatment schedule42
Capecitabine + bevacizumab combination Treatment Schedule
Day 1-14 Capecitabine:Tabletstakentwiceaday(morningandeveningdoses)for14dayswithin30minutesaftertheendofameal(breakfastanddinner)
Takentwicedailyonday1through14followedby7-dayrest,every3weeks
Day 1 Bevacizumab:IV infusionover90minutes(about30or60minutesafterthefirstorsecondtime)
Onceevery3weeks
What are the possible side effects?42
• Abdominal abscess• Arterial thromboembolism• Diarrhea• Gastrointestinal perforation• Hand-and-foot syndrome • Hypersensitivity• Hypertension • Infusion reactions• Nausea/vomiting• Thrombocytopenia• Woundhealingcomplications
Please see the Glossary for definition of side effects appearing in italics. To help you manage your side effects, please see Managing Side Effects section.
Talk to your healthcare professional if you have these symptoms. This is not a complete list of side effects. If you have any unexpected effects while taking Capecitabine + bevacizumab, contact your healthcare professional.
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CAPE
CITA
BIN
E +
Bev
aciz
umab
Capecitabine + Bevacizumab (CAPECITABINE + Bevacizumab)
What is it?
Capecitabine + bevacizumabisachemotherapycombinationcontainingcapecitabine andbevacizumab (BEV) .25-26
What is it used for?
Capecitabine + BEVcombinationisusedtotreatmetastatic CRCthathasspreadoutside ofthecolonand/orrectum.42
How is it given?
Capecitabineisavailableastabletsthataretakenbymouth,andswallowedwhole withwater.BEVisgivenintoavein(intravenouslyorIV).42
How often is it given?
Capecitabinetabletsaretakenwithin30minutesaftertheendofameal(breakfastand dinner),twiceaday(morningandeveningdoses),andBEVisgivenonceevery14days.42
46
FOLFOXIRI treatment schedule46
FOLFOXIRI combination Treatment Schedule
Day 1 Oxaliplatin + Irinotecan + LV:IV infusionover2hours followedby
5-FU:continuousIV infusionover48hours
Onceevery2weeks
What are the possible side effects?46
• Anemia • Diarrhea• Nausea/vomiting• Neurotoxicity/neuropathy• Neutropenia• Stomatitis/mucositis• Thrombocytopenia
Please see the Glossary for definition of side effects appearing in italics. To help you manage your side effects, please see Managing Side Effects section.
Talk to your healthcare professional if you have these symptoms. This is not a complete list of side effects. If you have any unexpected effects while taking FOLFOXIRI, contact your healthcare professional.
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FOLF
OX
IRI
5-FU/Leucovorin/Irinotecan/ Oxaliplatin (FOLFOXIRI)
What is it?
FOLFOXIRIisachemotherapycombinationtreatmentcontaining5-fluorouracil (5-FU), leucovorin(LVorfolinicacid),irinotecanandoxaliplatin .25-26
What is it used for?
FOLFOXIRIisusedtotreatadvancedormetastatic CRC .46
How is it given?
FOLFOXIRIisgivenintoavein(intravenouslyorIV).46
How often is it given?
FOLFOXIRIisgivenevery2weeks.46
48
FOLFOXIRI + bevacizumab treatment schedule47
FOLFOXIRI + bevacizumab combination Treatment Schedule
Day 1 Bevacizumab BEV:IV infusion(firstinfusionover90minutes, secondinfusionover1hour,andsubsequentinfusionsover30minutes) followedbyFOLFOXIRI
FOLFOXIRIOxaliplatin + Irinotecan + LV:IV infusionover2hours followedby
5-FU:continuousIV infusionover48hours
Onceevery2weeks
What are the possible side effects?47
• Abdominal abscess • Anemia • Arterial thromboembolism• Diarrhea• Gastrointestinal perforation• Hypertension • Nausea/vomiting• Neurotoxicity/neuropathy• Neutropenia• Stomatitis/mucositis• Thrombocytopenia• Woundhealingcomplications
Please see the Glossary for definition of side effects appearing in italics. To help you manage your side effects, please see Managing Side Effects section.
Talk to your healthcare professional if you have these symptoms. This is not a complete list of side effects. If you have any unexpected effects while taking FOLFOXIRI + bevacizumab, contact your healthcare professional.
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FOLF
OX
IRI +
Bev
aciz
umab
5-FU/Leucovorin/Irinotecan/ Oxaliplatin + Bevacizumab (FOLFOXIRI + Bevacizumab)
What is it?
FOLFOXIRI+bevacizumabisachemotherapycombinationtreatmentcontaining5-fluorouracil (5-FU), leucovorin(LVorfolinicacid),irinotecan,oxaliplatinandbevacizumab (BEV) .25-26
What is it used for?
FOLFOXIRI+BEVcombinationisusedtotreatadvancedormetastatic CRC.AdditionofBEV toFOLFOXIRIcombinationincreasestreatmenteffectiveness.47
How is it given?
FOLFOXIRI+BEVcombinationisgivenintoavein(intravenouslyorIV).47
How often is it given?
FOLFOXIRI+BEVisgivenonceevery2weeks.47
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IXO treatment schedule28,48
IXO combination Treatment Schedule
Day 1 Oxaliplatin:IV infusionover2hoursfollowedby
Irinotecan:IV infusionover1hour
Onceevery3weeks
Day 1-14 Capecitabine:Tabletstakentwiceaday(morningandeveningdoses)for14dayswithin30minutesaftertheendofameal(breakfastanddinner)
Capecitabineistakenin21daycycles-takecapecitabinefor 14daysandthenstoptakingitfor7days
What are the possible side effects?48
• Anemia• Diarrhea• Nausea/vomiting• Neurotoxicity/neuropathy• Neutropenia
Please see the Glossary for definition of side effects appearing in italics. To help you manage your side effects, please see Managing Side Effects section.
Talk to your healthcare professional if you have these symptoms. This is not a complete list of side effects. If you have any unexpected effects while taking IXO, contact your healthcare professional.
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IXO
Irinotecan/Capecitabine/ Oxaliplatin (IXO)
What is it?
IXOisachemotherapydrugcombinationconsistingofirinotecan,capecitabine andoxaliplatin .25-26
What is it used for?
IXOisusedtotreatmetastatic CRC .48
How is it given?
Capecitabineisavailableastabletsthataretakenbymouth,andswallowedwhole withwater.Irinotecanandoxaliplatinaregivenintoavein(intravenouslyorIV).48
How often is it given?
