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NCCN Guidelines for Patients



Rectal Cancer, Version 1.2017



5-FU and capecitabine

5-FU and capecitabine

Guide 18

maps a treatment path that starts with

intense but less harsh regimens. After either regimen,

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

There are two options for first-line treatment. One

option is 5-FU/LV. Receiving 5-FU by infusion is

preferred over bolus injection. The second option is

capecitabine. Bevacizumab may be added to either


The side effects of these regimens aren’t usually

as bad as those caused by oxaliplatin or irinotecan.

Thus, if the cancer progresses, you should start

supportive care if the side effects were too harsh. If

not too harsh, second-line options may be of help.

Second-line options

If the cancer progresses, options include regimens

with oxaliplatin, irinotecan, or both. Targeted therapy

may be added. Bevacizumab is preferred over ziv-

aflibercept and ramucirumab.

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, there are multiple

options. Some of the second-line treatments may be

an option if not received before.

Cetuximab or panitumumab may be options for

tumors with normal


genes. You must not have

received either drug before. Either drug added

to irinotecan may be an option. If you can’t take

irinotecan, either drug can be used alone.

There are two other options if the cancer has

progressed on all other regimens. One option is to

receive regorafenib. The other option is trifluridine

with tipiracil.

Joining a clinical trial may be an option. Ask your

doctor if there is a trial that is right for you. If there

are no other options, supportive care may give you

relief from symptoms.

Guide 18. 5-FU and capecitabine


What are first-line options?

• 5-FU/LV ± bevacizumab

• Capecitabine ± bevacizumab

What are second-line options?

• FOLFOX or CAPEOX ± bevacizumab

• FOLFIRI or irinotecan ± bevacizumab or

ziv-aflibercept or ramucirumab

• Irinotecan + oxaliplatin ± bevacizumab

• Pembrolizumab or nivolumab if dMMR or MSI-H

What are third-line and beyond options?

• Some second-line regimens if not received before

• Irinotecan + cetuximab or panitumumab for

tumors with normal



• Cetuximab or panitumumab for tumors with




• Regorafenib

• Trifluridine + tipiracil

• Clinical trial

• Best supportive care