SlideShare a Scribd company logo
1 of 39
Download to read offline
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
What You Should Know About
Colorectal Cancer
Bruce Lin, M.D.
November 29, 2018
Hematology-Oncology
Virginia Mason Medical Center
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Learning Objectives
• Epidemiology of colorectal cancer
• Rick factors
• Colon cancer screening
• Management of colon cancer based on stage
• Management of rectal cancer
• Surveillance for colorectal cancer survivors
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
medicinenet.co
m
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
chemotherapyadvices.com
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Epidemiology
• 4th most frequent cancer in the US
 95,270 new cases of colon cancer estimated in 2018
 43,030 new cases of rectal cancer
 25% higher incidence in men than women
 20% higher incidence in African Americans than in
whites
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
• Incidence higher in developed countries
• 75% occurs as “sporadic cancer”
• Remaining cases occur in high risk populations
 Inherited conditions, inflammatory bowel disease
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
• 2nd leading cause of cancer death in US
 50,630 will die of colorectal cancer
 25% higher mortality in men
 20% higher mortality in African Americans
• Decreasing incidence and mortality
 Incidence rates have declined about 4% per year
 Mortality has decreased by 35% from 1990 to 2007
• Increasing incidence in patients younger than 50
 Incidence rates will increase by 90.0% for colon cancer and
124.2% for rectal cancer in patients 20-34 y/o by 2030
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Jemal A et al: Cancer statistics, 2007
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Colorectal Cancer Incidence Trends by Age and Sex,
1992-2007
American Cancer Society
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Risk Factors
 Familial syndromes
 Familial adenomatous polyposis (FAP)
• 0.5 – 1% of all colorectal cancer
• Mutation of APC tumor suppressor gene key in the wnt-signaling
pathway
– APC mutations also found in 80-85% of sporadic colorectal cancers
• Hundreds to thousands of polyps
• Extracolonic manifestations
– Small-bowel adenoma or adenocarcinoma, gastric adenoma and cancer, fundic
gland polyps, adrenal adenomas and cancers, thyroid cancer, and desmoid tumor
• 95% have polyps by age 35, without colectomy, almost 100% will
develop colon cancer at mean age of 39
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Modern Pathology
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
 Hereditary nonpolyposis colorectal cancer (HNPCC, Lynch
Syndrome)
• 5% of all colorectal cancers
• Caused by mutations in DNA mismatch repair enzymes, MSH-2,
MLH-1, PMS-1, PMS-2, and MSH-6
– Also occurs in 10-15% of sporadic colon cancer
• Extracolonic manifestations including ovarian, pancreatic, breast,
biliary, endometrial, gastric, genitourinary, and small bowel cancers
• Can have up to 10 polyps
• 80% lifetime risk of colorectal cancer, mean age of diagnosis is 44
• Two-thirds occur in the proximal colon
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
• Inflammatory bowel disease
 Ulcerative colitis
• 5-10% increased risk of colon cancer by 20 years after time
of diagnosis
 Crohn’s disease
• May have a role in colon cancer in the ileocolic region
• No increased risk if no colonic involvement
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
• Adenomatous polyps
Tubular Adenoma
5% risk of cancer
Tubulovillous adenoma
20% risk of cancer
Villous Adenoma
40% risk of cancer
 Size of polyp
 <1 cm - <1% risk of cancer
 1 cm – 10% risk of cancer
 2 cm – 15% risk of cancer
Wikipedia.org
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
• Personal history of colorectal cancer
 1.5 – 3% risk of second colorectal cancer in first 5
years after resection of first one
• Family history in first-degree relative (parent,
sibling, or child)
 Two times the risk of general population
 Risk further increased if two first-degree relatives with
colorectal cancer or diagnosed below 50-60 years of
age
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
• Sporadic cancer
 Age - 90% of cases in patients older than 50
 Environmental and lifestyle factors
• Based on observational studies, causal relationship unproven
• Associated with a small or uncertain increased risk
Risk Factor Comments
Diabetes mellitus - Up to 38% increased risk
Alcohol - 2-3 drinks per day – 21% increased risk
- ≥4 drinks per day – 52% increased risk
Obesity (BMI ≥ 25 kg/m2) - 1.5-fold increased risk
- 12% increased in CRC mortality
Cigarette smoking - 18% increased risk
- 25% increase in CRC mortality
Red meat or processed meat - Increased risk of left sided tumors
- Counterbalanced by benefits such as iron
