Colonic adenocarcinoma

LIZA D MARIPOSQUE MD1ST Year Famed ResidentChart Roundrsquos Presentor

Jan 28 2009

A case of BS 60 years old male from Sindangan Zamboanga del Norte came in for further work-up of intermittent abdominal pain after colonic polypectomy 1 month PTA and a white plaque on the left tonsil 1 month PTA

No weight loss no changes in bowel movement no melena no changes in the caliber of stool no fever

Previously smoker amp occasional alcoholicNo food allergy Allergy to Tranexamic acidHFD HPN Colonic CA

PAST MEDICAL HISTORYHPN - 7 Yrs 13090-180

- maintenance Olmesartan 40mg OD amp Verapamil 40mg OD

Previous Hospitalization1996 ndash BPUD by endoscopy (PSH) 2004 ndash SP Cholecystectomy (PSH)2005 ndash External Hemorrhoids Grade I

- Hyperplastic polyp rectosigmoid by Bx amp SP sigmoidoscopy

(Siliman Medrsquol Center) 2006 ndash Cecal Diverticulosis by CT-scan

- Erosive Antral Gastritis by endoscopy (PSH)

Sept 2008 ndash Colonic Diverticulitis (PSH)

Dec 2008 ndash Colonic AdenoCA well

differentiated by Bx SP Polypectomy

(Siliman Medrsquol Center)

PHYSICAL EXAMINATIONS

Conscious anxious NIRD

VS BP=14090 PR=71bpm RR=25cpm

T=365C Wt=79kg

SKIN Fair no lesions

HEENT Anecteric sclerae pinkish palpebral conjuctivae slightly yellowish buccal mucosa w white plaque on the L erythematous tonsil not enlarge and no exudates noted

Neck no lympadenopathyCL ECE harsh breath sounds no

rales no wheeze

CVS DHS NRRR no murmurAbdomen globular NABS flabby

nontender no hepatomegaly no mass palpated

GUT (-)KPSExtremities no bipedal edema

strong pulsesCNS WNL

ADMITTING IMPRESSIONS

TC COLONIC CANCER HPN LEUKOPLAKIA

COURSE IN THE WARD

DAY 1 (Upon admission)- Diet low fat low salt- labs requested- Venoclysis started KVO- meds given1 Olmesartan (Olmetec) 40mg 1 tab OD2 Verapamil (Isoptin) 40mg 1 tab OD3 Hexetidine (Bactidol) gargle solution TID

PC meals4 Esomeprazole (Nexium) 40 mg 1 tab OD- referred to gastroentologist for consult- referred to cardiologist for CP clearance

A case of BS 60 years old male from Sindangan Zamboanga del Norte came in for further work-up of intermittent abdominal pain after colonic polypectomy 1 month PTA and a white plaque on the left tonsil 1 month PTA

No weight loss no changes in bowel movement no melena no changes in the caliber of stool no fever

Previously smoker amp occasional alcoholicNo food allergy Allergy to Tranexamic acidHFD HPN Colonic CA

PAST MEDICAL HISTORYHPN - 7 Yrs 13090-180

- maintenance Olmesartan 40mg OD amp Verapamil 40mg OD

Previous Hospitalization1996 ndash BPUD by endoscopy (PSH) 2004 ndash SP Cholecystectomy (PSH)2005 ndash External Hemorrhoids Grade I

- Hyperplastic polyp rectosigmoid by Bx amp SP sigmoidoscopy

(Siliman Medrsquol Center) 2006 ndash Cecal Diverticulosis by CT-scan

- Erosive Antral Gastritis by endoscopy (PSH)

Sept 2008 ndash Colonic Diverticulitis (PSH)

Dec 2008 ndash Colonic AdenoCA well

differentiated by Bx SP Polypectomy

(Siliman Medrsquol Center)

PHYSICAL EXAMINATIONS

Conscious anxious NIRD

VS BP=14090 PR=71bpm RR=25cpm

T=365C Wt=79kg

SKIN Fair no lesions

HEENT Anecteric sclerae pinkish palpebral conjuctivae slightly yellowish buccal mucosa w white plaque on the L erythematous tonsil not enlarge and no exudates noted

Neck no lympadenopathyCL ECE harsh breath sounds no

rales no wheeze

CVS DHS NRRR no murmurAbdomen globular NABS flabby

nontender no hepatomegaly no mass palpated

GUT (-)KPSExtremities no bipedal edema

strong pulsesCNS WNL

ADMITTING IMPRESSIONS

TC COLONIC CANCER HPN LEUKOPLAKIA

COURSE IN THE WARD

DAY 1 (Upon admission)- Diet low fat low salt- labs requested- Venoclysis started KVO- meds given1 Olmesartan (Olmetec) 40mg 1 tab OD2 Verapamil (Isoptin) 40mg 1 tab OD3 Hexetidine (Bactidol) gargle solution TID

PC meals4 Esomeprazole (Nexium) 40 mg 1 tab OD- referred to gastroentologist for consult- referred to cardiologist for CP clearance

PAST MEDICAL HISTORYHPN - 7 Yrs 13090-180

- maintenance Olmesartan 40mg OD amp Verapamil 40mg OD

Previous Hospitalization1996 ndash BPUD by endoscopy (PSH) 2004 ndash SP Cholecystectomy (PSH)2005 ndash External Hemorrhoids Grade I

- Hyperplastic polyp rectosigmoid by Bx amp SP sigmoidoscopy

(Siliman Medrsquol Center) 2006 ndash Cecal Diverticulosis by CT-scan

- Erosive Antral Gastritis by endoscopy (PSH)

Sept 2008 ndash Colonic Diverticulitis (PSH)

Dec 2008 ndash Colonic AdenoCA well

differentiated by Bx SP Polypectomy

(Siliman Medrsquol Center)

PHYSICAL EXAMINATIONS

Conscious anxious NIRD

VS BP=14090 PR=71bpm RR=25cpm

T=365C Wt=79kg

SKIN Fair no lesions

HEENT Anecteric sclerae pinkish palpebral conjuctivae slightly yellowish buccal mucosa w white plaque on the L erythematous tonsil not enlarge and no exudates noted

Neck no lympadenopathyCL ECE harsh breath sounds no

rales no wheeze

CVS DHS NRRR no murmurAbdomen globular NABS flabby

nontender no hepatomegaly no mass palpated

GUT (-)KPSExtremities no bipedal edema

strong pulsesCNS WNL

ADMITTING IMPRESSIONS

TC COLONIC CANCER HPN LEUKOPLAKIA

COURSE IN THE WARD

DAY 1 (Upon admission)- Diet low fat low salt- labs requested- Venoclysis started KVO- meds given1 Olmesartan (Olmetec) 40mg 1 tab OD2 Verapamil (Isoptin) 40mg 1 tab OD3 Hexetidine (Bactidol) gargle solution TID

PC meals4 Esomeprazole (Nexium) 40 mg 1 tab OD- referred to gastroentologist for consult- referred to cardiologist for CP clearance

Sept 2008 ndash Colonic Diverticulitis (PSH)

Dec 2008 ndash Colonic AdenoCA well

differentiated by Bx SP Polypectomy

(Siliman Medrsquol Center)

PHYSICAL EXAMINATIONS

Conscious anxious NIRD

VS BP=14090 PR=71bpm RR=25cpm

T=365C Wt=79kg

SKIN Fair no lesions

HEENT Anecteric sclerae pinkish palpebral conjuctivae slightly yellowish buccal mucosa w white plaque on the L erythematous tonsil not enlarge and no exudates noted

Neck no lympadenopathyCL ECE harsh breath sounds no

rales no wheeze

CVS DHS NRRR no murmurAbdomen globular NABS flabby

nontender no hepatomegaly no mass palpated

GUT (-)KPSExtremities no bipedal edema

strong pulsesCNS WNL

ADMITTING IMPRESSIONS

TC COLONIC CANCER HPN LEUKOPLAKIA

COURSE IN THE WARD

DAY 1 (Upon admission)- Diet low fat low salt- labs requested- Venoclysis started KVO- meds given1 Olmesartan (Olmetec) 40mg 1 tab OD2 Verapamil (Isoptin) 40mg 1 tab OD3 Hexetidine (Bactidol) gargle solution TID

PC meals4 Esomeprazole (Nexium) 40 mg 1 tab OD- referred to gastroentologist for consult- referred to cardiologist for CP clearance

PHYSICAL EXAMINATIONS

Conscious anxious NIRD

VS BP=14090 PR=71bpm RR=25cpm

T=365C Wt=79kg

SKIN Fair no lesions

HEENT Anecteric sclerae pinkish palpebral conjuctivae slightly yellowish buccal mucosa w white plaque on the L erythematous tonsil not enlarge and no exudates noted

Neck no lympadenopathyCL ECE harsh breath sounds no

rales no wheeze

CVS DHS NRRR no murmurAbdomen globular NABS flabby

nontender no hepatomegaly no mass palpated

GUT (-)KPSExtremities no bipedal edema

strong pulsesCNS WNL

ADMITTING IMPRESSIONS

TC COLONIC CANCER HPN LEUKOPLAKIA

COURSE IN THE WARD

DAY 1 (Upon admission)- Diet low fat low salt- labs requested- Venoclysis started KVO- meds given1 Olmesartan (Olmetec) 40mg 1 tab OD2 Verapamil (Isoptin) 40mg 1 tab OD3 Hexetidine (Bactidol) gargle solution TID

PC meals4 Esomeprazole (Nexium) 40 mg 1 tab OD- referred to gastroentologist for consult- referred to cardiologist for CP clearance

HEENT Anecteric sclerae pinkish palpebral conjuctivae slightly yellowish buccal mucosa w white plaque on the L erythematous tonsil not enlarge and no exudates noted

Neck no lympadenopathyCL ECE harsh breath sounds no

rales no wheeze

CVS DHS NRRR no murmurAbdomen globular NABS flabby

nontender no hepatomegaly no mass palpated

GUT (-)KPSExtremities no bipedal edema

strong pulsesCNS WNL

ADMITTING IMPRESSIONS

TC COLONIC CANCER HPN LEUKOPLAKIA

COURSE IN THE WARD

DAY 1 (Upon admission)- Diet low fat low salt- labs requested- Venoclysis started KVO- meds given1 Olmesartan (Olmetec) 40mg 1 tab OD2 Verapamil (Isoptin) 40mg 1 tab OD3 Hexetidine (Bactidol) gargle solution TID

PC meals4 Esomeprazole (Nexium) 40 mg 1 tab OD- referred to gastroentologist for consult- referred to cardiologist for CP clearance

CVS DHS NRRR no murmurAbdomen globular NABS flabby

nontender no hepatomegaly no mass palpated

GUT (-)KPSExtremities no bipedal edema

strong pulsesCNS WNL

ADMITTING IMPRESSIONS

TC COLONIC CANCER HPN LEUKOPLAKIA

COURSE IN THE WARD

DAY 1 (Upon admission)- Diet low fat low salt- labs requested- Venoclysis started KVO- meds given1 Olmesartan (Olmetec) 40mg 1 tab OD2 Verapamil (Isoptin) 40mg 1 tab OD3 Hexetidine (Bactidol) gargle solution TID

PC meals4 Esomeprazole (Nexium) 40 mg 1 tab OD- referred to gastroentologist for consult- referred to cardiologist for CP clearance

ADMITTING IMPRESSIONS

TC COLONIC CANCER HPN LEUKOPLAKIA

COURSE IN THE WARD

DAY 1 (Upon admission)- Diet low fat low salt- labs requested- Venoclysis started KVO- meds given1 Olmesartan (Olmetec) 40mg 1 tab OD2 Verapamil (Isoptin) 40mg 1 tab OD3 Hexetidine (Bactidol) gargle solution TID