Capecitabinetabletsaretakentwiceadayfor14days.Irinotecanandoxaliplatin areinfusedonceevery3weeks.48
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Diarrhea:Avoidfoodshighinfibre(freshfruit,rawvegetables,wholegrains,bran,nuts,andseeds);Eatfrequentsmallmealsofcookedfruits/vegetables,rice,leanmeats,fishorchicken,bananas,applesauce,toast;Eliminatemilkandmilkproducts,caffeineandalcohol;Avoidgreasy,spicyorsugaryfoods;Drinkplentyoffluidsbyincreasingfluidintakeasmuchasyoucan(8-12eightozcups/day);Takeantidiarrhealmedicationsasprescribedbyyourhealthcareprofessionaloraccordingtopackageinstructions;Formoredietarytips,askyourhealthcareprofessionaltoreferyoutoadietician.Comfortmeasuresinclude:Sitzbaths(awarmwaterbathwherethewatercoversonlythehipsandbuttocks);Usesoothingwipes;Usehaemorrhoidbarriercreamsasneeded.
F
Fever:See“Neutropenia”.
Febrile neutropenia:See“Neutropenia”.
G
Gastrointestinal perforation:Treatmentusuallyinvolvessurgerytorepairtheperforation(hole).Sometimes,asmallpartoftheintestinemustberemoved.Atemporarycolostomy(asurgicalprocedurethatbringsoneendofthelargeintestineoutthroughtheabdominalwall,andallowsstoolsmovingthroughtheintestinedrainintoabagattachedtotheabdomen)orileostomy(asurgerytoremovepartorallofyoursmallintestinethatisblockedordiseased)maybeneeded.Antibioticsalonecanbeusedinrarecasestotreatpatientswhoseperforationshaveclosedontheirown.
H
Hand-and-foot syndrome:Applymoisturizertohandsandfeetliberallyandoften.Sitorlieonpaddedsurfacesofchairsormattresses.Raiselegswheneverpossiblewithcushions.Placeapillowbetweenkneesorwearpyjamas(preventsrubbinglegsduringsleep).Wearloose-fittingclothesandloose-fittingcomfortableshoes.Avoidthefollowing:Exposureofhandsandfeettoheatsuchashotwater;vigorousrubbingtopalmsandsoleswhenwashingorapplyingmoisturizers;activitiesthatcauserubbingofskinsurfaces;anyunnecessarywalking,joggingorvigorousexercise;andwalkingwithbarefeet.Toalleviatediscomforttrycoldpacksandothercoldontheaffectedareasprocedures(avoidcoldpacksifyouareonoxaliplatin-basedchemotherapyregimenasitmaymaketheneurotoxicitysymptomsworse),andover-the-counterpainmedication(e.g.acetaminophen).Tohelpsoothedry,irritatedskin,applyUdderlySmooth®UdderCreamorBagBalm® ointment2-3timesaday.
Headache:Over-the-countermedicationssuchasacetaminophen,ibuprofenoraspirinmaybeprescribedtotreatheadache.Ifyouhaveableedingdisorder,youshouldavoidaspirin.Alwaystalktoyourhealthcareprofessionalbeforetakinganymedications.
Hepatotoxicity:Treatment-relatedliverproblemsmightoccur.Youmayexperiencenausea,jaundice,swollenabdomen,painintheupperabdomen,ormentalconfusionasaresultofchemotherapy-inducedliverdamage.Thereisnotreatment forliverdamageonceitoccurs.Yourhealthcareprofessionalwilladviseyoutostoptakinganymedicationsthatareprocessedthroughtheliver,andmayprescribemedicationsthathelpreducethesymptomsofliverdamagesuchasadiuretictoreducefluidaccumulationorswellingbymakingyouurinateoutextrafluid.Ifyourliverisnotfunctioningproperlyavoidthefollowing:alcohol,acetaminophen,medicationsthathavecausedliverdysfunctioninthepast,andmedicationstotreathighbloodcholesterollevels,suchasatorvastatinorsimvastatin.Talktoyourhealthcareprofessionalbeforechanginganymedications.
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Managing Side Effects
Thissectionisdesignedtohelpyoumanagesideeffectswhichyoumayhaveinresponsetoyourtreatmentasdescribedunder“What are the possible side effects?”inthePersonalized Treatment Section ofthisguide.Foryourconvenience,sideeffectswiththetipsonhowtomanagethemarelistedinalphabeticalorderbelow.
A
Abdominal pain:Managementofabdominal painsdependsontheircauseandseverity,andcanbecontrolledwithover-the-countermedications.Changesindietinawaythathelpseithersloworspeedtheintestinalactivitycanhelpcontrol,andinsomecasespreventabdominalcramps.Dairy,soy,fatorwheatglutenproductsarenottoleratedwellbypatientsfollowingtreatmentforCRC.Yourhealthcareprofessionalcanassistyouinchoosingtherightover-the-countermedication,andmakingchangestoyourdiettohelpcontrolorpreventabdominal pain.
Allergic reaction:See“Hypersensitivity/Allergicreaction” .
Alopecia(hairloss):Usuallynewhairshouldregrowintheweeksormonthsaftertreatment.Insomecases,itmightnotregrow,whichismorecommonafterradiotherapythanafterchemotherapy.Tohelp youcopewiththehairlossconsiderthefollowing:Youmaywishtocutyourhairbeforeitstartsfalling outastheexperienceoflosingthehairissometimesworsethandealingwithitonceit’sgone;forwomen,planaheadandshopforawigbeforeyourhairisgone,especiallyifyouwishtomatchyournaturalcolor;wearinghatsorheadscarvesaregoodalternativesoracomplimenttoawig;avoidexposuretothesun,andcoveryourheadorusesunscreenonyourscalp.SkinthathasbeencoveredwithhairmaybeparticularlysensitivetoUVrays;askyourinsurancecompanyiftheycoverthecostofthewig;treatyournewhairgentlyonceitgrowsback,andavoidchemicals,bleach,peroxideorcolors.Considergettinginvolvedina“LookGood…FeelBetter”program,acommunity-based,free,nationalservicethatteachesfemalecancerpatientsbeautytechniquestohelprestoretheirappearanceandself-imageduringchemotherapyandradiationtreatments.Formoreinformationgotowww.lookgoodfeelbetter.org.
