Managing Relapsed Rectal Cancer: Concerns About Chemotherapy and Liver Function

Recurrence of colorectal cancer?

Two years ago, I was diagnosed with stage III rectal cancer.
After surgery and chemotherapy, I recovered well and lived normally for about two years.
During a recent routine check-up, a recurrence was found in the pelvic area.
My original surgical oncologist mentioned that the location was not suitable for surgery due to the risk of adhesions and referred me to a hematology-oncology specialist.
Initially, blood tests revealed elevated liver enzymes, with GOT and GPT levels over 200 and 500, respectively.
The cause was unclear.
After hospitalization and treatment, the levels decreased to the 70s and over 200, which are still significantly above normal.
The doctor then advised me to start taking the out-of-pocket chemotherapy drug Esmya (Ulipristal Acetate).
Since this is an out-of-pocket medication, it poses a financial burden.
I researched online and found that this medication can affect liver function and is contraindicated in patients with liver dysfunction.
However, the doctor assured me that the medication would be fine and has minimal side effects.
Given that my liver enzyme levels are still high, is it safe for me to start this chemotherapy drug? Are there any other better treatment options for my recurrent cancer?

LHF, 50~59 year old female. Ask Date: 2021/06/30

Dr. Chen Sirong reply Oncology

LHF / 58 years old / Male
1.
Can I start taking this chemotherapy drug with my liver enzymes still being so high?
A: Regardless of liver function, it is essential to continuously monitor liver function while taking this medication.
If liver function continues to deteriorate, we may need to switch medications.
Don't worry; it means to take things as they come.
Chemotherapy drugs can only be used for a limited time due to the body becoming intolerant or cancer cells developing resistance.
Typically, chemotherapy can be administered for a short period of 3 months to as long as 2-3 years.
In reality, there are not many options available.
Since you have already started this treatment, continue until the body can no longer tolerate it or the medication becomes ineffective, maximizing the drug's therapeutic effect.
2.
Are there other better treatment options for recurrent cancer?
A: If the cancer is localized to the pelvic cavity and you have not previously received radiation therapy, you might consider proton therapy as a self-paid option, or photon therapy covered by health insurance.
The effectiveness of adjuvant chemotherapy is also worth considering.
Wishing you peace of mind.
Taoyuan Hospital, Dr.
Chen Si-Rong.

Reply Date: 2021/06/30

More Info

Managing relapsed rectal cancer, especially when there are concerns about liver function, is a complex and nuanced process. Given your history of stage III rectal cancer and the recent discovery of a recurrence in the pelvic area, it is understandable to have concerns about the implications of chemotherapy on your liver health.

Firstly, it is important to recognize that the liver plays a crucial role in metabolizing many chemotherapy drugs, including the one you mentioned, Atezolizumab (often referred to as "Atezolizumab capsules" in some contexts). Elevated liver enzymes, such as GOT (AST) and GPT (ALT), can indicate liver stress or damage, which is particularly concerning when considering chemotherapy. The normal range for these enzymes is typically around 10-40 U/L for AST and 7-56 U/L for ALT, but these values can vary slightly depending on the laboratory.

In your case, the initial liver enzyme levels were significantly elevated, which could be attributed to several factors, including the cancer itself, potential liver metastasis, or even the side effects of previous treatments. The subsequent reduction in these enzyme levels is a positive sign, but the values still being above normal suggests that your liver is not functioning optimally.

When it comes to starting a new chemotherapy regimen, particularly one that can affect liver function, it is crucial to weigh the risks and benefits. While your oncologist may have assessed that the benefits of starting Atezolizumab outweigh the risks, it is essential to have an open dialogue about your concerns. You should discuss the following points with your healthcare provider:
1. Liver Function Monitoring: Ensure that there is a plan in place for regular monitoring of your liver function during treatment. This includes frequent blood tests to track your liver enzymes and overall liver health.

2. Alternative Treatments: Inquire about other treatment options that may be available for your relapsed rectal cancer. Depending on the specifics of your case, options may include targeted therapies, immunotherapy, or clinical trials that may not have the same impact on liver function.

3. Supportive Care: Ask about supportive measures that can help protect your liver during chemotherapy. This may include dietary modifications, supplements, or medications that support liver health.

4. Second Opinion: If you are feeling uncertain about the proposed treatment plan, seeking a second opinion from another oncologist or a liver specialist could provide additional insights and options.

5. Understanding Side Effects: Make sure you fully understand the potential side effects of Atezolizumab, particularly concerning liver function. Knowing what symptoms to watch for can help you respond quickly if complications arise.

6. Patient Advocacy: Don’t hesitate to advocate for yourself. If you feel uncomfortable starting a treatment with elevated liver enzymes, express this to your doctor. It’s important that you feel confident and informed about your treatment decisions.

In summary, while your oncologist may believe that starting Atezolizumab is appropriate, it is vital to ensure that your liver function is adequately monitored and that you are aware of all your treatment options. The management of relapsed rectal cancer, particularly with underlying liver concerns, requires a careful and collaborative approach between you and your healthcare team. Your health and well-being should always be the top priority, and you deserve to have all your questions answered and concerns addressed.

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