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Treatment Name: FOLFOX + Bevacizumab (Avastin®)

FOLFOX + Bevacizumab (Avastin®) is a Chemotherapy Regimen for Colon Cancer

How does FOLFOX + Bevacizumab work?
Each chemotherapy drug in this treatment is designed to kill cancer cells. Bevacizumab stops the growth of blood vessels that supply nutrition to the tumors.

FOL - folinic acid (leucovorin)
F - fluorouracil (5-FU)
OX - oxaliplatin (Eloxatin®)
+
Bevacizumab 
(Avastin®)

Goals of therapy: 
FOLFOX + bevacizumab can be given to shrink tumors early in treatment of a colon cancer patient with a goal of then removing the cancer by surgery. If the stage and grade of cancer are favorable, such as early stage colorectal cancer, the goal is to cure. If it is advanced colorectal cancer, or metastatic, then chemotherapy can still decrease disease symptoms and extend life.

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Schedule

  • Folinic acid (Leucovorin) intravenous infusion (I.V.), given over two hours before fluorouracil on Day 1
  • Oxaliplatin I.V. given over two hours on Day 1
  • Fluorouracil (5-FU) I.V. push, usually given over 3 to 5 minutes on Day 1
  • Fluorouracil (5-FU) continuous I.V. infusion (via home-infusion pump) over 46 hours beginning Day 1 and ending on Day 2
  • Bevacizumab I.V. given over 30 to 90 minutes on Day 1

Typically, all medications are started on the same day. 

FOLFOX + Bevacizumab  is usually given in an outpatient health care infusion center, allowing the cancer patient to go home afterwards. Often, this treatment can take upwards of four to five hours.

Each two-day FOLFOX treatment is repeated every 14 days. This is known as one Cycle. Each cycle may be repeated indefinitely. Duration of therapy may last many months, or years, depending upon response, tolerability, and number of cycles prescribed.

Click here for common FOLFOX plus Bevacizumab starting doses.

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Side Effects

In a multi-drug regimen, each medication has unique side effects. When these medicines are given together, drug-related side effects reported in clinical studies give the best estimate of what to expect. In clinical studies, the most common side effects with FOLFOX + Bevacizumab are seen here:

Side effect videos Side Effect Videos
Fatigue Fatigue Nausea and VomitingNausea and VomitingDiarrheaDiarrheaPainPainNeutropenic FeverNeutropenic Fever

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Monitoring

How often is monitoring needed? 
Labs (blood tests) are usually checked before each treatment.  Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), blood pressure, and urine protein level. CEA (carcinoembryonic antigen) may be checked every six weeks to monitor tumor response.

How often is imaging needed? 
Imaging, such as computerized tomography (CT) scan and/or magnetic resonance imaging (MRI), is checked before treatment.  These are repeated after every few cycles or about every six weeks.

How might blood test results/imaging affect treatment? 
Depending upon the results, your doctor may advise to continue FOLFOX + Bevacizumab as planned, reduce the dose of future treatments, delay the next dose until the side effect goes away, or switch to an alternative therapy. The dose of oxaliplatin may be reduced if persistent (lasting more than 14 days) tingling, pain, numbness, or burning are experienced. Fluorouracil or oxaliplatin doses may be reduced for avoiding infection if the white blood cells, known as neutrophils, drop too low. Doses may also be lowered if the platelet count drops too low, or for severe side effects such as severe mouth sores or diarrhea. Other dose reductions may be recommended by your doctor.

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ChemoExperts Tips

  • Patients will have an infusion pump strapped to their body for 2 days to allow fluorouracil (5-FU) to continuously infuse into a vein. The I.V. line is connected at the end of the chemotherapy session by a nurse. When the infusion is finished the patient will have to go back to the infusion center or hospital to have it disconnected unless a home health nurse comes to the patient’s home to do this
  • A pharmacist should ALWAYS review your medication list to ensure that drug interactions are prevented or managed appropriately

  • Clinical trials may exist for colon cancer. Ask your doctor if any studies or cancer research are currently enrolling in your area. If not, go to clinicaltrials.gov to search for other centers offering study medications

Patient Assistance & Co-payment Coverage

Patients under the age of 65 years, or those with private insurance plans:
If you have insurance and are looking for patient assistance or copay assistance for FOLFOX + Bevacizumab (Avastin®), we have provided links that may help.

Visit our Patient Assistance page and click the links to various patient assistance programs for help paying for FOLFOX + Bevacizumab (Avastin®). Depending upon your income, they may be able to help cover the cost of:

  • Folinic acid
  • Fluorouracil
  • Bevacizumab
  • Oxaliplatin

For Branded medications (may be available for generic medications too), check with the manufacturer to determine if a co-pay card is offered and if it could reduce your monthly copay.

  • If you are uninsured, check with the manufacturer to determine if you are eligible to receive medication at no cost.