Anemia:Anemiaisthemostcommoncauseoftiredness,weaknessorfatigue.Tohelpdealwiththesesymptomsgetplentyofrestbytakingnapsduringtheday,andgotobedearlierthanusual;Eatawell-balanceddiet,andasktospeaktoanutritionist,whowillhelpyouchoosegood,strengtheningfoodsthatappealtoyou;trytostayactiveandtakeshortwalksaslightexercisemayhelp;restrictunnecessaryactivities,saveyourenergybydoingthethingsthatarereallyimportant,andletothershelpyoubytakingoversomechoresandtasks.
Arterial thromboembolism:See“Thromboembolism”.
D
Dehydration(lackofappropriateamountoffluidinthebody):Cancerpatientsmusthaveadequatefluidtoremovetoxinsfromthebodyaswellasproteinsreleasedbydyingcells.Takeinasmuchfluidonaspossibleonadailybasis,butdonotdrinkproductscontainingelectrolytes(suchassportsdrinks)unlessinstructedtodosobyyourhealthcareprofessional.Incasesofseveredehydration,hydrationtherapy throughIVisusuallyadministeredinthehospitalsetting.
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The words in the
Managing Side
Effects section
marked in italics
can be found
in the Glossary.
Neurotoxicity/neuropathy:Duringinfusion,wearablankettokeepwarm;Avoidactivitiesthatrequireyoutogooutdoorsduringcoldweather,andifyougoout,makesureyoudresswarmly;Coveryourskinbeforeyouentercoldplaces;Don’ttouchcoldsurfacesorobjects,orwashyourhandswithcoldwater;Avoidbreathingindeeplywhenexposedtocoldairoutsideortoairconditioners;Donotuseicetosoothemouthsoresoreasenausea;andAvoideatingfrozenorcoldfoods,anddrinkingcoldbeveragesorusingice.
Neutropenia(lowwhitebloodcellcount):Rarely,cancerpatientsmayexperienceneutropenia,whichincludesinfectionsandfever/febrile neutropenia,fromchemotherapyorasaresultoftheirunderlyingcancer.Dependingonthecauseofneutropenia,yourhealthcareprofessionalwilldeterminethetreatmentthatisrightforyou.Ifthefeverisdeterminedtoberelatedtoaninfection,treatmentwillbeprescribedfortheinfection.Forabacterialinfection,antibioticsareusuallyprescribed;forviralinfections,theusualtreatmentisoftenrestandplentyoffluids,althoughantiviraldrugsmaybeusedtotreatsomeviruses.Ifaninfection-relatedfeverisveryhigh,over-the-countermedicationssuchasacetaminophen,ibuprofenmaybeprescribedtoreducethefeverandassociateddiscomfort.Ifyouhaveableedingdisorder,youshouldavoidthesemedications.Alwaystalktoyourhealthcareprofessionalbeforetakinganymedications.Whileitmaybedifficulttopreventfeversresultingfrominfectionsduetoneutropenia,somemeasurestohelppreventinfectionsmayinclude:avoidingscratchesandcutsviagentlehandlingoftheskin;frequenthand-washing;pattingskindryratherthanrubbing;thoroughcookingoffood;reducinghumancontactsoastoreducethepotentialofcontractinganinfection:andavoidinggardeningandhandlingpetlitters.
P
Pain(joint,muscle,bone,chest/thorax,abdomen,head/headache,orrectum):Medicationscanbeusedforpainrelief,andareusuallyselectedaccordingtotheneedsofthepatient.Forsomekindsofpainrelatedtocancer,non-prescriptionover-the-countermedicationssuchasacetaminophen,ibuprofen,maybesufficient.Forotherdegreesandkindsofpain,prescriptionmedicationsareused.Yourhealthcareprofessionalwilldeterminewhichtypeofmedicationisappropriateforyourtypeofpain .
Pulmonary embolism:“Thromboembolism”.
S
Skin rash:See“Hypersensitivity/allergicreaction”.
Skin reactions(rash,acne,itching,nailchanges,andinfusion-relatedreactions):See“Skinreaction/acne”.
Skin reaction/acne:Forskinreactions,uselotionsthatdonotcontainalcoholtocooltheskin.Ifyourrashisaresultofanallergic reactiontoadrug,yourhealthcareprofessionalmaystopthedrug.Forminor,non-allergicskinreactions,yourhealthcareprofessionalmayrecommendoneofthefollowing:corticosteroidcreamtoreducehelpinflammation;antihistaminetohelpreducesymptomsofanallergic reaction,suchasrash,hivesandshortnessofbreath;analgesics,over-the-countermedicationssuchasacetaminophenoraspirin,tohelprelievepainassociatedwitharash.Tohelpmanagearash:Wearloose,non-bindingclothing;usemildsoapwithoutperfumes;dryyourskincarefullyafterbathing;avoidharshchemicals;protectyourskinfromthesunwithsunscreensorlong,looseclothing;trynottoscratch,andtalktoyourhealthcareprofessionalaboutanti-acnemedications.
Stomatitis/mucositis:Forthetreatmentofstomatitis(mouthsores):Practicegoodoralcarebyfrequentlyrinsingthemouthwithsaline/saltwaterandbrushingteeth2-3timesperday;mouthwashes(saltandsodamouthwashcanhelprelievemouthsoresaswellasmedicatedmouthwashes;suckonicechipstominimizethedamagefromchemotherapydrugs(avoidcoldpacksifyouareonoxaliplatin-basedchemotherapyregimenasitmaymaketheneurotoxicitysymptomsworse);avoidveryhotfoods,carbonatedbeverages,andeatsoftfoodsuntilthesoresheal.Forthetreatmentofmucositis(inflammationofthemucosa)whetherinthemouth,pharynx,esophagus,trachea,bowel,bladderorrectum:Avoidingirritationbykeepingfoodorstoolssoftandpreventingtraumaofanykind;uselocalanalgesic(pain-killing)mixtures,antibioticsorsteroids;keephydratedbytakinginfluids;andeatfoodslowinfibreifyouhavebowelreaction.
