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YOUNG ADULT CRC:
A GLOBAL CHALLENGE
• Rebecca Siegel MPH American Cancer Society
• Deborah Alsina Bowel Cancer UK
• T. Pet...
Increasing colorectal cancer incidence in
young adults in the US
Rebecca Siegel, MPH
Early-onset CRC Summit
March 19, 2016
Among <50 years: 14,200 cases and 3,300 deaths
Estimated numbers of new cases & deaths in 2016
Top 5 cancers, ages 20-49 years
Lung (16%)
Colorectum (13%)
Brain (9%)
Leukemia (7%)
Pancreas (6%)
Breast (27%)
Lung (13%)...
Anatomy of the colorectum
(right-side)
(left-side)
Subsite distribution by sex and age
25%
25%
43%
7%
Male, < 50 yrs
proximal
distal
rectum
other
38%
25%
31%
6%
Male, 50+ yr...
Racial/ethnic distribution by age
66%
15%
12%
5%
2%
77%
12%
7%
3%
1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Non-Hispanic
White...
0
50
100
150
200
250
300
350
400
Rateper100,000
Age at diagnosis
Men
Women
Source: SEER 18 delay-adjusted rates, 2008-2012...
0
10
20
30
40
50
60
70
1975 1980 1985 1990 1995 2000 2005 2010
Rateper100,000
Colorectum, -3% per year
Colon, -3% per year...
The American Surgeon, Oct 2003
SEER 9, 5,383 patients 20-39
1973-1999
Cancer Epidemiol, Biomarkers, &
Prevention, June 200...
Incidence trends by age: 50+ versus 20-49
Source: SEER 9 delay-adjusted rates, 1975-2012; 2-yr moving average.
0
2
4
6
8
1...
Increase is confined to the left side
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
1975-77 1980-82 1985-87 1990-92 1995-97 2000-02 2005...
Proportion of CRC diagnoses in young adults
7%
6%
8%
64%
11%
9%
14%
55%
0% 10% 20% 30% 40% 50% 60% 70%
CRC
Colon
Rectum
Po...
Trends in young adults by stage at diagnosis
Source: SEER 9 delay-adjusted rates, 1975-2012; 3-year moving average.
0
0.5
...
Trends in young adults by race/ethnicity
0
2
4
6
8
10
12
14
Non-Hispanic
white
Colorectum
Colon
Rectum
0
2
4
6
8
10
12
14
...
Trends in young adults by 10-year age group
40-49
1.9% annually since 1994
30-39
2.2% annually since 1988
20-29
3.8% annua...
Timing and magnitude of increase by 10-year age group
1975 1980 1985 1990 1995 2000 2005 2010
Colon
Rectum
Colon
Rectum
Co...
Age-specific trends in CRC from 20-64 years
0.1
1
10
100
1975-77 1980-82 1985-87 1990-92 1995-97 2000-02 2005-07 2010-12
I...
Opposing trends within ages 50-59 years
0
5
10
15
20
25
30
35
40
Rectum
0
10
20
30
40
50
60
70
80
Incidencerateper100,000
...
Increasing risk in successive generations since mid-century
1988 vs 1943 birth cohort:
colon, 3X higher risk
rectum, 4X hi...
CRC testing prevalence by age
Source: National Health Interview Survey.
12
16
33
45
52 53
15
20
43
60
67
65
12
19
44
56
64...
State variation in incidence rates by age
50+ years20-49 years
Stage distribution: early vs. later onset
33%
38%
26%
3%
40%
35%
20%
5%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Localized Re...
Five-year relative survival
Data Sources: Trends, SEER 9 registries, 1975-2011; Stage-specific, SEER 18 registries, 2005-2...
CRC mortality trends
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
1975 1980 1985 1990 1995 2000 2005 2010
Deathsper100,000
20-49 years
...
Strategies for reducing colorectal cancer risk
 Maintain a healthy weight
 Be physically active
 Consume a healthy diet...
Who should begin screening before 50?
High risk Age to begin
Familial adenomatous polyposis (FAP) 10-12 years
Lynch syndro...
Who else should begin screening before 50?
Increased risk Age to begin
Cancer/adenomas in a first-degree
relative
40 years...
Conclusion
CRC incidence rates continue to increase in young adults
ACTION ITEMS
 Early screening when appropriate
 Incr...
Thank you!
Screening test use in ages 40-49 years
0
2
4
6
8
10
12
14
2000 2003 2005 2008 2010 2013
Percent
Ever routine endoscopy
0
2...
Why doesn’t screening begin earlier?
• Increase unknown during previous evidence review (mid 2000s)
• Now in beginning sta...
