Incorporating neoadjuvant chemotherapy into locally advanced colon cancer treatment pathways: real life experience of implementing FOxTROT

The international FOxTROT trial, recently published in the Journal of Clinical Oncology, (ref awaited) is the first randomised controlled trial testing neoadjuvant chemotherapy (NAC) with oxaliplatin and 5-fluorouracil in locally advanced but operable colon cancer. 1053 patients with operable, radiologically staged T3-T4, N1-2, M0 colon cancer were recruited from over 100 sites in the UK, Sweden and Denmark. Patients were randomised to 6 weeks of planned chemotherapy before resectional surgery, followed by adjuvant chemotherapy; or upfront surgery followed by adjuvant chemotherapy (total 18 weeks in both arms). NAC was safe and, compared with standard treatment, there was no increase in surgical complications, a higher R0 rate (95% vs 89%, p0.001), and significant primary and nodal pathological downstaging. The trial met its primary endpoint with fewer patients experiencing recurrent or residual disease at 2 years with NAC compared with control: (16.8% vs 21.2%, risk ratio=0.74, p=0.042). Rapid translation of these results into patient benefit is expected, particularly as the chemotherapeutic agents are already used routinely and do not incur any additional cost or toxicity. However, offering NAC as standard care for advanced colon cancer requires adaptations to current treatment pathways so presents organisational challenges. To date, the Leeds Cancer Centre, St James's University Hospital, UK has commenced 64 patients on the novel pathway following presentation and adoption of the FOxTROT results. Here, we describe our experience and share strategies developed across the MDT to minimise impact on person hours, service capacity and budget, whilst building patient safety and confidence.