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Hypersensitivity/allergic reaction:Medicationssuchasantihistamines,epinephrineandsteroidscanbeusedtotreatallergic reactions.Severereactionsmayrequireothertherapy,suchascorticosteroids,oxygentherapy,narcotics,orpulmonaryrehabilitationforbreathingdifficulties/shortnessofbreathorintravenous fluidstoboostbloodpressureinanaphylacticshock.Tohelpmanagebreathingdifficulties,therearethingsyoucandoeverydaysuchas:relaxationtechniquestocontrolyourbreathing(meditation,yoga,ordeepbreathingexercises);promoteoxygenation(aircirculation)throughoutyourlungstohelppreventinfection andpneumoniawithbreathingexercisesorphysicalactivity;useaspirometer,adevicethatmakesyoubreatheslowlyanddeeply,tomaintainoxygenation;findakindofexercisethatyoucantolerateanddoitdaily;avoidsmokingandsmoke-filledenvironments;andreduceanxietyandmanagestress.
Itisdifficulttopredictwhichpatientswilldevelopanallergic reactiontotheirCRC therapies,whichmakesitdifficulttoprevent.Ifyoudevelopatreatment-relatedallergic reaction,talktoyourhealthcareprofessionalaboutavailableremediesthatarerightforyou.
Hypertension(highbloodpressure):HighbloodpressurecandeveloptemporarilyasaresultoftreatmentforCRC.Youmayexperiencerapidpulse,fluidretention,headache,orothersymptomsofhighbloodpressure.Tohelplowerbloodpressure,engageinregularaerobicexercise,weightreduction(ifoverweight)andsaltrestriction.Ifyourbloodpressureisstillhighafteryoutriedtheseoptions,yourhealthcareprofessionalmayprescribeantihypertensivemedicationsdesignedtolowerbloodpressure.
I
Infection:See“Neutropenia”.
Infusion reactions:See“Hypersensitivity/”.
M
Mucositis:See“Stomatitis/mucositis”.
N
Nausea/vomiting:Thefollowingtipscanhelpyoumanagenauseaandvomiting.Eating tips:Ifyourtreatmentcausesnausea,donoteatforatleast1or2hoursbeforetreatment,oreatalightmealbeforeyourtreatment;eatwhatappealstoyou,anddon’tforceyourselftoeatunappealingfoods;inplaceoflargermeals,eatmorefrequentandsmallermealsandsnacksbeforehungersetsinsincefeelingsofhungercanmakeyournauseaworse;avoidfoodsthathaveastrongodour,arehighinfat,orarefried,spicy,orverysweet;restaftereating,sittingupratherthanlyingdown;andifyouhavemorningnausea,tryeatingdryfoodslikecereal,toast,orcrackers,unlessyouhavesoresinyourthroatormouth,orverylittlesaliva.Drinking tips:Limitdrinksthatleaveyoufeelingbloated;drinkslowly,withastrawifithelpsyoutodrinkmoreslowly;drinkroom-temperatureliquidsfrequently,andinsmallamounts;anddrinkcool(notcold(re:mayexacerbateneuropathy),clear,unsweetenedjuicesorflat,light-colouredsoftdrinkswithoutcaffeine.
Foodsthatareeasyonyourstomachincludecannedfruit,cookedcereal,rice,noodles,potatoes,clearliquids(sportsdrinks,clearsoftdrinkssuchasgingerale),tea,broth,andwater.
Ifyouarevomiting,avoideatingordrinkinguntilit’sundercontrol,thentrysmallamountsofclearliquidsandworkuptoafullliquiddietorasoftdiet.Ifyouhavenauseaandvomitingthatissevereorlastsmorethanaday,oryoucan’tkeepliquidsdown,contactyourhealthcareprofessional,andheorshemaysuggestantinauseamedicationorothertreatment.
Formoredietarytips,askyourhealthcareprofessionaltoreferyoutoadietician.
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Colorectal Cancer Glossary4,25,26,49
5-fluorouracil (5-FU):Adrugusedasatreatmentusuallyforcolorectal cancer.Itisatypeofanti-metabolite(adrugthatisverysimilartonaturalchemicalsinanormalcellularreactionsbutdifferentenoughtointerferewithcelldivisionandfunction).AlsoseeFluorouracil .
5-FU:See5-fluorouracil .
A
Abdomen:Theareaofthebodythatcontainsthepancreas,stomach,intestines,liver,gallbladder,andotherorgans.
Abdominal:Havingtodowiththeabdomen,whichisthepartofthebodybetweenthechestandthehipsthatcontains thepancreas,stomach,intestines,liver,gallbladder,andotherorgans.
Abscess:Anenclosedcollectionofpusintissues,organs,orconfinedspacesinthebody.Anabscessisasignofinfection andisusuallyswollenandinflamed.
Adjuvant therapy:Treatmentgivenaftertheprimary(main)treatmentisreceived,andallvisiblesignsofthecancer removed,tohelpincreasethechancesofacure.Adjuvant therapymayincludechemotherapy,radiation therapyorothertherapy.AlsoseeNeoadjuvant therapy .
Alopecia:Thelackorlossofhairfromareasofthebodywherehairisusuallyfound.Alopeciacanbeasideeffectofsomecancertreatments.
Anemia:Aconditioninwhichthenumberofredbloodcellsisbelownormal,resultinginareductionintheamountofoxygenthatcanbecarriedtothevariousbodypartsandtissues,causingfatigueortiredness,weakness,troublebreathing,rapidheartbeat,dizziness,lightheadedness,inabilitytoconcentrate,orheadache.
Antibody:Aproteinmadebyplasmacells(atypeofwhitebloodcell)inresponsetoanantigen(asubstancethatcausesthebodytomakeaspecificimmuneresponse).Eachantibodycanbindtoonlyonespecificantigen.Thepurposeofthisbindingistohelpdestroytheantigen.Someantibodiesdestroyantigensdirectly.Othersmakeiteasierforwhitebloodcellstodestroytheantigen.AlsoseeMonoclonal antibody .
Arterial thromboembolism:Theblockingofanarterybyaclotofforeignmaterial.Thiscanbedoneastreatmenttoblocktheflowofbloodtoatumour.Alsocalledembolization.
B
Bevacizumab:Itisnotchemotherapybutisgivenincombinationwithaspecifictypeofchemotherapy.Whilechemotherapyattacksthetumourdirectly,bevacizumabwhichisamonoclonal antibodyattacksthebloodvesselsthatsurroundthetumour.Inordertogrowandspread,tumoursneedaconstantsupplyofoxygenandothernutrients.Tumours getthissupplybycreatingtheirownnetworkofbloodvessels.Thisprocessiscalledangiogenesis,andbevacizumabworksbyblockingangiogenesis.Bypreventingthegrowthofnewbloodvessels,bevacizumabhelpsstarvethetumourofoxygenandothernutrients.Thismakesithardforthetumourtogrow.