Harms & limitations of colonoscopy screening
• 33% of patients report at least 1 GI symptom following the
procedure
• Seri...
ACS screening guidelines – average risk
Men and women, ages 50+ Frequency
Fecal occult blood test (FOBT)
with at least 50%...
35-39
30-34
25-29
20-24
0
2
4
6
8
10
12
1978
1981
1984
1987
1990
1993
1996
1999
2002
2005
20-49
Canada
UK
0
20
40
60
80
10...
65 64 65
55
73
77
66
65
45
72
58 58 58
50
66
68
59
56
42
68
6 6 7
5
7
9
7
9
4 4
0
10
20
30
40
50
60
70
80
overall (50-
75)...
Factors that influence population cancer trends
Detection/imaging
practices
Risk factors
Screening behaviors MortalityInci...
Colorectal cancer risk factors: medical and family history
Relative risk
Family history
1 first-degree relative 2.2
More t...
Increase risk: Relative risk Trend
Alcohol consumption (heavy vs.
nondrinkers)
1.6
Obesity 1.2
Red meat consumption 1.2
Pr...
Deborah Alsina
Executive Director
Bowel Cancer UK
Charity of the Year
2013/2014
Young Adult CRC: A Global Challenge
Deborah Alsina
Chief Executive
Bowel Cancer UK
2ND ANNUA...
Charity of the Year
2013/2014
What I am going to talk about:
 Introduction to colorectal cancer in the
UK
 Overview of e...
Charity of the Year
2013/2014
Who we are..
Bowel Cancer UK is determined to
save lives and improve the quality
of life of ...
Charity of the Year
2013/2014
What we do
• We support research
• We educate
• We campaign
• We are determined and ambitious
Charity of the Year
2013/2014
Colorectal cancer in the UK
The UK’s 2nd biggest cancer killer
Over 41,000 diagnosed
and ove...
Routes to diagnosis for under 50s
Screen
Detecte
d
GP
Referra
l
Urgent
GP
Referral
Non-
urgent
Other
Out-
patient
Inpatien...
Never Too Young
Delays in diagnosis
Gender delays
• 54% of men were sent to a specialist after only 1 or 2 GP
visits compared with only 35% of women.
• 15% of...
Solutions: Awareness & education
As of March 2015
Broadcast – 32 million people
Print – 11 million people
Social media ...
Solutions: clinical change
• GPs as gatekeepers – who to refer?
• NICE (England and Wales) and SIGN (Scotland) referral
gu...
Risk Assessment Tool for Colorectal Cancers
High Risk groups
Genetic conditions – e.g. Lynch syndrome, FAP
Campaign led to Royal College of Pathology guidance –
all...
Finding solutions
Partnership between all key
professional bodies
Met Tuesday 15th March to
discuss how to improve the
ide...
Solutions: a guide & films for people
diagnosed under 50
Charity of the Year
2013/2014
I can’t wait to….
... wake up and not have cancer as my first thought
... be able to dye my ...
Charity of the Year
2013/2014
Charity of the Year
2013/2014
Thank you
Deborah Alsina
Deborah.alsina@bowelcanceruk.org.uk
00 44 207 940 1768
@deborahalsi...
Colorectal cancer in Nigeria
T. Peter Kingham MD FACS
Director, Global Cancer Disparity Initiatives
Memorial Sloan Ketteri...
• Cancer in low- and middle-income countries
(LMIC)
• African Research Group for Oncology (ARGO)
• Young patients with col...
Cancer is a growing problem in LMIC
• By 2050 70% of the predicted 24 million
people with cancer will reside in LMIC
– Lif...
Cancer case fatality is high in LMIC
– Ratio of incidence of cancer: mortality rate
annually = 75% in LMIC
(More deaths th...
Tertiary care hospital in Malawi
Gyorki, Archives of Surgery, 2012
Late stage patients
CRC in Nigeria
• Characteristics of CRC among Nigerians
– early age of onset
– aggressive disease pattern
– bulky tumors
–...
Increasing Incidence of CRC
Ilorin, Nigeria
• By 2030, 20 million cancer deaths
worldwide with 2/3 in LMIC
• CRC is the 2n...
Comparison of Nigerian and American patients
Saluja, Surgery, 2013
Stage-matched Survival
North America Stage III
West Africa Stage III
North America Stage IV
West Africa Stage IV
0 2 4 6 8...
Who gets CRC in West Africa?
Prospective data collection
• A multicenter study involving 4 tertiary health facilities in
S...
