Cancer of the Colon and Rectum
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Cancer of the Colon and Rectum







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Cancer of the Colon and Rectum Cancer of the Colon and Rectum Presentation Transcript

  • Colorectal CancerRobert Miller
  • Third Most Common Cancerin Men and Women
  • Odds of Developing Colorectalcancer in the US (2007-9)~ 5%Type Men WomenAny Cancer 45% (1in 2) 38% (1 in 3)Breast 12% (1 in 8)Colorectal 5% (1in 19) 4.8% (1 in 21)Prostate 16% (1in 6)
  • Declining Incidence last 30y
  • Third Most Lethal Cancer inMen and Women
  • Declining Mortality in MenUS Data 1930 to 2009
  • Declining Mortality in WomenUS Data 1930 to 2009
  • Odds of Dying of Colorectalcancer in the US (2007-9) ~ 2%Type Men WomenAny Cancer 23% (1in 4) 19% (1 in 5)Breast 2.8% (1 in 36)Colorectal 2.11% (1in 47) 1.94% (1 in 52)Prostate 2.8% (1in 36)
  • Most patients are diagnosed before they have symptoms because ofscreening or the findings of rectal blood (hematochezia) or anemiaAbdominal pain — 44 percentChange in bowel habit — 43 percentHematochezia or melena — 40 percentWeakness — 20 percentAnemia — 11 percentWeight loss — 6 percentPatients who are symptomatic at diagnosis have a somewhat worseprognosis. In one report, the five-year survival rate for symptomatic (49%)and asymptomatic patients (71%)Symptoms
  • Median Age of Patients withcolon and rectal cancer (2005-2009)Site Male FemaleColon 69y 73yRectum 64y 66y
  • Colon8% less than50yRectum14% less than50yAge Distributionfrom the NCDBfor 2000- 2012
  • ScreeningColonoscopyevery 10 yearsstarting at theage of 50 unlesshigh risk
  • How should family history effect the ageto start screening colonoscopy?First-degree (share one half genes) = parent, child or siblingSecond-degree (share one quarter genes) = grandparents, uncle,niece
  • Workup or Evaluation Prior to Decidingon Treatment for Colon Cancer
  • Pathology Report• Confirm that it is malignant (usually adenocarcinoma)• Information about stage: depth in invasion and lymph nodes involved(look at 12 nodes)• Surgical margins (to ensure complete removal)• Other prognostic risk factors: grade, vascular invasion, perineuralinvasion• Genetic risk factors: MSI (microsatellite instability) testing/ MMR proteinto look for Lynch syndrome• Gene mutation testing: KRAS and BRAF that will determine whether thepatient would benefit from anti EGFR drugs (cetuximab, panitumumab,regorafenib)
  • Workup or Evaluation Prior to Decidingon Treatment for Rectal Cancer
  • T2 T3NodesTransrectal Endoscopic Ultrasound
  • Accuracy of Imaging in StagingRectal CancerSite Ultrasound CT MRITumor 80-95% 65-75% 75-85%Nodes 70-75% 55-65% 60-65%
  • Staging
  • Staging: T (tumor stage)
  • Stage Depth of InvasionT1 submucosaT2 muscularis propriaT3 Pericolorectal tissueT4a Surface of visceral peritoneumT4b Into other organs/structuresStaging: T (tumor stage)
  • Staging: N (lymph node stage)
  • Stage Nodes InvolvedN0 0N1a 1N1b 2, 3N2a 4, 6N2b 7 or moreStaging: N (lymph node stage)
  • Colon Cancer Stage Distribution
  • Rectal Cancer Stage Distribution
  • Treatment of colorectalcancer• Early stages are treated with surgery• More advanced stages have surgery followedby chemotherapy (colon) or radiation andchemotherapy prior to surgery (rectum)• Metastatic or recurrent disease treated withchemotherapy or targeted therapy andpossibly radiation, surgical resection or RFablation
  • Survival in Months Drug Regimen14.8 months bolus 5FU/LV17.4 months Infusional 5FU/LV20.1 months irinotecan (Camptosar) +5FU/LV20.3 months camptosar = 5FU + bevacizumab (Avastin)21.5 months FOLFIRI then FOLFOX25.1 months irinotecan/5FU + avastin +oxaliplatin (Eloxatin)New Drugs for Colorectal Cancer
  • There are now seven different classes of drugs withsignificant antitumor activity:• 5-fluorouracil [5-FU] which is usually given with leucovorin, capecitabine,(Xeloda) tegafur plus uracil• Irinotecan (Camptosar)• Oxaliplatin (Eloxatin)• Cetuximab (Erbitux) and panitumumab (Vectibix), two monoclonalantibodies (MoAbs) directed against the epidermal growth factor receptor(EGFR) if KRAS wild type• Bevacizumab (Avastin), a MoAb targeting vascular endothelial growthfactor (VEGF)• Aflibercept, a recombinant fusion protein consisting of vascularendothelial growth factor (VEGF) binding portions from the human VEGFreceptors 1 and 2 fused to the Fc portion of human immunoglobulin G1,• Regorafenib, a small molecule inhibitor of multiple kinases
  • 30 Year Trends in 5 Year SurvivalSite 1975 2008Colon 51% 65%Rectum 48% 68%
  • Stage and 5 Year SurvivalUS Data 2002- 2008Stage Incidence SurvivalAll 100% 64%Local 39% 90%Regional 36% 70%Distant 20% 12%
  • Survival with Colon Cancer
  • Survival with Rectal Cancer
  • 5 Year Survival from NCDBStage Colon RectumI 77.5% 77.7%II 66.6% 63.2%III 54.5% 58.0%IV 9.6% 9.8%
  • Colorectal CancerRobert Miller