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Colorectal Cancer
Colorectal cancer is the second most common cancer in Palestine, primarily affecting males, with an incidence rate of 16.4 per 100,000. It often develops from benign polyps in the colon or rectum and is influenced by both acquired and inherited genetic mutations, with various modifiable and non-modifiable risk factors. Diagnostic methods include colonoscopy and staging is critical for determining treatment options, with a 5-year survival rate varying significantly by cancer stage.
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Colorectal Cancer
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- 2. Learning Key-points • Epidemiologyof colorectal cancer in Palestine. • Aetiologies and risk factors of colorectal cancer. • Colorectal cancer genetics. • How colorectal cancer develops? • Types of colorectal cancer. • Clinical features of colorectal cancer. • Colorectal cancer imaging and staging. • Screening and prevention. • Lines of management.
- 4. What is ColorectalCancer? • Colorectal cancer starts in the colon or the rectum. • These cancers can also be called colon cancer or rectal cancer, depending on where they start. • Colon cancer and rectal cancer are often grouped together because they have many features in common.
- 6. Colorectal Cancer (PMOH2021) • Is the second most common cancer in Palestine. • The most common cancer among males. • Incidence rate in West Bank: 16.4 per 100,000 population. • 463 new cases. Top 10 reported cancer per 100,000 population in West Bank
- 7. Colorectal Cancer Mortality(PMOH 2021) Proportional distribution of the most reported cancer deaths of all reported cancer deaths, West Bank, 2021 ~ 177 case die each year in West Bank due to colorectal cancer
- 8. Aetiology What Causes ColorectalCancer? • Inherited gene mutations • Familial adenomatous polyposis (FAP). • Gardner syndrome. • Lynch syndrome (hereditary non-polyposis colon cancer or HNPCC). • Peutz-Jeghers syndrome. • MUTYH-associated polyposis (MAP). • Acquired gene mutations Most cases of colorectal cancer, the DNA mutations that lead to cancer are acquired during a person’s life rather than having been inherited.
- 9. Genetics • Colorectal cancercaused by DNA mutations that: 1. Turn on oncogenes. Or 2. Turn off tumor suppressor genes. • Most due to sporadic mutations, but some due to known mutations. • E.g., Adenomatous Polyposis Coli Gene (APC) … Tumor suppressor gene. • Other mutations: • K-RAS • P53
- 10. Risk Factors …(1) Modifiable Risk Factors: • Obesity. • Low physical activity. • Diet: • Diet that’s high in red meat (e.g., pork, beef, liver). • Processed meats (e.g., hot dog, luncheon meats). • Low-fiber, high-fat diet. • Cooking meat at very high temp. • Low blood vit. D may increase the risk of colorectal cancer. • Smoking. • Alcohol use. • Streptococcus bovis Bacteremia.
- 11. Risk Factors …(2) Non-modifiable Risk Factors: • Age > 50 • Hx of colorectal polyps or colorectal cancer. • IBD – Crohn's dz, ulcerative colitis. • A family history of colorectal cancer or adenomatous polyps. • Having an inherited syndrome • Lynch syndrome (HNPCC) • Familial adenomatous polyposis (FAP) • Peutz-Jeghers syndrome (PJS) • MUTYH-associated polyposis (MAP) • T2-DM • Ethnicity – Africans Americans, Ashkenazi Jews. Rarely associated
- 12. How Does ColorectalCancer Start? • Most colorectal cancers start as polyps in the colon or rectum. • Polyps can change into cancer over many years, but not all polyps become cancer. • There are different types of polyps.
- 13. How Colorectal CancerSpreads? • Direct extension (invasion) – though the wall of the colon/rectum. • Blood circulation – to distant parts of the body (e.g., liver, lungs, …) • Lymphatics – regionally. • Transperitoneal and intraluminal.