Nigerian patients present at young age
• Median ages
– Nigeria: 53 years
– USA: 68 years
• % younger than 50
years:
– Nige...
USA
Nigeria
Rectal cancer is most common in
Nigeria
• 65% elective, 35% emergency
Location # Percentage
Left colon 4 2%
Transverse col...
Patients present late in Nigeria
Presenting stage % Nigeria
(n=145)
% USA
(SEER)
I 0% 39%
II 9% 36%
IIIa 27% -
IV 64% 20%
Metastatic pattern is different
Site Nigeria MSKCC
Peritoneal 63% 5%
Liver 60% 48%
Mortality rates in Nigeria are high
• No evidence of disease: 36 (21%)
• Alive with disease: 61 (36%)
• Dead of disease: 6...
No difference in presentation in young
patients
<50 years
N=72
>50 years
N=106
Rectal bleeding 33 (46%) 75 (71%)
Right col...
Is the biology different?
Gene mutations found in Nigerian
(Blue) and MSKCC (Red) patients
How do we identify earlier stage
patients?
Symptoms of patients with rectal
bleeding
Symptoms N=100
-change in stool caliber 48%
-pellet like stool 24%
-None 52%
Wei...
Pts with cancer
N=20
Pts without cancer
N=80
P value
Saw MD for bleeding 16 (80%) 67 (83.8%)
Duration of rectal
bleeding (...
Summary of colonoscopy study
• 20/100 with CRC= 20%
• 16/100 with stage 2,3 Polyps= 21.0%
• Weight loss and pellet like st...
Knowledge regarding rectal bleeding is
mixed
• 82 pts with questionnaire regarding beliefs on
rectal bleeding:
– Hereditar...
Colorectal cancer incidence is rising
• Patients with CRC present at young age in
Nigeria, and most LMIC
• Screening is ab...
Early-Onset Colorectal Cancer in
Australia and Asia
Presented at :
Early Age Onset Colorectal Cancer Summit 2016, New York...
Colorectal Cancer Worldwide
Colorectal Cancer (CRC) in Australia
• CRC – 13.5% if all new cancers in both sexes
17,070 new CRC cases in 2015 (55% male...
Age-specific CRC incidence, 2015
Source: Australian Institute of Health and Welfare
90%10%
2-3%
CRC incidence and mortality, 1968 to 2012
Source: Australian Institute of Health and Welfare
• CRC is increasing in young adults aged <50 years in USA
• CRC screening for early-onset CRC is not justified at a
popula...
Bowel Cancer in Young Adults in Australia
Reports from Australia/NZ
• New Zealand reports no rise in early-onset CRC (Shah et
al 2012)
– Stable or decreased 25-64 (...
0
20
40
60
80
100
120
140
1990 1995 2000 2005 2010
40-44
45-49
50-54
55-59
0
1
2
3
4
5
6
7
8
9
10
1990 1995 2000 2005 2010...
Early-Onset CRC Incidence in South AUSTRALIA
20-39 Years 40-59 Years
0
1
2
3
4
5
6
7
8
9
10
1990 2000 2010
20-24
25-29
30-...
CRC incidence in ASIA (1955-1999)
Sung et al. Lancet Oncol. 2005;6(11):871-6.
RC incidence in ASIA (1993-1997)
Sung et al. Lancet Oncol. 2005;6(11):871-6.
CRC incidence in ASIA (1983-2002)
Center M, Jemal A, Ward E. Cancer Epidemiol Biomarkers Prev. 2009;18(6):1688-94.
Early-Onset CRC Incidence in JAPAN (1976-1994)
Takada et al. Dis Colon Rectum. 2002;45(9):1249-54.
Early-Onset CRC Incidence in JAPAN (1978-2004)
@ Confidential Unpublished data
Early-Onset CRC Incidence in KOREA (1999-2009)
Shin et al. Cancer research and treatment. 2012;44(4):219-26.
CRC Incidence in KOREA vs JAPAN (1999-2012)
Yoon et al. Epidemiology and health. 2015;37:e2015038.
Seydaoglu et al. Turkish Journal of Gastroenterology. 2013;24(6):521-31.
Early-Onset CRC Incidence in TURKEY (1993-2008)
Early-Onset CRC in SINGAPORE
Early-Onset CRC in ASIAN COUNTRIES
Men 30-49 years Women 30-49 years
Colorectal cancer mortality in HONG KONG,
JAPAN, SOUTH KOREA, AND SINGAPORE.
Shin A, Jun...
AUSTRALIA
•Highest incidence rate of CRC in the world
•Incidence of CRC in people aged >50 has been stabilized or
declinin...
