Chemotherapy is among the most commonly used cancer treatments. While more than 100 different chemotherapy drugs have been approved, most patients are treated with a regimen that combines several types of chemotherapy, because combining chemotherapy medications often makes treatment more effective. FOLFOX is one chemotherapy combination frequently used to treat certain gastrointestinal cancers.
“FOLFOX chemotherapy has been used a lot in colorectal cancer, both for Stage 3 and Stage 4 disease,” explains Marwan G. Fakih, M.D., chief of gastrointestinal medical oncology at City of Hope® Cancer Center Duarte. “This combination has an acceptable side effect profile and can be used as a backbone therapy to which other drugs may be added.”
This article covers the basics on FOLFOX chemotherapy and how it works, including:
- What is FOLFOX?
- Types of cancer treated with FOLFOX
- Is there a standard FOLFOX regimen?
- FOLFOX side effects
If you or a loved one has been diagnosed with colorectal cancer or another form of cancer and would like a second opinion, call us 24/7 at (877) 834-8941.
What Is FOLFOX?
Medical oncologists are cancer doctors that specialize in using medications to treat cancer. They work with patients and their care teams to determine which combination of chemotherapy drugs may be most effective, taking into account the patient’s overall health, unique diagnosis and wishes. FOLFOX may be used to treat colorectal cancer.
FOLFOX is an acronym based on the names of the three drugs in this chemotherapy combo:
- Folinic acid, also called leucovorin calcium (FOL)
- Fluorouracil, sometimes referred to as 5-FU (F)
- Oxaliplatin, a common chemotherapy medication (OX)
“This combination of two chemo drugs and folinic acid – which is a vitamin-like compound that enhances the activity of fluorouracil – has been adopted in the management of multiple tumor types,” Dr. Fakih says.
For patients with Stage 3 colorectal cancer, FOLFOX may be used alongside or after surgery to reduce the risk that cancer will recur.
“In Stage 4 disease, FOLFOX can be used as neoadjuvant therapy, meaning it’s given before surgical resection of liver metastases,” Dr. Fakih says. “But it can also be used as a treatment for managing advanced Stage 4 disease.”
FOLFOX chemotherapy has been used in the treatment of colorectal cancer for more than 20 years.
“Over that time, the research into using these drugs for colorectal cancer has involved well over 50,000 patients, so confidence levels in deciding when and where it should be used are quite high,” Dr. Fakih adds.
Is FOLFOX a Strong Chemo?
FOLFOX is not necessarily a stronger chemotherapy combination than many others, Dr. Fakih says. But he stresses that every patient – and every cancer diagnosis – is different.
“Patients should discuss the goals for their therapy with their physician, including the risks and benefits,” he says. “If we look at FOLFOX as a standalone backbone treatment without anything on top of it, it's a fairly well-tolerated regimen if used for three to four months.”
How It’s Administered
Like many chemotherapy treatments, FOLFOX is administered intravenously, meaning it’s delivered into a vein using a small, thin tube. This is usually done at a cancer hospital or clinic by nurses who are specially trained in administering cancer treatments.
“Patients are monitored during treatment,” says Dr. Fakih, “and appropriate adjustments to their dosing can be made according to how they're responding to treatment.”
Types of Cancer Treated with FOLFOX
FOLFOX chemotherapy is most often used to treat advanced-stage colorectal cancer.
“FOLFOX is considered standard of care for Stage 3 colorectal cancer for preventing recurrence,” says Dr. Fakih, adding that it may also be used to shrink a tumor before it’s removed in surgery.
For patients with Stage 4 gastric cancer, FOLFOX is often recommended in combination with immunotherapy or targeted therapy drugs, based on the tumor’s genetic profile.
However, FOLFOX is sometimes also used to treat:
- Pancreatic cancer
- Stomach cancer
- Appendix cancer
- Small intestinal cancer
- Biliary cancer
But it’s important to remember that “it’s not a one-size-fits-all approach,” Dr. Fakih says.
Is There a Standard FOLFOX Regimen?
Patients who receive FOLFOX chemotherapy usually receive one cycle of chemo, then wait about two weeks before starting another cycle. During each treatment session:
- Folinic acid (FOL) and oxaliplatin (OX) are delivered intravenously for about two hours.
- Fluorouracil (F) is injected into a vein for about five minutes.
- A small pump is placed that will deliver more fluorouracil over the next 46 hours, after the patient returns home.
After recovering at home over the next 12 or so days, the patient starts another cycle of FOLFOX. The total treatment time can run from a few months up to six months.
Dr. Fakih stresses that treatment plans do vary based on a wide range of factors, from a patient’s age and overall health to the cancer’s stage and whether it’s spread beyond its original location.
“Other things that we have to take into consideration include the patient’s performance status, whether he or she has baseline neuropathy, or nerve damage, since oxaliplatin can make this worse, and how well the bone marrow is functioning,” he explains. “All of these factor into our decision making.”
FOLFOX Side Effects
FOLFOX, like many types of chemotherapy, can cause a wide range of side effects. About one in 10 people who receive FOLFOX chemotherapy experience issues, including:
- Neuropathy
- Low blood cell counts, which can increase the risk of infection or bleeding and bruising
- Nausea or vomiting
- Diarrhea or constipation
- Fatigue
- Mouth sores or ulcers
- Loss of appetite
- Minor hair loss
- Stomach or abdominal pain
- Fever
The most notable side effect for patients who receive chemotherapy that includes oxaliplatin is neuropathy, which refers to changes to the nerves that can cause numbness, tingling or unusual sensations.
“We do counsel patients that FOLFOX can cause acute and delayed neuropathy,” explains Dr. Fakih. “Cold sensitivity is common and can occur for up to five days and sometimes longer with the use of oxaliplatin. So if patients touch something really cold, they’ll get tingling or numbness for a few seconds.”
While this level of neuropathy isn’t dangerous, it can feel odd or uncomfortable. And because extended use of oxaliplatin can cause long-term nerve changes, many doctors recommend dropping this drug from a FOLFOX regimen after around eight cycles of chemo.
In terms of other, more common chemotherapy side effects such as fatigue or nausea, “what I typically tell patients is that this will take about 20% away from your energy level,” Dr. Fakih says. After that time, most people bounce back to feeling better. “With FOLFOX, we see these constitutional symptoms, but thankfully, they're typically manageable.”
If you or a loved one has been diagnosed with colorectal cancer or another form of gastrointestinal cancer and would like a second opinion, call us 24/7 at (877) 834-8941.