Oral Chemotherapies for Colorectal Cancer

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2. • Speaker(s): Dr. Anna Varghese
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5. Disclaimer:
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6. Speakers:
Dr. Anna Varghese is an assistant attending in the
Gastrointestinal Oncology Service at Memorial
Sloan-Kettering Cancer Center. She completed
medical school at Case Western Reserve
University in Cleveland, Ohio, her internal
medicine residency at Beth Israel Deaconess
Medical Center in Boston, Massachusetts, and
her medical oncology fellowship training at
MSKCC in New York City. At MSKCC, her clinical
and research interests center on developing new
treatments for patients with colorectal cancers
and cancers of unknown primary.

7. Oral Chemotherapy for
Colorectal Cancer
Anna Varghese MD
Memorial Sloan Kettering Cancer Center
3/11/15

8. Outline
• Commonly used medications for colorectal
cancer
• Standard oral chemotherapy for colorectal
cancer
– Capecitabine
– Regorafenib
• Experimental oral chemotherapy
– TAS-102

9. Commonly used medications for
colorectal cancer
Chemotherapy Brand Name Other Names Intravenous
(IV) or oral
5-Fluorouracil Adrucil ™ 5-FU Intravenous
Oxaliplatin Eloxatin™ Oxali Intravenous
Irinotecan Camptosar™ CPT-11, Irino Intravenous
Cetuximab Erbitux™ Cetux Intravenous
Bevacizumab Avastin™ Bev Intravenous
Panitumumab Vectibix™ P-mab Intravenous
Capecitabine Xeloda™ Cape Oral
Regorafenib Stivarga™ Oral

10. Commonly used medications for
colorectal cancer
Commonly given combinations:
FOLFOX : 5-Fluorouracil + Leucovorin +
Oxaliplatin
FOLFIRI: 5-Fluororuacil + Leucovorin +
Irinotecan
Capeox = XELOX = Capecitabine and Oxaliplatin
Capeiri : Capecitabine and Irinotecan
Chemotherapy
5-Fluorouracil
Oxaliplatin
Irinotecan
Cetuximab
Bevacizumab
Panitumumab
Capecitabine
Regorafenib

11. Commonly used medications for
colorectal cancer
Commonly given combinations:
FOLFOX: 5-Fluorouracil + Leucovorin + Oxaliplatin
FOLFIRI: 5-Fluororuacil + Leucovorin + Irinotecan
Capeox (XELOX): Capecitabine and Oxaliplatin
Capeiri: Capecitabine and Irinotecan
Chemotherapy Brand Name Other Names Intravenous
(IV) or oral
5-Fluorouracil Adrucil ™ 5-FU Intravenous
Oxaliplatin Eloxatin™ Oxali Intravenous
Irinotecan Camptosar™ CPT-11, Irino Intravenous
Cetuximab Erbitux™ Cetux Intravenous
Bevacizumab Avastin™ Bev Intravenous
Panitumumab Vectibix™ P-mab Intravenous
Capecitabine Xeloda™ Cape Oral
Regorafenib Stivarga™ Oral

12. CAPECITABINE

13. Capecitabine: The Basics
• What is it?
– Oral form of 5-FU
• How is it given?
– Oral
– Tablets
• 150mg or 500mg tablets
• How often do you have to take it?
– Twice a day
– Multiple possible schedules
• 3 week schedule: 2 weeks on / 1 week off
• 2 week schedule: 1 week on / 1 week off
Genentech.com

14. Capecitabine: When can you use it?
• Stage II or Stage III colon cancer
– 6 months of adjuvant chemotherapy
• Oral / IV option: Capeox
• All IV option: FOLFOX
• Stage II or III rectal cancer
– Chemotherapy with FOLFOX or Capeox
– Concurrent radiation therapy and chemotherapy
• Stage IV colorectal cancer

15. Capecitabine: Is the pill as good as the
intravenous form of 5-FU?
• Yes!
• We use these interchangeably.
• Capecitabine is as effective as 5-FU.
– Studies comparing capeox and FOLFOX
demonstrated that capeox is no worse than
FOLFOX in first-line treatment.

16. Capecitabine: What are the common
side effects?
• Lowering of the neutrophil count (neutropenia)
• Lowering of the platelet count (thrombocytopenia)
• Rash on the hands and feet (hand-foot syndrome)
• Nausea and vomiting
• Diarrhea or constipation
• Poor appetite
• Cardiac complications
Ascopost.com

17. Capecitabine: Who should not take it?
• People with poor kidney function.
• People who cannot metabolize the drug.

18. Capecitabine: How do you know if it’s
right for you?
• Your doctor can help you decide, but only you
can know this.
• How do you feel about a mediport?
• How important is it to limit visits to the clinic?
• Are you the kind of person who can take pills
reliably?
• Will the burden of twice daily medications
become overwhelming?

19. Example
• You have just undergone surgery for your
colon cancer and were found to have stage III
colon cancer in which 2 lymph nodes had
evidence of cancer.
• Your doctor has recommended 6 months of
“adjuvant” chemotherapy with either FOLFOX
or Capeox.
• How do you decide which one?