and vitamin B12
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Protective Factors Comments
Physical activity, exercise -27% risk reduction of proximal colon cancer
-26% risk reduction of distal colon cancer
- Exercise 150 minutes per week
Fruits and vegetable - Mixed data, benefit limited to distal colon cancer
- Little benefit associated with > 100 g/day of intake
Fiber - Controversial
- Fiber from unprocessed wheat bran better than
processed forms
Folate/folic acid - Controversial, benefit might be limited to dietary
rather than supplemental intake
Vitamin B6 (pyridoxine) - 10-20% risk reduction of colorectal cancer
Calcium - Recommended for prevention of colonic adenomas
by American college of Gastroenterology
Vitamin D - Poor vitamin D status associated with increased
colon cancer risk
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Protective Factors Comments
Magnesium - Associated with 40% risk reduction of colorectal
cancer in women in a Swedish study
Garlic - Controversial, listed as probable protective factor by
American Institute of Cancer Research, but very
limited credible evidence per FDA.
Fish/omega-3 fatty acids - Modest 12% risk reduction of colorectal cancer
Aspirin/NSAIDs -20 – 40% risk reduction of colonic adenomas and
colorectal cancer incidence
- Protective effect in patients with Lynch syndrome
- Newer data suggests mortality benefit might be
limited to small subset of patients with specific
mutation
- Can cause GI ulcers, NSAIDs use may also cause
cardiovascular side effect
- USPSTF recommends against routine use of aspirin
and NSAIDs to prevent colorectal cancer in average
risk individuals
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Carcinogenesis
Gastroenterology, vol. 138, issue 6, p. 2059-2072
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Screening Recommendations
USPSTF Recommendation Statement 2016
JAMA. 2016;315(23):2564-2575. doi:10.1001/jama.2016.5989
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
JAMA. 2016;315(23):2564-2575. doi:10.1001/jama.2016.5989
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
ACS Guideline for CRC Screening
• 2018 guideline update recommends starting
screening at 45 years and older
 Average risk of CRC
 High-sensitivity stool-based test or visual exams such
as colonoscopy, CT colonography, or flexible
sigmoidoscopy
 May not be covered by most insurance
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Screening for High Risk Patients
• HNPCC
 Colonoscopy every 1-3 years starting at ages 20-25
• FAP
 Screening colonoscopies as early as age 10
• IBD
 AGA
• Colonoscopy should start after 8 years in patients with pancolitis, 15
years in patients with colitis limited to left colon
• Repeated every one to two years
• Recommendation similar for both ulcerative colitis and Crohn’s
disease
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Workup
• Pathology review
• Colonoscopy
• CBC, platelets, chemistry profile, CEA
• Chest/abdominal/pelvic CT with contrast
• PET-CT not routinely indicated
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Staging
National Cancer Institute
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Staging, Incidence, and Treatment
Stage I Stage II Stage III Stage IV
Staging T1, N0, M0
T2, N0, M0
A: T3, N0, M0
B: T4, N0, M0
A: T1-2, N1, M0
B: T3-4, N1, M0
C: Any T, N2, M0
Any T, Any N, M1
Definition Invades submucosa
(T1) or muscular
propria (T2)
Invades subserosa,
nonperitonealized
pericolic/perirectal
tissues (T3) or
invades other
organs/structures/
visceral peritoneum
(T4)
Involves 1 to 3 (N1)
or more (N2) lymph
nodes
Involves distant
metastases
Incidence 15% 25% 35% 25%
Usual treatment Surgery Surgery with or
without
chemotherapy
Surgery adjuvant
chemotherapy
Chemotherapy
with or without
surgery
AJCC Staging Manual, Sixth Edition
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
AJCC Staging Manual, Seventh Edition
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
AJCC Staging Manual, Seventh Edition
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Treatment
• Stage 0
 Cured by endoscopic resection alone
• Stage I
 Surgery alone is curative for more than 85% of patients
• Stage II
 Benefit of adjuvant chemotherapy only 3% in 3-year disease-free and overall
survivals
 Adjuvant chemotherapy in patients with T4 disease or high risk features
• Grade 3-4, lymphatic/vascular invasion, bowel obstruction, < 12 lymph nodes examined, perineural
invasion, localized perforation, or close, indeterminate or positive margins
 Multi-gene assay panels (Oncotype DX Colon Cancer, ColoPrint) not yet
standard
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
 Stage III
◦ 5-year survival rate is 30-50% with surgery only
◦ Adjuvant chemotherapy for 6 months is standard of care
 Stage IV
◦ Without therapy, median survival only 5-6 months
◦ Systemic combination chemotherapy