PC meals4 Esomeprazole (Nexium) 40 mg 1 tab OD- referred to gastroentologist for consult- referred to cardiologist for CP clearance

COURSE IN THE WARD

DAY 1 (Upon admission)- Diet low fat low salt- labs requested- Venoclysis started KVO- meds given1 Olmesartan (Olmetec) 40mg 1 tab OD2 Verapamil (Isoptin) 40mg 1 tab OD3 Hexetidine (Bactidol) gargle solution TID

PC meals4 Esomeprazole (Nexium) 40 mg 1 tab OD- referred to gastroentologist for consult- referred to cardiologist for CP clearance

DAY 2

VS BP= 11080-12080 mmHg T=36-366 0C RR= 18-19 cpm

PR= 72-82 bpmNo complaintsCt scan of the whole abdomen plain amp contrast was requestedCP-cleared

DAY 3VS BP = 11080-13080 mmHg

T = 36-365 0C RR = 19-20 cpm

PR = 72-82 bpm

Complaint of hematocheziaExternal hemorrhoids was inflamedCT-scan of whole abdomen was rescheduledMeds given1 Policresulin + Cinchocaine (Faktu) ointment 20g apply to rectal area every after BMHot sitz bath BID

Day 4VS BP = 12070-150100 mmHg

T = 36-368 0C RR = 19-20 cpm

PR = 72-80 bpm CT-scan of the whole abdomen donePatient was anxiousStill with blood streak stool IVF was discontinuedFlavonoid + Hisperidin (Daflon) 500mg 1 tab BID

DAY 3VS BP = 11080-13080 mmHg

T = 36-365 0C RR = 19-20 cpm

PR = 72-82 bpm

Complaint of hematocheziaExternal hemorrhoids was inflamedCT-scan of whole abdomen was rescheduledMeds given1 Policresulin + Cinchocaine (Faktu) ointment 20g apply to rectal area every after BMHot sitz bath BID

Day 4VS BP = 12070-150100 mmHg

T = 36-368 0C RR = 19-20 cpm

PR = 72-80 bpm CT-scan of the whole abdomen donePatient was anxiousStill with blood streak stool IVF was discontinuedFlavonoid + Hisperidin (Daflon) 500mg 1 tab BID

Day 4VS BP = 12070-150100 mmHg

T = 36-368 0C RR = 19-20 cpm

PR = 72-80 bpm CT-scan of the whole abdomen donePatient was anxiousStill with blood streak stool IVF was discontinuedFlavonoid + Hisperidin (Daflon) 500mg 1 tab BID

Day 5

VS BP = 12070-13090 mmHg T = 362-366 0C RR = 18-19 cpm

PR = 73-78 bpmNo complaintHigh fiber diet givenGastro consultsMeds continuously given

Day 6Patient discharged with the ff meds

1Olmesartan (Olmetec) 40mg 1 tab OD2 Verapamil (Isoptin) 40mg 1 tab OD3 Policresulin + Cinchocaine (Faktu)

ointment 20g apply to rectal area every after BM

4 Flavonoid + Hisperidin (Daflon) 500mg 1 tab BID Patient was advised to ff-up

FINAL DIAGNOSIS

Colonic Adenocarcinoma ndash well differentiatedDiverticulosis ndash ascending colon (Cecum)Lower Gastro-intestinal bleeding secondary to External hemorrhoidsHypertensive Cardiovascular DiseaseSP Polypectomy (121708)SP Cholecystectomy (2004)

DISCUSSIONS

Cancer includes various types of malignant neoplasms caused by abnormal or uncontrolled cell growth

Overall incidence

bull In 2007

1444920 new cases of invasive cancer diagnosed

ndash 1048707 Men 766860 cases

ndash 1048707 Women 678060 cases

559650 deaths cancer

ndash 1048707 Men 289550

ndash 1048707 Women 270100

Cancer incidence has been decreasing by about 2 each year since 1992

bull Race

Incidence varies among racial and ethnic groups

The basis for these differences is unclear

Incidence by type

Men

Prostate 33

Lung and bronchus 13

Colon and rectum 10

Bladder 7

Women

Breast 32

Lung and bronchus 12

Colon and rectum 11

Endometrium 6Ovary 3

Cancer of the large bowel is second only to lung cancer as a cause of cancer death in the United States Colorectal cancer generally occurs in individuals gt50 yearsMost colorectal cancers regardless of etiology arise from adenomatous polyps A polyp is a grossly visible protrusion from the mucosal surface and may be classified pathologically as

1 Juvenile polyp ndash nonneoplastic hamartoma 2 Hyperplastic polyp - hyperplastic mucosal

proliferation 3 Adenomatous polyp

Only adenomas are clearly premalignant and only a minority of such lesions ever develop into cancer

Population-screening studies and autopsy surveys have revealed that adenomatous polyps may be found in the colons of gt30 of middle-aged or elderly people (lt1 become malignant)

Most polyps produce no symptoms and remain clinically undetected

Occult blood in the stool may be found in lt5 of patients with such lesions

Etiology

Exact mechanisms are not fully understood and are largely dependent on the underlying cancer

2 cardinal features of cancer

1 Abnormal or uncontrolled cell growth carcinogenesis is the process that transforms a normal cell to a cancer cell - Involves genetic alterations leading to alterations in DNA affecting cell- Genetic change can occur in a variety of genes- Point mutation in the K-ras protooncogenes mutation in p53 tumor supressor gene allelic loss of supressor gene in chromosome 17q amp 18q

2 Tissue invasion and metastasis

Clinically the probability of an adenomatous polyp becoming a cancer depends on the gross appearance of the lesion its histologic features and its size Adenomatous polyps may be pedunculated (stalked) or sessile (flat-based) Cancers develop more frequently in sessile polyps Histologically adenomatous polyps may be tubular villous (ie papillary) or tubulovillous Villous adenomas most of which are sessile become malignant gt3x as often as tubular adenomas

The likelihood that any polypoid lesion in the large bowel contains invasive cancer is related to the size of the polyp

lt15 cm =lt2 in lesions negligible 15 to 25 cm = intermediate 2-10 in lesions gt25 cm = substantial (10) in lesions

Risk Factors

Carcinogens exposure

Race

Hereditary

Consumption of animal fat or high fat diet

Low fiber diet

Ingestion of animal fats leads to an increased proportion of anaerobes in the gut microflora resulting in the conversion of normal bile acids into carcinogens

Mortality from colorectal cancer is directly correlated with per capita consumption of calories meat protein and dietary fat and oil as well as elevations in the serum cholesterol concentration and mortality from coronary artery disease

Dietary fiber accelerates intestinal transit time thereby reducing the exposure of colonic mucosa to potential carcinogens and diluting these carcinogens because of enhanced fecal bulk

A diet low in fiber may lead to chronic constipation and diverticulosis

Diagnostic Approach bull The diagnosis of cancer relies most heavily on

invasive tissue biopsy and should never be made without obtaining tissue Define extent of disease and prognosis

Staging

Clinical staging physical examination radiographs isotopic scans CT and other imaging procedures Pathologic staging histologic examination of all tissues removed during a surgical procedure The most widely used system of staging is the TNM system

Classification

Codified by the International Union Against Cancer and the American Joint Committee on Cancer

Categorizes tumors on the basis of

Size of the primary tumorlesion Presence of nodal involvement Presence of metastatic disease

Other anatomic staging systems for some tumors

- Dukes classification for colorectal cancer

Treatment ApproachInitial steps

bull Create a treatment plan Determine whether treatment approach should be curative or palliative Use standard treatment protocols or ongoing clinical research protocols

Treatment is specific to the type of cancer as well as stage bull Treatment options

1 Surgery 2 Radiation3 Chemotherapy4 Biological therapy

Manage disease and treatment complications Assess response to treatment

Assess the physiologic reserve of the patient Age

Karnofsky performance status (lt70 indicates poor prognosis)

1048707 100 Normal no complaints no evidence of disease 1048707 90 Able to carry on normal activity minor signs and symptoms of disease 1048707 80 Normal activity with effort some signs and symptoms of disease 1048707 70 Cares for self unable to carry on normal activity or do active work 1048707 60 Requires occasional assistance but is able to care for most of needs 1048707 50 Requires considerable assistance and frequent medical care 1048707 40 Disabled requires special care and assistance 1048707 30 Severely disabled hospitalization is indicated although death is not imminent 1048707 20 Very sick hospitalization necessary active supportive treatment is necessary 1048707 10 Moribund fatal processes progressing rapidly 1048707 0 Dead

Monitoring

bull Assess response to treatment Careful physical examination Periodic imaging studies

If imaging studies have become normal repeat biopsy of previously involved tissue to document complete response by pathologic criteria

Biopsies are not usually required if there is macroscopic residual disease Exceptions include testicular cancer where residual mass may be benign teratoma and Hodgkinrsquos disease where residual mass may be scar

Tumor markers

Carcinoembryonic antigen adenocarcinoma of the colon pancreas lung breast ovary CA 19-9 colon pancreatic breast cancer

bull At completion of treatment

If patient is free of disease follow regularly for disease recurrence If patient is not free of disease consider salvage therapy

Response Evaluation Criteria in Solid Tumors (RECIST) Criteria

Complete response disappearance of all evidence of disease

Partial response 30 decrease in the sums of the longest diameters

Progressive disease 20 or greater increase in the sums of the longest diameters

Stable disease change that does not meet any of these criteria

Pain

25ndash50 of patients present with pain at diagnosis 33 have pain associated with treatment 75 have pain with progressive disease

Nausea

Acute emesis most common occurs with 24 hours of treatment Delayed emesis occurs within 1ndash7 days after treatment Anticipatory emesis occurs before the delivery of chemotherapy

Effusions

1048707 Symptomatic effusions in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor 1048707 Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy ge6 months

Maintain quality of life by treating

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

FINAL DIAGNOSIS

Colonic Adenocarcinoma ndash well differentiatedDiverticulosis ndash ascending colon (Cecum)Lower Gastro-intestinal bleeding secondary to External hemorrhoidsHypertensive Cardiovascular DiseaseSP Polypectomy (121708)SP Cholecystectomy (2004)

DISCUSSIONS

Cancer includes various types of malignant neoplasms caused by abnormal or uncontrolled cell growth

Overall incidence

bull In 2007

1444920 new cases of invasive cancer diagnosed

ndash 1048707 Men 766860 cases

ndash 1048707 Women 678060 cases

559650 deaths cancer

ndash 1048707 Men 289550

ndash 1048707 Women 270100

Cancer incidence has been decreasing by about 2 each year since 1992

bull Race

Incidence varies among racial and ethnic groups

The basis for these differences is unclear

Incidence by type

Men

Prostate 33

Lung and bronchus 13

Colon and rectum 10

Bladder 7

Women

Breast 32

Lung and bronchus 12

Colon and rectum 11

Endometrium 6Ovary 3

Cancer of the large bowel is second only to lung cancer as a cause of cancer death in the United States Colorectal cancer generally occurs in individuals gt50 yearsMost colorectal cancers regardless of etiology arise from adenomatous polyps A polyp is a grossly visible protrusion from the mucosal surface and may be classified pathologically as

1 Juvenile polyp ndash nonneoplastic hamartoma 2 Hyperplastic polyp - hyperplastic mucosal

proliferation 3 Adenomatous polyp

Only adenomas are clearly premalignant and only a minority of such lesions ever develop into cancer

Population-screening studies and autopsy surveys have revealed that adenomatous polyps may be found in the colons of gt30 of middle-aged or elderly people (lt1 become malignant)

Most polyps produce no symptoms and remain clinically undetected

Occult blood in the stool may be found in lt5 of patients with such lesions

Etiology

Exact mechanisms are not fully understood and are largely dependent on the underlying cancer

