Colon cancer

1. Synchronous
a. Colonoscopy
b. Chest/abdominal/pelvic CT
c. FBC, PLT, chemistry profile
d. CEA
e. KRAS
f. needle biopsy, if clinically indicated
g. PET scan only if potentially surgically curable M1 disease

2. Adjuvant
a. 5FU/leucovorin
- leucovorin 500mg/m2 given as 2h infusion and repeated weekly x 6; 5FU 500mg/m2 given bolus 1h after start of leucovorin and repeted 6 x weekly. Every 8 weeks for 4 cycles
- 5FU 370-400mg/m2 + leucovorin 200mg/m2 daily x 5d, every 28d x 6 cycles

b. Capecitabine 1250mg/m2 bd D1-14 every 3 weeks x 24 wks

c. FLOX
- 5FU 500mg/m2 IV bolus weekly x 6 + leucovorin 500mg/m2 IV weekly x 6, each 8 week cycle x 3 with oxaliplatin 85mg/m2 IV administered on weeks 1,3 and 5 of each 8 week cycle x 3

d. FOLFOX 4
oxaliplatin 85mg/m2 IV over 2h D1
leucovorin 400mg/m2 IV over 2h D1
5FU 400mg/m2 IV bolus on D1 then 1200mg/m2/day x 2 days (total 2400mg/,2 over 46-48 hr) continuous infusion
Repeat every 2 weeks

3. Advanced or metastatic disease
a. FOLFOX 4
Oxaliplatin 85mg.m2 IV over 2 hours D1
Leucovorin 200mg/m2 IV over 2 hours D1 & 2
Followed on D 1 & 2 by 5FU 400mg/m2 IV bolus then 600mg/m2 IV over 22 hours continuous infusion
Repeat every 2 weeks

b. mFOLFOX 6
Oxaliplatin 85mg/m2 IV over 2 hours D1
Leucovorin 400mg/m2 IV over 2 hours D1
5FU 400mg/m2 IV bolus on D1 then 1200mg/m2/day x 2 days (total 2400mg/m2 over 46-48h) continuous infusion
Repeat every 2 weeks

c. CapeOX
Oxaliplatin 130mg/m2 D1
Capecitabine 850-1000mg/m2 bd for 14 days
Repeat every 3 weeks

d. FOLFIRI
(i)
Irinotecan 180mg/m2 IV over 30-120 minutes D1
Leucovorin 200mg/m2 IV infusion to match duration of irinotecan infusion, D1 & 2
Followed on D1 & 2 by 5FU 400mg/m2 IV bolus then 600mg/m2 IV over 22 hours continuous infusion
Repeat every 2 weeks
(ii)
Irinotecan 180mg/m2 IV over 30-120 min D1
Leucovorin 400mg/m2 IV infusion to match duration of irinotecan infusion D1
5FU 400mg/m2 IV bolus D1 then 1200mg/m2/day x 2 days (total 2400mg/m2 over 46-48h) continuous infusion
Repeat every 2 weeks

e. Bevacizumab + 5FU containing regimens
Bevacizumab5mg/kg IV every 2 weeks + 5FU and leucovorin/FOLFOX/FOLFIRI
Bevacizumab 7.5mg/kg IV every 3 weeks + CapeOX

f. Capecitabine 2000-2500mg/m2/day PO in 2 divided doses, D1-14 flw by 7 days rest/ Repeat every 3 weeks

g. Bolus or infusional 5FU/leucovorin
i. Roswell-Park regimen
Leucovorin 500mg/m2 IV over 2 hours D1/8/15/22/29/36
5FU 50mg/m2 IV bolus 1 hour after start of leucovorin, D1/8/15/22/29/36
Repeat every 8 weeks

ii. Biweekly
Leucovorin 200mg/m2 IV over 2 hours D1 & 2
5FU 400mg/m2 IV bolus then 600mg/m2 IV over 22 hours continuous infusion D1 & 2
Repeat every 2 weeks

iii. Simplified biweekly infusional 5FU/LV (sLV5FU2)
Leucovorin 400mg/m2 IV over 2 hours on D1 followed by 5FU bolus 400mg/m2 and then 1200mg/m2/day x 2 days (total 2400mg/m2 over 46/48 h) continuous infusion
Repeat every 2 weeks

iv. Weekly
Leucovorin 20mg/m2 as 2 h infusion
5FU 500mg/m2 bolus administered 1h after LV infusion
Repeat every week
5FU 2600mg/m2 by 24h infusion plus leucovorin 500mg/m2
Repeat every week

h. FOLFOXIRI
Irinotecan 165mg/m2 IV D1, oxaliplatin 85mg/m2 D1
Leucovorin 400mg/m2 D1, fluorouracil 3200mg/m2 over 48h
Continuous infusion starting on D1
Repeat every 2 weeks

i. Irinotecan 300-350mg/m2 IV over 30-90 minutes D1 repeat every 3 wks

j. Cetuximab (KRAS wild type gene only) +/- irinotecan
Cetuximb 400mg/m2 1st infusion then 250mg/m2 IV weekly
Or
Cetuximab 500mg/m2 IV every 2 weeks
+/-
Irinotecan 300-350mg/m2 IV every 3 weeks
Or
Irinotecan 180mg/m2 IV every 2 weeks
Or
Irinotecan 125mg/m2 every week for 4 weeks
Every 6 weeks

k. Cetuximab (KRAS wild type gene only)
Cetuximab 400mg/m2 1st infusion then 250mg/m2 IV weekly

l. Panitumumab (KRAS wild type gene only)
Panitumumab 6mg/kg IV over 60 minutes every week

4. Surveillance
a. history and physical every 3-6 mo for 2y, then every 6 mo for total of 5y
b. CEA every 3-6 mo for 2y, then every 6 mo for a total of 5y for T2 or greater lesions
c. Chest/abdominal/pelvic CT annually x 3y for patients at high risk for recurrence
d. Colonoscopy in 1y except if no preoperative colonoscopy due to obstructing esion, colonoscopy in 3-6 mo: if advanced adenoma repeat in 1y then if no advanced adenoma repeat in 3y then every 5y
e. PET (serial CEA elevation)
f. Breast exam q1-3y btw ages 20-40, annual mammogram >40 yo, high risk = breast MRI and mammogram annually
g. Cervical CA, prostate CA screening