What is Known about CRC in Young Adults
• Rectal and Distal Colon Predominance
• High Grade Mucinous and Signet Ring Histo...
Problems about CRC in Young Adults
• Reports of outcome vary between studies
• Age boundary for definition of early-onset ...
Australian Bowel Cancer Screening Guidelines
National Bowel Cancer Screening Program
Factors in Diagnostic Delay
• Patient-associated factors
– CRC not considered to be cause of symptoms
– Some groups less l...
How to address
• Increasing awareness in physicians and patients
• Potential risk modification/reduction approaches
• Iden...
Acknowledgement
© Copyright The University of Melbourne 2009
QUALITY OF LIFE SYMPOSIUM:
”TOOLS YOU CAN USE”
Martha Raymond MA CPN Michael’s Mission
Susan Peterson PhD MPH University o...
Martha Raymond, MA CPN
Early Age Onset Colorectal Cancer Summit
March 19, 2016
New York, New York
Patient Voices:
The Curr...
Total of 125 Patients, Survivors & Caregivers
participated in the focus groups:
48 Male (38%)
77 Female (62%)
Sample group...
3%
9%
35%
31%
14%
7%
Under 25
25 to 29
30 to 34
35 to 39
40 to 44
45 to 49
Age at Diagnosis
0% 3%
49%
48%
Stage 1
Stage 2
Stage 3
Stage 4
Initial Stage at Diagnosis
46%
23%
11%
20%
Emergency Room
Primary Care
OB / GYN
Gastroenterologist
How were you diagnosed?
3%2%
3%
10%
34%
35%
13%
No Symptoms
0 to 3 months
3 to 6 months
6 to 12 months
12 to 18 months
18 to 24 months
24+ months
...
Yes: 7 (6%) No: 118 (94%)
Do you feel there were any obstacles in
the diagnostic process?
“Yes – young & otherwise health...
What additional areas of support would
have been helpful?
 Therapist/Social Worker/Navigator support
 Caregiver/Family s...
 Living a life of purpose – living in the present
 Spirituality – reflection – devotion
 Giving back – helping others -...
“I am stronger than I ever thought possible”
“I wish I had made my health a priority”
“Don’t take ‘no’ for an answer - ...
How to identify individuals under age 50 who most likely
would benefit from screening
Why is there such a large increase...
Be more thorough when explaining diagnosis and
treatment options
Understand that cancer affects the entire family –
not ...
The needs are clear:
 What can we do to better educate and raise
awareness about young adult colorectal cancer?
 What ca...
• Focus Group Participants
• Dr. Tom Weber
• Mrs. Cindy Borassi and CCCF Team
• Ms. Caitlyn ‘Caity’ Grand and MM Team
• Co...
Optimizing Psychosocial
Support for Young Adult
Colorectal Cancer Survivors
Susan K. Peterson, PhD, MPH
Professor, Behavio...
Cancer Survivorship
• Cancer survivorship = the state or process of
living after a diagnosis of cancer
• Encompasses not o...
• Low social support → diminished ability to cope
& manage illness, worse health outcomes
• Emotional distress → impaired ...
Psychosocial health care is integral to
cancer care and survivorship
Institute of Medicine (2008)
• Need for psychological...
Standard to improve psychosocial care for
cancer survivors
Health and Medicine Division (HMD), formerly IOM, National
Acad...
Psychosocial needs of cancer survivors &
services to address them
Health and Medicine Division (HMD), formerly IOM, Nation...
• Care standards and clinical practice guidelines
for psychosocial aspect of oncology care
– Distress screening, referral ...
• Was patient’s emotional well-being assessed
within 1 month of first oncology visit?
• If a problem was identified, was a...
• Quality of life concerns
– Managing distress & emotions related to cancer,
treatment, and fear of recurrence
“Not sick n...
• Survivorship care program
• Fertility and reproductive medicine program
• Psychosocial program
– Psychological assessmen...
“Addressing psychosocial needs should be an
integral part of quality cancer care. All components
of the health care system...
GETTING YOUR AFFAIRS IN ORDER:
A Legal Perspective
• March 19, 2016
LegalHealth
• Since 2001, LegalHealth has partnered with medical
professionals to address the non-medical needs of low-
in...
Objectives
• Provide overview of common concerns for
young adults with cancer:
–Employment Rights and Responsibilities
–Di...
Employment:
Common Questions
Are there laws that protect me in the workplace if I
want to continue working?
Do I have to d...
152
Americans With Disabilities Act
• Applies to all employers with 15 or more employees
• Employer cannot discriminate ag...
153
What if I have to stop working?
