Seeking advice: continuing with chemo or seizing the opportunity of surgery?

or is he more of a generalist?  (Most outside of major cancer centers are more generalists - hematology oncologists.)  If you haven't sought the opinion of a colorectal specialist, then that's what I would recommend.

On a side note, I had a close family friend, an MD with a super reputation push for me to be treated by a gyn oncologist because my cancer was found on my ovary.  However, my cancer was a colorectal tumor, and would not have responded to any treatments a gyn oncologist would have had for me.  I respect the family friend, but in my case his recommendation didn't fit.  He later agreed that a gyn oncologist would have been the wrong move.  Friends are wonderful, but you want experts here.

Don't go to a colorectal surgeon just because the cancer in the liver is CRC.  You need a liver surgeon.  

Chemo shrinks tumors but they will return in MOST cases when chemo is stopped.  Surgery can be curative, but with so much cancer in so many areas, most surgeons won't operate.  Actually,  many doctors don't 'bother' to remove rectal cancers if the cancer has already spread. They treat with chemo only.  I have a local friend who never had the rectal tumor removed and cancer continues to spread to other areas.  When I spoke with them recently, I asked why it has been in place for 3 years now and 'too low' was the answer. They're at CTCA and never heard of 'Barbie Butt'.  

tanstaafl said:

mCRC is seldom cured by chemo

mCRC is seldom cured by chemo alone, surgery is almost always necessary for chemo free NED, 5 yrs or a cure.  Aggressive patients are more often able to combine chemo and whittle down sites in 1-3 surgeries.  Often part of these tasks will be most readily done by heavy hitters, at the regional, national or world class level if the disease is normally not considered operable.

The trick is to prepare as a patient, physically-biologically and information wise, and recover well from surgery, quickly.  Then  either return to chemo or the next surgery until the cancer sites are gone.   Too many patients have too long windows between chemo and surgery, like 3-6 weeks before and 3-6 weeks after.  This is due to conservatism of the surgeons, too heavy chemo cycles, Avastin issues not addressed well, and lack of heavy duty, therapeutic nutrition to speed and improve recovery.

A more biologically based approach would vary with the patient details and organs operated on, involving major blood vessels etc.  However IV 5FU chemo during surgery is actually possible and has been done successfully in the literature for the primary CRC surgery.  

Avastin is often the big sticker, witheld 6 weeks away from either side of surgery.  Avastin is an anti VEGF-A drug.  We use IV vitamin C and cimetidine instead, to reduce VEGF-A formed related to  CA19-9 and LDH markers.  Biologically, both vit C and cimetidine can be used even during surgery for improved CRC and surgery results, although this is not well known medically these days.  We've had great results by taking informed control of as much of the situation as possible.  We had cimetidine used by the surgeon,  had chemo used within 12 - 24 hours of surgery, and IV vitamin C within 8 hrs after surgery.  The questions are who can support you and how do you finesse normal medical obstruction in the hospitals and from (sub)"standard medical" advise.

Our surgeons were already using celecoxib for CRC surgeries.

We use IV vitamin C, really potent supplements, celecoxib (Celebrex) and cimetidine on AFP, CEA and CA19-9 producing cancer cells, along with mild daily 5FU chemo.   The comparable patients of our doctors and in the literature died out years ago.

Do you consider 3-6 weeks too long if CRC hasn't metastasized?

tanstaafl said:

Yes

Yes, why add risk if you can avoid it.  The fact is that you really don't absolutely know about mets' absence or eradicability.  Every patient that recurs is a probable system failure to me. Especially if the CEA and CA19-9 did not drop to low levels in a week or two after surgery, assuming they also are getting the extra high dose nutrients and anti-inflammatories.

Bear in mind, we can fundamentally reduce excess VEGF-A with targeted cimetidine and IV vitamin C and have not even used Avastin in 7 years.

 In Japan, many studies with straight 5FU started at two weeks.  If the patient is in good shape before surgery and recovers well on advanced nutrients that specifcally speed healing with stronger new tissue, one should be able to count by days when to start 5FU. But drs will likely react with shock or derision. 

I sent in a referral request for the MRI (I'm scheduled to be done with chemo and radiation this Friday) to my surgeon's office as she requested one the week after I was done. The doctors that I spoke to at DFCI said that they're finding better results in waiting longer after chemoradiation before surgery. That is, the usualy six weeks is getting pushed out to eight to ten weeks on surgery for CRC. The potential reasons are more time to heal and more time for the radiation and 5FU to do their work. The anecdotal comments that I've seen indicate that your body starts to feel better from the radiation after about two weeks but that the radiation continues to do its work for a while. I don't know how long Xeloda keeps working after you stop taking it but the side-effects on me were minimal after a few days of adjustment. I'm pretty sure that the surgeon will schedule an appointment shortly after the MRI so I can discuss early surgery with her. If the cancer was only in the rectum, though, I would think that the radiation took care of it. If it has spread already, then it has already spread. If it hasn't, then wouldn't it be inert by now? I understand that there can be residual cells hanging around, maybe dead or potentially alive and maybe surgery takes care of those.

NHMike said:

I sent in a referral request

I sent in a referral request for the MRI (I'm scheduled to be done with chemo and radiation this Friday) to my surgeon's office as she requested one the week after I was done. The doctors that I spoke to at DFCI said that they're finding better results in waiting longer after chemoradiation before surgery. That is, the usualy six weeks is getting pushed out to eight to ten weeks on surgery for CRC. The potential reasons are more time to heal and more time for the radiation and 5FU to do their work. The anecdotal comments that I've seen indicate that your body starts to feel better from the radiation after about two weeks but that the radiation continues to do its work for a while. I don't know how long Xeloda keeps working after you stop taking it but the side-effects on me were minimal after a few days of adjustment. I'm pretty sure that the surgeon will schedule an appointment shortly after the MRI so I can discuss early surgery with her. If the cancer was only in the rectum, though, I would think that the radiation took care of it. If it has spread already, then it has already spread. If it hasn't, then wouldn't it be inert by now? I understand that there can be residual cells hanging around, maybe dead or potentially alive and maybe surgery takes care of those.

My comments are centered on best timing for metastatic colon cancer without radiation with resistant small residuals leftover perhaps more embedded (there was), our case, with daily immunochemo.  

In the literature that I used, for Japan, they don't (didn't?) use radiation for rectal cancer but rather used a more precise form of surgery.  Then they treated everybody, colon or rectal, at two weeks.  

We can also treat to some degree without the 5FU as an immune/mild adjunct only option, but I have to admit 5FU does a lot of the heavy lift.  For a lot of the curatively resected patients, the wait time may be less important because chemo intensity to burn out the remaining cells/sites below a certain development is more important than longer treatment time or constant exposure.  

Without neoadjuvant chemo/radiation and with good blood testing, a lot of the metastatic patients that weren't curatively resected with only stray cellls leftover, are clearly identifiable at 1-2 weeks after surgery (hence my focus on colon cancer pts).  Some part of these metastatic patients are the ones that probably benefit most from tight followup on (immuno)chemo.

The chemo my wife takes UFT, which largely stops working in about 12 hours and is largely gone from circulation in 24 hours, although it lingers and binds in tumor tissue longer.  For xeloda figure about twice as long.  We overcome the wound healing issue on supernutrition before and after surgery, and avoiding complications.  One, she wouldn't restart chemo with an obvious complication and the supernutrition/IV vitamin C patients can avoid a lot of common complications.