2 cardinal features of cancer

1 Abnormal or uncontrolled cell growth carcinogenesis is the process that transforms a normal cell to a cancer cell - Involves genetic alterations leading to alterations in DNA affecting cell- Genetic change can occur in a variety of genes- Point mutation in the K-ras protooncogenes mutation in p53 tumor supressor gene allelic loss of supressor gene in chromosome 17q amp 18q

2 Tissue invasion and metastasis

Clinically the probability of an adenomatous polyp becoming a cancer depends on the gross appearance of the lesion its histologic features and its size Adenomatous polyps may be pedunculated (stalked) or sessile (flat-based) Cancers develop more frequently in sessile polyps Histologically adenomatous polyps may be tubular villous (ie papillary) or tubulovillous Villous adenomas most of which are sessile become malignant gt3x as often as tubular adenomas

The likelihood that any polypoid lesion in the large bowel contains invasive cancer is related to the size of the polyp

lt15 cm =lt2 in lesions negligible 15 to 25 cm = intermediate 2-10 in lesions gt25 cm = substantial (10) in lesions

Risk Factors

Carcinogens exposure

Race

Hereditary

Consumption of animal fat or high fat diet

Low fiber diet

Ingestion of animal fats leads to an increased proportion of anaerobes in the gut microflora resulting in the conversion of normal bile acids into carcinogens

Mortality from colorectal cancer is directly correlated with per capita consumption of calories meat protein and dietary fat and oil as well as elevations in the serum cholesterol concentration and mortality from coronary artery disease

Dietary fiber accelerates intestinal transit time thereby reducing the exposure of colonic mucosa to potential carcinogens and diluting these carcinogens because of enhanced fecal bulk

A diet low in fiber may lead to chronic constipation and diverticulosis

Diagnostic Approach bull The diagnosis of cancer relies most heavily on

invasive tissue biopsy and should never be made without obtaining tissue Define extent of disease and prognosis

Staging

Clinical staging physical examination radiographs isotopic scans CT and other imaging procedures Pathologic staging histologic examination of all tissues removed during a surgical procedure The most widely used system of staging is the TNM system

Classification

Codified by the International Union Against Cancer and the American Joint Committee on Cancer

Categorizes tumors on the basis of

Size of the primary tumorlesion Presence of nodal involvement Presence of metastatic disease

Other anatomic staging systems for some tumors

- Dukes classification for colorectal cancer

Treatment ApproachInitial steps

bull Create a treatment plan Determine whether treatment approach should be curative or palliative Use standard treatment protocols or ongoing clinical research protocols

Treatment is specific to the type of cancer as well as stage bull Treatment options

1 Surgery 2 Radiation3 Chemotherapy4 Biological therapy

Manage disease and treatment complications Assess response to treatment

Assess the physiologic reserve of the patient Age

Karnofsky performance status (lt70 indicates poor prognosis)

1048707 100 Normal no complaints no evidence of disease 1048707 90 Able to carry on normal activity minor signs and symptoms of disease 1048707 80 Normal activity with effort some signs and symptoms of disease 1048707 70 Cares for self unable to carry on normal activity or do active work 1048707 60 Requires occasional assistance but is able to care for most of needs 1048707 50 Requires considerable assistance and frequent medical care 1048707 40 Disabled requires special care and assistance 1048707 30 Severely disabled hospitalization is indicated although death is not imminent 1048707 20 Very sick hospitalization necessary active supportive treatment is necessary 1048707 10 Moribund fatal processes progressing rapidly 1048707 0 Dead

Monitoring

bull Assess response to treatment Careful physical examination Periodic imaging studies

If imaging studies have become normal repeat biopsy of previously involved tissue to document complete response by pathologic criteria

Biopsies are not usually required if there is macroscopic residual disease Exceptions include testicular cancer where residual mass may be benign teratoma and Hodgkinrsquos disease where residual mass may be scar

Tumor markers

Carcinoembryonic antigen adenocarcinoma of the colon pancreas lung breast ovary CA 19-9 colon pancreatic breast cancer

bull At completion of treatment

If patient is free of disease follow regularly for disease recurrence If patient is not free of disease consider salvage therapy

Response Evaluation Criteria in Solid Tumors (RECIST) Criteria

Complete response disappearance of all evidence of disease

Partial response 30 decrease in the sums of the longest diameters

Progressive disease 20 or greater increase in the sums of the longest diameters

Stable disease change that does not meet any of these criteria

Pain

25ndash50 of patients present with pain at diagnosis 33 have pain associated with treatment 75 have pain with progressive disease

Nausea

Acute emesis most common occurs with 24 hours of treatment Delayed emesis occurs within 1ndash7 days after treatment Anticipatory emesis occurs before the delivery of chemotherapy

Effusions

1048707 Symptomatic effusions in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor 1048707 Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy ge6 months

Maintain quality of life by treating

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

DISCUSSIONS

Cancer includes various types of malignant neoplasms caused by abnormal or uncontrolled cell growth

Overall incidence

bull In 2007

1444920 new cases of invasive cancer diagnosed

ndash 1048707 Men 766860 cases

ndash 1048707 Women 678060 cases

559650 deaths cancer

ndash 1048707 Men 289550

ndash 1048707 Women 270100

Cancer incidence has been decreasing by about 2 each year since 1992

bull Race

Incidence varies among racial and ethnic groups

The basis for these differences is unclear

Incidence by type

Men

Prostate 33

Lung and bronchus 13

Colon and rectum 10

Bladder 7

Women

Breast 32

Lung and bronchus 12

Colon and rectum 11

Endometrium 6Ovary 3

Cancer of the large bowel is second only to lung cancer as a cause of cancer death in the United States Colorectal cancer generally occurs in individuals gt50 yearsMost colorectal cancers regardless of etiology arise from adenomatous polyps A polyp is a grossly visible protrusion from the mucosal surface and may be classified pathologically as

1 Juvenile polyp ndash nonneoplastic hamartoma 2 Hyperplastic polyp - hyperplastic mucosal

proliferation 3 Adenomatous polyp

Only adenomas are clearly premalignant and only a minority of such lesions ever develop into cancer

Population-screening studies and autopsy surveys have revealed that adenomatous polyps may be found in the colons of gt30 of middle-aged or elderly people (lt1 become malignant)

Most polyps produce no symptoms and remain clinically undetected

Occult blood in the stool may be found in lt5 of patients with such lesions

Etiology

Exact mechanisms are not fully understood and are largely dependent on the underlying cancer

2 cardinal features of cancer

1 Abnormal or uncontrolled cell growth carcinogenesis is the process that transforms a normal cell to a cancer cell - Involves genetic alterations leading to alterations in DNA affecting cell- Genetic change can occur in a variety of genes- Point mutation in the K-ras protooncogenes mutation in p53 tumor supressor gene allelic loss of supressor gene in chromosome 17q amp 18q

2 Tissue invasion and metastasis

Clinically the probability of an adenomatous polyp becoming a cancer depends on the gross appearance of the lesion its histologic features and its size Adenomatous polyps may be pedunculated (stalked) or sessile (flat-based) Cancers develop more frequently in sessile polyps Histologically adenomatous polyps may be tubular villous (ie papillary) or tubulovillous Villous adenomas most of which are sessile become malignant gt3x as often as tubular adenomas

The likelihood that any polypoid lesion in the large bowel contains invasive cancer is related to the size of the polyp

lt15 cm =lt2 in lesions negligible 15 to 25 cm = intermediate 2-10 in lesions gt25 cm = substantial (10) in lesions

Risk Factors

Carcinogens exposure

Race

Hereditary

Consumption of animal fat or high fat diet

Low fiber diet

Ingestion of animal fats leads to an increased proportion of anaerobes in the gut microflora resulting in the conversion of normal bile acids into carcinogens

Mortality from colorectal cancer is directly correlated with per capita consumption of calories meat protein and dietary fat and oil as well as elevations in the serum cholesterol concentration and mortality from coronary artery disease

Dietary fiber accelerates intestinal transit time thereby reducing the exposure of colonic mucosa to potential carcinogens and diluting these carcinogens because of enhanced fecal bulk

A diet low in fiber may lead to chronic constipation and diverticulosis

Diagnostic Approach bull The diagnosis of cancer relies most heavily on

invasive tissue biopsy and should never be made without obtaining tissue Define extent of disease and prognosis

Staging

Clinical staging physical examination radiographs isotopic scans CT and other imaging procedures Pathologic staging histologic examination of all tissues removed during a surgical procedure The most widely used system of staging is the TNM system

Classification

Codified by the International Union Against Cancer and the American Joint Committee on Cancer

Categorizes tumors on the basis of

Size of the primary tumorlesion Presence of nodal involvement Presence of metastatic disease

Other anatomic staging systems for some tumors

- Dukes classification for colorectal cancer

Treatment ApproachInitial steps

bull Create a treatment plan Determine whether treatment approach should be curative or palliative Use standard treatment protocols or ongoing clinical research protocols

Treatment is specific to the type of cancer as well as stage bull Treatment options

1 Surgery 2 Radiation3 Chemotherapy4 Biological therapy

Manage disease and treatment complications Assess response to treatment

Assess the physiologic reserve of the patient Age

Karnofsky performance status (lt70 indicates poor prognosis)

1048707 100 Normal no complaints no evidence of disease 1048707 90 Able to carry on normal activity minor signs and symptoms of disease 1048707 80 Normal activity with effort some signs and symptoms of disease 1048707 70 Cares for self unable to carry on normal activity or do active work 1048707 60 Requires occasional assistance but is able to care for most of needs 1048707 50 Requires considerable assistance and frequent medical care 1048707 40 Disabled requires special care and assistance 1048707 30 Severely disabled hospitalization is indicated although death is not imminent 1048707 20 Very sick hospitalization necessary active supportive treatment is necessary 1048707 10 Moribund fatal processes progressing rapidly 1048707 0 Dead

Monitoring

bull Assess response to treatment Careful physical examination Periodic imaging studies

If imaging studies have become normal repeat biopsy of previously involved tissue to document complete response by pathologic criteria

Biopsies are not usually required if there is macroscopic residual disease Exceptions include testicular cancer where residual mass may be benign teratoma and Hodgkinrsquos disease where residual mass may be scar

Tumor markers

Carcinoembryonic antigen adenocarcinoma of the colon pancreas lung breast ovary CA 19-9 colon pancreatic breast cancer

bull At completion of treatment

If patient is free of disease follow regularly for disease recurrence If patient is not free of disease consider salvage therapy

Response Evaluation Criteria in Solid Tumors (RECIST) Criteria

Complete response disappearance of all evidence of disease

Partial response 30 decrease in the sums of the longest diameters

Progressive disease 20 or greater increase in the sums of the longest diameters

Stable disease change that does not meet any of these criteria

Pain

25ndash50 of patients present with pain at diagnosis 33 have pain associated with treatment 75 have pain with progressive disease

Nausea

Acute emesis most common occurs with 24 hours of treatment Delayed emesis occurs within 1ndash7 days after treatment Anticipatory emesis occurs before the delivery of chemotherapy

Effusions

1048707 Symptomatic effusions in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor 1048707 Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy ge6 months

Maintain quality of life by treating

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Cancer incidence has been decreasing by about 2 each year since 1992

bull Race

Incidence varies among racial and ethnic groups

The basis for these differences is unclear

Incidence by type

Men

Prostate 33

Lung and bronchus 13

Colon and rectum 10

Bladder 7

Women

Breast 32

Lung and bronchus 12

Colon and rectum 11

Endometrium 6Ovary 3

Cancer of the large bowel is second only to lung cancer as a cause of cancer death in the United States Colorectal cancer generally occurs in individuals gt50 yearsMost colorectal cancers regardless of etiology arise from adenomatous polyps A polyp is a grossly visible protrusion from the mucosal surface and may be classified pathologically as

