From bowel frequency, pain, and more, many colorectal cancer treatments lead to digestive side effects. Join this webinar with Dr. Cathy Eng to learn all about the digestive system, the side effects that are common due to CRC treatment, and how to manage those side effects.

1. OUR WEBINAR WILL BEGIN SHORTLY

2. Side Effects: Digestive Side Effects

3. TODAY’S
WEBINAR
01 Ask a question in the panel on the right side of
your screen
QUESTIONS
02 Watch a recording of this webinar on the Fight
CRC website. Visit FightCRC.org
WEBINAR ARCHIVE
03 Follow along on Twitter. Use the hashtag
#CRCWebinar
TWEET ALONG!

4. Resources
Fight CRC offers a wide
variety of resources for
those touched by colorectal
cancer. Visit FightCRC.org
to view, download, and
order the latest resources.

5. The information and services provided by Fight Colorectal Cancer are for general informational
purposes only. The information and services are not intended to be substitutes for professional
medical advice, diagnoses or treatment.
If you are ill, or suspect that you are ill, see a doctor immediately. In an emergency, call 911 or go to the
nearest emergency room.
Fight Colorectal Cancer never recommends or endorses any specific physicians, products or
treatments for any condition.

6. TODAY’S
PRESENTER
Cathy Eng, MD, FACP, FASCO
Cathy Eng, MD, FACP, FASCO, Professor of Medicine, Hematology and Oncology, and is the
Co-Director of GI Oncology and Co-Leader of the Gastrointestinal Cancer Research Program.
She joined the faculty at Vanderbilt-Ingram Cancer Center in July 2019.
Her primary clinical research interests include clinical trials involving innovative drugs for the
treatment of colorectal, anal, and appendiceal cancers. She has a specific interest in young
colorectal cancer patients as well as the role of immunotherapy in HPV-associated cancers.
She has published multiple publications in these GI malignancies.
Nationally, Dr. Eng has served in multiple leadership roles for ASCO, ASCO GI, ECOG, and the
NCI Rectal/Anal Task Force. She has most recently been chosen to serve as the Vice-Chair for
the SWOG GI Committee and the NCI GI Steering Committee.

7. Management of Digestive Side Effects of
Colorectal Cancer Treatment
Cathy Eng, MD, FACP, FASCO
• David H. Johnson Chair in Surgical and
Medical Oncology
• Professor of Medicine, Hematology and
Oncology
• Co-Director, GI Oncology
• Co-Leader, Gastrointestinal Cancer
Research Program
• Director, Young Adults Cancer Initiative
• May 27, 2020
• Contact Info: cathy.eng@vumc.org
• Twitter: @cathyengmd

8. Discussion Points
ADJUVANT
CHEMOTHERAPY
RADIATION
THERAPY
SYSTEMIC
CHEMOTHERAPY
POST-OPERATIVE

9. Adjuvant chemotherapy
Offered following
surgical resection Regimens:
Stage II – optional
Stage III –
FOLFOX
CapeOx (Xelox)
Capecitabine
(xeloda)
5-FU
Treatment Options

10. Adjuvant
Chemotherapy:
FOLFOX/CapeOx
• Baking soda rinses
• Good dental care
Mouth sores
• Alternate Zofran (ondansetron) and Compazine
(prochlorperazine) or other similar medications
• Zofran – 15% of pts constipation
• Compazine – drowsiness
• Emend (for delayed nausea) +/- oral steroids
• Severe nausea: olanzapine
• Anticipatory nausea: Ativan or other anti-anxiety
medication
Nausea/vomiting
• Platinum sensation
• Impacts dietary habits
• Consider tart drinks: Grapefruit juice, etc.,
Taste

11. Adjuvant
Chemotherapy
• Subjective sensation of throat closing off (not
life threatening)
• Resolves ~ 5 days after chemo administration
Cold induced neuropathy
• Median of > 4M of therapy
• Follow closely
• May be permanent
• Can you button your buttons? Dose it impact
your writing or walking?
• *Fall precautions
• Do not wait until neuropathy negatively
impacts regular daily living
• Anti-neuropathic medications
• Gabapentin
• Lyrica
• Acupuncture
Cumulative peripheral neuropathy

12. FOLFOX/CapeOx: Bowel Motility
Diarrhea:
• Imodium
• Lomotil
• Anti-spasmotic
• Metamucil (6-8 ozs of water to
add bulk to stool)
• Tincture of opium
Constipation
• Zofran (15% of pts will be
constipated)
• Miralax daily
• Senekot S 2x’s/day (max = 8
tabs/daily

