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What is the FLOT chemotherapy regimen and how does it work?

Medically reviewed by Kristianne Hannemann, PharmD. Last updated on May 14, 2025.

Official Answer by Drugs.com

FLOT is a combination chemotherapy regimen that includes fluorouracil, leucovorin, oxaliplatin, and docetaxel. It is primarily used to treat cancers of the stomach and esophagus. It is typically administered in 14-day cycles, 4 cycles before surgery (neoadjuvant) and 4 after surgery (adjuvant), to improve surgical outcomes and reduce cancer recurrence.

What Does FLOT Stand For?

FLOT is an acronym for the four medications in the chemotherapy regimen:

Because these drugs target rapidly dividing cells, they are particularly effective against cancer cells, which grow and divide more quickly than most normal cells.

When Is FLOT Chemotherapy Used?

FLOT chemotherapy is primarily used to treat cancers of the stomach, esophagus (food pipe), and the gastroesophageal junction (the area where the stomach joins the esophagus). It is most commonly recommended for patients with localized or resectable (operable) tumors, where surgery is possible, and the patient is healthy enough to tolerate combination chemotherapy.

FLOT is considered a first-line treatment for resectable gastric and gastroesophageal junction cancer, and may also be used in esophageal cancer treatment based on oncologist recommendations.

Perioperative Setting (Before and After Surgery)

FLOT is typically given both before (neoadjuvant) and after (adjuvant) surgery. This approach is called perioperative chemotherapy. The cycles before surgery help shrink the tumor, making it easier to remove, while the cycles after surgery aim to destroy any remaining cancer cells and reduce the risk of recurrence.

This regimen is now considered a standard of care for patients with resectable gastric, gastroesophageal junction, and esophageal adenocarcinoma, based on clinical trial data showing improved survival compared to older regimens.

Locally Advanced Disease

FLOT is especially used for locally advanced, non-metastatic cancers, where the tumor has not spread to distant organs but may be large or involve nearby structures.

Metastatic Gastric Cancer

There is emerging evidence that FLOT can also be used in the first-line treatment of metastatic (stage IV) gastric cancer, although its primary and most established role remains in the perioperative setting for resectable disease.

How Is FLOT Administered?

FLOT chemotherapy is given intravenously, typically through a cannula, central line, PICC line, or portacath. It is usually given in cycles, with each cycle lasting 14 days (2 weeks). Most patients have a total of 8 cycles, with surgery to remove the cancer after cycle 4. Each cycle typically consists of the following steps:

Steroid premedication: You usually take dexamethasone (a steroid) tablets for 3 days, starting the day before chemotherapy begins, to help prevent side effects.

Day 1 (at the hospital or chemotherapy unit):

Day 2:

Days 3 to 14:

Supportive medications: Antiemetics like ondansetron are given to prevent nausea, and growth factors such as filgrastim may be administered after chemotherapy to support white blood cell counts.

Cycle repetition: After the 24-hour infusion of 5FU, there is a break. The next cycle begins on day 15.

Your healthcare provider may provide different instructions than the example cycle above. Treatment duration and dosing may be adjusted based on patient tolerance.

How Effective Is FLOT Chemotherapy?

The FLOT chemotherapy regimen’s effectiveness has been evaluated in several large clinical trials and real-world studies, often in comparison to older regimens or chemoradiotherapy. It has proven effective even in high-risk patients with locally advanced disease.

Survival Outcomes

Related questions

Tumor Response and Pathological Outcomes

What Are the Side Effects of FLOT Chemotherapy?

FLOT chemotherapy can cause a range of side effects, affecting various organs and body systems. The severity and type of side effects can vary from person to person.

Common Side Effects

Serious Side Effects

To reduce the risk of side effects, your healthcare team will administer premedications (e.g., antihistamine, corticosteroid). You also may receive a medication known as a granulocyte-colony stimulating factor (G-CSF) to help boost your white blood cell count to reduce the risk of infection. Make sure to wash your hands often and avoid people who are sick. Dose adjustments may be required to help manage side effects.