1 Juvenile polyp ndash nonneoplastic hamartoma 2 Hyperplastic polyp - hyperplastic mucosal

proliferation 3 Adenomatous polyp

Only adenomas are clearly premalignant and only a minority of such lesions ever develop into cancer

Population-screening studies and autopsy surveys have revealed that adenomatous polyps may be found in the colons of gt30 of middle-aged or elderly people (lt1 become malignant)

Most polyps produce no symptoms and remain clinically undetected

Occult blood in the stool may be found in lt5 of patients with such lesions

Etiology

Exact mechanisms are not fully understood and are largely dependent on the underlying cancer

2 cardinal features of cancer

1 Abnormal or uncontrolled cell growth carcinogenesis is the process that transforms a normal cell to a cancer cell - Involves genetic alterations leading to alterations in DNA affecting cell- Genetic change can occur in a variety of genes- Point mutation in the K-ras protooncogenes mutation in p53 tumor supressor gene allelic loss of supressor gene in chromosome 17q amp 18q

2 Tissue invasion and metastasis

Clinically the probability of an adenomatous polyp becoming a cancer depends on the gross appearance of the lesion its histologic features and its size Adenomatous polyps may be pedunculated (stalked) or sessile (flat-based) Cancers develop more frequently in sessile polyps Histologically adenomatous polyps may be tubular villous (ie papillary) or tubulovillous Villous adenomas most of which are sessile become malignant gt3x as often as tubular adenomas

The likelihood that any polypoid lesion in the large bowel contains invasive cancer is related to the size of the polyp

lt15 cm =lt2 in lesions negligible 15 to 25 cm = intermediate 2-10 in lesions gt25 cm = substantial (10) in lesions

Risk Factors

Carcinogens exposure

Race

Hereditary

Consumption of animal fat or high fat diet

Low fiber diet

Ingestion of animal fats leads to an increased proportion of anaerobes in the gut microflora resulting in the conversion of normal bile acids into carcinogens

Mortality from colorectal cancer is directly correlated with per capita consumption of calories meat protein and dietary fat and oil as well as elevations in the serum cholesterol concentration and mortality from coronary artery disease

Dietary fiber accelerates intestinal transit time thereby reducing the exposure of colonic mucosa to potential carcinogens and diluting these carcinogens because of enhanced fecal bulk

A diet low in fiber may lead to chronic constipation and diverticulosis

Diagnostic Approach bull The diagnosis of cancer relies most heavily on

invasive tissue biopsy and should never be made without obtaining tissue Define extent of disease and prognosis

Staging

Clinical staging physical examination radiographs isotopic scans CT and other imaging procedures Pathologic staging histologic examination of all tissues removed during a surgical procedure The most widely used system of staging is the TNM system

Classification

Codified by the International Union Against Cancer and the American Joint Committee on Cancer

Categorizes tumors on the basis of

Size of the primary tumorlesion Presence of nodal involvement Presence of metastatic disease

Other anatomic staging systems for some tumors

- Dukes classification for colorectal cancer

Treatment ApproachInitial steps

bull Create a treatment plan Determine whether treatment approach should be curative or palliative Use standard treatment protocols or ongoing clinical research protocols

Treatment is specific to the type of cancer as well as stage bull Treatment options

1 Surgery 2 Radiation3 Chemotherapy4 Biological therapy

Manage disease and treatment complications Assess response to treatment

Assess the physiologic reserve of the patient Age

Karnofsky performance status (lt70 indicates poor prognosis)

1048707 100 Normal no complaints no evidence of disease 1048707 90 Able to carry on normal activity minor signs and symptoms of disease 1048707 80 Normal activity with effort some signs and symptoms of disease 1048707 70 Cares for self unable to carry on normal activity or do active work 1048707 60 Requires occasional assistance but is able to care for most of needs 1048707 50 Requires considerable assistance and frequent medical care 1048707 40 Disabled requires special care and assistance 1048707 30 Severely disabled hospitalization is indicated although death is not imminent 1048707 20 Very sick hospitalization necessary active supportive treatment is necessary 1048707 10 Moribund fatal processes progressing rapidly 1048707 0 Dead

Monitoring

bull Assess response to treatment Careful physical examination Periodic imaging studies

If imaging studies have become normal repeat biopsy of previously involved tissue to document complete response by pathologic criteria

Biopsies are not usually required if there is macroscopic residual disease Exceptions include testicular cancer where residual mass may be benign teratoma and Hodgkinrsquos disease where residual mass may be scar

Tumor markers

Carcinoembryonic antigen adenocarcinoma of the colon pancreas lung breast ovary CA 19-9 colon pancreatic breast cancer

bull At completion of treatment

If patient is free of disease follow regularly for disease recurrence If patient is not free of disease consider salvage therapy

Response Evaluation Criteria in Solid Tumors (RECIST) Criteria

Complete response disappearance of all evidence of disease

Partial response 30 decrease in the sums of the longest diameters

Progressive disease 20 or greater increase in the sums of the longest diameters

Stable disease change that does not meet any of these criteria

Pain

25ndash50 of patients present with pain at diagnosis 33 have pain associated with treatment 75 have pain with progressive disease

Nausea

Acute emesis most common occurs with 24 hours of treatment Delayed emesis occurs within 1ndash7 days after treatment Anticipatory emesis occurs before the delivery of chemotherapy

Effusions

1048707 Symptomatic effusions in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor 1048707 Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy ge6 months

Maintain quality of life by treating

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Incidence by type

Men

Prostate 33

Lung and bronchus 13

Colon and rectum 10

Bladder 7

Women

Breast 32

Lung and bronchus 12

Colon and rectum 11

Endometrium 6Ovary 3

Cancer of the large bowel is second only to lung cancer as a cause of cancer death in the United States Colorectal cancer generally occurs in individuals gt50 yearsMost colorectal cancers regardless of etiology arise from adenomatous polyps A polyp is a grossly visible protrusion from the mucosal surface and may be classified pathologically as

1 Juvenile polyp ndash nonneoplastic hamartoma 2 Hyperplastic polyp - hyperplastic mucosal

proliferation 3 Adenomatous polyp

Only adenomas are clearly premalignant and only a minority of such lesions ever develop into cancer

Population-screening studies and autopsy surveys have revealed that adenomatous polyps may be found in the colons of gt30 of middle-aged or elderly people (lt1 become malignant)

Most polyps produce no symptoms and remain clinically undetected

Occult blood in the stool may be found in lt5 of patients with such lesions

Etiology

Exact mechanisms are not fully understood and are largely dependent on the underlying cancer

2 cardinal features of cancer

1 Abnormal or uncontrolled cell growth carcinogenesis is the process that transforms a normal cell to a cancer cell - Involves genetic alterations leading to alterations in DNA affecting cell- Genetic change can occur in a variety of genes- Point mutation in the K-ras protooncogenes mutation in p53 tumor supressor gene allelic loss of supressor gene in chromosome 17q amp 18q

2 Tissue invasion and metastasis

Clinically the probability of an adenomatous polyp becoming a cancer depends on the gross appearance of the lesion its histologic features and its size Adenomatous polyps may be pedunculated (stalked) or sessile (flat-based) Cancers develop more frequently in sessile polyps Histologically adenomatous polyps may be tubular villous (ie papillary) or tubulovillous Villous adenomas most of which are sessile become malignant gt3x as often as tubular adenomas

The likelihood that any polypoid lesion in the large bowel contains invasive cancer is related to the size of the polyp

lt15 cm =lt2 in lesions negligible 15 to 25 cm = intermediate 2-10 in lesions gt25 cm = substantial (10) in lesions

Risk Factors

Carcinogens exposure

Race

Hereditary

Consumption of animal fat or high fat diet

Low fiber diet

Ingestion of animal fats leads to an increased proportion of anaerobes in the gut microflora resulting in the conversion of normal bile acids into carcinogens

Mortality from colorectal cancer is directly correlated with per capita consumption of calories meat protein and dietary fat and oil as well as elevations in the serum cholesterol concentration and mortality from coronary artery disease

Dietary fiber accelerates intestinal transit time thereby reducing the exposure of colonic mucosa to potential carcinogens and diluting these carcinogens because of enhanced fecal bulk

A diet low in fiber may lead to chronic constipation and diverticulosis

Diagnostic Approach bull The diagnosis of cancer relies most heavily on

invasive tissue biopsy and should never be made without obtaining tissue Define extent of disease and prognosis

Staging

Clinical staging physical examination radiographs isotopic scans CT and other imaging procedures Pathologic staging histologic examination of all tissues removed during a surgical procedure The most widely used system of staging is the TNM system

Classification

Codified by the International Union Against Cancer and the American Joint Committee on Cancer

Categorizes tumors on the basis of

Size of the primary tumorlesion Presence of nodal involvement Presence of metastatic disease

Other anatomic staging systems for some tumors

- Dukes classification for colorectal cancer

Treatment ApproachInitial steps

bull Create a treatment plan Determine whether treatment approach should be curative or palliative Use standard treatment protocols or ongoing clinical research protocols

Treatment is specific to the type of cancer as well as stage bull Treatment options

1 Surgery 2 Radiation3 Chemotherapy4 Biological therapy

Manage disease and treatment complications Assess response to treatment

Assess the physiologic reserve of the patient Age

Karnofsky performance status (lt70 indicates poor prognosis)

1048707 100 Normal no complaints no evidence of disease 1048707 90 Able to carry on normal activity minor signs and symptoms of disease 1048707 80 Normal activity with effort some signs and symptoms of disease 1048707 70 Cares for self unable to carry on normal activity or do active work 1048707 60 Requires occasional assistance but is able to care for most of needs 1048707 50 Requires considerable assistance and frequent medical care 1048707 40 Disabled requires special care and assistance 1048707 30 Severely disabled hospitalization is indicated although death is not imminent 1048707 20 Very sick hospitalization necessary active supportive treatment is necessary 1048707 10 Moribund fatal processes progressing rapidly 1048707 0 Dead

Monitoring

bull Assess response to treatment Careful physical examination Periodic imaging studies

If imaging studies have become normal repeat biopsy of previously involved tissue to document complete response by pathologic criteria

Biopsies are not usually required if there is macroscopic residual disease Exceptions include testicular cancer where residual mass may be benign teratoma and Hodgkinrsquos disease where residual mass may be scar

Tumor markers

Carcinoembryonic antigen adenocarcinoma of the colon pancreas lung breast ovary CA 19-9 colon pancreatic breast cancer

bull At completion of treatment

If patient is free of disease follow regularly for disease recurrence If patient is not free of disease consider salvage therapy

Response Evaluation Criteria in Solid Tumors (RECIST) Criteria

Complete response disappearance of all evidence of disease

Partial response 30 decrease in the sums of the longest diameters

Progressive disease 20 or greater increase in the sums of the longest diameters

Stable disease change that does not meet any of these criteria

Pain

25ndash50 of patients present with pain at diagnosis 33 have pain associated with treatment 75 have pain with progressive disease

Nausea

Acute emesis most common occurs with 24 hours of treatment Delayed emesis occurs within 1ndash7 days after treatment Anticipatory emesis occurs before the delivery of chemotherapy

Effusions

1048707 Symptomatic effusions in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor 1048707 Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy ge6 months

Maintain quality of life by treating

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Cancer of the large bowel is second only to lung cancer as a cause of cancer death in the United States Colorectal cancer generally occurs in individuals gt50 yearsMost colorectal cancers regardless of etiology arise from adenomatous polyps A polyp is a grossly visible protrusion from the mucosal surface and may be classified pathologically as

1 Juvenile polyp ndash nonneoplastic hamartoma 2 Hyperplastic polyp - hyperplastic mucosal

proliferation 3 Adenomatous polyp

Only adenomas are clearly premalignant and only a minority of such lesions ever develop into cancer

