Could you briefly review the major side effects of the chemotherapy regimens? Which are most bothersome to patients?
The chemotherapy regimens and the two backbones that are most commonly used are FOLFIRI and FOLFOX. Then some CAPOX, which is capecitabine with oxaliplatin. With FOLFIRI and FOLFOX, the risk of grade 3 and 4 diarrhea is about the same. The risk of grade 1 and 2 diarrhea is higher with FOLFIRI than FOLFOX. With FOLFIRI, you're more likely to see alopecia, and about 80% of the patients will lose their hair.
You also have the risk of neutropenia. With FOLFOX, you have the risk of neurotoxicity, which after a cumulative dose of 750 to 850 mg/m2 becomes quite significant. The problem for a majority of the patients, although the neurotoxicity may improve, it never really goes away and stays at a baseline of grade 1. For about 1% to 2% of patients, it stays at about grade 3, which is pretty significant and incapacitating. It usually happens after the fourth or fifth month of treatment, so this is where you want to be cognizant of it.
The other risk to oxaliplatin is significant thrombocytopenia in about 5% of patients, about grade 3 or 4, which could prohibit those patients to receive further therapy. This is mostly due to hypersplenism, which induces sinusoidal obstruction. In a few patients you'll have to remove the spleen if indicated.
Unresectable Colon Cancer: Case 1
68-year-old man was diagnosed with advanced, unresectable colon cancer has just started treatment with FOLFIRI plus bevacizumab.