13. Adjuvant chemotherapy:
FOLFOX or CapeOx
• Hand-foot skin syndrome
• More common with capecitabine
• Preference: 500 mg tabs only
• Painful, dry, scaly hands and feet
• Heavy emollients
• Consider a dose reduction
• -1 tablet
• Udderly cream, etc.,
• Reduce use of alcohol-based cleansers
• Sun hypersensitivity: ALL CHEMO
• Atypical chest pain: All 5-FU/capecitabine
based treatment
https://www.cmaj.ca/content/184/15/e818

14. Systemic
Chemotherapy
FOLFOXIRI
• Rarely XELIRI (CapeIRI)
FOLFIRI
Regorafenib
Lonsurf
Immunotherapy

15. FOLFOXIRI
and FOLFIRI
Hair loss
• Pls notify RN
Abdominal cramping during
administration
Tearing of eyes, runny nose
• Drop in *WBC, RBC, and platelets
• 50% of pts neutropenic
• May need neulasta
• Refer to FOLFOX slides
FOLFOXIRI
• Mild diarrhea
• Slight impact on blood counts
FOLFIRI

16. Targeted Therapy
Bevacizumab Anti-EGFR therapy (cetuximab or
panitumumab)
Increased blood pressure (30%) Rash
Bowel perforation (rare) Low magnesium
Poor wound healing (rare) Allergic reaction (cetuximb especially in SE
USA)
Nose bleeds Skin fissures
Nasal septum perforation (rare) Fungal infections of nail bed
Osteonecrosis (rare) Mild diarrhea
Hypertrichosis (increased growth of
eyelashes)

17. Anti-EGFR therapy
side effects
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3228080/; https://link.springer.com/article/10.1007/s12094-018-1953-x
• Anti-acne topical
• Anti-acne medications
• Sunscreen
• Vinegar water rinses

18. Regorafenib (Stivarga)
• Fatigue
• Abnormal liver function tests
• High blood pressure
• Mild drop in blood counts
• Similar to bevacizumab
• Hand-foot skin reaction
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4576906/

19. Lonsurf
•Neutropenia
•30% of all pts
•Check blood counts
•Nausea
•Fatigue

20. Recent additions:
Immunotherapy and BRAF inhibitors
• Immunotherapy
• Rash
• Anemia
• Thyroid dysfunction
• Pituitary dysfunction
• Inflammation of lungs (rare)
• Inflammation of colon (rare) and risk of perforation
• BRAF inhibitors
• Superficial squamous cell carcinoma (13%)
• Follow up with dermatologist biannually

21. Bowel regimen while on
pain medications
•Stool softeners daily
•Miralax daily
•Senesot S twice/day (8 tabs
max/day)
•Prune juice
•Suppository or enema (if
approved by your doctor)
•Hydrate

22. Radiation therapy

23. Radiation
Therapy
Toxicities
• Increased bowel motility: Imodium and/or Lomotil
• Cramping: may be an early sign of dehydration
• Avoid heavy dairy, significant caffeine, and spicy
foods
• Radiation dermatitis
• Similar to a sunburn
• Lanolin, etc.,
• Hemorrhoids
• Sitz baths
• Fatigue
• Drop in blood counts: red and white blood cells,
and platelets
Acute:
• Bowel dysfunction
• Hot flashes
• Sexual dysfunction
• Urinary dysfunction
Chronic

24. Post operative bowel management
• Variability in stool consistency
• Diarrhea
• Metamucil (3-4 ozs of water)
• Metaucil wafers
• Imodium
• Tincture of opium
• Constipation
• Miralax daily
• Metamucil (6-8 ozs of water)
• Scar tissue formation
• Nonspecific sensation

25. Conclusions:
•Communicate to your oncology team:
• APP (NP/PA)
• RN
• Pharm D
• Medical, surgical, interventional
radiology, and/or radiation oncology
•If your supportive medications are not
working, PLS call your oncology team
or the MD on call
•If you have a fever (T> 100.4), chills,
uncontrolled nausea, vomiting or
diarrhea, go to the ER or call 911.
•If you are not passing any stool or gas,
and your stomach is swollen, call your
surgeon/medical oncologist
IMMEDIATELY

26. QUESTION AND
ANSWER
Type in your questions on the panel on
the right side of your screen

27. Fight Colorectal Cancer Mission
We FIGHT to cure colorectal cancer and serve as relentless champions of
hope for all affected by this disease through informed patient support,
impactful policy change, and breakthrough research endeavors.

28. THANK YOU