Important Considerations During Treatment

FLOT chemotherapy requires careful monitoring and management to optimize outcomes and minimize risks. Key considerations include:

Summary

FLOT chemotherapy contains a combination of fluorouracil, leucovorin, oxaliplatin, and docetaxel. It is highly effective for resectable gastroesophageal and gastric adenocarcinomas, offering superior survival and tumor response rates compared to both chemoradiotherapy (CROSS) and older chemotherapy regimens (ECF/ECX). The benefits are most pronounced when patients complete the full perioperative regimen. Side effects are common, but they are generally manageable with medications and lifestyle changes.

References
  1. Ajani, J. A., et. al. 2016. Gastric Cancer, Version 3.2016, NCCN Clinical Practice Guidelines in Oncology. Journal of the National Comprehensive Cancer Network : JNCCN, 14(10), 1286–1312. https://doi.org/10.6004/jnccn.2016.0137
  2. Ajani, J. A., et. al. 2023. Esophageal and Esophagogastric Junction Cancers, Version 2.2023, NCCN Clinical Practice Guidelines in Oncology. In: JNCCN. https://doi.org/10.6004/jnccn.2023.0019
  3. Al-Batran, et. al. 2019. Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): a randomised, phase 2/3 trial. Lancet (London, England), 393(10184), 1948–1957. https://doi.org/10.1016/S0140-6736(18)32557-1
  4. Cancer Research UK. 2024. FLOT. Accessed on May 14, 2025 at https://www.cancerresearchuk.org/about-cancer/treatment/drugs/fluorouracil-leucovorin-oxaliplatin-docetaxel-flot
  5. Docetaxel [package insert]. Updated 2023. Meitheal Pharmaceuticals Inc. Accessed on May 14, 2025 at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9fb533da-a7ba-4c2b-8e4f-8e336ba55d12
  6. EviQ. 2023. Gastric and gastroesophageal neoadjuvant/adjuvant FLOT (fluorouracil leucovorin oxaliplatin and DOCEtaxel). Accessed on May 14, 2025 at https://www.eviq.org.au/medical-oncology/upper-gastrointestinal/gastric-and-oesophageal-adjuvant-and-neoadjuvant/2038-gastric-and-gastroesophageal-neoadjuvant-adju
  7. Fluorouracil injection [package insert]. Updated 2024. Accord Healthcare, Inc. Accessed on May 13, 2025 at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=8eff167f-203a-4a81-b2fc-d8773bc3555e
  8. Guan, W. L., et. al. 2023. Gastric cancer treatment: recent progress and future perspectives. Journal of hematology & oncology, 16(1), 57. https://doi.org/10.1186/s13045-023-01451-3
  9. Hoeppner, J., et. al. 2025. Perioperative Chemotherapy or Preoperative Chemoradiotherapy in Esophageal Cancer. The New England journal of medicine, 392(4), 323–335. https://doi.org/10.1056/NEJMoa2409408
  10. National Cancer Institute. Gastric Cancer Treatment (PDQ) - Health Professional Version. Accessed on May 13, 2025 at https://www.cancer.gov/types/stomach/hp/stomach-treatment-pdq#_49
  11. Oxaliplatin [package insert]. Updated 2023. Nextgen Pharmaceuticals LLC. Accessed May 13, 2025 at https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=95b05292-36a1-4946-b8b3-835a3a77f4a7
  12. Paszt, A., et. al. 2023. Impact of neoadjuvant FLOT treatment of advanced gastric and gastroesophageal junction cancer following surgical therapy. Frontiers in surgery, 10, 1148984. https://doi.org/10.3389/fsurg.2023.1148984
  13. Sara, J. D., et. al. 2018. 5-fluorouracil and cardiotoxicity: a review. Therapeutic advances in medical oncology, 10, 1758835918780140. https://doi.org/10.1177/1758835918780140
  14. Serra, F., et. al. 2025. Real-life effectiveness of FLOT in resectable gastric cancer: existing challenges. Drugs in context, 14, 2024-10-7. https://doi.org/10.7573/dic.2024-10-7
  15. Wang, L. 2024. Trial Establishes Preferred Treatment for Some People with Esophageal Cancer. National Cancer Institute. Accessed on  May 13, 2025 at https://www.cancer.gov/news-events/cancer-currents-blog/2024/esophageal-cancer-flot-perioperative-chemotherapy

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