Patterns of Care in Medical Oncology

1. Patterns of Care in Medical Oncology Neoadjuvant and Adjuvant Treatment of Rectal Cancer

2. To approximately how many patients with rectal cancer have you administered neoadjuvant chemoradiation therapy in the past year?

3. Preoperative radiation therapy combined with capecitabine and oxaliplatin versus radiation therapy combined with 5-FU and oxaliplatin for patients with resectable rectal cancer Protocol ID: NSABP-R-04, Target Accrual: 1,606 (Open) 5-FU + radiation therapy Continuous infusion 5-FU 225 mg/m2 per day for 5 days per week on days of planned radiation therapy (RT*) R 5-FU + radiation therapy + oxaliplatin Same as arm 1, with oxaliplatin 50 mg/m2 weekly x 5 during RT* *4,500 cGy in 25 fractions over five weeks with a 540-cGy boost in three fractions for nonfixed tumors or a 1,080-cGy boost in six fractions for fixed tumors Source: NSABP-R-04 Protocol, November 24, 2008.

4. Preoperative radiation therapy combined with capecitabine and oxaliplatin versus radiation therapy combined with 5-FU and oxaliplatin for patients with resectable rectal cancer Protocol ID: NSABP-R-04, Target Accrual: 1,606 (Open) Capecitabine + radiation therapy Capecitabine 825 mg/m2 BID 5 days per week on days of planned RT* R Capecitabine + radiation therapy + oxaliplatin Same as arm 3, with oxaliplatin 50 mg/m2 weekly x 5 during RT* *4,500 cGy in 25 fractions over five weeks with a 540-cGy boost in three fractions for nonfixed tumors or a 1,080-cGy boost in six fractions for fixed tumors Source: NSABP-R-04 Protocol, November 24, 2008.

5. When administering a fluoropyrimidine during radiation therapy, which regimen do you generally recommend?

6. Patients who receive 5-FU/LV with radiation therapy for neoadjuvant treatment of rectal cancer and have positive nodes in the resection specimen postoperatively should generally receive which of the following regimens?

7. Have you used oxaliplatin off protocol as part of neoadjuvant chemoradiation therapy for rectal cancer? CI n = 12; PO n = 22

8. Have you used bevacizumab off protocol as part of neoadjuvant chemoradiation therapy for rectal cancer? CI n = 0; PO n = 7

9. For the patient with rectal cancer at the anal verge who achieves a clinical complete response with a negative biopsy of the primary site after neoadjuvant chemoradiation therapy, surveillance with delayed resection at recurrence is acceptable.

10. Case 6: Rectal Cancer • A 65-year-old man in average health • T3N0 rectal cancer by endoscopic ultrasound • Lesion is 8 centimeters from the anal verge

11. Case 7: Rectal Cancer • A 65-year-old man in average health • T3N1 rectal cancer (2 enlarged lymph nodes on endoscopic ultrasound) • Lesion is 8 centimeters from the anal verge

12. Case 8: Rectal Cancer After Neoadjuvant Treatment and with Complete Pathologic Response Evident on Resection, Including Absence of Residual Nodal Disease • Man in average health • T3N1 rectal cancer (2 enlarged lymph nodes on endoscopic ultrasound) • Lesion is 8 centimeters from the anal verge • Undergoes neoadjuvant chemoradiation therapy with XELOX/CAPOX • Complete pathologic response evident on resection