Population-screening studies and autopsy surveys have revealed that adenomatous polyps may be found in the colons of gt30 of middle-aged or elderly people (lt1 become malignant)

Most polyps produce no symptoms and remain clinically undetected

Occult blood in the stool may be found in lt5 of patients with such lesions

Etiology

Exact mechanisms are not fully understood and are largely dependent on the underlying cancer

2 cardinal features of cancer

1 Abnormal or uncontrolled cell growth carcinogenesis is the process that transforms a normal cell to a cancer cell - Involves genetic alterations leading to alterations in DNA affecting cell- Genetic change can occur in a variety of genes- Point mutation in the K-ras protooncogenes mutation in p53 tumor supressor gene allelic loss of supressor gene in chromosome 17q amp 18q

2 Tissue invasion and metastasis

Clinically the probability of an adenomatous polyp becoming a cancer depends on the gross appearance of the lesion its histologic features and its size Adenomatous polyps may be pedunculated (stalked) or sessile (flat-based) Cancers develop more frequently in sessile polyps Histologically adenomatous polyps may be tubular villous (ie papillary) or tubulovillous Villous adenomas most of which are sessile become malignant gt3x as often as tubular adenomas

The likelihood that any polypoid lesion in the large bowel contains invasive cancer is related to the size of the polyp

lt15 cm =lt2 in lesions negligible 15 to 25 cm = intermediate 2-10 in lesions gt25 cm = substantial (10) in lesions

Risk Factors

Carcinogens exposure

Race

Hereditary

Consumption of animal fat or high fat diet

Low fiber diet

Ingestion of animal fats leads to an increased proportion of anaerobes in the gut microflora resulting in the conversion of normal bile acids into carcinogens

Mortality from colorectal cancer is directly correlated with per capita consumption of calories meat protein and dietary fat and oil as well as elevations in the serum cholesterol concentration and mortality from coronary artery disease

Dietary fiber accelerates intestinal transit time thereby reducing the exposure of colonic mucosa to potential carcinogens and diluting these carcinogens because of enhanced fecal bulk

A diet low in fiber may lead to chronic constipation and diverticulosis

Diagnostic Approach bull The diagnosis of cancer relies most heavily on

invasive tissue biopsy and should never be made without obtaining tissue Define extent of disease and prognosis

Staging

Clinical staging physical examination radiographs isotopic scans CT and other imaging procedures Pathologic staging histologic examination of all tissues removed during a surgical procedure The most widely used system of staging is the TNM system

Classification

Codified by the International Union Against Cancer and the American Joint Committee on Cancer

Categorizes tumors on the basis of

Size of the primary tumorlesion Presence of nodal involvement Presence of metastatic disease

Other anatomic staging systems for some tumors

- Dukes classification for colorectal cancer

Treatment ApproachInitial steps

bull Create a treatment plan Determine whether treatment approach should be curative or palliative Use standard treatment protocols or ongoing clinical research protocols

Treatment is specific to the type of cancer as well as stage bull Treatment options

1 Surgery 2 Radiation3 Chemotherapy4 Biological therapy

Manage disease and treatment complications Assess response to treatment

Assess the physiologic reserve of the patient Age

Karnofsky performance status (lt70 indicates poor prognosis)

1048707 100 Normal no complaints no evidence of disease 1048707 90 Able to carry on normal activity minor signs and symptoms of disease 1048707 80 Normal activity with effort some signs and symptoms of disease 1048707 70 Cares for self unable to carry on normal activity or do active work 1048707 60 Requires occasional assistance but is able to care for most of needs 1048707 50 Requires considerable assistance and frequent medical care 1048707 40 Disabled requires special care and assistance 1048707 30 Severely disabled hospitalization is indicated although death is not imminent 1048707 20 Very sick hospitalization necessary active supportive treatment is necessary 1048707 10 Moribund fatal processes progressing rapidly 1048707 0 Dead

Monitoring

bull Assess response to treatment Careful physical examination Periodic imaging studies

If imaging studies have become normal repeat biopsy of previously involved tissue to document complete response by pathologic criteria

Biopsies are not usually required if there is macroscopic residual disease Exceptions include testicular cancer where residual mass may be benign teratoma and Hodgkinrsquos disease where residual mass may be scar

Tumor markers

Carcinoembryonic antigen adenocarcinoma of the colon pancreas lung breast ovary CA 19-9 colon pancreatic breast cancer

bull At completion of treatment

If patient is free of disease follow regularly for disease recurrence If patient is not free of disease consider salvage therapy

Response Evaluation Criteria in Solid Tumors (RECIST) Criteria

Complete response disappearance of all evidence of disease

Partial response 30 decrease in the sums of the longest diameters

Progressive disease 20 or greater increase in the sums of the longest diameters

Stable disease change that does not meet any of these criteria

Pain

25ndash50 of patients present with pain at diagnosis 33 have pain associated with treatment 75 have pain with progressive disease

Nausea

Acute emesis most common occurs with 24 hours of treatment Delayed emesis occurs within 1ndash7 days after treatment Anticipatory emesis occurs before the delivery of chemotherapy

Effusions

1048707 Symptomatic effusions in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor 1048707 Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy ge6 months

Maintain quality of life by treating

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Only adenomas are clearly premalignant and only a minority of such lesions ever develop into cancer

Population-screening studies and autopsy surveys have revealed that adenomatous polyps may be found in the colons of gt30 of middle-aged or elderly people (lt1 become malignant)

Most polyps produce no symptoms and remain clinically undetected

Occult blood in the stool may be found in lt5 of patients with such lesions

Etiology

Exact mechanisms are not fully understood and are largely dependent on the underlying cancer

2 cardinal features of cancer

1 Abnormal or uncontrolled cell growth carcinogenesis is the process that transforms a normal cell to a cancer cell - Involves genetic alterations leading to alterations in DNA affecting cell- Genetic change can occur in a variety of genes- Point mutation in the K-ras protooncogenes mutation in p53 tumor supressor gene allelic loss of supressor gene in chromosome 17q amp 18q

2 Tissue invasion and metastasis

Clinically the probability of an adenomatous polyp becoming a cancer depends on the gross appearance of the lesion its histologic features and its size Adenomatous polyps may be pedunculated (stalked) or sessile (flat-based) Cancers develop more frequently in sessile polyps Histologically adenomatous polyps may be tubular villous (ie papillary) or tubulovillous Villous adenomas most of which are sessile become malignant gt3x as often as tubular adenomas

The likelihood that any polypoid lesion in the large bowel contains invasive cancer is related to the size of the polyp

lt15 cm =lt2 in lesions negligible 15 to 25 cm = intermediate 2-10 in lesions gt25 cm = substantial (10) in lesions

Risk Factors

Carcinogens exposure

Race

Hereditary

Consumption of animal fat or high fat diet

Low fiber diet

Ingestion of animal fats leads to an increased proportion of anaerobes in the gut microflora resulting in the conversion of normal bile acids into carcinogens

Mortality from colorectal cancer is directly correlated with per capita consumption of calories meat protein and dietary fat and oil as well as elevations in the serum cholesterol concentration and mortality from coronary artery disease

Dietary fiber accelerates intestinal transit time thereby reducing the exposure of colonic mucosa to potential carcinogens and diluting these carcinogens because of enhanced fecal bulk

A diet low in fiber may lead to chronic constipation and diverticulosis

Diagnostic Approach bull The diagnosis of cancer relies most heavily on

invasive tissue biopsy and should never be made without obtaining tissue Define extent of disease and prognosis

Staging

Clinical staging physical examination radiographs isotopic scans CT and other imaging procedures Pathologic staging histologic examination of all tissues removed during a surgical procedure The most widely used system of staging is the TNM system

Classification

Codified by the International Union Against Cancer and the American Joint Committee on Cancer

Categorizes tumors on the basis of

Size of the primary tumorlesion Presence of nodal involvement Presence of metastatic disease

Other anatomic staging systems for some tumors

- Dukes classification for colorectal cancer

Treatment ApproachInitial steps

bull Create a treatment plan Determine whether treatment approach should be curative or palliative Use standard treatment protocols or ongoing clinical research protocols

Treatment is specific to the type of cancer as well as stage bull Treatment options

1 Surgery 2 Radiation3 Chemotherapy4 Biological therapy

Manage disease and treatment complications Assess response to treatment

Assess the physiologic reserve of the patient Age

Karnofsky performance status (lt70 indicates poor prognosis)

1048707 100 Normal no complaints no evidence of disease 1048707 90 Able to carry on normal activity minor signs and symptoms of disease 1048707 80 Normal activity with effort some signs and symptoms of disease 1048707 70 Cares for self unable to carry on normal activity or do active work 1048707 60 Requires occasional assistance but is able to care for most of needs 1048707 50 Requires considerable assistance and frequent medical care 1048707 40 Disabled requires special care and assistance 1048707 30 Severely disabled hospitalization is indicated although death is not imminent 1048707 20 Very sick hospitalization necessary active supportive treatment is necessary 1048707 10 Moribund fatal processes progressing rapidly 1048707 0 Dead

Monitoring

bull Assess response to treatment Careful physical examination Periodic imaging studies

If imaging studies have become normal repeat biopsy of previously involved tissue to document complete response by pathologic criteria

Biopsies are not usually required if there is macroscopic residual disease Exceptions include testicular cancer where residual mass may be benign teratoma and Hodgkinrsquos disease where residual mass may be scar

Tumor markers

Carcinoembryonic antigen adenocarcinoma of the colon pancreas lung breast ovary CA 19-9 colon pancreatic breast cancer

bull At completion of treatment

If patient is free of disease follow regularly for disease recurrence If patient is not free of disease consider salvage therapy

Response Evaluation Criteria in Solid Tumors (RECIST) Criteria

Complete response disappearance of all evidence of disease

Partial response 30 decrease in the sums of the longest diameters

Progressive disease 20 or greater increase in the sums of the longest diameters

Stable disease change that does not meet any of these criteria

Pain

25ndash50 of patients present with pain at diagnosis 33 have pain associated with treatment 75 have pain with progressive disease

Nausea

Acute emesis most common occurs with 24 hours of treatment Delayed emesis occurs within 1ndash7 days after treatment Anticipatory emesis occurs before the delivery of chemotherapy

Effusions

1048707 Symptomatic effusions in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor 1048707 Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy ge6 months

Maintain quality of life by treating

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Etiology

Exact mechanisms are not fully understood and are largely dependent on the underlying cancer

2 cardinal features of cancer

1 Abnormal or uncontrolled cell growth carcinogenesis is the process that transforms a normal cell to a cancer cell - Involves genetic alterations leading to alterations in DNA affecting cell- Genetic change can occur in a variety of genes- Point mutation in the K-ras protooncogenes mutation in p53 tumor supressor gene allelic loss of supressor gene in chromosome 17q amp 18q

2 Tissue invasion and metastasis

Clinically the probability of an adenomatous polyp becoming a cancer depends on the gross appearance of the lesion its histologic features and its size Adenomatous polyps may be pedunculated (stalked) or sessile (flat-based) Cancers develop more frequently in sessile polyps Histologically adenomatous polyps may be tubular villous (ie papillary) or tubulovillous Villous adenomas most of which are sessile become malignant gt3x as often as tubular adenomas

The likelihood that any polypoid lesion in the large bowel contains invasive cancer is related to the size of the polyp

lt15 cm =lt2 in lesions negligible 15 to 25 cm = intermediate 2-10 in lesions gt25 cm = substantial (10) in lesions

Risk Factors

Carcinogens exposure

Race

Hereditary

Consumption of animal fat or high fat diet

Low fiber diet

Ingestion of animal fats leads to an increased proportion of anaerobes in the gut microflora resulting in the conversion of normal bile acids into carcinogens