- 14. Colorectal Polyps • Adenomatouspolyps (adenomas). • Tubular • Villous • Tubulovillous • Hyperplastic polyps and inflammatory polyps. • Sessile serrated polyps (SSP) and traditional serrated adenomas (TSA). Pre-cancerous Not pre-cancerous
- 15. Types of colorectalcancer • Adenocarcinomas (most common) • Carcinoid tumors • Gastrointestinal stromal tumors (GISTs) – not common in the colon. • Lymphomas • Sarcomas (rare)
- 16. Familial Adenomatous Polyposis(FAP) • Rare autosomal dominant dz caused by hereditary mutations in the APC tumor suppressor gene. • Characterized by hundreds or thousands or polyps inside the colon or rectum. • Polyps may also form in the stomach, jejunum, and ileum. • بهذا ينصابو راح األولى الدرجة من األقارب المرض 100 .% ف ال األقارب لكل نعمل زم سنة كل للقولون ناظور األولى الدرجة من .
- 17. Clinical Features • Symptomsvary with the anatomic location of the tumor. SYMPTOMS: • A persistent change in your bowel habits. • Melena or hematochezia / mucus in stool. • Persistent abdominal discomfort (cramps, gas or pain). • A feeling that bowel doesn't empty completely. • Weakness or fatigue. • Unexplained weight loss.
- 18. Diagnostics • Fecal OccultBlood Test (FOBT) • Fecal Immunochemical Test (FIT) • Flexible Sigmoidoscopy • Digital Rectal Exam (DRE) • Carcinoembryonic Antigen (CEA) • CT Colonography Every 5 y • Colonoscopy • Double Contrast Barium Enema Screening tools only
- 19. Fecal Occult BloodTest البراز في الخفي الدم اختبار
- 20. Colonoscopy Click to seea video
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- 22. Diagnosis Steps • Historyand physical examination. • Tests to look for blood in stool – FOBT, FIT, … • Blood tests – CBC, liver enzymes, CEA. • Diagnostic colonoscopy. • Biopsy. ….…
- 23. Staging • Clinical stagingis done with: • CT scan of chest, abdomen, and pelvis. • Physical examination (ascites, hepatomegaly, lymphadenopathy). • TNM system. • T1-T4 indicates the depth of tumor penetration into the bowel wall. • N0-N2 represents the involvement of regional lymph nodes. • M0-M1 denotes the absence or presence of distant metastases.
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- 25. 5-Year Survival Rates Forcolon cancer Stage 5-Year Survival Rate Localized 91% Regional 72% Distant 14% All stages combined 64% For rectal cancer Stage 5-Year Survival Rate Localized 90% Regional 73% Distant 17% All stages combined 67%
- 26. Lines of Management… (1) 1- Surgery for early-stage colon cancer • Polypectomy • Endoscopic mucosal resection • Laparoscopic surgery 2- Surgery for more advanced colon cancer • Partial colectomy • Colostomy • Lymph node removal 3- Surgery for advanced cancer
- 27. Lines of Management… (2) 4- Chemotherapy 5- Radiotherapy 6- Targeted drug therapy 7- Immunotherapy 8- Palliative care
- 28. Prevention/Screening Can Colorectal CancerBe Prevented? • Avoid modifiable risk factors (high-weight, low physical activity, smoking, alcohol consumption, high fat diet, processed meats, …) • Colorectal screening for people ages >45 … protection for 10 ys.
- 29. Follow Up • Stoolguaiac test. • Annual CT scan of abdomen/pelvis and CXR for up to 5 years. • Colonoscopy at 1 year and then every 3 years. • CEA levels are checked periodically (every 3 to 6 months).
- 30. Key points • Colorectalcancer usually begins as a benign polyp that may develop on the inner wall of the colon or rectum as people get older. • Acquired mutations of colorectal cancer is commonest than inherited mutations, and certain risk factors associated with acquired mutations. • Gold standard diagnostic tool for colorectal cancer is colonoscopy. • Preventive colonoscopy every 10 years is recommended for people >45y.
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