• Jonker D, Rumble RB, Maroun J, Gastrointestinal Cancer Disease Site Group. The role of oxaliplatin combined with 5-fluorouracil and folinic acid in the first and second-line treatment of advanced colorectal cancer: a clinical practice guideline. Toronto (ON): Cancer Care Ontario (CCO); 2006 Dec 8. 33 p. (Evidence-based series; no. 2-22). [15 references]

Refer to Appendix 1 in Section 2 of the original guideline document for recommended dosages and schedules.

Combination oxaliplatin, short-term infusional 5-fluorouracil (5FU), and folinic acid (FA) (FOLFOX) is an important component of therapy, and oxaliplatin should be made available for the treatment of advanced colorectal cancer.

First-line Therapy

• FOLFOX was shown to be superior to bolus 5FU/FA/irinotecan (IFL) in one trial. The FOLFOX regimen has superior median survival and tumour response rates. Compared with IFL, FOLFOX has lower incidences of severe nausea, vomiting, diarrhea, and febrile neutropenia, but higher peripheral neuropathy.
• Short-term infusional 5FU/FA in combination with either oxaliplatin (FOLFOX) or irinotecan (FOLFIRI) are both acceptable alternatives for fit patients when combination therapy is the preferred treatment. Choice of first-line therapy may rely on patient factors and preferences, for example, less neuropathy with irinotecan versus less alopecia with oxaliplatin.

Second-line Therapy

• After progression on first-line anti-thymidylate synthase monotherapy (e.g., 5FU/FA; capecitabine), irinotecan is the standard second-line therapy. FOLFOX is a reasonable alternative for patients with contraindications to the use of second-line irinotecan.
• After progression on both irinotecan and an anti-thymidylate synthase agent, FOLFOX is the preferred therapy. Recent trials suggest that, as compared to FOLFOX alone, FOLFOX combined with bevacizumab provides additional survival benefits.

None provided

The recommendations are supported by randomized controlled trials (RCTs) and meta-analyses.

• Jonker D, Rumble RB, Maroun J, Gastrointestinal Cancer Disease Site Group. The role of oxaliplatin combined with 5-fluorouracil and folinic acid in the first and second-line treatment of advanced colorectal cancer: a clinical practice guideline. Toronto (ON): Cancer Care Ontario (CCO); 2006 Dec 8. 33 p. (Evidence-based series; no. 2-22). [15 references]

Not applicable: The guideline was not adapted from another source.

2005 (revised 2006 Dec)

Program in Evidence-based Care - State/Local Government Agency [Non-U.S.]

The Program in Evidence-based Care (PEBC) is a Province of Ontario initiative sponsored by Cancer Care Ontario and the Ontario Ministry of Health and Long-Term Care.

Cancer Care Ontario
Ontario Ministry of Health and Long-Term Care

Gastrointestinal Cancer Disease Site Group

The members of the Gastrointestinal Cancer Disease Site Group (DSG) disclosed potential conflicts of interest relating to the topic of this practice guideline. Two of the guideline authors reported no conflicts of interest. One of the guideline authors reported research involvement with the pharmaceutical company that manufactures the chemotherapy agent recommended in this guideline. No other Gastrointestinal Cancer Disease Site Group member declared any conflicts with respect to this report.

The following is available:

• Browman GP, Levine MN, Mohide EA, Hayward RSA, Pritchard KI, Gafni A, et al. The practice guidelines development cycle: a conceptual tool for practice guidelines development and implementation. J Clin Oncol 1995;13(2):502-12.

None available

This NGC summary was completed by ECRI on December 1, 2006. The information was verified by the guideline developer on January 19, 2007. This summary was updated by ECRI Institute on April 9, 2008.