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
◦ Limited hepatic or pulmonary metastasis
 Resection of metastatic disease significantly increases survival
 Evaluation by multidisciplinary team regarding resectability
 Upfront systemic chemotherapy for conversion to resectability, only
10-15% of patients are converted to truly resectable
◦ Resection of primary tumor not necessary unless
obstructed or perforated
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Rectal Cancer
• Stage I
 Excision/surgery
• Stage II, Stage III
 Neo-adjuvant chemo/XRT (5-6 weeks) followed by surgery and 4
months of adjuvant chemotherapy
• Lower rate of local recurrence, toxicities, and higher rate of sphincter
preservation
• Stage IV
 Management similar to colon cancer
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Surveillance
• H&P every 3-6 months for 2 years then every 6 months
for a total of 5 years
• CEA every 3-6 months for 2 years, then every 6 months
for a total of 5 years
• C/A/P CT annually x 3-5 years for patients at high risk
• Colonoscopy in 1 year except if no preoperative
colonoscopy due to obstructing lesion, colonoscopy in 3-
6 months
 If advanced adenoma, repeat in 1 year
 If no advanced adenoma, repeat in 3 years, then every 5 years.
• PET-CT not routinely recommended
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
THANK YOU!
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Question 1
A 47-year-old woman is evaluated for abdominal discomfort of 3 months’
duration accompanied by a change in stool caliber. Her medical history is
otherwise noncontributory, and her family history is unremarkable. Physical
examination, including rectal examination, is normal. Results of fecal occult
blood testing are positive. Colonoscopy reveals a 3-cm sigmoid tumor
confirmed as adenocarcinoma on biopsy. On resection of the mass, tumor
invasion of the muscularis propria is identified, in addition to metastases in one
regional lymph node. The postoperative recovery is uneventful, and the patient
presents for a follow-up office visit.
Which of the following is the most appropriate next step in management?
(A) Adjuvant chemotherapy
(B) Radiation therapy
(C)Observation
(D)Immunohistochemical staining of the tumor
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Question 2
A 50-year-old woman is evaluated for a routine follow-up visit. Her history
includes a diagnosis of stage II colon cancer 2 years ago for which she
underwent a surgical resection and received no adjuvant therapy. On physical
examination, she appears healthy. Cardiopulmonary and abdominal
examinations are normal. Laboratory studies include a serum CEA
concentration that has increased from a recent baseline measurement of < 5
ng/mL to 41 ng/mL. At CT scan of the abdomen shows six hepatic lesions
measuring from 2 to 7 cm. Multiple pulmonary nodules of < 1 cm are noted on
CT scan of the lung. On biopsy, the liver lesions are confirmed as
adenocarcinoma consistent with the initial primary tumor.
Which of the following is the most appropriate next step in management?
(A) Abdominal and chest PET
(B) Hepatic resection
(C)Systemic chemotherapy
(D)Colonoscopy
(E) Pulmonary nodule biopsy
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Question 3
A 78-year-old woman is evaluated for worsening symptoms of metastatic
colorectal cancer. At diagnosis 5 months ago, she had an 11-cm liver lesion,
extensive large pulmonary nodules, and a 5-cm sigmoid mass. She underwent
resection of the primary tumor to relieve obstructive symptoms but developed
multiple pulmonary emboli postoperatively. Her initial treatment regimen
consisted of 5-fluorouracil and oxaliplatin but resulted in disease progression
after 8 weeks of therapy. Currently, she cannot care for herself because of
cancer-related symptoms and is mostly bedbound.
Which of the following is the most appropriate next step in management?
(A) Irinotecan chemotherapy
(B) Palliative care
(C)Cryotherapy
(D)Radiotherapy
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Question 4
A 61-year-old woman is evaluated after a 2-month history of bright red blood on
defecation and a change in stool caliber. The medical history is otherwise
noncontributory, and the family history is unremarkable. On physical
examination, a tumor is palpated just above the anal sphincter. Laboratory
studies indicated a hemoglobin of 11.1 g/dL. Liver chemistry studies are
normal. CT of the abdomen reveals a distal rectal mass. Adenocarcinoma of
the rectum is confirmed by biopsy.
Which of the following is the most appropriate next step in management?
(A) Preoperative radiation therapy plus chemotherapy
(B) Preoperative chemotherapy
(C)Abdominoperitoneal resection
(D)Preoperative radiation therapy
© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center
Answers
• 1. A
• 2. C
• 3. B
• 4. A