BEV:seeBevacizumab .
Biomarker:Alsocalledmolecularmarker,isabiologicalmoleculefoundinblood,otherbodyfluids,ortissuesthatisasignofanormalorabnormalprocess,orofaconditionordisease.Abiomarkermaybeusedtoseehowwellthebodyrespondstoatreatmentforadiseaseorcondition.Alsocalledmolecularmarker.
Biomarker Testing:Atestofblood,orotherbodyfluidortissuesdonetolookforabiomarkerofaconditionordisease. Abiomarkermaybeusedtoseehowwellthebodyrespondstoatreatmentforadiseaseorcondition.
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Thrombocytopenia(lowplateletcount):Plateletsarethecellsthatformbloodclotsthatstopbleeding.Lowplateletcountcancausebleeding.Checkwithyourhealthcareprofessionalbeforetakinganykindofmedication,vitamin,orpill.SomemedicationslikeASA(Aspirin)canaffectbloodclotting,andcontributetobleeding.Tohelppreventbleeding:Useaverysofttoothbrushorcottonswab;blowyournosegently,anduseaverysofttissue;trynottocutornickyourselfwithanysharpitems,andifyoushave,switchtoanelectricrazor;andavoidactivitiesthatcouldcauseaninjury,likecontactsports.
Thromboembolism(orembolism):IfyouareatriskforbloodclotformationasaresultofyourCRC treatment,yourhealthcareprofessionalwillprescribeanticoagulantdrugsuchaswarfarinorheparintohelppreventbloodclots.
For more information on description/symptoms, cause, remedy/treatment, and prevention of side effects, and ways to manage them, visit Colorectal Cancer Association of Canada website at www.colorectal-cancer.ca/en/treatments/addressing-effects/.1
Talk to your healthcare professional if you have additional questions or need more information on your possible side effects and how to manage them.
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D
Dehydration:Aconditioncausedbythelossoftoomuchwaterfromthebody.Severediarrheaorvomitingcancausedehydration .
Differentiation(differentiated):Incancer,referstohowmature(developedordifferentiated)thecancercellsareinatumour.Differentiatedtumourcellsresemblenormalcellsandtendtogrowandspreadataslowerratethanundifferentiatedorpoorlydifferentiatedtumourcells,whichlackthestructureandfunctionofnormalcellsandgrowuncontrollably.
DNA:Themoleculesinsidecellsthatcarrygeneticinformationandpassitfromonegenerationtothenext.Alsocalleddeoxyribonucleicacid.
E
EGFR:Theproteinfoundonthesurfaceofsomecellsandtowhichepidermalgrowthfactorbinds,causingthecellstodivide.Itisfoundatabnormallyhighlevelsonthesurfaceofmanytypesofcancercells,sothesecellsmaydivideexcessivelyinthepresenceofepidermalgrowthfactor.Alsocalledepidermal growth factor receptor,ErbB1,andHER1.
Embolism:Ablockinanarterycausedbybloodclotsorothersubstances,suchasfatglobules,infectedtissue,or cancercells.
Epidermal growth factor receptor:seeEGFR
External beam radiation therapy:Amachinelocatedoutsidethebodyisusedtodirectradiationatthecancerandsurroundingtissue.Thistypeofradiationisusedtotreatmosttypesofcancer,anditisdoneonanoutpatientbasis.PatientstypicallyreceiveonetreatmenteverydayfromMondaythroughFridayandacourseoftreatmentmaycontinueforseveralweeks.
F
Febrile neutropenia:Aconditionmarkedbyfeverandalower-than-normalnumberofneutrophilsintheblood.Aneutrophilisatypeofwhitebloodcellthathelpsfightinfection.Havingtoofewneutrophilsincreasestheriskofinfection . AlsoseeNeutropenia .
Fluoropyrimidine:Oneofagroupofsubstancesusedtotreatcancer.Afluoropyrimidineisatypeofantimetaboliteincludingdrugssuchascapecitabineandfluorouracil(5-FU).
Fluorouracil:Anticancerdrugusedtotreatsymptomsofcancerofthecolon,breast,stomach,andpancreas.Itisalsousedinacreamtotreatcertainskinconditions.FluorouracilstopscellsfrommakingDNAanditmaykillcancercells.Itisatypeofantimetabolitewhichinterfereswithcellgrowth.Alsocalled5-fluorouraciland5-FU .
G
Gastrointestinal:Referstothestomachandintestines.AlsocalledGI.
Gastrointestinal perforation:Aholethatdevelopsthroughtheentirewallofthestomach,smallintestine,largebowel, orgallbladder.
Gene:Thefunctionalandphysicalunitofhereditypassedfromparenttooffspring.GenesarepiecesofDNA,andmostgenescontaintheinformationformakingaspecificprotein .
H
Hand-and-foot syndrome:Aconditionmarkedbypain,swelling,numbness,tingling,orrednessofthehandsorfeet. Itsometimesoccursasasideeffectofcertainanticancerdrugs.Alsocalledpalmar-plantarerythrodysesthesia.
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Biopsy:Aprocedureinwhichasampleofcanceroustissueisremovedforanalysisunderthemicroscopetohelppreciselydiagnosethetypeofcanceranditsgrade.
Bolus:Asingledoseofadrugorothersubstancegivenoverashortperiodoftime.Itisusuallygivenbyinfusionorinjectionintoabloodvessel.Itmayalsobegivenbymouth.
Brachytherapy:Atypeofcontactradiation therapythatusesasealedradioactivesource(animplant),whichisplacedinornearthetumour,andmakesitpossibletotreatcancerwithhighradiationdosesinaveryfocusedmanner.
BRAF gene:AgenethatmakesaproteincalledB-RAF,whichisinvolvedinsendingsignalsincellsandincellgrowth.Thisgenemaybemutated(changed)inmanytypesofcancer,whichcausesachangeintheB-RAFprotein.Thiscanincreasethegrowthandspreadofcancercells.
BRAF Mutation:AmutationintheBRAF genethatmakespatientswithcolorectal cancernon-responsivetotreatmentswithcetuximabandpanitumumab .
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Cancer:Atermtodescribediseasesinwhichabnormalcellsdivideuncontrollablyandcaninvadenearbytissues.Alsocalledmalignancy.