Family and Medical Leave Act (FMLA)
• FMLA protects the job of an employee who needs t...
154
How will I support myself if
I have to stop working?
• Short term disability – Seven states (CA, HI, NY,
NJ,RI, & PR) ...
Advanced Planning
• What legal documents should I have prepared to
protect me and help my family assist me if
needed?
155
Health Care Proxy
• Health Care Proxy allows an agent to make
health care decisions for you if you become
incapacitated.
•...
Living Will
• A statement of one’s wishes with respect to one
or a number of potential end of life medical care
decisions....
Power of Attorney
• Power of Attorney - a form that allows an
individual to name an agent to handle the
person’s personal ...
Wills
• A document in which a person specifies how her
property will be distributed upon her death.
• Must be competent to...
Property That Does Not
Pass Under a Will
• Pensions and retirement plans with designated
beneficiaries
• Life insurance if...
What about digital assets (the cloud) and
social media access permission?
• Will or POA can address digital property
• Mak...
Access to Social Media Upon Death
– Facebook: Special request for deceased person’s
account:
https://www.facebook.com/help...
What happens to my debt if I am no longer
able to pay?
• Laws vary state by state
• Family is generally not personally res...
164
Where can I go for legal help?
Resources:
National Cancer Legal Resource Network:
http://www.nclsn.org/
If reside in N...
Unique Complexities Facing Young
Adult Patients and their Families
March 19th, 2016
Carolyn Fulton, LCSW-R
Clinical Social...
Content for today’s Discussion
• Defining theYoung Adult
‒ PrioritiesTypical for theYoung Adult
‒ theYoungAdult facing Can...
Defining theYoung Adult
• Young adulthood is 18-35 (Erickson, 1959)
• Developmental priorities typical at this stage (D’Ag...
TheYoung Adult Facing Cancer
InTheirWords:
• “special set of psychological and social challenges”
• “youth and health are ...
Needs of theYoung Adult Patient
– Body of literature on the young adult cancer experience (distinct from
pediatric, adult ...
TheYoung Adult within their Family
• The SingleYoung Adult
- Are they living on their own, with roommates, interested in d...
Young Adult Cancer Experience – Couples
Individual Challenges
• Isolation
• Interruption in Developmental
Milestones
• Est...
Cancer and the Family
• Rolland (2005): “illness, disability, and death are universal experiences in
families”. Health car...
Brief Overview of FamilyTherapy
• Attends to the form or structure of interactions; family maps and patterns
of relating
•...
Systemic Interventions to Consider
• Value and Explore Multiple Perspectives
– Family members think differently about thei...
EngagingYoung Adults andTheir Families
• Who is present during clinic and treatment visits?
• If multiple friends or famil...
Important Considerations
• Body Image
• Sexual Functioning
• Quality of Life Goals may differ from older patients
• Fertil...
Collaboration between Oncologist and
Mental Health Provider Key
• Patients may open up to their social workers/psychologis...
Case Example
Brittany is a 28 year old female, recently engaged, diagnosed with Stage IV
colorectal cancer. She lived with...
Working with Brittany and her Family
Beginning Phase ofTreatment:
- She held back from life goals, with the hopes that she...
Working with Brittany and her Family (Cont.)
End Phase ofTreatment
-in Brittany’s case, it was realized that her cancer wa...
What this Case Example Illustrates
• Despite so much loss, young adults can continue to make milestones as
individuals and...
KnowingYour Resources
• Explore Support Programs offered by your institutions by Psychiatry and
SocialWork Departments
• K...
Program Development
Support Group Implementation:
Young Adult Couples
YoungAdult Patients
Young Adult Caregivers
Young Adu...
Contact Information
Carolyn Fulton, LCSW-R
fultonc@mskcc.org
646-888-3532
Fertility Preservation
Before Cancer Treatment:
Developing a Program to Improve
Practice
Treatment of cancer may affect fertility
Surgery
Resection of reproductive structures
Radiation
Fibrosis of reproductive s...
Fertility effects of treatment for colorectal
cancer include…
Males
• Loss of spermatogonial
stem cells → impaired
sperm p...
Fertility preservation options for patients with
colorectal cancer include…
Males
• Sperm banking
• Electroejaculation
• T...
Professional guidelines highlight the need for
clinicians to address fertility
Barriers for clinicians in discussing fertility
• Lack of knowledge
• Lack of resources
• Don’t know where to refer
• Conc...
A systematic approach can help in developing a
program to help clinicians address fertility
Plan
Develop an
Infrastructure...
A systematic approach can help in developing a
program to help clinicians address fertility
Plan
Develop an
Infrastructure...