20. Adjuvant Capeox vs. Adjuvant FOLFOX
FOLFOX Capeox
Medications 5-Fluorouracil,
leucovorin, and
oxaliplatin
Capecitabine and oxaliplatin
Method of administration IV
Requires mediport
Oral and IV
Visits Every 2 weeks Every 3 weeks
Number of treatments /
clinic visits
12 8
PROS •Requires a mediport •Does not require a mediport
or 48 hour infusion
•Fewer visits
CONS •Requires a mediport
•More visits
•Fewer doses of oxaliplatin 
higher dose of oxaliplatin 
increased side effects
•Increased pressure on patient
•Adherence

21. Capecitabine: How do you think you
get it?
Doctor writes a
prescription.
Pharmacy
mails drug to
your home.

22. Capecitabine: How should you get it?
Doctor writes a prescription.
Doctor’s office calls your insurance company
to find out what specialty pharmacy to use.
Doctor’s office sends prescription to
specialty pharmacy.
Doctor’s office may need to complete a
prior authorization form.
Pharmacy then coordinates mailing
the drug to your home.

23. Capecitabine: How do you actually
get it?
Doctor writes a prescription.
Doctor’s office calls your insurance company
to find out what specialty pharmacy to use.
Doctor’s office sends prescription to
specialty pharmacy.
Doctor’s office may need to complete a
prior authorization form.
Pharmacy then coordinates mailing
the drug to your home.
Patient calls doctor’s office.
Patient calls insurance.
Patient calls pharmacy.
Patient calls doctor’s office.
Patient calls insurance.
Patient calls pharmacy.
Patient calls doctor’s office.
Patient calls insurance.
Patient calls pharmacy.

24. Capecitabine: How do you take it?
• Twice a day
• Within 30 minutes of eating a meal
• Swallow whole

25. REGORAFENIB

26. Regorafenib: The Basics
• What is it?
– Blocks several different proteins thought to be
important in cancer growth
• How is it given?
– Oral
– 40mg Tablets
• How often do you have to take it?
– Once a day
– 4 tablets
– 4 week schedule: 3 weeks on / 1 week off

27. Regorafenib: When can you use it?
• Metastatic colorectal cancer that has
progressed or grown despite 5-FU,
capecitabine, oxaliplatin, irinotecan,
cetuximab, and panitumumab

28. Regorafenib: What are the side effects?
• Fatigue and weakness
• Rash on the hands and feet (hand-foot syndrome)
• Bleeding
• High blood pressure (hypertension)
• Neurologic abnormalities
• Bowel perforation
• Impaired wound healing
• Liver damage

29. Regorafenib: How do you know if it’s
right for you?
• Your doctor can help you decide, but only you
can know this.
• Are you the kind of person who can take pills
reliably?
• Will the burden of taking daily medications
become overwhelming?

30. Regorafenib: How do you get it?
Doctor writes a prescription.
Doctor’s office calls your insurance company
to find out what specialty pharmacy to use.
Doctor’s office sends prescription to
specialty pharmacy.
Doctor’s office may need to complete a
prior authorization form.
Pharmacy then coordinates mailing
the drug to your home.

31. Regorafenib: How do you take it?
• Once a day at the same time each day
• Swallow whole
• Take with a meal

32. Oral chemo: How do you remember
to take it?
• Alarms
• Pill box – separate from your other
medications

33. When should you call your doctor or
go to a local Emergency Room?
Question ER or 911 Call your
doctor
If you develop chest pain, chest pressure,
or unexplained shortness of breath?
X
If you develop new neurologic changes? X
If you develop a rash on your hands and
feet?
X
If you develop unexplained fatigue, but
you can still get out of bed and take care of
your personal care?
X
If you develop darkening of your skin, eyes,
or urine, but you still otherwise feel OK?
X
If you are worried about a symptom? XXXXXXX

34. Question Do Don’t
What if I miss my dose? Do skip the dose. Do not take extra or double
the dose.
What if I can’t swallow the
pills?
Do talk to your doctor.
Do take the pills whole.
Do not crush the pills
unless you talk with your
doctor or pharmacist.
What if I’m having side
effects?
Do talk to your doctor. Do not ignore your
symptoms! Trust your
instincts.
Dos and Don’ts of Oral Chemotherapy

35. NEW DRUGS:
TAS-102

36. TAS-102: The Basics
• What is it?
– Inhibits DNA synthesis directly
– Inhibits an enzyme important for DNA replication
• How is it given?
– Oral
– Tablets

37. TAS-102: Promising studies
Lancet Oncology 2012
Ascopost.com

38. TAS-102: What side effects have been
seen?
• Fatigue
• Diarrhea
• Nausea and Vomiting
• Poor appetite
• Lowering of the blood counts – neutrophils,
platelets, and hemoglobin

39. Summary
• Oral chemotherapy is an option for patients with
stages II, III, and IV colorectal cancer.
• The two FDA approved oral agents for colorectal
cancer are capecitabine and regorafenib.
• Oral chemotherapy is not right for everyone, but
it can be a good option for the right patient.
• Oral chemotherapy is still chemotherapy and
comes with risks.

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