More Related Content

What's hot

Spearheading cancer awareness by benda kithaka
Spearheading cancer awareness by benda kithakaSpearheading cancer awareness by benda kithaka
Spearheading cancer awareness by benda kithakaKesho Conference
 
5th Annual Early Age Onset Colorectal Cancer Summit - Session IV
5th Annual Early Age Onset Colorectal Cancer Summit - Session IV5th Annual Early Age Onset Colorectal Cancer Summit - Session IV
5th Annual Early Age Onset Colorectal Cancer Summit - Session IVColon Cancer Challenge Foundation
 
Epidemiology of Prostate Cancer in Puerto Rico
Epidemiology of Prostate Cancer in Puerto Rico Epidemiology of Prostate Cancer in Puerto Rico
Epidemiology of Prostate Cancer in Puerto Rico flasco_org
 
Epidemiology of Cancer
Epidemiology of CancerEpidemiology of Cancer
Epidemiology of Cancersourav goswami
 
What Men Told Us: Prostate Cancer Survey Results, Oct. 1, 2020
What Men Told Us: Prostate Cancer Survey Results, Oct. 1, 2020What Men Told Us: Prostate Cancer Survey Results, Oct. 1, 2020
What Men Told Us: Prostate Cancer Survey Results, Oct. 1, 2020Canadian Cancer Survivor Network
 
Current Issues Affecting Cancer Care in Puerto Rico
Current Issues Affecting Cancer Care in Puerto RicoCurrent Issues Affecting Cancer Care in Puerto Rico
Current Issues Affecting Cancer Care in Puerto Ricoflasco_org
 
4th Annual Early Age Onset Colorectal Cancer Summit: Transforming Family Heal...
4th Annual Early Age Onset Colorectal Cancer Summit: Transforming Family Heal...4th Annual Early Age Onset Colorectal Cancer Summit: Transforming Family Heal...
4th Annual Early Age Onset Colorectal Cancer Summit: Transforming Family Heal...Colon Cancer Challenge Foundation
 
Impact of COVID-19 on Cancer Patients and Their Ability to Receive Treatment
Impact of COVID-19 on Cancer Patients and Their Ability to Receive TreatmentImpact of COVID-19 on Cancer Patients and Their Ability to Receive Treatment
Impact of COVID-19 on Cancer Patients and Their Ability to Receive TreatmentCanadian Cancer Survivor Network
 
Implementing prevention AYA survivors
Implementing prevention AYA survivorsImplementing prevention AYA survivors
Implementing prevention AYA survivorsGraham Colditz
 
Strategies for Accelerating Translation of Research Findings into Cancer Prev...
Strategies for Accelerating Translation of Research Findings into Cancer Prev...Strategies for Accelerating Translation of Research Findings into Cancer Prev...
Strategies for Accelerating Translation of Research Findings into Cancer Prev...Graham Colditz
 
Cancer - Introduction, Control & Screening
Cancer - Introduction, Control & ScreeningCancer - Introduction, Control & Screening
Cancer - Introduction, Control & ScreeningDr. Animesh Gupta
 
World Cancer Day
World Cancer DayWorld Cancer Day
World Cancer DayEMMAIntl
 
New Trends in the Management of Metastatic Prostate Cancer
New Trends in the Management of Metastatic Prostate CancerNew Trends in the Management of Metastatic Prostate Cancer
New Trends in the Management of Metastatic Prostate Cancerflasco_org
 