Capecitabine:Belongstoafamilyofmedicationscalledthefluoropyrimidines(medicationsthatinterferewiththegrowthofcellsthatrapidlydivideinthebody,includingcancercells).Capecitabineisaninactivesubstanceonitsown.Whencapecitabineistaken,itischangedinthebody,mostlywithinthetumour (cancercells),tobecomethecommonlyusedcancermedicationcalled5-fluorouracil(alsoknownas5-FU).Insomepatients5-FUwillkillcancercellsanddecreasethesizeofthetumour .
Carcinoma in situ:Alsocalledstage0cancer,itisagroupofabnormalcellsthatareconfinedtotheplaceinthebodywheretheyfirstformed,anddonotspread.Theseabnormalcellsmaybecomecancerousandspreadintonearbynormaltissue.Inthebowel,in-situcarcinomaistypicallyseenonthesurfaceof apolyp .
Cell:Theindividualunitthatmakesupthetissuesofthebody.Alllivingthingsaremadeupofoneormorecells.
Cetuximab:Amonoclonal antibodythatrecognizesandattachestocolorectal cancercellsthatexpressepidermal growth factor receptor (EGFR)withnon-mutated(wild-type)KRASafterfailureofchemotherapy regimenscontainingfluoropyrimidine,oxaliplatin,andirinotecan,andpreventsthecancercellsfromgrowinganddividing.
Chemoradiation:Treatmentthatcombineschemotherapywithradiation therapy.Alsocalledchemoradiotherapy.
Chemotherapy:Drugtreatmentsthathelpdestroycancercellsbyinterferingwiththecancercellsabilitytodivide.Thesedrugtreatmentsaretypicallygiveneveryfewweekstherebyallowingnormaltissuesandbloodcountstorecoverintheinterval.
Clinical Trial:Aresearchstudydesignedtoansweraquestionabouttheeffectivenessofnewtherapiesornewwaysofusingalreadyexistingtherapies,anddeterminewhethertheyaresafeandeffective.
Colorectal:Havingtodowiththecolonortherectum.
Colorectal cancer:Cancerthatdevelopsinthecolon(thelongestpartofthelargeintestine)and/ortherectum(thelastseveralinchesofthelargeintestinebeforetheanus).AlsoreferredtoasCRC .
CRC:SeeColorectal cancer .
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Locally advanced cancer:Adescriptivetermtodescribecancerthathasspreadfromwhereitstartedontheinnersurfaceofthebowel,throughthebowelwalltoinvolvenearbytissuesorlymph nodes .
LV:SeeLeucovorin .
Lymph node:Alsocalledlymphgland,isaroundedmassoflymphatictissue.Lymph nodesfilterlymph(lymphaticfluid)andcantrapforawhilecancercellsthatareleavinganorgan.Inthebowel,lymph nodesarepresentonthesurfaceofthebowelandalongthebloodvesselsgoingtothebowel.Removingthemisanimportantaspectoftheinitialsurgery.Whenthemaligs areinvolvedincolorectal(bowel)cancers,theStageautomaticallybecomes3(or4ifdistantorgansarealsoinvolved).
M
Malignant:Cancerous.Malignantcellscaninvadeanddestroynearbytissueandspreadtootherpartsofthebody.
Metastasis(ormetastases):Thespreadofcancerfromonepartofthebodytoanother.Atumourformedbycancerouscellsthathavespreadfromitsoriginallocationiscalleda“metastatictumour”ora“metastasis”orthepluralform,“metastases”,ifthereismorethanone.Themetastatictumourcontainscellsthatarelikethosewhichcamefromtheoriginal(primary)tumour .
Metastatic:Acancerthathasspreadfromwhereitstarted(primarytumour)toother(distant)partsofthebodysuchas theliverandlungs.
Mitomycin C:AnticancerdrugthatdamagesDNA,preventingcelldivision,whichleadstocancer celldeath.
Monoclonal antibody:Asubstancesuchasproteinwhichismadeinthelaboratory.Theseantibodiesaredesignedtohaveanexactattractionforcertainmoleculesfoundonthesurfaceofcells,includingcancercells.Therearemanykindsofmonoclonalantibodies.Eachmonoclonal antibodyismadetofindonesubstance.Monoclonalantibodiesaredesignedtotargetthemalignant(cancerous)cellsthatformthetumour,andareusedtotreatsometypesofcancer.AlsoseeTargeted therapy .
Mucosa:Alsocalledmucous membraneisthemoist,innerliningofsomeorgansandbodycavitiessuchasthenose,mouth,lungs,andstomach.Glandsinthemucosamakemucus(athick,slipperyfluid).
Mucositis:Acomplicationofsomecancertherapiesinwhichtheliningofthedigestivesystembecomesinflamed.Oftenseenassoresinthemouthorstomatitis .
Mucous membrane:Themoist,innerliningofsomeorgansandbodycavities(suchasthenose,mouth,lungs,andstomach).Glandsinthemucous membranemakemucus(athick,slipperyfluid).Alsocalledmucosa .
Mutation:AnychangeintheDNAofacell . Mutationsmaybecausedbymistakesduringcelldivision,ortheymaybecausedbyexposuretoDNA-damagingagentsintheenvironment.Mutationscanbeharmful,beneficial,orhavenoeffect.Iftheyoccurincellsthatmakeeggsorsperm,theycanbeinherited;ifmutationsoccurinothertypesofcells,theyarenotinherited.Certainmutationsmayleadtocancerorotherdiseases.
N
Neoadjuvant therapy:Treatmentgivenbeforetheprimarysurgicaltreatment.Examplesofneoadjuvant therapyincludechemotherapy, radiation therapy, or other therapies. Neoadjuvant therapyisusuallygiventomakethesurgeryeasierandmoreeffective.AlsoseeAdjuvant therapy .
Neurological or neurologic:Havingtodowithnervesorthenervoussystem.
Neuropathy:Anerveproblemthatcausespain,numbness,tingling,swelling,ormuscleweaknessindifferentpartsofthebody.Itusuallybeginsinthehandsorfeetandgetsworseovertime.Neuropathymaybecausedbyphysicalinjury,infection,toxicsubstances,disease(suchascancer,diabetes,kidneyfailure,ormalnutrition),ordrugs,includinganticancerdrugs.Alsocalledperipheralneuropathy.
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Hepatotoxicity:Poisonousorharmfultotheliver.Hepaticreferstotheliver,andtoxicityistheextenttowhichsomethingispoisonousorharmful.
HiPEC:SeeHyperthermic Intraperitoneal Chemotherapy .