Mortality from colorectal cancer is directly correlated with per capita consumption of calories meat protein and dietary fat and oil as well as elevations in the serum cholesterol concentration and mortality from coronary artery disease

Dietary fiber accelerates intestinal transit time thereby reducing the exposure of colonic mucosa to potential carcinogens and diluting these carcinogens because of enhanced fecal bulk

A diet low in fiber may lead to chronic constipation and diverticulosis

Diagnostic Approach bull The diagnosis of cancer relies most heavily on

invasive tissue biopsy and should never be made without obtaining tissue Define extent of disease and prognosis

Staging

Clinical staging physical examination radiographs isotopic scans CT and other imaging procedures Pathologic staging histologic examination of all tissues removed during a surgical procedure The most widely used system of staging is the TNM system

Classification

Codified by the International Union Against Cancer and the American Joint Committee on Cancer

Categorizes tumors on the basis of

Size of the primary tumorlesion Presence of nodal involvement Presence of metastatic disease

Other anatomic staging systems for some tumors

- Dukes classification for colorectal cancer

Treatment ApproachInitial steps

bull Create a treatment plan Determine whether treatment approach should be curative or palliative Use standard treatment protocols or ongoing clinical research protocols

Treatment is specific to the type of cancer as well as stage bull Treatment options

1 Surgery 2 Radiation3 Chemotherapy4 Biological therapy

Manage disease and treatment complications Assess response to treatment

Assess the physiologic reserve of the patient Age

Karnofsky performance status (lt70 indicates poor prognosis)

1048707 100 Normal no complaints no evidence of disease 1048707 90 Able to carry on normal activity minor signs and symptoms of disease 1048707 80 Normal activity with effort some signs and symptoms of disease 1048707 70 Cares for self unable to carry on normal activity or do active work 1048707 60 Requires occasional assistance but is able to care for most of needs 1048707 50 Requires considerable assistance and frequent medical care 1048707 40 Disabled requires special care and assistance 1048707 30 Severely disabled hospitalization is indicated although death is not imminent 1048707 20 Very sick hospitalization necessary active supportive treatment is necessary 1048707 10 Moribund fatal processes progressing rapidly 1048707 0 Dead

Monitoring

bull Assess response to treatment Careful physical examination Periodic imaging studies

If imaging studies have become normal repeat biopsy of previously involved tissue to document complete response by pathologic criteria

Biopsies are not usually required if there is macroscopic residual disease Exceptions include testicular cancer where residual mass may be benign teratoma and Hodgkinrsquos disease where residual mass may be scar

Tumor markers

Carcinoembryonic antigen adenocarcinoma of the colon pancreas lung breast ovary CA 19-9 colon pancreatic breast cancer

bull At completion of treatment

If patient is free of disease follow regularly for disease recurrence If patient is not free of disease consider salvage therapy

Response Evaluation Criteria in Solid Tumors (RECIST) Criteria

Complete response disappearance of all evidence of disease

Partial response 30 decrease in the sums of the longest diameters

Progressive disease 20 or greater increase in the sums of the longest diameters

Stable disease change that does not meet any of these criteria

Pain

25ndash50 of patients present with pain at diagnosis 33 have pain associated with treatment 75 have pain with progressive disease

Nausea

Acute emesis most common occurs with 24 hours of treatment Delayed emesis occurs within 1ndash7 days after treatment Anticipatory emesis occurs before the delivery of chemotherapy

Effusions

1048707 Symptomatic effusions in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor 1048707 Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy ge6 months

Maintain quality of life by treating

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Clinically the probability of an adenomatous polyp becoming a cancer depends on the gross appearance of the lesion its histologic features and its size Adenomatous polyps may be pedunculated (stalked) or sessile (flat-based) Cancers develop more frequently in sessile polyps Histologically adenomatous polyps may be tubular villous (ie papillary) or tubulovillous Villous adenomas most of which are sessile become malignant gt3x as often as tubular adenomas

The likelihood that any polypoid lesion in the large bowel contains invasive cancer is related to the size of the polyp

lt15 cm =lt2 in lesions negligible 15 to 25 cm = intermediate 2-10 in lesions gt25 cm = substantial (10) in lesions

Risk Factors

Carcinogens exposure

Race

Hereditary

Consumption of animal fat or high fat diet

Low fiber diet

Ingestion of animal fats leads to an increased proportion of anaerobes in the gut microflora resulting in the conversion of normal bile acids into carcinogens

Mortality from colorectal cancer is directly correlated with per capita consumption of calories meat protein and dietary fat and oil as well as elevations in the serum cholesterol concentration and mortality from coronary artery disease

Dietary fiber accelerates intestinal transit time thereby reducing the exposure of colonic mucosa to potential carcinogens and diluting these carcinogens because of enhanced fecal bulk

A diet low in fiber may lead to chronic constipation and diverticulosis

Diagnostic Approach bull The diagnosis of cancer relies most heavily on

invasive tissue biopsy and should never be made without obtaining tissue Define extent of disease and prognosis

Staging

Clinical staging physical examination radiographs isotopic scans CT and other imaging procedures Pathologic staging histologic examination of all tissues removed during a surgical procedure The most widely used system of staging is the TNM system

Classification

Codified by the International Union Against Cancer and the American Joint Committee on Cancer

Categorizes tumors on the basis of

Size of the primary tumorlesion Presence of nodal involvement Presence of metastatic disease

Other anatomic staging systems for some tumors

- Dukes classification for colorectal cancer

Treatment ApproachInitial steps

bull Create a treatment plan Determine whether treatment approach should be curative or palliative Use standard treatment protocols or ongoing clinical research protocols

Treatment is specific to the type of cancer as well as stage bull Treatment options

1 Surgery 2 Radiation3 Chemotherapy4 Biological therapy

Manage disease and treatment complications Assess response to treatment

Assess the physiologic reserve of the patient Age

Karnofsky performance status (lt70 indicates poor prognosis)

1048707 100 Normal no complaints no evidence of disease 1048707 90 Able to carry on normal activity minor signs and symptoms of disease 1048707 80 Normal activity with effort some signs and symptoms of disease 1048707 70 Cares for self unable to carry on normal activity or do active work 1048707 60 Requires occasional assistance but is able to care for most of needs 1048707 50 Requires considerable assistance and frequent medical care 1048707 40 Disabled requires special care and assistance 1048707 30 Severely disabled hospitalization is indicated although death is not imminent 1048707 20 Very sick hospitalization necessary active supportive treatment is necessary 1048707 10 Moribund fatal processes progressing rapidly 1048707 0 Dead

Monitoring

bull Assess response to treatment Careful physical examination Periodic imaging studies

If imaging studies have become normal repeat biopsy of previously involved tissue to document complete response by pathologic criteria

Biopsies are not usually required if there is macroscopic residual disease Exceptions include testicular cancer where residual mass may be benign teratoma and Hodgkinrsquos disease where residual mass may be scar

Tumor markers

Carcinoembryonic antigen adenocarcinoma of the colon pancreas lung breast ovary CA 19-9 colon pancreatic breast cancer

bull At completion of treatment

If patient is free of disease follow regularly for disease recurrence If patient is not free of disease consider salvage therapy

Response Evaluation Criteria in Solid Tumors (RECIST) Criteria

Complete response disappearance of all evidence of disease

Partial response 30 decrease in the sums of the longest diameters

Progressive disease 20 or greater increase in the sums of the longest diameters

Stable disease change that does not meet any of these criteria

Pain

25ndash50 of patients present with pain at diagnosis 33 have pain associated with treatment 75 have pain with progressive disease

Nausea

Acute emesis most common occurs with 24 hours of treatment Delayed emesis occurs within 1ndash7 days after treatment Anticipatory emesis occurs before the delivery of chemotherapy

Effusions

1048707 Symptomatic effusions in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor 1048707 Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy ge6 months

Maintain quality of life by treating

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Risk Factors

Carcinogens exposure

Race

Hereditary

Consumption of animal fat or high fat diet

Low fiber diet

Ingestion of animal fats leads to an increased proportion of anaerobes in the gut microflora resulting in the conversion of normal bile acids into carcinogens

Mortality from colorectal cancer is directly correlated with per capita consumption of calories meat protein and dietary fat and oil as well as elevations in the serum cholesterol concentration and mortality from coronary artery disease

Dietary fiber accelerates intestinal transit time thereby reducing the exposure of colonic mucosa to potential carcinogens and diluting these carcinogens because of enhanced fecal bulk

A diet low in fiber may lead to chronic constipation and diverticulosis

Diagnostic Approach bull The diagnosis of cancer relies most heavily on

invasive tissue biopsy and should never be made without obtaining tissue Define extent of disease and prognosis

Staging

Clinical staging physical examination radiographs isotopic scans CT and other imaging procedures Pathologic staging histologic examination of all tissues removed during a surgical procedure The most widely used system of staging is the TNM system

Classification

Codified by the International Union Against Cancer and the American Joint Committee on Cancer

Categorizes tumors on the basis of

Size of the primary tumorlesion Presence of nodal involvement Presence of metastatic disease

Other anatomic staging systems for some tumors

- Dukes classification for colorectal cancer

Treatment ApproachInitial steps

bull Create a treatment plan Determine whether treatment approach should be curative or palliative Use standard treatment protocols or ongoing clinical research protocols

Treatment is specific to the type of cancer as well as stage bull Treatment options

1 Surgery 2 Radiation3 Chemotherapy4 Biological therapy

Manage disease and treatment complications Assess response to treatment

Assess the physiologic reserve of the patient Age

Karnofsky performance status (lt70 indicates poor prognosis)

1048707 100 Normal no complaints no evidence of disease 1048707 90 Able to carry on normal activity minor signs and symptoms of disease 1048707 80 Normal activity with effort some signs and symptoms of disease 1048707 70 Cares for self unable to carry on normal activity or do active work 1048707 60 Requires occasional assistance but is able to care for most of needs 1048707 50 Requires considerable assistance and frequent medical care 1048707 40 Disabled requires special care and assistance 1048707 30 Severely disabled hospitalization is indicated although death is not imminent 1048707 20 Very sick hospitalization necessary active supportive treatment is necessary 1048707 10 Moribund fatal processes progressing rapidly 1048707 0 Dead

Monitoring

bull Assess response to treatment Careful physical examination Periodic imaging studies

If imaging studies have become normal repeat biopsy of previously involved tissue to document complete response by pathologic criteria

Biopsies are not usually required if there is macroscopic residual disease Exceptions include testicular cancer where residual mass may be benign teratoma and Hodgkinrsquos disease where residual mass may be scar

Tumor markers

Carcinoembryonic antigen adenocarcinoma of the colon pancreas lung breast ovary CA 19-9 colon pancreatic breast cancer

bull At completion of treatment

If patient is free of disease follow regularly for disease recurrence If patient is not free of disease consider salvage therapy

Response Evaluation Criteria in Solid Tumors (RECIST) Criteria

Complete response disappearance of all evidence of disease

Partial response 30 decrease in the sums of the longest diameters

Progressive disease 20 or greater increase in the sums of the longest diameters

Stable disease change that does not meet any of these criteria

Pain

25ndash50 of patients present with pain at diagnosis 33 have pain associated with treatment 75 have pain with progressive disease

Nausea

Acute emesis most common occurs with 24 hours of treatment Delayed emesis occurs within 1ndash7 days after treatment Anticipatory emesis occurs before the delivery of chemotherapy

Effusions

1048707 Symptomatic effusions in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor 1048707 Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy ge6 months

Maintain quality of life by treating

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Ingestion of animal fats leads to an increased proportion of anaerobes in the gut microflora resulting in the conversion of normal bile acids into carcinogens

Mortality from colorectal cancer is directly correlated with per capita consumption of calories meat protein and dietary fat and oil as well as elevations in the serum cholesterol concentration and mortality from coronary artery disease

