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68

NCCN Guidelines for Patients

®

:

Rectal Cancer, Version 1.2017

Third-line and beyond

If the cancer progresses again, one of the 3 second-

line treatments may be an option. If not, your options

may include regorafenib or trifluridine with tipiracil.

There may also be a clinical trial that you could join.

Supportive care may give you relief from symptoms.

Irinotecan

Guide 16

maps a treatment path that starts with

FOLFIRI. After FOLFIRI, 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

Irinotecan is part of the FOLFIRI regimen. It should

be used with caution and at a low dose if you have

Gilbert’s disease. Gilbert’s disease is a health

problem that people are born with. The disease

impairs the liver from correctly processing bilirubin.

Irinotecan should be used with caution and at a low

dose if you have high bilirubin levels in your blood for

any reason.

Targeted therapy may be added to FOLFIRI.

Bevacizumab may help treat rectal cancer.

Cetuximab or panitumumab may help treat tumors

with normal

RAS

genes. However, neither is likely to

work if a

BRAF V600E

mutation is present.

Second-line options

FOLFIRI may not prevent the cancer from

progressing. If this happens, you may start to take

an oxaliplatin regimen—FOLFOX or CAPEOX.

Bevacizumab may be added.

Cetuximab or panitumumab may be options for

tumors with normal

RAS

genes. You must not have

received either drug before. Either drug may be

added to irinotecan. If you can’t take irinotecan,

either drug can be used alone.

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 may be an

option. If these drugs don’t work, your next options

include other second-line options listed above.

Third-line and beyond

If the cancer progresses again, one of the 4 second-

line treatments may be an option. If not, your options

may include regorafenib or trifluridine with tipiracil.

There may also be a clinical trial that you could join.

Supportive care may give you relief from symptoms.

6

Chemotherapy

Irinotecan

Guide 16. Irinotecan pathway

What are first-line options?

• FOLFIRI ±

◦◦ Bevacizumab

◦◦ Cetuximab or panitumumab for tumors with

normal

KRAS/NRAS

genes

What are second-line options?

• FOLFOX or CAPEOX ± bevacizumab

• Irinotecan + 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