CANCER.pptx Type of cancer and treatment of cancer.
CANCER.pptx Type of cancer and treatment of cancer.CANCER.pptx Type of cancer and treatment of cancer.
CANCER.pptx Type of cancer and treatment of cancer.kamal969161
 
Role of primary physicians in early detection of cancer
Role of primary physicians in early detection of cancerRole of primary physicians in early detection of cancer
Role of primary physicians in early detection of cancerVivek Verma
 

What's hot (20)

Spearheading cancer awareness by benda kithaka
Spearheading cancer awareness by benda kithakaSpearheading cancer awareness by benda kithaka
Spearheading cancer awareness by benda kithaka
 
5th Annual Early Age Onset Colorectal Cancer Summit - Session IV
5th Annual Early Age Onset Colorectal Cancer Summit - Session IV5th Annual Early Age Onset Colorectal Cancer Summit - Session IV
5th Annual Early Age Onset Colorectal Cancer Summit - Session IV
 
Epidemiology of Prostate Cancer in Puerto Rico
Epidemiology of Prostate Cancer in Puerto Rico Epidemiology of Prostate Cancer in Puerto Rico
Epidemiology of Prostate Cancer in Puerto Rico
 
Epidemiology of Cancer
Epidemiology of CancerEpidemiology of Cancer
Epidemiology of Cancer
 
What Men Told Us: Prostate Cancer Survey Results, Oct. 1, 2020
What Men Told Us: Prostate Cancer Survey Results, Oct. 1, 2020What Men Told Us: Prostate Cancer Survey Results, Oct. 1, 2020
What Men Told Us: Prostate Cancer Survey Results, Oct. 1, 2020
 
Current Issues Affecting Cancer Care in Puerto Rico
Current Issues Affecting Cancer Care in Puerto RicoCurrent Issues Affecting Cancer Care in Puerto Rico
Current Issues Affecting Cancer Care in Puerto Rico
 
4th Annual Early Age Onset Colorectal Cancer Summit: Transforming Family Heal...
4th Annual Early Age Onset Colorectal Cancer Summit: Transforming Family Heal...4th Annual Early Age Onset Colorectal Cancer Summit: Transforming Family Heal...
4th Annual Early Age Onset Colorectal Cancer Summit: Transforming Family Heal...
 
Impact of COVID-19 on Cancer Patients and Their Ability to Receive Treatment
Impact of COVID-19 on Cancer Patients and Their Ability to Receive TreatmentImpact of COVID-19 on Cancer Patients and Their Ability to Receive Treatment
Impact of COVID-19 on Cancer Patients and Their Ability to Receive Treatment
 
WEBINAR: Breast Screening and Breast Density
WEBINAR: Breast Screening and Breast DensityWEBINAR: Breast Screening and Breast Density
WEBINAR: Breast Screening and Breast Density
 
Cancer screening for seniors
Cancer screening for seniorsCancer screening for seniors
Cancer screening for seniors
 
5th Annual Early Age Onset Colorectal Cancer - Session VI
5th Annual Early Age Onset Colorectal Cancer - Session VI5th Annual Early Age Onset Colorectal Cancer - Session VI
5th Annual Early Age Onset Colorectal Cancer - Session VI
 
Implementing prevention AYA survivors
Implementing prevention AYA survivorsImplementing prevention AYA survivors
Implementing prevention AYA survivors
 
Strategies for Accelerating Translation of Research Findings into Cancer Prev...
Strategies for Accelerating Translation of Research Findings into Cancer Prev...Strategies for Accelerating Translation of Research Findings into Cancer Prev...
Strategies for Accelerating Translation of Research Findings into Cancer Prev...
 
Cancer - Introduction, Control & Screening
Cancer - Introduction, Control & ScreeningCancer - Introduction, Control & Screening
Cancer - Introduction, Control & Screening
 
Goals of Care: Changing the Game for Lung Cancer Patients
Goals of Care: Changing the Game for Lung Cancer PatientsGoals of Care: Changing the Game for Lung Cancer Patients
Goals of Care: Changing the Game for Lung Cancer Patients
 
World Cancer Day
World Cancer DayWorld Cancer Day
World Cancer Day
 
New Trends in the Management of Metastatic Prostate Cancer
New Trends in the Management of Metastatic Prostate CancerNew Trends in the Management of Metastatic Prostate Cancer
New Trends in the Management of Metastatic Prostate Cancer
 
CANCER.pptx Type of cancer and treatment of cancer.
CANCER.pptx Type of cancer and treatment of cancer.CANCER.pptx Type of cancer and treatment of cancer.
CANCER.pptx Type of cancer and treatment of cancer.
 