Hypersensitivity:Anexaggeratedresponsebytheimmune systemtoadrugorothersubstance.Alsocalledanallergic reaction .
Hypertension:Abloodpressureof140/90orhigher.Hypertensionusuallyhasnosymptoms.Itcanharmthearteriesandcauseanincreaseintheriskofstroke,heartattack,kidneyfailure,andblindness.Alsocalledhighbloodpressure.
Hyperthermic Intraperitoneal Chemotherapy(orHiPEC):isusedforcancersthatareconfinedtotheperitoneal(abdominal)cavityandareotherwisedifficulttotreatwithotheravailabletreatments.HiPECisatreatmentoptionforpatientswhosecancersaredifficulttotreatsuchasthosethatspreadtotheliningsurfacesoftheperitoneal(abdominal)cavityfromprimary colorectal cancer.“Intraperitoneal”meansthatthetreatmentisdeliveredtotheabdominalcavity,andterm“HyperthermicChemotherapy”meansthatthesolutioncontainingchemotherapy(anticancerdrugs)isheatedtoatemperaturethatishigherthannormalbodytemperature.
I
Immune system:Thecomplexgroupoforgansandcellsthatdefendsthebodyagainstinfectionsandotherdiseases.
Inflammation:Redness,swelling,pain,and/orafeelingofheatinanareaofthebody.Thisisaprotectivereactiontoinjury,disease,orirritationofthetissues.
Infusion:Amethodofinjectingfluids,includingdrugs,intothebloodstream.Alsocalledintravenous infusion .
Intra-abdominal:Insidetheabdomen(theareaofthebodythatcontainsthepancreas,stomach,intestines,liver,gallbladder,andotherorgans).
Intravenous:Givingchemotherapydrugintoavein.AlsocalledintravenouslyorIV.
Irinotecan:Anticancerdrugthatworksbykillingrapidlydividingcells,suchascancercells.
IV:seeIntravenous .
K
KRAS gene:Agenethatmaycausecancerwhenitismutated(changed).TheKRAS genemakestheKRASprotein,whichisinvolvedincellsignalingpathways,cellgrowth,andapoptosis(celldeath).AgentsthatblocktheactivityofthemutatedKRAS geneoritsproteinmaystopthegrowthofcancer.AlsocalledK-rasgene .
KRAS mutation:achange(ormutation)intheKRAS gene,whichwhenmutatedcanleadtocancer.Amutationinthisgenemakespatientswithcolorectal cancernon-responsivetotreatmentswithcetuximab andpanitumumab.AlsoseeGene and KRAS gene .
L
Leucovorin:Giventogetherwithanticancerdrugssuchasfluorouracil,tohelplessenthetoxiceffectsofthesemedications,thus“rescuing”thepatientwhilepermittingtheanticanceractivityofthedrugslikeFU.Italsoenhancestheeffectsoffluorouracilanditsderivativesbystabilizingthebindingofthedrug’smetabolitetoitstargetenzyme,thusprolongingdrugactivity.AlsocalledLVorfolinicacid.
Liver metastasis:Cancerthathasspreadfromtheoriginal(primary)tumourtotheliver.
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Radiochemotherapy:Cancertreatment,inwhichchemotherapy (5-FU or capecitabine)combinedwithradiation therapy,isusedbeforesurgerytoimprovethechancesofbettertumourcontrolandreducelocalrecurrences(cancerfromcomingback).
Recurrence:Cancerthathasrecurred(comeback),usuallyafteraperiodoftimeduringwhichthecancercouldnotbedetected.Thecancermaycomebacktothesameplaceastheoriginal(primary)tumourortoanotherplaceinthebody. Alsocalledrecurrent cancer .
Recurrent cancer:SeeRecurrence .
Resistant cancer:Cancerthatdoesnotrespondtotreatment.Thecancermayberesistantatthebeginningoftreatment,oritmaybecomeresistantduringtreatment.Alsocalledrefractorycancer .
S
Stomatitis:Inflammation(redness,swelling,pain,and/orafeelingofheat)orirritationofthemucous membranesinthemouth.Mucous membrane,alsocalledmucosa,isthemoist,innerliningofthemouth.
T
Targeted therapy:Atypeoftreatmentthatusesdrugsorothersubstances,suchasmonoclonalantibodies,tofindandattackspecificcancercells.Targeted therapymayhavefewersideeffectsthanothertypesofcancertreatments.
Therapy:AnotherwordforTreatment.
Thrombocytopenia:Aconditioninwhichthereisalower-than-normalnumberofplateletsintheblood.Itmayresultineasybruisingandexcessivebleedingfromwoundsorbleedinginmucous membranesandothertissues.
Thromboembolism:Formationinabloodvesselofaclot(thrombus)thatbreakslooseandiscarriedbythebloodstreamtopluganothervessel.Theclotmayplugavesselinthelungs(pulmonary embolism),brain(stroke),gastrointestinaltract,kidneys,orleg.Thromboembolismisanimportantcauseofmorbidity(disease)andmortality(death),especiallyinadults.Treatmentmayinvolveanticoagulants(bloodthinners),aspirin,orvasodilators(drugsthatrelaxandwidenvessels).
Toxicity:Theextenttowhichsomethingispoisonousorharmful.
Toxin:Apoisonmadebycertainbacteria,plants,oranimals,includinginsects.
Tumour:Anabnormalmassoftissuethatresultswhencellsdividemorethantheyshouldordonotdiewhentheyshould.Tumoursmaybebenign(notcancer),ormalignant(cancer).Alsocalledneoplasm.
V
Vascular endothelial growth factor:AlsocalledVEGF,isamoleculethathelpsnewbloodvesselstoform.ThereceptoristhepartofthecellthatreceivestheVEGFsignal.IdentifyingthesepolymorphismsmayhelpdoctorstodecidetousetargetedtherapiesagainstVEGFforthissubgroupofpeoplewithcoloncancer
VEGF:Seevascular endothelial growth factor .
W
Wound:Abreakintheskinorotherbodytissuescausedbyinjuryorsurgicalincision(cut).
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Neurotoxicity:Thetendencyofsometreatmentstocausedamagetothenervoussystem.
Neutropenia:Aconditioninwhichthereisalower-than-normalnumberofneutrophils(atypeofwhitebloodcell).SeeFebrile Neutropenia .