Plan
Establish a multidisciplinary advisory group
– Collaborate with clinicians from other services caring
for a high volu...
Plan
Consider designating one person as fertility specialist/navigator
– To provide services to patients
• Education, coun...
A systematic approach can help in developing a
program to help clinicians address fertility
Plan
Develop an
Infrastructure...
Develop an infrastructure
Develop resources for patient education
– Create your own
– Have created by partnering reproduct...
Develop an infrastructure
Develop resources for clinicians
– A clearly defined process for informing patients of their
fer...
Develop an infrastructure
Develop resources for clinicians
– Develop electronic prompts or reminders
• Reports of young pa...
Develop an infrastructure
Develop resources for clinicians
– Identify local reproductive specialists for referral
if there...
Develop an infrastructure
Develop resources for clinicians
– Select reproductive specialists to partner with based on
thei...
Develop an infrastructure
Develop resources for clinicians
– A clearly defined process for referring interested patients
t...
Develop an infrastructure
Develop resources for clinicians
– Create a library of references
• Treatment-related risks & fe...
Develop an infrastructure
Educate clinicians
– Invite reproductive specialists to present
– Use a variety of methods
• Did...
Develop an infrastructure
If implementing a fertility specialist/navigator role…
– Select appropriate provider
• NP/PA: me...
A systematic approach can help in developing a
program to help clinicians address fertility
Plan
Develop an
Infrastructure...
Implement
Disseminate information about the program and go live!
– Consider implementing in one practice or service
at a t...
Implement
Consider the challenges in ensuring the program is
institutionalized (that all patients receive information)
– V...
Implement
Consider the challenges in ensuring the program is sustainable
– How to maintain the improved practice of curren...
A systematic approach can help in developing a
program to help clinicians address fertility
Plan
Develop an
Infrastructure...
Evaluate
Compare with baseline assessment
– Patient survey – satisfaction w/ information received
– Clinician survey – kno...
A final word for patients…
ASK QUESTIONS
• How will my planned treatment affect my ability to have
children in the future?...
Early Age Onset Colorectal Cancer:
Chemotherapy During Pregnancy
Cynthia Gail Leichman, MD
March 19, 2016
Scope of the Problem
• CRC is increasing in the younger population
• Cancer during pregnancy is increasing
• Expected furt...
Chemotherapy During Pregnancy
ISSUES:
• Clinical suspicion for diagnosis
– Overlapping pregnancy symptoms may yield later ...
Chemotherapy During Pregnancy
RISKS OF CHEMOTHERAPY DURING PREGNANCY
• Fetal risks – First Trimester:
– Spontaneous aborti...
Chemotherapy During Pregnancy
Maternal Risk:
• Impaired survival secondary to treatment
delay
• Enhanced physical stress o...
Chemotherapy During Pregnancy
GENERALLY ACCEPTED PRINCIPLES
• Health of the mother should come first
• Chemotherapy should...
Chemotherapy During Pregnancy
WHAT DATA DO WE HAVE TO GUIDE DECISIONS?
• Likely few cases for any single oncologist
– 0.02...
Chemotherapy During Pregnancy
WHAT DATA DO WE HAVE TO GUIDE DECISIONS?
• Case reports and retrospective studies
– Summary ...
Chemotherapy During Pregnancy
November 5,2015
Study Overview
Chemotherapy During Pregnancy
• Fetal exposure to maternal cancer during pregnancy with or without
treatmen...
Study Design and Recruitment.
Amant F et al. N Engl J Med 2015;373:1824-1834
Chemotherapy During Pregnancy
3 CRC
Characteristics of the Children at Baseline.
Amant F et al. N Engl J Med 2015;373:1824-1834
Chemotherapy During Pregnancy
...
Cancer Treatment during Pregnancy for All Children and Those Categorized as Small for
Gestational Age.
Amant F et al. N En...
Cognitive Outcome.
Amant F et al. N Engl J Med 2015;373:1824-1834
Chemotherapy During Pregnancy
Bayley Scales of Infant
De...
Echocardiographic Data and Other Measurements of Cardiac Function at 36 Months.
Amant F et al. N Engl J Med 2015;373:1824-...
Conclusions
Chemotherapy During Pregnancy
• Prenatal exposure to maternal cancer with or without treatment did not
impair ...
Chemotherapy During Pregnancy
IN CONCLUSION:
• Given according to the best available data,
appropriate treatment for mater...
Chemotherapy During Pregnancy
References
1. Cardonick E, Iacobucci A. Use of chemotherapy during human pregnancy.
The Lanc...