Medicare and Medicaid patients (Patients 65 years or older):
The clinic providing treatment will likely pre-authorize medications and immune therapies such as FOLFOX + Bevacizumab (Avastin®) and are the best source to help you understand drug cost.

  • Ask to speak with a patient assistance technician or financial counselor at the clinic or hospital administering this therapy.

Emotional Wellness

What is Emotional Wellness?
Emotional wellness is having a positive outlook balanced with a realistic understanding of current life events. This requires both an awareness and acceptance of your emotions. It is with this knowledge that you can develop a plan to take the necessary actions to positively impact your life.

Emotional wellness uses an ongoing process to continually reflect on the stressors of life in a constructive manner to move forward and create happiness.

Because emotional wellness is deeply connected with physical, social, and spiritual wellness, pursuing it often becomes particularly difficult in times of major illness. Despite this difficulty, working toward emotional wellness has been connected to improved treatment outcomes and a higher likelihood of achieving goals of therapy.

Learn more about pursuing emotional wellness while receiving treatment with FOLFOX + Bevacizumab (Avastin®)

Individual Drug Label Information

Folinic acid (Leucovorin)

  • Folinic acid is an intravenous (I.V.) drug that is a derivative of folic acid, also known as vitamin B9
  • Is clear to slightly yellow in color
General Folinic Acid (Leucovorin) Side Effects
  • Seizures and fainting have been rarely reported
  • Click on the Folinic Acid (Leucovorin) package insert for all reported side effects and possible drug interactions
See DailyMed package insert.

Fluorouracil (Adrucil®)

  • Fluorouracil (5-FU) Is an intravenous (I.V.) drug
  • Recommended to be given only under the supervision of a qualified physician well versed in administering chemotherapy
General Fluorouracil (5-FU, Adrucil) Side Effects
  • Low white blood cell count (leucopenia and neutropenia)
  • Mouth and throat sores or ulcers (mucositis)
  • Diarrhea
  • Nausea and vomiting
  • Low red blood cell and platelet counts
  • Allergic reactions, rarely
  • Eye pain, light sensitivity, excess watering, visual changes
  • Headache
  • Skin conditions:  dryness, redness, tingling, light sensitivity, pain, swelling, loss of nails (hand-foot syndrome)
  • Dosage adjustments may be required for severe liver dysfunction
  • Click on the Fluorouracil (5-FU, Adrucil) package insert below for reported side effects and possible drug interactions

Side Effect Videos
Nausea and VomitingNausea and VomitingDiarrheaDiarrheaFatigue Fatigue PainPainNeutropenic FeverNeutropenic Fever

See DailyMed package insert.

Bevacizumab (Avastin®)

  • Bevacizumab is an intravenous (I.V.) drug
  • Use extreme caution in patients with a history of stomach and intestine perforations or disorders
  • Do not use 28 days before or after any surgery
  • Bleeding is more likely in patients taking this drug
  • Bevacizumab treatment may be delayed or stopped for: surgery, high blood pressure, protein in urine, severe infusion reactions
General Bevacizumab Side Effects
  • Infusion reactions: usually does not happen after first successful dose
  • Bleeding
  • Blood clots
  • Stomach and intestinal problems
  • Poor wound healing
  • High blood pressure
  • Protein leaking from kidneys into urine
  • Avoid during pregnancy, Bevacizumab is known to cause fetal harm
  • Ovarian failure
  • Click on the bevacizumab (Avastin) package insert below for reported side effects and possible drug interactions

Side Effect Videos
BleedingBleedingBlood ClotsBlood Clots

See DailyMed package insert.

Oxaliplatin (Eloxatin®)

  • Oxaliplatin is an intravenous (I.V.) drug
  • Allergic reactions have been reported and may occur within minutes. Certain drugs can be given to alleviate the symptoms: antihistamines, corticosteroids, or epinephrine
  • Oxaliplatin is usually diluted in a dextrose 5% I.V. bag and infused over 2 hours
  • Dosage adjustments may be required for liver dysfunction
General Oxaliplatin (Eloxatin) Side Effects
  • Nerve pain or tingling in feet and hands, loss of tendon reflexes
  • Oxaliplatin can make you very sensitive to cold things such as cold drinks or cold weather for a few days after receiving oxaliplatin. It is best to wear warm clothes in cold weather and to not drink cold liquids, especially those with ice, or hold cold objects in your hands for up to 2 days after each oxaliplatin infusion
  • Lung toxicity:  avoid with certain lung conditions
  • Low white blood cells, platelets, and red blood cells
  • Constipation
  • Diarrhea
  • Vomiting or nausea
  • Fatigue
  • Mouth sores
  • Change in liver function
  • Avoid during pregnancy, known to cause fetal harm
  • Click on the oxaliplatin (Eloxatin) package insert below for reported side effects and possible drug interactions

Side Effect Videos
Nausea and VomitingNausea and VomitingDiarrheaDiarrheaFatigue Fatigue ConstipationConstipationPainPain

See DailyMed package insert.

