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board review - Coggle Diagram

- - - - mosaic
      - IDEA
        
        shorter duration of tx 3 vs 6 months regimen
        
        international collaboration - six randomized phase III trials: SCOT (Short Course Oncology Treatment), TOSCA (Three or Six Colon Adjuvant), CALGB/SWOG (Cancer and Leukemia Group B/Southwest Oncology Group) 80702, IDEA France, ACHIEVE, and HORG (Hellenic Oncology Research Group).
        
        Objective was to evaluate the noninferiority of 3-month oxaliplatin-based adjuvant treatment vs 6-month treatment in patients with stage III colon cancer -prospectively designed, pooled analysis of individual patient data
        
        12,834 patients were enrolled in this study, and the primary endpoint was 3-year DFS. After a median follow-up of 41.8 months, the 3-year DFS rates were 74.6% (95% CI, 73.5-75.7) in the 3-month therapy group and 75.5% (95% CI, 74.4-76.7) in the 6-month group
        
        difference in 3-year DFS was only 0.9%. A subgroup analysis demonstrated that 3-month CAPOX was noninferior to 6-month CAPOX (HR, 0.95; 95% CI, 0.85-1.06), with 3-year DFS rates of 75.9% and 74.8%, respectively. In contrast to CAPOX, 6-month FOLFOX was superior to 3-month FOLFOX (HR, 1.16; 95% CI, 1.06-1.26; P [for superiority of 6-month therapy] = .001), with 3-year DFS rates of 76.0% and 73.6%, respectively.
        
        For patients with low-risk features (T1, T2, or T3 and N1), 3-month therapy with the combined treatments of CAPOX and FOLFOX was noninferior to 6-month therapy. The 3-year DFS rates were nearly identical: 83.1% and 83.3%, respectively (HR, 1.01; 95% CI, 0.90-1.12).
        
        patients with high-risk features (T4, N2, or both) experienced an improved 3-year DFS rate when treated with 6-month combined therapy. DFS rates for the 3-month and 6-month therapies were 62.7% and 64.4%, respectively (HR, 1.12; 95% CI, 1.03-1.23; P [for superiority] = .01).
        
        The incidence of toxicities, including diarrhea, neutropenia, thrombocytopenia, nausea, mucositis, fatigue, and hand-foot syndrome, was significantly lower in the 3-month therapy group. Neurotoxicity of grade ≥ 2 during active therapy and in the month after treatment cessation was also substantially lower in the 3-month group (16.6% with FOLFOX and 14.2% with CAPOX) than in the 6-month group (47.7% with FOLFOX and 44.9% with CAPOX).
        
        NCCN CAPOX for 3 months should be recommended for low-risk disease, while CAPOX or FOLFOX for 6 months should be recommended for high-risk disease
        
        unresolved questions
        
        does T4 and N2 carry the same poor prognosis?
        
        what to do for elderly populations?
      - in the US mFOLFOX6 regimen: the day 1 bolus 5-FU + a 46-hour infusion of 5-FU on days 1 and 2. This regimen is more convenient for the patient, and by eliminating the day 2 bolus 5-FU dose, the safety profile is improved; myelosuppression and gastrointestinal toxicities are reduced compared with the standard FOLFOX4 regimen (bolus on day 1,2)
  - - - T1-2
        
        tx is removal
        
        pts neeed f/up colonoscopy within 1 yr
    - - T3-4 N0
      - do not benefit from adjuvant tx
    - - any T, N=>1
      - benefit from adjuvant tx
        
        irinotecan is not beneficial
        
        5FU vs oxaliplatin based (FU or capecitabine)