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71

NCCN Guidelines for Patients

®

:

Rectal Cancer, Version 1.2017

6

Chemotherapy

Least toxic regimens

|

Review

Least toxic regimens

Guide 19

lists regimens that are likely to be the

least harmful to you. Infusional 5-FU/LV is an option.

5-FU has fewer severe side effects when given by

infusion rather than bolus. Another option is to take

capecitabine with or without bevacizumab.

Cetuximab or panitumumab may be an option. These

drugs treat tumors with normal

RAS

genes. Neither

drug is likely to work if a

BRAF V600E

mutation is

present.

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 first-line treatment works, you may find that you are

able to do more activities. In this case, the regimens

listed in the prior sections may be options. If first-line

drugs don’t work, supportive care may give you relief

from symptoms.

Review

†

†

There are five pathways used to treat advanced

rectal cancer.

†

†

The oxaliplatin pathway starts with either

FOLFOX or CAPEOX.

†

†

The irinotecan pathway starts with FOLFIRI.

†

†

The FOLFOXIRI pathway starts with both

oxaliplatin and irinotecan.

†

†

The 5-FU/LV and capecitabine pathway starts

with intense but less harsh regimens.

†

†

The least toxic pathway starts with regimens

likely to be the least harmful to you.

Guide 19. Least toxic pathway

What are first-line options?

• Infusional 5-FU/LV ± bevacizumab

• Capecitabine ± bevacizumab

• Cetuximab or panitumumab for tumors with

normal

KRAS/NRAS

genes

• Pembrolizumab or nivolumab if dMMR or MSI-H

What are second-line options?

• More intense chemotherapy

• Supportive care