Dietary fiber accelerates intestinal transit time thereby reducing the exposure of colonic mucosa to potential carcinogens and diluting these carcinogens because of enhanced fecal bulk

A diet low in fiber may lead to chronic constipation and diverticulosis

Diagnostic Approach bull The diagnosis of cancer relies most heavily on

invasive tissue biopsy and should never be made without obtaining tissue Define extent of disease and prognosis

Staging

Clinical staging physical examination radiographs isotopic scans CT and other imaging procedures Pathologic staging histologic examination of all tissues removed during a surgical procedure The most widely used system of staging is the TNM system

Classification

Codified by the International Union Against Cancer and the American Joint Committee on Cancer

Categorizes tumors on the basis of

Size of the primary tumorlesion Presence of nodal involvement Presence of metastatic disease

Other anatomic staging systems for some tumors

- Dukes classification for colorectal cancer

Treatment ApproachInitial steps

bull Create a treatment plan Determine whether treatment approach should be curative or palliative Use standard treatment protocols or ongoing clinical research protocols

Treatment is specific to the type of cancer as well as stage bull Treatment options

1 Surgery 2 Radiation3 Chemotherapy4 Biological therapy

Manage disease and treatment complications Assess response to treatment

Assess the physiologic reserve of the patient Age

Karnofsky performance status (lt70 indicates poor prognosis)

1048707 100 Normal no complaints no evidence of disease 1048707 90 Able to carry on normal activity minor signs and symptoms of disease 1048707 80 Normal activity with effort some signs and symptoms of disease 1048707 70 Cares for self unable to carry on normal activity or do active work 1048707 60 Requires occasional assistance but is able to care for most of needs 1048707 50 Requires considerable assistance and frequent medical care 1048707 40 Disabled requires special care and assistance 1048707 30 Severely disabled hospitalization is indicated although death is not imminent 1048707 20 Very sick hospitalization necessary active supportive treatment is necessary 1048707 10 Moribund fatal processes progressing rapidly 1048707 0 Dead

Monitoring

bull Assess response to treatment Careful physical examination Periodic imaging studies

If imaging studies have become normal repeat biopsy of previously involved tissue to document complete response by pathologic criteria

Biopsies are not usually required if there is macroscopic residual disease Exceptions include testicular cancer where residual mass may be benign teratoma and Hodgkinrsquos disease where residual mass may be scar

Tumor markers

Carcinoembryonic antigen adenocarcinoma of the colon pancreas lung breast ovary CA 19-9 colon pancreatic breast cancer

bull At completion of treatment

If patient is free of disease follow regularly for disease recurrence If patient is not free of disease consider salvage therapy

Response Evaluation Criteria in Solid Tumors (RECIST) Criteria

Complete response disappearance of all evidence of disease

Partial response 30 decrease in the sums of the longest diameters

Progressive disease 20 or greater increase in the sums of the longest diameters

Stable disease change that does not meet any of these criteria

Pain

25ndash50 of patients present with pain at diagnosis 33 have pain associated with treatment 75 have pain with progressive disease

Nausea

Acute emesis most common occurs with 24 hours of treatment Delayed emesis occurs within 1ndash7 days after treatment Anticipatory emesis occurs before the delivery of chemotherapy

Effusions

1048707 Symptomatic effusions in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor 1048707 Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy ge6 months

Maintain quality of life by treating

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Dietary fiber accelerates intestinal transit time thereby reducing the exposure of colonic mucosa to potential carcinogens and diluting these carcinogens because of enhanced fecal bulk

A diet low in fiber may lead to chronic constipation and diverticulosis

Diagnostic Approach bull The diagnosis of cancer relies most heavily on

invasive tissue biopsy and should never be made without obtaining tissue Define extent of disease and prognosis

Staging

Clinical staging physical examination radiographs isotopic scans CT and other imaging procedures Pathologic staging histologic examination of all tissues removed during a surgical procedure The most widely used system of staging is the TNM system

Classification

Codified by the International Union Against Cancer and the American Joint Committee on Cancer

Categorizes tumors on the basis of

Size of the primary tumorlesion Presence of nodal involvement Presence of metastatic disease

Other anatomic staging systems for some tumors

- Dukes classification for colorectal cancer

Treatment ApproachInitial steps

bull Create a treatment plan Determine whether treatment approach should be curative or palliative Use standard treatment protocols or ongoing clinical research protocols

Treatment is specific to the type of cancer as well as stage bull Treatment options

1 Surgery 2 Radiation3 Chemotherapy4 Biological therapy

Manage disease and treatment complications Assess response to treatment

Assess the physiologic reserve of the patient Age

Karnofsky performance status (lt70 indicates poor prognosis)

1048707 100 Normal no complaints no evidence of disease 1048707 90 Able to carry on normal activity minor signs and symptoms of disease 1048707 80 Normal activity with effort some signs and symptoms of disease 1048707 70 Cares for self unable to carry on normal activity or do active work 1048707 60 Requires occasional assistance but is able to care for most of needs 1048707 50 Requires considerable assistance and frequent medical care 1048707 40 Disabled requires special care and assistance 1048707 30 Severely disabled hospitalization is indicated although death is not imminent 1048707 20 Very sick hospitalization necessary active supportive treatment is necessary 1048707 10 Moribund fatal processes progressing rapidly 1048707 0 Dead

Monitoring

bull Assess response to treatment Careful physical examination Periodic imaging studies

If imaging studies have become normal repeat biopsy of previously involved tissue to document complete response by pathologic criteria

Biopsies are not usually required if there is macroscopic residual disease Exceptions include testicular cancer where residual mass may be benign teratoma and Hodgkinrsquos disease where residual mass may be scar

Tumor markers

Carcinoembryonic antigen adenocarcinoma of the colon pancreas lung breast ovary CA 19-9 colon pancreatic breast cancer

bull At completion of treatment

If patient is free of disease follow regularly for disease recurrence If patient is not free of disease consider salvage therapy

Response Evaluation Criteria in Solid Tumors (RECIST) Criteria

Complete response disappearance of all evidence of disease

Partial response 30 decrease in the sums of the longest diameters

Progressive disease 20 or greater increase in the sums of the longest diameters

Stable disease change that does not meet any of these criteria

Pain

25ndash50 of patients present with pain at diagnosis 33 have pain associated with treatment 75 have pain with progressive disease

Nausea

Acute emesis most common occurs with 24 hours of treatment Delayed emesis occurs within 1ndash7 days after treatment Anticipatory emesis occurs before the delivery of chemotherapy

Effusions

1048707 Symptomatic effusions in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor 1048707 Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy ge6 months

Maintain quality of life by treating

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Diagnostic Approach bull The diagnosis of cancer relies most heavily on

invasive tissue biopsy and should never be made without obtaining tissue Define extent of disease and prognosis

Staging

Clinical staging physical examination radiographs isotopic scans CT and other imaging procedures Pathologic staging histologic examination of all tissues removed during a surgical procedure The most widely used system of staging is the TNM system

Classification

Codified by the International Union Against Cancer and the American Joint Committee on Cancer

Categorizes tumors on the basis of

Size of the primary tumorlesion Presence of nodal involvement Presence of metastatic disease

Other anatomic staging systems for some tumors

- Dukes classification for colorectal cancer

Treatment ApproachInitial steps

bull Create a treatment plan Determine whether treatment approach should be curative or palliative Use standard treatment protocols or ongoing clinical research protocols

Treatment is specific to the type of cancer as well as stage bull Treatment options

1 Surgery 2 Radiation3 Chemotherapy4 Biological therapy

Manage disease and treatment complications Assess response to treatment

Assess the physiologic reserve of the patient Age

Karnofsky performance status (lt70 indicates poor prognosis)

1048707 100 Normal no complaints no evidence of disease 1048707 90 Able to carry on normal activity minor signs and symptoms of disease 1048707 80 Normal activity with effort some signs and symptoms of disease 1048707 70 Cares for self unable to carry on normal activity or do active work 1048707 60 Requires occasional assistance but is able to care for most of needs 1048707 50 Requires considerable assistance and frequent medical care 1048707 40 Disabled requires special care and assistance 1048707 30 Severely disabled hospitalization is indicated although death is not imminent 1048707 20 Very sick hospitalization necessary active supportive treatment is necessary 1048707 10 Moribund fatal processes progressing rapidly 1048707 0 Dead

Monitoring

bull Assess response to treatment Careful physical examination Periodic imaging studies

If imaging studies have become normal repeat biopsy of previously involved tissue to document complete response by pathologic criteria

Biopsies are not usually required if there is macroscopic residual disease Exceptions include testicular cancer where residual mass may be benign teratoma and Hodgkinrsquos disease where residual mass may be scar

Tumor markers

Carcinoembryonic antigen adenocarcinoma of the colon pancreas lung breast ovary CA 19-9 colon pancreatic breast cancer

bull At completion of treatment

If patient is free of disease follow regularly for disease recurrence If patient is not free of disease consider salvage therapy

Response Evaluation Criteria in Solid Tumors (RECIST) Criteria

Complete response disappearance of all evidence of disease

Partial response 30 decrease in the sums of the longest diameters

Progressive disease 20 or greater increase in the sums of the longest diameters

Stable disease change that does not meet any of these criteria

Pain

25ndash50 of patients present with pain at diagnosis 33 have pain associated with treatment 75 have pain with progressive disease

Nausea

Acute emesis most common occurs with 24 hours of treatment Delayed emesis occurs within 1ndash7 days after treatment Anticipatory emesis occurs before the delivery of chemotherapy

Effusions

1048707 Symptomatic effusions in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor 1048707 Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy ge6 months

Maintain quality of life by treating

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Classification

Codified by the International Union Against Cancer and the American Joint Committee on Cancer

Categorizes tumors on the basis of

Size of the primary tumorlesion Presence of nodal involvement Presence of metastatic disease

Other anatomic staging systems for some tumors

- Dukes classification for colorectal cancer

Treatment ApproachInitial steps

bull Create a treatment plan Determine whether treatment approach should be curative or palliative Use standard treatment protocols or ongoing clinical research protocols

Treatment is specific to the type of cancer as well as stage bull Treatment options

1 Surgery 2 Radiation3 Chemotherapy4 Biological therapy

Manage disease and treatment complications Assess response to treatment

Assess the physiologic reserve of the patient Age

Karnofsky performance status (lt70 indicates poor prognosis)

1048707 100 Normal no complaints no evidence of disease 1048707 90 Able to carry on normal activity minor signs and symptoms of disease 1048707 80 Normal activity with effort some signs and symptoms of disease 1048707 70 Cares for self unable to carry on normal activity or do active work 1048707 60 Requires occasional assistance but is able to care for most of needs 1048707 50 Requires considerable assistance and frequent medical care 1048707 40 Disabled requires special care and assistance 1048707 30 Severely disabled hospitalization is indicated although death is not imminent 1048707 20 Very sick hospitalization necessary active supportive treatment is necessary 1048707 10 Moribund fatal processes progressing rapidly 1048707 0 Dead

Monitoring

bull Assess response to treatment Careful physical examination Periodic imaging studies

If imaging studies have become normal repeat biopsy of previously involved tissue to document complete response by pathologic criteria

Biopsies are not usually required if there is macroscopic residual disease Exceptions include testicular cancer where residual mass may be benign teratoma and Hodgkinrsquos disease where residual mass may be scar

Tumor markers

Carcinoembryonic antigen adenocarcinoma of the colon pancreas lung breast ovary CA 19-9 colon pancreatic breast cancer

bull At completion of treatment

If patient is free of disease follow regularly for disease recurrence If patient is not free of disease consider salvage therapy

Response Evaluation Criteria in Solid Tumors (RECIST) Criteria

Complete response disappearance of all evidence of disease

Partial response 30 decrease in the sums of the longest diameters

Progressive disease 20 or greater increase in the sums of the longest diameters

Stable disease change that does not meet any of these criteria

Pain

25ndash50 of patients present with pain at diagnosis 33 have pain associated with treatment 75 have pain with progressive disease