EPIDEMIOLOGY:
WHAT IS DRIVING THE INCREASING
INCIDENCE OF YA CRC?
Christine Sardo-Molmenti PhD MPH mailman School of
Publi...
EAO CRC Risk Factors:
Literature Review
Christine L. Sardo Molmenti, MPH, PhD
Postdoctoral Research Scientist
NIH/NCI R25T...
APC Change-based predictedincidence rates of colon cancer
by agecompared with incidence rate in 2010
Bailey RB, JAMA 2015
Colorectal cancer
Factors that increase risk Factors that decrease risk
Heredity and Medical History RR
Family history
• 1...
Adenoma-to-carcinoma sequence
Fearon and Vogelstein, Cell, 61, 759-767, 1990
Terzic et al, Gastroenterology 138(6), 2101-2...
Risk factors for EAO CRC
• Are they environmental?
• Are they lifestyle/behavioral?
• What is the timing of exposure?
• Wh...
Aims
1. Characterize modifiable risk factors relevant to early age
onset colorectal neoplasia
2. Summarize the potential b...
Literature Review
141 articles identified
1939 to 2016
107 retrieved (34 requested)
“Young”
onset
• <50
• ≤45
• ≤40
• ≤30
...
Literature Review
141 articles identified
1939 to 2016
107 retrieved (34 requested)
“Young”
onset
• <50
• ≤45
• ≤40
• ≤30
...
What is the state of the EAO risk factor research?
Descriptive
Experimental
Clinical trials,
intervention
studies
Observat...
Risk factor related studies
18 observational studies
• 8 cohort
• 10 case control
Areas of study
• Obesity
• Diabetes
• Oc...
12 studies related to obesity and EAO CRC
Cohort studies
Year
First
Author
Age Study population Outcome
1992
Lee and
Paffenbarger
< 55 and ≥ 55 17,595 Harvard Alumn...
Case-control
Year
First
Author
Age Study population Outcome
1992 Le Marchand 49-63 52,539 male Hawaiian residents Positive...
Link between obesity and colorectal cancer
• Distribution of fat is a major determinant of
health
• Epidemiologic evidence...
Diabetes, physical activity, dietary
factors, occupational exposures
1 cohort study
5 case control studies
Chen et al, 2012
Age-and sex-specific risks of colorectal cancers in
diabetic patients
Year First
author
Objective Age Stu...
Chen et al, 2012
Age-and sex-specific risks of colorectal cancers in
diabetic patients
Year First
author
Objective Age Stu...
5 Case control studies
Year First
author
Title Age Study population Risk factor
outcomes
2013 Rosato Risk factors for youn...
1. Rosato et al, 2013
Risk factors for young-onset CRC
Year First
author
Title Age Study population Risk factor
outcomes
2...
Rosato et al, 2013
Risk factors for young-onset CRC
Year First
author
Title Age Study population Risk factor
outcomes
2013...
Year First
author
Title Age Study population Risk factor
outcomes
2013 Rosato Risk factors for young
onset CRC
≤ 45 3 Ital...
Year First
author
Title Age Study population Risk factor
outcomes
2013 Rosato Risk factors for young
onset CRC
≤ 45 3 Ital...
2. Cox et al, 2011
School milk and risk of colorectal cancer: A
national case-control study
Year First
author
Title Age St...
Cox et al, 2011
School milk and risk of colorectal cancer: A
national case-control study
Year First
author
Title Age Study...
3. Imperiale et al, 2008
Risk factors for advanced sporadic colorectal
neoplasia in persons <50
Study objectives:
• Identi...
Imperiale et al, 2008
Risk factors for advanced sporadic colorectal
neoplasia in persons <50
Factors that differed between...
4. La Vecchia et al, 1994
A case-control study of diabetes mellitus and
cancer risk
Year First
author
Title Age Study popu...
La Vecchia et al, 1994
A case-control study of diabetes mellitus and
cancer risk
Year First
author
Title Age Study populat...
5. Peters et al, 1989
A case-control study of occupational and
dietary factors in CRC in young men by subsite
Year First
a...
Potential biological links to EAO CRC
• Early postnatal period is a period of physiologic change
• Direct evidence that ep...
Hypothesized mechanisms
Adapted from Lynch et al, Cancer Epidemiol Biomarkers Prev, 2010
Sedentary
behavior
Diet,
sedentar...
Points of prevention
Birth Colorectal neoplasia
Initiation Promotion Progression
Colorectal cancer
Mechanisms of tumor-sup...
Precursor to colorectal cancer
• >95% of sporadic colorectal cancers arise from the
adenomatous polyp
• 30% to 40% of the ...
