Hello. Thank you for joining me today. When we think about symptom management in colorectal cancer patients, we often know that these symptoms rarely occur in isolation. Pain contributes to anorexia, nausea contributes to dehydration, and poor nutritional intake worsens fatigue. As advanced practice providers, our job is not simply to prescribe another medication, but to help identify underlying causes, intervene early, and help preserve patient's functional status and quality of life as much as possible. When looking at these symptoms and their management through a GI oncology APP perspective, we can first talk about pain. Oxaliplatin-induced neuropathy is a unique aspect of pain management in GI oncology. Recently, cryotherapy during oxaliplatin administration has been investigated as a prophylactic way of managing this toxicity. Traditionally, we educate patients to avoid cold exposure because oxaliplatin frequently causes acute cold-induced neuropathy. However, a randomized phase two study evaluated controlled cooling of the hands and feet at 11 degrees Celsius during the oxaliplatin infusion. At 12 weeks, 100% of patients in the cooling group remained free of grade 2 or greater neuropathy compared with approximately 81% receiving the usual care. Although these results are encouraging, cryotherapy remains investigational and we need larger studies before recommending routinely. For patients receiving oxaliplatin who do develop neuropathy, duloxetine is an evidence-based supported option, typically starting at 30 milligrams daily and increasing to 60 milligrams as tolerated. We should also assess for functional impairment and consider oxaliplatin dose modification before neuropathy becomes irreversible.

In GI oncology, our most emetogenic regimens include multi-drug chemotherapy combinations such as FOLFIRINOX or FOLFOXIRI and require aggressive prophylaxis for both acute and delayed chemotherapy-induced nausea and vomiting. A four-drug antiemetic regimen is generally recommended, including a NK-1 receptor antagonist, a 5-HT3 receptor antagonist, a corticosteroid, and an atypical antipsychotic such as olanzapine. Olanzapine and dexamethasone should be continued orally on days two through four for prophylaxis for delayed nausea and vomiting.

Fatigue is another symptom we frequently underestimate and can be difficult to manage as it's often a result of multiple factors. As APPs, we should avoid automatically contributing to this fatigue to chemotherapy, but rather evaluate for underlying reversible causes such as dehydration, nutritional deficiencies, sleep disturbances, or underlying anxiety or depression. In colorectal cancer patients who have undergone bowel resection, particularly terminal ileal resection, consider evaluating for B12 deficiency as a contributing factor. Physical activity remains one of our strongest evidence-based intervention and carries an NCCN category one recommendation. We should be encouraging our patients to engage in manageable activities such as short daily walks and light resistant exercises tailored to their performance status. For patients experiencing significant functional decline, early physical therapy and nutrition referrals can be particularly beneficial.

Anorexia and cachexia are especially relevant in advanced GI malignancies. Early dietician involvement is essential and we should encourage our patients to eat small, frequent, high protein, calorie dense meals and oral nutritional supplements. We should also address contributing symptoms such as nausea, mucositis, taste alterations and diarrhea before escalating appetite stimulating medications. Low-dose olanzapine at 2.5 to 5 milligrams daily is an option supported by emerging evidence for improving appetite and weight gain in patients with advanced cancer. Megestrol or short-acting corticosteroids may be considered in select patients, although risks such as thromboembolism, hyperglycemia, and fluid retention must be weighed carefully. And importantly, early palliative care involvement should be viewed as an extension of excellent oncology care, not just a last resort.