How would you treat metastatic colon cancer in patients on dialysis?

What would you consider in the first and second line settings with intact MMR/MSI?

2 Answers

Mednet MemberInvited Expert

Medical Oncology · Johns Hopkins University School of Medicine

Answered on

Fortunately, our standard regimen of 5FU and oxaliplatin are quite safe to administer for patients with chronic renal insufficiency/on dialysis:

- 5FU is cleared through non-renal mechanisms and does not require any dose adjustments

- BUT...exposure to capecitabine is higher in patients with renal insufficiency and frankly not recommended with severe renal impairment. So I would not substitute capecitabine for 5FU

- Oxaliplatin can be safely given. Some recommend a 30% reduction in the dose if the CrCl is <30, but others do not....

- But, the hemodialysis should be performed on the same day as the oxaliplatin administration

Irinotecan is more complicated. While SN-38 is only to a small degree excreted by the kidneys, and there are no formal dose reduction guidelines, there have been numerous case reports of excess toxicity for patients with CRI. I would generally not risk giving irinotecan for a patient on dialysis, but if a patient is desperate for a second-line option, then I would start with a significant (50 - 75%) dose reduction of the irinotecan.

Monoclonal antibodies are generally not cleared through the kidneys (they are cleared by by catabolism and the "RES"). Thus, bevacizumab, aflibercept, ramucirumab, cetuximab, and panitumumab require no dose adjustment for patients undergoing dialysis.

Finally, to my knowledge, there are no data on the use of regorafenib nor TAS-102 in patients with severe renal impairment/dialysis, and I would generally not use these.

Mednet MemberInvited Expert

Medical Oncology · Rutgers Cancer Institute of New Jersey

Answered on

I generally agree with Dr Pishvaian. I would like to emphasize that capecitabine is completely contraindicated. Dose should be reduced for GFR < 30 ml/min but this is not safe for dialysis patients and cannot be given on a continuous basis.

Neither FU or platinums need any dose adjustment and I usually give irinotecan at 50% dose reduction.

In the case of drugs cleared renally, chemotherapy can be given the day before dialysis if absolutely necessary. Coordination with the dialysis team is essential.