Jung et al, 2015
Risk factorsfor colorectalneoplasiain personsaged 30 to 39
years and 40-49 years
• To investigate risk fa...
Characteristicsofcolorectaladenoma recurrenceamong
individuals under 50 compared to those 50 yearsof ageor
older
Sardo Mol...
Aim
Investigate various demographic, lifestyle, and tumor
characteristics and odds of colorectal adenoma recurrence in
ind...
Preliminary Results
Less likely among <50 More likely among <50
• Non-Hispanic whites
• Previous polyps
• Aspirin use
• Se...
Age (years)
Age< 50 years Age ≥ 50 years
OR (95% CI)* P value OR (95% CI) P value
Female ref. - ref. -
Male 1.687 (0.360, ...
Implications for young-onset CRC
• History of previous polyps appears to be a stronger risk factor
for recurrence among th...
EAO CRC Risk factors summary
• Suggested link between early obesity and young onset colorectal cancer
• Evidence of an ass...
Next steps
1. Etiology of early onset CRC requires further investigation
o Case control studies
o Cohort studies
o Randomi...
ADOLESCENT BODY MASS INDEX AND
INFLAMMATION IN RELATION TO
COLORECTAL CANCER RISK
Elizabeth D. Kantor, PhD MPH
Department ...
Background
Rationale
 Colorectal cancer (CRC) is the third most
common cancer among men and women in
the US
Siegel et al, CA Cancer ...
Rationale
 Epidemiologic research has largely focused on
the role of adult exposures in the development
of CRC
 Know rel...
Body Mass Index & CRC
 Convincing evidence that adult body mass
index is positively associated with CRC risk
BMI CR
C
Body Mass Index & CRC
 Convincing evidence that adult body mass
index is positively associated with CRC risk
BMI CR
C
Ste...
Inflammation & CRC
 Chronic inflammation implicated in CRC
etiology
 Various lines of evidence point to the
involvement ...
Early-life?
 Relatively little known about how early-life BMI
relates to risk of CRC
 No prior studies have evaluated th...
Kantor ED et al, Gut,
Aims
 To evaluate the associations between late-
adolescent BMI and inflammation, as
measured by erythrocyte sedimentatio...
Significance
 Finding evidence of association between
early-life exposure and CRC could help us
better understand etiolog...
Methods
Study Population
 Study population drawn from a cohort of men
conscribed in Swedish military between 1969
and 1976
 Cons...
Details on Conscription
Men completed extensive examinations
Recorded in the Swedish Military Conscription
Register
Exposure Assessment: BMI
 At conscription, height and weight measured
by trained personnel
 BMI categories:
 Underweigh...
Exposure Assessment: BMI
 At conscription, height and weight measured
by trained personnel
 BMI categories:
 Underweigh...
Exposure Assessment: ESR
 Venous blood collected at examination, from
which ESR was measured
 Non-specific marker of inf...
Outcome Ascertainment
 CRC cases identified by linkage to the Swedish
national cancer registry
 Men followed from date o...
Analyses
 Cox regression
 Covariates
selected from
available registry
data
Variable
Age at conscription
Household crowdi...
Study Design
1969-1976 201
0
BMI & ESR
Measurement
Men not followed into late adulthood.
Ages 16-20 in 1969-76.
CRC
?
Results
Late Adolescent ESR, BMI & CRC
Cohort
N (%)
Case
N (%)
Model 1a
HR (95% CI)
Model 2b
HR (95% CI)
Model 3b,c
HR (95% CI)
Bo...
Late Adolescent ESR, BMI & CRC
Cohort
N (%)
Case
N (%)
Model 1a
HR (95% CI)
Model 2b
HR (95% CI)
Model 3b,c
HR (95% CI)
Bo...
Late Adolescent ESR, BMI & CRC
Cohort
N (%)
Case
N (%)
Model 1a
HR (95% CI)
Model 2b
HR (95% CI)
Model 3b,c
HR (95% CI)
Bo...
The Second Annual Early Age Onset Colorectal Cancer Summit
The Second Annual Early Age Onset Colorectal Cancer Summit
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The Second Annual Early Age Onset Colorectal Cancer Summit

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This ground breaking program provided both survivors and health care professionals the opportunity to leverage each other's insights and an opportunity for all to hear "state-of-the-science" presentations on the epidemiology, pathogenesis, genomics and optimal multidisciplinary care of EAO-CRC.

The 2016 EAO CRC Summit featured keynote addresses from leading clinicians, epidemiologists and researchers from Europe, Africa, Australia and the nation's leading cancer centers and advocacy organizations.

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