Nausea

Acute emesis most common occurs with 24 hours of treatment Delayed emesis occurs within 1ndash7 days after treatment Anticipatory emesis occurs before the delivery of chemotherapy

Effusions

1048707 Symptomatic effusions in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor 1048707 Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy ge6 months

Maintain quality of life by treating

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Treatment ApproachInitial steps

bull Create a treatment plan Determine whether treatment approach should be curative or palliative Use standard treatment protocols or ongoing clinical research protocols

Treatment is specific to the type of cancer as well as stage bull Treatment options

1 Surgery 2 Radiation3 Chemotherapy4 Biological therapy

Manage disease and treatment complications Assess response to treatment

Assess the physiologic reserve of the patient Age

Karnofsky performance status (lt70 indicates poor prognosis)

1048707 100 Normal no complaints no evidence of disease 1048707 90 Able to carry on normal activity minor signs and symptoms of disease 1048707 80 Normal activity with effort some signs and symptoms of disease 1048707 70 Cares for self unable to carry on normal activity or do active work 1048707 60 Requires occasional assistance but is able to care for most of needs 1048707 50 Requires considerable assistance and frequent medical care 1048707 40 Disabled requires special care and assistance 1048707 30 Severely disabled hospitalization is indicated although death is not imminent 1048707 20 Very sick hospitalization necessary active supportive treatment is necessary 1048707 10 Moribund fatal processes progressing rapidly 1048707 0 Dead

Monitoring

bull Assess response to treatment Careful physical examination Periodic imaging studies

If imaging studies have become normal repeat biopsy of previously involved tissue to document complete response by pathologic criteria

Biopsies are not usually required if there is macroscopic residual disease Exceptions include testicular cancer where residual mass may be benign teratoma and Hodgkinrsquos disease where residual mass may be scar

Tumor markers

Carcinoembryonic antigen adenocarcinoma of the colon pancreas lung breast ovary CA 19-9 colon pancreatic breast cancer

bull At completion of treatment

If patient is free of disease follow regularly for disease recurrence If patient is not free of disease consider salvage therapy

Response Evaluation Criteria in Solid Tumors (RECIST) Criteria

Complete response disappearance of all evidence of disease

Partial response 30 decrease in the sums of the longest diameters

Progressive disease 20 or greater increase in the sums of the longest diameters

Stable disease change that does not meet any of these criteria

Pain

25ndash50 of patients present with pain at diagnosis 33 have pain associated with treatment 75 have pain with progressive disease

Nausea

Acute emesis most common occurs with 24 hours of treatment Delayed emesis occurs within 1ndash7 days after treatment Anticipatory emesis occurs before the delivery of chemotherapy

Effusions

1048707 Symptomatic effusions in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor 1048707 Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy ge6 months

Maintain quality of life by treating

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Assess the physiologic reserve of the patient Age

Karnofsky performance status (lt70 indicates poor prognosis)

1048707 100 Normal no complaints no evidence of disease 1048707 90 Able to carry on normal activity minor signs and symptoms of disease 1048707 80 Normal activity with effort some signs and symptoms of disease 1048707 70 Cares for self unable to carry on normal activity or do active work 1048707 60 Requires occasional assistance but is able to care for most of needs 1048707 50 Requires considerable assistance and frequent medical care 1048707 40 Disabled requires special care and assistance 1048707 30 Severely disabled hospitalization is indicated although death is not imminent 1048707 20 Very sick hospitalization necessary active supportive treatment is necessary 1048707 10 Moribund fatal processes progressing rapidly 1048707 0 Dead

Monitoring

bull Assess response to treatment Careful physical examination Periodic imaging studies

If imaging studies have become normal repeat biopsy of previously involved tissue to document complete response by pathologic criteria

Biopsies are not usually required if there is macroscopic residual disease Exceptions include testicular cancer where residual mass may be benign teratoma and Hodgkinrsquos disease where residual mass may be scar

Tumor markers

Carcinoembryonic antigen adenocarcinoma of the colon pancreas lung breast ovary CA 19-9 colon pancreatic breast cancer

bull At completion of treatment

If patient is free of disease follow regularly for disease recurrence If patient is not free of disease consider salvage therapy

Response Evaluation Criteria in Solid Tumors (RECIST) Criteria

Complete response disappearance of all evidence of disease

Partial response 30 decrease in the sums of the longest diameters

Progressive disease 20 or greater increase in the sums of the longest diameters

Stable disease change that does not meet any of these criteria

Pain

25ndash50 of patients present with pain at diagnosis 33 have pain associated with treatment 75 have pain with progressive disease

Nausea

Acute emesis most common occurs with 24 hours of treatment Delayed emesis occurs within 1ndash7 days after treatment Anticipatory emesis occurs before the delivery of chemotherapy

Effusions

1048707 Symptomatic effusions in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor 1048707 Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy ge6 months

Maintain quality of life by treating

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Monitoring

bull Assess response to treatment Careful physical examination Periodic imaging studies

If imaging studies have become normal repeat biopsy of previously involved tissue to document complete response by pathologic criteria

Biopsies are not usually required if there is macroscopic residual disease Exceptions include testicular cancer where residual mass may be benign teratoma and Hodgkinrsquos disease where residual mass may be scar

Tumor markers

Carcinoembryonic antigen adenocarcinoma of the colon pancreas lung breast ovary CA 19-9 colon pancreatic breast cancer

bull At completion of treatment

If patient is free of disease follow regularly for disease recurrence If patient is not free of disease consider salvage therapy

Response Evaluation Criteria in Solid Tumors (RECIST) Criteria

Complete response disappearance of all evidence of disease

Partial response 30 decrease in the sums of the longest diameters

Progressive disease 20 or greater increase in the sums of the longest diameters

Stable disease change that does not meet any of these criteria

Pain

25ndash50 of patients present with pain at diagnosis 33 have pain associated with treatment 75 have pain with progressive disease

Nausea

Acute emesis most common occurs with 24 hours of treatment Delayed emesis occurs within 1ndash7 days after treatment Anticipatory emesis occurs before the delivery of chemotherapy

Effusions

1048707 Symptomatic effusions in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor 1048707 Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy ge6 months

Maintain quality of life by treating

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Tumor markers

Carcinoembryonic antigen adenocarcinoma of the colon pancreas lung breast ovary CA 19-9 colon pancreatic breast cancer

bull At completion of treatment

If patient is free of disease follow regularly for disease recurrence If patient is not free of disease consider salvage therapy

Response Evaluation Criteria in Solid Tumors (RECIST) Criteria

Complete response disappearance of all evidence of disease

Partial response 30 decrease in the sums of the longest diameters

Progressive disease 20 or greater increase in the sums of the longest diameters

Stable disease change that does not meet any of these criteria

Pain

25ndash50 of patients present with pain at diagnosis 33 have pain associated with treatment 75 have pain with progressive disease

Nausea

Acute emesis most common occurs with 24 hours of treatment Delayed emesis occurs within 1ndash7 days after treatment Anticipatory emesis occurs before the delivery of chemotherapy

Effusions

1048707 Symptomatic effusions in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor 1048707 Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy ge6 months

Maintain quality of life by treating

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Response Evaluation Criteria in Solid Tumors (RECIST) Criteria

Complete response disappearance of all evidence of disease

Partial response 30 decrease in the sums of the longest diameters

Progressive disease 20 or greater increase in the sums of the longest diameters

Stable disease change that does not meet any of these criteria

Pain

25ndash50 of patients present with pain at diagnosis 33 have pain associated with treatment 75 have pain with progressive disease

Nausea

Acute emesis most common occurs with 24 hours of treatment Delayed emesis occurs within 1ndash7 days after treatment Anticipatory emesis occurs before the delivery of chemotherapy

Effusions

1048707 Symptomatic effusions in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor 1048707 Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy ge6 months

Maintain quality of life by treating

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Pain

25ndash50 of patients present with pain at diagnosis 33 have pain associated with treatment 75 have pain with progressive disease

Nausea

Acute emesis most common occurs with 24 hours of treatment Delayed emesis occurs within 1ndash7 days after treatment Anticipatory emesis occurs before the delivery of chemotherapy

Effusions

1048707 Symptomatic effusions in tumors responsive to systemic therapy usually do not require local treatment but respond to the treatment for the underlying tumor 1048707 Symptomatic effusions in tumors unresponsive to systemic therapy may require local treatment in patients with a life expectancy ge6 months

Maintain quality of life by treating

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Nutrition

Use a prognostic nutritional index based on Albumin levels

Triceps skin-fold thickness

Transferrin levels

Delayed-type hypersensitivity skin test

Or use a defined threshold for nutritional intervention

gt10 unexplained body weight loss

Serum transferrin level lt1500 mgL (150 mgdL)

Serum albumin level lt34gL (34 gdL)

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Supportive care

Depression

Serotonin reuptake inhibitor - Fluoxetine (10ndash20 mgd) -

Sertraline (50ndash150 mgd) - Paroxetine (10ndash20 mgd)

Tricyclic antidepressant - Amitriptyline (50ndash100 mgd) -

Desipramine (75ndash150 mgd)

Allow 4ndash6 weeks for response Effective therapy should be continued ge 6 months after resolution of symptoms

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

If therapy is unsuccessful other classes of antidepressants may be used

In addition to medication psychosocial interventions may be of benefit

Support groups

Psychotherapy

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Psychological support for

Depression

Incidence is about 25 overall in patients with cancer

Cosmetic changes

Loss of control over life

Sexual dysfunction

Survivor guilt

Damocles syndrome (fear of relapse)

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Prevention

bull Preventive strategies focus on risk factor modification

Smoking cessation

Diet modification

bull Early detection

o Routine health screening

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Screening Guidelines for Colorectal Cancer

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ave Risk

50 yrs 1 Annual FOBT or

2 Flexible sigmoidoscopy q 5yrs or

3 Both or

4 Air contrast Ba enema q 5yrs or colonoscopy q 10 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Adenomatous Polyps

50 yrs Colonoscopy 1st detection then colonoscopy in 3 yrs If no further polyps colonoscopy q 5 yrs If polyps colonoscopy q 3 yrs Annual colonoscopy for gt5yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Colorectal CA

Diagnosis

Pretreatment colonoscopy then at least q 12mosafter curative resection then colonoscopy after 3 yrs then colonoscopy after 5 yrsif no new lesions

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Ulcerative colitis crohnrsquos colitis

diagnosis then after 8yrs for pancolitis after 15 yrs for L-sided colitis

Colonoscopy w multiple Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

FAP 10-12Yrs Annoul flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Attenuated FAP

20 Yrs Annual flexible sigmoidoscopy upper endoscopy q 1-3yrs after polyps appear

HNPCC 20-25 Yrs

Colonoscopy q 1-2 yrs endometrial aspiration Bx q 1-2 yrs

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

POPrsquoN INITIAL AGE

RECOMMENDATION SCREENING TEST

Familial Colorectal CA 1st degree relative

40 yrs or 10 yrs before the age of the youngest affected relative

Colonoscopy q 5yrs increase freqif multiple family members are affected especially before 50 yrs old

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Prognosis

Current treatment techniques result in cure of gt50 of patients diagnosed with cancer

5-year survival rate for white patients 5-year survival rate for African-American patients bull Basis for variable mortality rate among racial and ethnic groups remains unclear

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

Most common causes of death in patients with cancer

Infection (leading to circulatory failure)

Respiratory failure

Hepatic failure

Renal failure

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically

End-of-life decisions

bull Speak frankly with patient and family about course of disease

bull Determine whether patient would prefer home or hospice care

bull Ask patient for advanced directive and review periodically