Skip to Main Content

++

Case History

++

Image not available. A 76-year-old man presents with an obstructing carcinoma of the sigmoid colon for which he undergoes an emergency Hartmann's procedure. At surgery, multiple peritoneal and liver metastases are noted. He survives the operation, but 4 weeks after surgery is eating poorly, has right upper abdominal pain, and is spending all his time indoors. He has a history of hypertension which is controlled with β blockers. He lives 24 km from the cancer unit with his 74-year-old wife, who is in good health but has partial sight, so does not drive.

What is his prognosis and how will it be affected by palliative chemotherapy?

What are his options for first-line chemotherapy and what factors would influence the recommendation for treatment?

For how long should first-line chemotherapy be continued?

When should first-line chemotherapy be considered to have failed and what are the options for subsequent lines of treatment?

++

Background

++

What is his prognosis and how will it be affected by palliative chemotherapy?

++

Image not available. The 5-year survival with metastatic disease is less than 5%. The median survival without treatment is 6–9 months. Current treatments can increase median survival to 18–20 months. Asymptomatic patients have prolonged median survival, longer symptom-free period and longer time to disease progression if chemotherapy is started immediately rather than delaying until symptoms develop. 5-fluorouracil/folinic acid (5-FU/FA) confers survival benefit over supportive care (median survival 11.7 and 8 months; 1-year survival 50% and 34%, respectively).1 Oxaliplatin or irinotecan in combination with 5-FU/FA have further improved response rates and survival.

++

What are his options for first-line chemotherapy and what factors would influence the recommendation for treatment?

++ ++
Table Graphic Jump Location
Table 27.1Current (2006) NICE guidelines for first-line and second-line chemotherapy options for metastatic colorectal cancer
++
Infusional 5-FU/FA
++

Infusional 5-FU regimens are costly and often require permanent vascular access and/or admission to hospital. They are superior to bolus regimens in terms of progression-free survival, response rates, toxicity and quality of life, but equally effective in terms of overall survival.

++
Oral fluoropyrimidines
++

Capecitabine and tegafur/uracil (UFT) mimic protracted venous infusional 5-FU. Potential benefits include convenience, fewer hospital visits, elimination of risks of indwelling central venous catheter, different toxicity profile and fewer treatment-related hospitalizations. Compared with the Mayo regimen, capecitabine has been shown to achieve a markedly superior response rate, superior safety profile, equivalent time to progression and equivalent overall survival.2 Studies have shown that capecitabine is effective and ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.