NCCN Guidelines for Patients
Rectal Cancer, Version 1.2017
Part 6 presents the chemotherapy
pathways used to treat advanced rectal
cancer. There are many options. If one
option doesn’t work or stops working,
another option is given.
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.
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
However, neither is likely to work if a
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
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.
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
Cetuximab or panitumumab may be options for
tumors with normal
genes. You must not have
received either drug before. Either drug may be
added to FOLFIRI or irinotecan. If you can’t take
irinotecan, either drug can be used alone.
Guide 15. Oxaliplatin pathway
What are first-line options?
• FOLFOX ±
◦◦ Cetuximab or panitumumab for tumors with
• CAPEOX ± bevacizumab
What are second-line options?
• FOLFIRI or irinotecan ±
◦◦ Bevacizumab or ziv-aflibercept or ramucirumab
◦◦ Cetuximab or panitumumab 1) for tumors with
genes and 2) if neither
drug was received before
• Cetuximab or panitumumab 1) for tumors with
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
• Trifluridine + tipiracil
• Clinical trial
• Best supportive care