Cancer
CancerCancer
Cancer
 
Role of primary physicians in early detection of cancer
Role of primary physicians in early detection of cancerRole of primary physicians in early detection of cancer
Role of primary physicians in early detection of cancer
 

Similar to Colon cancer 2018 - Dr Lin

Breast-Cancer-final.ppt
Breast-Cancer-final.pptBreast-Cancer-final.ppt
Breast-Cancer-final.pptSean916250
 
Prevention of cancer in women
Prevention of cancer in women Prevention of cancer in women
Prevention of cancer in women vandana bansal
 
Kidney cancer murphy
Kidney cancer murphyKidney cancer murphy
Kidney cancer murphyCheryl Peters
 
Aliments Anti-Cancer
Aliments Anti-CancerAliments Anti-Cancer
Aliments Anti-CancerLuís Rita
 
Pancreatic Cancer Facts 2009 Npf
Pancreatic Cancer Facts 2009 NpfPancreatic Cancer Facts 2009 Npf
Pancreatic Cancer Facts 2009 Npfpdallen1
 
The prevention of cancer: what can I do? | Dr Natacha Sorour
The prevention of cancer: what can I do? | Dr Natacha SorourThe prevention of cancer: what can I do? | Dr Natacha Sorour
The prevention of cancer: what can I do? | Dr Natacha SorourDDHHS_Library
 
Diet, obesity, lifestyle and cancer prevention: epidemiologic perspectives
Diet, obesity, lifestyle and cancer prevention: epidemiologic perspectives Diet, obesity, lifestyle and cancer prevention: epidemiologic perspectives
Diet, obesity, lifestyle and cancer prevention: epidemiologic perspectives Graham Colditz
 
pathology of pancreatic tumors.pptx
pathology of pancreatic tumors.pptxpathology of pancreatic tumors.pptx
pathology of pancreatic tumors.pptxDrAhmedR
 
'Cancer' class for UG 6th sem
'Cancer' class for UG 6th sem'Cancer' class for UG 6th sem
'Cancer' class for UG 6th semDr.Kuntala Ray
 
Third Annual Early Age Onset Colorectal Cancer Symposium - Optimizing Outcome...
Third Annual Early Age Onset Colorectal Cancer Symposium - Optimizing Outcome...Third Annual Early Age Onset Colorectal Cancer Symposium - Optimizing Outcome...
Third Annual Early Age Onset Colorectal Cancer Symposium - Optimizing Outcome...Colon Cancer Challenge Foundation
 
Colorectal Cancer Risk & Risk Reduction: Jan 2017 #CRCWebinar
Colorectal Cancer Risk & Risk Reduction: Jan 2017 #CRCWebinarColorectal Cancer Risk & Risk Reduction: Jan 2017 #CRCWebinar
Colorectal Cancer Risk & Risk Reduction: Jan 2017 #CRCWebinarFight Colorectal Cancer
 
Carcinoma Prostate: etiopathogenesis and staging- 2022 guidelines
Carcinoma Prostate: etiopathogenesis and staging- 2022 guidelinesCarcinoma Prostate: etiopathogenesis and staging- 2022 guidelines
Carcinoma Prostate: etiopathogenesis and staging- 2022 guidelinesDr. Naina Kumar Agarwal
 
2013-cervical-cancer-guideline-presentation-en.pptx
2013-cervical-cancer-guideline-presentation-en.pptx2013-cervical-cancer-guideline-presentation-en.pptx
2013-cervical-cancer-guideline-presentation-en.pptxssuser45ba6e
 
Risk factors for pancreatic cancer
Risk factors for pancreatic cancerRisk factors for pancreatic cancer
Risk factors for pancreatic cancerPete Prestipino
 
Genetic Testing for Cancer Risk
Genetic Testing for Cancer RiskGenetic Testing for Cancer Risk
Genetic Testing for Cancer Riskflasco_org
 