O
Oxaliplatin:AnticancerdrugwhichattachestotheDNA(geneticmaterialcontainedinthecell)andinterfereswithcelldivision,causingtheeventualdeathofthecancer cell .
P
Palliative care:Aspecializedareaofhealthcarethatfocusesonrelievingandpreventingthesufferingofpatients,andisgiventoimprovethequalityoflifeofpatientswhohaveaseriousorlife-threateningdisease.Thegoalofpalliative careistopreventortreatasearlyaspossiblethesymptomsofadisease,sideeffectscausedbytreatmentofadisease,andpsychological,social,andspiritualproblemsrelatedtoadiseaseoritstreatment.Alsocalledcomfortcare,supportivecare,andsymptommanagement.Unlikehospicecare,palliativemedicineisappropriateforpatientsinalldiseasestages,includingthoseundergoingtreatmentforcurableillnessesandthoselivingwithchronicdiseases,aswellaspatientswhoarenearingtheendoflife.
Panitumumab:Amonoclonal antibodythatrecognizesandattachestocolorectal cancercellsthatexpressepidermal growth factor receptor (EGFR)withnon-mutated(wild-type)KRASafterfailureofchemotherapy regimenscontainingfluoropyrimidine,oxaliplatin,andirinotecan,andpreventsthecancercellsfromgrowinganddividing.
Partial liver resection for colorectal liver metastasis:Surgerytoremovetissueorpartofanorgan, inthiscasealiver,towhichcancerhasspread.
Polyp:Agrowththatprotrudesfromamucous membrane,whichisthemoistinnerliningofcavitiessuchasthenose,mouth,stomachandbowel.
Primary colorectal cancer:Heretheword“primary”describeswherethecanceroriginated.Inthiscaseacancerstartinginthebowel(specificallythecolonorrectum).
Protein:Amoleculemadeupofaminoacidsthatareneededforthebodytofunctionproperly.Proteinsarethebasisofbodystructuressuchasskinandhairandofsubstancessuchasenzymes,cytokines,andantibodies.
Proteinuria:Higher-than-normalamountofproteinintheblood.
Pseudo-adjuvant chemotherapy:Beyondpartial liver resection,therationaleforpseudo-adjuvant chemotherapylacksscientificevidence,despitesomepromisingdata.
Pulmonary:Havingtodowiththelungs.
Pulmonary embolism:Ablockinanarteryofthelungcausedbybloodclotsorothersubstances,suchasfatglobules,infectedtissue,orcancercells.
R
Radiation therapy(alsocalledradiotherapy):Theuseofhigh-energyradiationfromx-rays,gammarays,neutrons,protons,andothersourcestokillcancercellsandshrinktumours.AlsoseeExternal beam radiation therapyandbrachytherapy .
Radioactive:Asubstancethatgivesoffradiation.
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Canadian Resources for Patients
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Formoreusefullinkstovariousresources,pleasevisitColorectalCancerAssociationofCanadaat www.colorectal-cancer.ca.
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8.GerardJ,BonnetainF,ConroyT,etal.PreoperativeradiotherapywithorwithoutconcurrentfluorouracilandleucovorininT3-4rectalcancers:ResultsofFFCD9203.JClinOncol2006;24:4620-5.
9.BossetJF,ColletteL,CalaisG,etal,fortheEORTCRadiotherapyGroupTrial22921.Chemotherapywithpreoperativeradiotherapyinrectalcancer.NEnglJMed2006;355:1114-23.
10.WongR,BerryS,SpithoffK,etal.PreoperativeorPostoperativeTherapyfortheManagementofPatientswithStageIIorIIIRectalCancer:GuidelineRecommendations.AQualityInitiativeofthePrograminEvidence-BasedCare(PEBC),CancerCareOntario(CCO)Evidence-BasedSeries#2-4:Section1,ReportDate:July15,2008
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Ongoing Research and the Future of Treatment
OngoingresearchinCRChasleadtoadvancesintreatmentandnewwaysto managesideeffectsrelatedtotreatment,whichhelpedimprovedtheoutlook andqualityoflifeformanypeoplelivingwiththisdisease.
Alwaysinsearchofmoreeffectivetreatments,manyclinical trialsaredone totestdifferentcombinationsofdrugsthatarealreadyusedseparatelyto treatCRC .
OngoingresearchinCRCcanbefoundinClinicalTrials.gov,aregistryandresultsdatabaseoffederallyandprivatelysupportedclinical trialsconductedinthe UnitedStatesandaroundtheworld.ByvisitingClinicalTrials.govwebsiteatclinicaltrials.gov,youcanfindinformationaboutthepurposeofatrial,whomayparticipateinit,locationswhereitisbeingconducted,andphonenumbersfor moredetails.Thisinformationshouldbeusedtogetherwithadvicefromyourhealthcareprofessionals.
FormoreinformationaboutongoingresearchanddevelopmentinCRC, youcanalsovisitCanadianCancerEncyclopediafromtheCanadian CancerSocietyatinfo.cancer.caorColorectalCancerAssociationof Canadaatwww.colorectal-cancer.ca.
Where to find Support…
IfyouorsomeoneclosetoyouhasbeennewlydiagnosedwithCRCorin activetreatment,youdon’thavetogothroughthisalone.
CRCsupportgroupsexistinseveralcommunitiesacrossCanadawhichoffer meetingswherepatients,caregiversandfamiliescansharetheirexperiences, offerhelpandprovideinformation.Becauseeveryone’scancerexperienceis different,connectingwithotherswhoaregoingthroughsimilarexperiencecan helpyoulearnhowtodealwithmanyeverydayissues,maketoughdecisions andcopewitharangeofemotions.1,2
Help is available…
Canadian Cancer Society:Formoreinformationortofindasupportgroup inyourarea,contacttheCanadianCancerSocietybycallingtoll-freenumber at1-888-939-3333,orvisitthewebsitewww.cancer.caandclickon Support/Servicestab.1,2
Colorectal Cancer Association of Canada:Forinformationaboutsupport groupsinyourarea,calltoll-freenumber1-877-50COLON(26566),orvisitthe websiteatwww.colorectal-cancer.ca.1,2
Because
of ongoing
research, new
discoveries
help contribute
to constant
change in
knowledge and
understanding
of cancer. This
information
helps researchers
and healthcare
professionals
to develop
practices
in prevention,
detection and
treatment of
CRC, as well
as improving
the quality
of life of
people with
this disease.
Colorectal CancerAssociation of Canada
69
Colorectal CancerAssociation of Canada
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