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57

NCCN Guidelines for Patients

®

:

Colon Cancer, Version 1.2017

Part 6 presents the chemotherapy

pathways used to treat advanced colon

cancer. There are many options. If one

option doesn’t work or stops working,

another option is given.

Oxaliplatin

Guide 16

maps a treatment path that starts with

oxaliplatin. After oxaliplatin, there are other options

for second-line treatment and beyond. Some of these

options depend on what treatment you’ve had before.

First-line options

FOLFOX and CAPEOX are the two options for first-

line treatment. Bevacizumab may be added to either

regimen. Cetuximab or panitumumab can be added

to FOLFOX to treat tumors with normal

RAS

genes

that are in the left side of the colon. However, neither

is likely to work if a

BRAF V600E

mutation is present.

Oxaliplatin can harm your nervous system. Stopping

oxaliplatin—but not the other drugs—after 3 months

of use may prevent harm. Keep taking the other

drugs for 6 months. If the cancer progresses,

oxaliplatin may be restarted if it was stopped due to

side effects. You should only restart if the side effects

have ended.

Capecitabine in the CapeOx regimen can cause a

side effect known as hand-foot syndrome. Symptoms

include redness, swelling, and pain on the palms

of the hands, bottoms of feet, or both. Sometimes

blisters appear. Your dose of capecitabine may be

changed at the earliest signs of hand-foot syndrome.

Second-line options

Oxaliplatin may not prevent the cancer from

progressing. If this happens, you may start FOLFIRI

or irinotecan. Bevacizumab, ziv-aflibercept, or

ramucirumab may be added. Bevacizumab is

preferred due to less harsh side effects and lower

costs.

Cetuximab or panitumumab may be options for

tumors with normal

RAS

genes. Tumors can be in

any part of the colon. You must not have received

either drug before. Cetuximab or panitumumab may

be added to FOLFIRI or irinotecan. Either drug can

be used alone if you can’t take irinotecan.

6

Chemotherapy

Oxaliplatin

Guide 16. Oxaliplatin pathway

What are first-line options?

• FOLFOX ±

◦◦ Bevacizumab

◦◦ Cetuximab or panitumumab for left-side tumors

with normal

KRAS/NRAS

genes

• CAPEOX ± bevacizumab

What are second-line options?

• FOLFIRI or irinotecan ±

◦◦ Bevacizumab or ziv-aflibercept or ramucirumab

◦◦ Cetuximab or panitumumab 1) for tumors with

normal

KRAS/NRAS

genes and 2) if neither

drug was received before

• Cetuximab or panitumumab 1) for tumors with

normal

KRAS/NRAS

genes and 2) if neither drug

was received before

• Pembrolizumab or nivolumab if dMMR or MSI-H

What are third-line and beyond options?

• Some second-line regimens if not received before

• Regorafenib

• Trifluridine + tipiracil

• Clinical trial

• Best supportive care