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NCCN Guidelines for Patients



Rectal Cancer, Version 1.2017


Overview of cancer treatments

Targeted therapy

You may develop an infection, fever, change in voice,

mouth sores, and high blood pressure.

Your hands and feet may become red and have pain.

This is called hand-foot skin reaction. It is important

to remove calluses on hands and feet before starting


Rare but serious side effects of regorafenib include

heart attack, holes in the gut, abnormal passage

between body parts, and severe bleeding. Liver

damage may be severe. Very rarely, brain damage



Ziv-aflibercept works by acting as a decoy. VEGF

thinks ziv-aflibercept is a surface receptor and

attaches to it. Thus, ziv-aflibercept traps VEGF so

it is unable to bind to the real receptor. Hence its

other name is VEGF-trap. By trapping VEGF, growth

signals caused by VEGF within endothelial cells

won’t be started.

Ziv-aflibercept is given by infusion. You’ll receive it

over the course of about 1 hour every two weeks. It

is given with chemotherapy.

While taking ziv-aflibercept, you may have diarrhea,

mouth sores, voice changes, and nose bleeds.

You may have headaches and stomach pain. You

may feel tired. Loss of appetite and weight loss are

common. Tests may show low blood cell counts,

protein in urine, liver inflammation, increased blood

pressure, or kidney damage.

Rare but serious side effects include blood clots,

holes in the gut, abnormal passage between body

parts, and severe bleeding. Infections may be

serious. Very rarely, brain damage occurs.

EGFR pathway

Cell growth is started by growth signals. EGFR is one

of the surface receptors in rectal cancer cells that

can trigger growth signals. When EGF (






actor) attaches to EGFR, the chemical

pathway that sends growth signals is turned on.

Some people with rectal cancer have abnormal

changes in their gene that controls EGFRs. These

changes cause the cancer cells to have too many

EGFRs. For a small group of people, the EGFRs

may be overactive.

With too many or overactive EGFRs, new cancer

cells form quickly. There are two medicines used

to block the growth signals from EGFRs.


Figure 14

. These medicines don’t work if the cancer

cells have mutations in






Cetuximab treats rectal cancer by attaching to the

ends of EGFRs that are outside of the cell. Thus,

EGF is blocked from attaching and triggering growth

signals. Cetuximab also attracts immune cells that

help to kill the cancer cells.

Cetuximab is given by infusion, usually once a

week or every other week. It may take 2 hours to

receive the first dose. Later doses will take only

1 hour. Cetuximab may be given with or without


Common side effects of cetuximab are skin

problems. These problems include acne-like rash,

dry skin, eye inflammation, and skin infections.

Other common side effects are diarrhea and loss of

appetite. Blood magnesium levels may drop. Rare

but serious side effects include a severe reaction to

the infusion and lung damage.