BREAKING BRAF
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Treating BRAF MSS
Although different Oncologists favour slightly different drugs and regimens, the guide below is the generally accepted pathway for the treatment of BRAF MSS for most NHS patients. This may differ if you have additional gene mutations, or have additional medical issues.
There are additional private drug and diagnostic options available and we have indicated where optional drugs are private prescription (such as Bevacizumab/Avastin at First Line Chemotherapy).
This guide doesn't include trial drugs or yet-to-be-licensed drugs.
Surgery
Depending upon the size and location of your tumour/s, and any potential blockages caused by these, you may or may not have surgery before starting treatment - see section below for how and why such decisions are made.
Neoadjuvant or
Adjuvant
These terms simply indicate whether you have Chemotherapy (first line treatment) before or after surgery.
Neoadjuvant treatment helps to shrink the tumour/s as much as possible, before surgery, to improve results.
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Adjuvant treatment happens after surgery. This chemotherapy happens after surgery because:
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You were admitted as an emergency with a bowel blockage and operated on before finding out that you had bowel cancer
OR
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2. You were admitted for surgery soon after diagnosis because your tumour was
blocking, or about to block, your bowel and cause complications.
First Line Treatment: Chemotherapy
You can expect to start on either a 5-Fluorouracil (5FU) or Capecitabine based Chemotherapy treatment. This might also include Oxaliplatin, Irinotecan and – if you’re paying for it alongside NHS treatment, or a private healthcare patient – Bevacizumab (primary brand name: Avastin). You’ll see terms such as CAPOX, FOLFOX, FOLFOXIRI, FOLFIRI, etc. This is a way of notating the various medicines that comprise your treatment.
For example, FOLFOXIRI is FOLF (5FU) + OX (Oxalaplatin) + IRI (Irinotecan).
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Your Oncologist will decide what dosage to give you and this may change through your treatment, based on your health, blood results, other mutations, your response and your side effects. It is really important you keep a record and tell your team about any side effects you experience, as they may be able to reduce the dose and improve your tolerance.
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There are exceptions to this - it depends upon your cancer, your progression, where your metastases are located and other medical and mutation factors that your Oncologist will take into account. Your Oncologist is the best person to speak to about your individual medical situation.
Second Line Treatment
There are many factors that will determine whether you’ll be given additional chemotherapy treatment. These include how your cancer responded to the first line treatment and whether you’ve had a treatment break.
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Alternatively, you may be put onto the next line of treatment which is commonly known as BEACON and involves the drugs Cetuximab and Encorafenib. These drugs are known as Targeted Cancer Drugs and are not chemotherapy based. They help your body to control the way cancer cells grow. and have been specifically licensed for BRAF MSS.
You may even have been asked to participate in a drug trial (though this is uncommon as Second Line) or you may be given Lonsurf with Bevacizumab (also known as Avastin).
There are exceptions to this - it depends upon your cancer, your progression, where your metastases are located and other medical and mutation factors that your Oncologist will take into account. Your Oncologist is the best person to speak to about your individual medical situation.
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For most people, either another line of chemotherapy or BEACON is the standard Second Line treatment for BRAF MSS.
Third Line Treatment
Depending upon which drugs you've received under second line treatment, the results you've achieved from second line treatment, if you have had a treatment break whilst you've been NED (No Evidence of Disease), and other factors, you may be offered a Chemotherapy Re-challenge. This means re-using drugs that have been used in previous treatment lines.
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If your Second line treatment was chemotherapy-based you should now be put onto a non-chemotherapy treatment which is commonly known as BEACON and involves the drugs Cetuximab and Encorafenib (see above).
You may have been recommended to participate in a drug trial, or you may be given Lonsurf (Trifluridine Tipiracil) with or without Bevacizumab. Alternatively, you may be offered a drug called Regorafenib instead.
There are exceptions to this - it depends upon your cancer, your progression, where your metastases are located and other medical and mutation factors that your Oncologist will take into account. Your Oncologist is the best person to speak to about your individual medical situation.
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At this stage, if you haven't already, it is important to know your biomarkers, and your TMB (Tumour Mutational Burden), value. These can help inform Oncology decisions about what treatment might work best for you. For example, If you are MSS but have a high TMB, you might be eligible for an immunotherapy trial currently underway in the UK. This is why many in our community advocate private ctDNA tests.
See our 'Biomarkers' and 'Diagnostics' sections for more information.
Fourth Line Treatment and Beyond
In terms of fourth line treatment (plus), it is usual to receive Regorafenib or Lonsurf (with or without Bevacizumab) at this stage, whichever you haven't yet received.
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However, there are exceptions to this.:
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You may have been recommended to participate in a drug trial
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You may be asked to participate in a first-receiver group of a new drug (at Dec. 2024, we are imminently awaiting NICE's approval of Fruquitinib)
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You may be able to request a chemotherapy re-challenge if you haven't yet had one - this will depend upon how well you are, where your metastases are, blood-work and other factors.
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You may be told that further treatment is inadvisable for Quality of Life purposes. This is a decision that you should be actively involved in with your Oncologist and don't be afraid to disagree - this is your decision.
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You may want to get a second opinion, at this stage so you know all of your options, before deciding what to do next. See our section 'Second Opinions' for details of how to get one.
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There are exceptions to this - it depends upon your cancer, your progression, where your metastases are located and other medical and mutation factors that your Oncologist will take into account. Your Oncologist is the best person to speak to about your individual medical situation.