FLOT is a combination chemotherapy regimen used primarily in the treatment of locally advanced stomach and gastroesophageal junction cancer. The acronym represents the four drugs involved: Fluorouracil, Leucovorin, Oxaliplatin, and Docetaxel. This intensive, multi-agent approach is often administered before and after surgery in a perioperative setting to maximize the chances of a successful outcome. This treatment is associated with a range of side effects that require careful monitoring and proactive management.
Common Systemic Reactions
Patients undergoing the FLOT regimen frequently experience profound fatigue, which is often described as a pervasive, whole-body exhaustion unrelieved by rest. This is considered one of the most common complaints, impacting daily functioning and persisting throughout the treatment cycle.
The rapid turnover of healthy cells targeted by chemotherapy also leads to significant gastrointestinal distress. Nausea and vomiting are highly prevalent, requiring prophylactic antiemetic medication to keep symptoms controlled. Diarrhea is also a frequent side effect, caused by damage to the fast-dividing cells lining the digestive tract.
The mucosal lining of the mouth can also be affected, leading to mucositis, which manifests as painful sores or ulcers inside the mouth and throat. Alopecia, or hair loss, is a nearly universal reaction due to the inclusion of Docetaxel in the regimen. Hair thinning typically begins a few weeks after the first treatment, affecting the scalp, eyebrows, and other body hair. While this is a temporary effect, patients should be prepared for the likelihood of complete hair loss.
Specific Toxicities of FLOT Components
The unique effects of FLOT stem directly from the individual drugs, particularly Oxaliplatin and Docetaxel, which cause distinct, dose-limiting toxicities. Oxaliplatin is known for inducing peripheral neuropathy, a condition affecting the nerves outside of the brain and spinal cord. This neuropathy presents in two distinct forms: acute and chronic.
Acute Neuropathy
Acute Oxaliplatin neuropathy occurs during or immediately following the infusion and is often triggered or worsened by exposure to cold temperatures. Patients may experience a pins-and-needles sensation in the hands and feet, or a feeling of jaw tightness and throat spasms when drinking cold liquids. These acute symptoms are typically transient, resolving within a few days after the infusion.
Chronic Neuropathy
Chronic peripheral neuropathy is cumulative, meaning it becomes more pronounced with each successive cycle of treatment. This form presents as persistent numbness and tingling in the extremities, potentially affecting fine motor skills like buttoning a shirt or writing. The chronic toxicity is a major concern as it can be dose-limiting, sometimes requiring a reduction or discontinuation of the Oxaliplatin component to prevent permanent nerve damage.
Docetaxel is a primary cause of myelosuppression, which is a reduction in bone marrow activity leading to decreased production of blood cells. This effect is most concerning for neutropenia, a drop in the absolute neutrophil count (ANC), which significantly impairs the body’s ability to fight bacterial infections. Prophylactic use of granulocyte colony-stimulating factors (G-CSF) is often prescribed to stimulate white blood cell production.
Docetaxel also frequently causes fluid retention, or edema, leading to swelling, most noticeably in the lower legs, feet, and face. This fluid retention can cause rapid weight gain and, in rare but serious cases, affect the lungs or heart. Steroid premedication, such as dexamethasone, is typically administered before Docetaxel infusions to prevent or minimize the severity of this reaction. Docetaxel also contributes to dermatological issues, including changes to the nails, which may become brittle, discolored, or separate from the nail bed.
At-Home Management Strategies
Managing the common side effects at home focuses on comfort, maintaining nutrition, and preventing complications. For nausea, patients should take all antiemetic medications exactly as prescribed, even if they are not actively feeling sick, as prevention is more effective than treatment. Eating small, frequent meals throughout the day instead of three large ones can help settle the stomach and ensure continuous caloric intake.
To combat diarrhea, a temporary shift toward a bland, low-fiber diet is often recommended, focusing on foods like white rice, bananas, and toast. Conversely, constipation, which can be a side effect of certain anti-nausea drugs, may be managed by increasing fluid intake and gentle physical activity.
Maintaining meticulous oral hygiene is paramount for managing mucositis, which includes gentle brushing with a soft toothbrush and rinsing the mouth several times a day with a salt and baking soda solution. The pervasive fatigue can be partially mitigated by incorporating short periods of light exercise, such as walking, into the daily routine. Patients should prioritize hydration by consistently drinking plenty of fluids, which supports kidney function and replaces fluids lost from vomiting or diarrhea. Protecting the skin and nails involves using moisturizers and avoiding harsh chemicals or trauma to the hands and feet.
Recognizing Emergency Situations
Patients receiving FLOT must be aware of certain signs that demand immediate medical attention, as they represent potentially life-threatening complications. Febrile neutropenia is a time-sensitive oncologic emergency, defined by a single oral temperature of \(100.4^\circ\)F (\(38.0^\circ\)C) or higher. Any fever must be reported to the oncology team immediately, as it may be the sole indicator of a severe infection requiring urgent antibiotic treatment.
Severe allergic reactions, though rare, can occur during or shortly after the infusion of any chemotherapy drug. Symptoms such as difficulty breathing, wheezing, swelling of the face or throat, or a generalized rash require an emergency response. Uncontrolled bleeding or unexplained bruising, signs of a dangerously low platelet count, must also be reported without delay.
Inability to keep fluids down due to persistent vomiting, or symptoms of severe dehydration such as dizziness and confusion, warrant urgent contact with the care team.