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64

NCCN Guidelines for Patients

®

:

Rectal Cancer, Version 1.2017

5

Metastatic disease

Metastases at recurrence

and pelvis are needed. Imaging should be done prior

to adjuvant treatment.

Adjuvant treatment is based on whether you had

chemotherapy before. If not, preferred options are

FOLFOX and CAPEOX. Otherwise, you may receive

FLOX, capecitabine, or 5-FU/LV. Six months of

chemotherapy is preferred.

If you’ve had chemotherapy, observation is an

option. Observation is a period of testing to assess

for cancer growth. Another option is chemotherapy.

Targeted therapy may be added but more research is

needed. Regimens are listed in Part 6. Six months of

chemotherapy is preferred.

Option 2

Option 2 starts with neoadjuvant chemotherapy.

FOLFOX and CAPEOX are preferred regimens.

FLOX, capecitabine, or 5-FU/LV are other options.

After 2 to 3 months of chemotherapy, you may

receive primary treatment. One option is a

metastasectomy. Local treatment may be added. It

includes ablation and SBRT. Local treatment without

surgery is another option. However, NCCN experts

prefer surgery over local treatment alone.

Results of primary treatment should be assessed

with CT with contrast. Scans of your chest, abdomen,

and pelvis are needed. Imaging should be done prior

to adjuvant treatment.

Adjuvant treatment is based on the success of

neoadjuvant treatment. If neoadjuvant chemotherapy

worked, you may re-start that treatment or take

FOLFOX. Together, chemotherapy given before and

after surgery should not exceed 6 months. A third

option is observation.

If neoadjuvant treatment didn’t work, you may

have two options. One option is chemotherapy.

Targeted therapy may be added but more research

is needed. Regimens are listed in Part 6. Six months

of chemotherapy is preferred. The second option is

observation.

HAI ± 5-FU/LV

Instead of systemic chemotherapy after surgery, HAI

may be an option. Systemic 5-FU/LV may be added.

NCCN experts advise that this option should only be

received at treatment centers with much experience

in this method. More research is needed to learn how

well this treatment works.

Guide 14

lists nonsurgical options for liver or lung

metastases present at recurrence. Options are based

on your history of chemotherapy. Options for people

who had FOLFOX or CAPEOX in the past 12 months

are explained below. Options for everyone else are

listed in Part 6.

FOLFOX or CAPEOX ≤12 months

Two options are FOLFIRI and irinotecan. Targeted

therapy may be added. Bevacizumab is preferred but

other options are ziv-aflibercept or ramucirumab. If

the tumor has normal

RAS

genes, other options are

to add panitumumab or cetuximab to chemotherapy.

However, these drugs won’t likely work if the tumor

has a

BRAF V600E

mutation.

The cancer cells may have a dMMR system or

MSI-H. The MMR system is explained in Part 2. In

this case, nivolumab or pembrolizumab is an option.

After chemotherapy

Chemotherapy may greatly shrink the tumors. If they

shrink enough, surgery to cure the cancer may be

an option. However, this doesn't happen often. If

surgery is possible, tests to assess the tumor size

are advised every two months during chemotherapy.

Bevacizumab should be stopped 6 weeks before

surgery. It will increase your chance for a stroke,

bleeding, and other arterial events. These events

are even more likely if you are older than 65 years.