Cancer of the Colon and Rectum
-
Upload
robert-j-miller-md -
Category
Health & Medicine
-
view
1.413 -
download
2
description
Transcript of Cancer of the Colon and Rectum
![Page 1: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/1.jpg)
Colorectal CancerRobert Miller MD
www.aboutcancer.com
![Page 2: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/2.jpg)
Third Most Common Cancer in Men and Women
![Page 3: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/3.jpg)
Odds of Developing Colorectal cancer in the US (2007-9)~ 5%
Type Men Women
Any Cancer 45% (1in 2) 38% (1 in 3)
Breast 12% (1 in 8)
Colorectal 5% (1in 19) 4.8% (1 in 21)
Prostate 16% (1in 6)
![Page 4: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/4.jpg)
Declining Incidence last 30y
![Page 5: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/5.jpg)
Third Most Lethal Cancer in Men and Women
![Page 6: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/6.jpg)
Declining Mortality in Men US Data 1930 to 2009
![Page 7: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/7.jpg)
Declining Mortality in Women US Data 1930 to 2009
![Page 8: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/8.jpg)
Odds of Dying of Colorectal cancer in the US (2007-9) ~ 2%
Type Men Women
Any Cancer 23% (1in 4) 19% (1 in 5)
Breast 2.8% (1 in 36)
Colorectal 2.11% (1in 47)
1.94% (1 in 52)
Prostate 2.8% (1in 36)
![Page 9: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/9.jpg)
Most patients are diagnosed before they have symptoms because of screening or the findings of rectal blood (hematochezia) or anemia
Abdominal pain — 44 percentChange in bowel habit — 43 percentHematochezia or melena — 40 percentWeakness — 20 percentAnemia — 11 percentWeight loss — 6 percent
Patients who are symptomatic at diagnosis have a somewhat worse prognosis. In one report, the five-year survival rate for symptomatic (49%) and asymptomatic patients (71%)
Symptoms
![Page 10: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/10.jpg)
Median Age of Patients with colon and rectal cancer (2005-2009)
Site Male Female
Colon 69y 73y
Rectum 64y 66y
![Page 11: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/11.jpg)
Colon
8% less than 50y
Rectum
14% less than 50y
Age Distribution from the NCDB for 2000- 2012
![Page 12: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/12.jpg)
Screening
Colonoscopy every 10 years starting at the age of 50 unless high risk
![Page 13: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/13.jpg)
![Page 14: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/14.jpg)
![Page 15: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/15.jpg)
How should family history effect the age to start screening colonoscopy?
First-degree (share one half genes) = parent, child or siblingSecond-degree (share one quarter genes) = grandparents, uncle, niece
![Page 16: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/16.jpg)
Workup or Evaluation Prior to Deciding on Treatment for Colon Cancer
![Page 17: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/17.jpg)
Pathology Report• Confirm that it is malignant (usually adenocarcinoma)• Information about stage: depth in invasion and lymph nodes
involved (look at 12 nodes)• Surgical margins (to ensure complete removal)• Other prognostic risk factors: grade, vascular invasion,
perineural invasion• Genetic risk factors: MSI (microsatellite instability) testing/
MMR protein to look for Lynch syndrome• Gene mutation testing: KRAS and BRAF that will determine
whether the patient would benefit from anti EGFR drugs (cetuximab, panitumumab, regorafenib)
![Page 18: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/18.jpg)
Workup or Evaluation Prior to Deciding on Treatment for Rectal Cancer
![Page 19: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/19.jpg)
T2 T3
Nodes
Transrectal Endoscopic Ultrasound
![Page 20: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/20.jpg)
Accuracy of Imaging in Staging Rectal Cancer
Site Ultrasound
CT MRI
Tumor 80-95% 65-75% 75-85%
Nodes 70-75% 55-65% 60-65%
![Page 21: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/21.jpg)
Staging
![Page 22: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/22.jpg)
Staging: T (tumor stage)
![Page 23: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/23.jpg)
Stage Depth of Invasion
T1 submucosa
T2 muscularis propria
T3 Pericolorectal tissue
T4a Surface of visceral peritoneum
T4b Into other organs/structures
Staging: T (tumor stage)
![Page 24: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/24.jpg)
Staging: N (lymph node stage)
![Page 25: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/25.jpg)
Stage Nodes Involved
N0 0
N1a 1
N1b 2, 3
N2a 4, 6
N2b 7 or more
Staging: N (lymph node stage)
![Page 26: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/26.jpg)
![Page 27: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/27.jpg)
Colon Cancer Stage Distribution
![Page 28: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/28.jpg)
Rectal Cancer Stage Distribution
![Page 29: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/29.jpg)
NCCN.org
![Page 30: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/30.jpg)
![Page 31: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/31.jpg)
Treatment of colorectal cancer
• Early stages are treated with surgery• More advanced stages have surgery
followed by chemotherapy (colon) or radiation and chemotherapy prior to surgery (rectum)
• Metastatic or recurrent disease treated with chemotherapy or targeted therapy and possibly radiation, surgical resection or RF ablation
![Page 32: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/32.jpg)
Survival in Months Drug Regimen
14.8 months bolus 5FU/LV17.4 months Infusional 5FU/LV20.1 months irinotecan (Camptosar) +5FU/LV20.3 months camptosar = 5FU + bevacizumab (Avastin)21.5 months FOLFIRI then FOLFOX25.1 months irinotecan/5FU + avastin +oxaliplatin (Eloxatin)
New Drugs for Colorectal Cancer
![Page 33: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/33.jpg)
There are now seven different classes of drugs with significant antitumor activity:
• 5-fluorouracil [5-FU] which is usually given with leucovorin, capecitabine, (Xeloda) tegafur plus uracil
• Irinotecan (Camptosar)• Oxaliplatin (Eloxatin)• Cetuximab (Erbitux) and panitumumab (Vectibix), two
monoclonal antibodies (MoAbs) directed against the epidermal growth factor receptor (EGFR) if KRAS wild type
• Bevacizumab (Avastin), a MoAb targeting vascular endothelial growth factor (VEGF)
• Aflibercept, a recombinant fusion protein consisting of vascular endothelial growth factor (VEGF) binding portions from the human VEGF receptors 1 and 2 fused to the Fc portion of human immunoglobulin G1,
• Regorafenib, a small molecule inhibitor of multiple kinases
![Page 34: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/34.jpg)
30 Year Trends in 5 Year Survival
Site 1975 2008
Colon 51% 65%
Rectum 48% 68%
![Page 35: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/35.jpg)
Stage and 5 Year Survival US Data 2002- 2008
Stage Incidence Survival
All 100% 64%
Local 39% 90%
Regional 36% 70%
Distant 20% 12%
![Page 36: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/36.jpg)
Survival with Colon Cancer
![Page 37: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/37.jpg)
Survival with Rectal Cancer
![Page 38: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/38.jpg)
5 Year Survival from NCDB
Stage Colon Rectum
I 77.5% 77.7%
II 66.6% 63.2%
III 54.5% 58.0%
IV 9.6% 9.8%
![Page 39: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/39.jpg)
www.adjuvantonline.com
![Page 40: Cancer of the Colon and Rectum](https://reader034.fdocuments.net/reader034/viewer/2022052523/554b379ab4c905da088b558b/html5/thumbnails/40.jpg)
Colorectal CancerRobert Miller MD
www.aboutcancer.com