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References

Hochster HS, Hart LL, Ramanathan RK, et al. Safety and efficacy of oxaliplatin and fluoropyrimidine regimens with or without bevacizumab as first-line treatment of metastatic colorectal cancer: results of the TREE study. J Clin Oncol. 2008;26:3523-3529.

Created: August 31, 2015 Updated: February 25, 2018

What is Colon Cancer?

A disease of the cells from the large intestine.  Colon cancer is the third most common cancer among both men and women.  Known causes include:  family history, poor diet, sedentary lifestyle, obestity, diabetes, history of colon polyps, smoking, heavy alcohol use, prior radiation treatment to abdomen for other cancers, and old age.  The stage can vary at diagnosis and throughout treatment.  Stages of colon cancer use Tumor, Node, Metastasis (TNM) staging as well as Stage Grouping using Stages I, II, III, or IV.  The effectiveness of the treatment may depend upon the stage at diagnosis.

NOTE: Treatment Options listed below are not all-inclusive. Other treatments may be available. ChemoExperts provides drug information and does not recommend any one treatment over another. Only your Doctor can choose which therapy is appropriate for you.

Common Starting Doses

  • Folinic acid (Leucovorin) 350-400 mg/m2 intravenous infusion (I.V.) over 2 hours before fluorouracil on Day 1
  • Fluorouracil 400 mg/m2 I.V. push over 3 to 5 minutes on Day 1
  • Oxaliplatin 85 mg/m2 I.V. over two hours on Day 1
  • Fluorouracil 2400 mg/m2 continuous I.V. infusion via home-infusion pump over 46 hours beginning Day 1 and ending on Day 2
  • Bevacizumab 5 mg/kg I.V. infusion over 30 to 90 minutes on Day 1

What is an I.V. push?

An intravenous medication that is usually prepared in a syringe and infused by vein over a short period of time, such as 15 minutes or less

What is a CBC?

A Complete Blood Count (CBC) is a frequently ordered blood test that tells clinicians the status of your: 1) White blood cell count, 2) Hemoglobin, and 3) Platelet count at the time the test was taken.

Common uses:
1) White blood cell count (WBC): is used to determine infection risk, or response to chemotherapy. Certain chemotherapy agents may harm our good infection-fighting cells. Sometimes chemotherapy may need to be delayed to allow these cells to recover.

2) Hemoglobin: is used to determine if someone is anemic. Anytime the hemoglobin is below 12 g/dL, the person is said to be anemic. Red blood cell transfusions, and sometimes iron can be given to restore the hemoglobin level, but anemia treatment should always aim at treating the underlying cause or condition.

3) Platelet count: is used to determine if the risk of bleeding is increased or if a platelet transfusion is required to prevent bleeding. Certain medications that increase bleeding risk, such as: aspirin, certain chemotherapy agents, and blood thinners, may need to be stopped temporarily until the platelet count is within a safe range.

What is a CMP?

A Comprehensive Metabolic Panel (CMP) is a frequently ordered blood test that tells clinicians the status of your: 1) Electrolytes & Acid/Base status2) Kidney function, 3) Liver function, 4) Blood sugar, and 5) Calcium at the time the test was taken. It is commonly used to monitor liver and kidney function when beginning new medications such as chemotherapy. A total of 14 tests are run simultaneously and are shown below.

Electrolytes & Acid/Base status:
1) Sodium, 2) Potassium, 3) Carbon dioxide, 4) Chloride

Kidney Function:
5) BUN (blood urea nitrogen), 6) Serum creatinine (Scr)

Liver Function:
7) AST, 8) ALT, 9) Total bilirubin, 10) Alk Phos, 11) Albumin, 12) Total protein

Blood sugar:
13) Serum glucose

Calcium:
14) Serum calcium

What does "cure" mean?

The word “cure” means there are no cancer cells left in the body and cancer will never come back. Depending on the cancer type and stage, this may be the true goal of therapy. However, it is very difficult to prove all cancer cells are gone. Even though images, like X-rays and MRI’s, and blood tests may not show any signs of cancer, there can be a small amount of cancer cells still left in the body. Because of this, doctors use the word “remission” is used more often. This means there are no signs or symptoms of cancer. Patients in remission are followed closely for any signs of cancer returning. Sometimes, more chemotherapy may be given while in remission to prevent the cancer from coming back. Doctors usually do not consider a patient “cured” until the chance of cancer returning is extremely low. If cancer does return, it usually happens within 5 years of having a remission. Because of this, doctors do not consider a patient cured unless the cancer has not come back within 5 years of remission. The five-year cutoff does not apply to all cancers.

What is Leucovorin?

Leucovorin is not a chemotherapy agent. It is a special form of folic acid (vitamin B9) that helps increase the effectiveness of fluorouracil. Folic acid should NOT be confused with leucovorin (foliNic acid) as it does not work the same way.