Similar to Colon cancer 2018 - Dr Lin (20)

Genetics: Beyond BRCA, Reem Saadeh-Haddad, MD
Genetics: Beyond BRCA, Reem Saadeh-Haddad, MDGenetics: Beyond BRCA, Reem Saadeh-Haddad, MD
Genetics: Beyond BRCA, Reem Saadeh-Haddad, MD
 
Breast-Cancer-final.ppt
Breast-Cancer-final.pptBreast-Cancer-final.ppt
Breast-Cancer-final.ppt
 
Colon cancer awareness
Colon cancer awarenessColon cancer awareness
Colon cancer awareness
 
Prevention of cancer in women
Prevention of cancer in women Prevention of cancer in women
Prevention of cancer in women
 
Kidney cancer murphy
Kidney cancer murphyKidney cancer murphy
Kidney cancer murphy
 
Aliments Anti-Cancer
Aliments Anti-CancerAliments Anti-Cancer
Aliments Anti-Cancer
 
Pancreatic Cancer Facts 2009 Npf
Pancreatic Cancer Facts 2009 NpfPancreatic Cancer Facts 2009 Npf
Pancreatic Cancer Facts 2009 Npf
 
The prevention of cancer: what can I do? | Dr Natacha Sorour
The prevention of cancer: what can I do? | Dr Natacha SorourThe prevention of cancer: what can I do? | Dr Natacha Sorour
The prevention of cancer: what can I do? | Dr Natacha Sorour
 
Diet, obesity, lifestyle and cancer prevention: epidemiologic perspectives
Diet, obesity, lifestyle and cancer prevention: epidemiologic perspectives Diet, obesity, lifestyle and cancer prevention: epidemiologic perspectives
Diet, obesity, lifestyle and cancer prevention: epidemiologic perspectives
 
pathology of pancreatic tumors.pptx
pathology of pancreatic tumors.pptxpathology of pancreatic tumors.pptx
pathology of pancreatic tumors.pptx
 
Myriad corporate presentation toma january 2011
Myriad corporate presentation toma january 2011Myriad corporate presentation toma january 2011
Myriad corporate presentation toma january 2011
 
Genetics of Cancer
Genetics of Cancer Genetics of Cancer
Genetics of Cancer
 
'Cancer' class for UG 6th sem
'Cancer' class for UG 6th sem'Cancer' class for UG 6th sem
'Cancer' class for UG 6th sem
 
Third Annual Early Age Onset Colorectal Cancer Symposium - Optimizing Outcome...
Third Annual Early Age Onset Colorectal Cancer Symposium - Optimizing Outcome...Third Annual Early Age Onset Colorectal Cancer Symposium - Optimizing Outcome...
Third Annual Early Age Onset Colorectal Cancer Symposium - Optimizing Outcome...
 
Colorectal Cancer Risk & Risk Reduction: Jan 2017 #CRCWebinar
Colorectal Cancer Risk & Risk Reduction: Jan 2017 #CRCWebinarColorectal Cancer Risk & Risk Reduction: Jan 2017 #CRCWebinar
Colorectal Cancer Risk & Risk Reduction: Jan 2017 #CRCWebinar
 
Carcinoma Prostate: etiopathogenesis and staging- 2022 guidelines
Carcinoma Prostate: etiopathogenesis and staging- 2022 guidelinesCarcinoma Prostate: etiopathogenesis and staging- 2022 guidelines
Carcinoma Prostate: etiopathogenesis and staging- 2022 guidelines
 
2013-cervical-cancer-guideline-presentation-en.pptx
2013-cervical-cancer-guideline-presentation-en.pptx2013-cervical-cancer-guideline-presentation-en.pptx
2013-cervical-cancer-guideline-presentation-en.pptx
 
Risk factors for pancreatic cancer
Risk factors for pancreatic cancerRisk factors for pancreatic cancer
Risk factors for pancreatic cancer
 
CCSN Breast Screening for Women in the 40s(1).pptx
CCSN Breast Screening for Women in the 40s(1).pptxCCSN Breast Screening for Women in the 40s(1).pptx
CCSN Breast Screening for Women in the 40s(1).pptx
 
Genetic Testing for Cancer Risk
Genetic Testing for Cancer RiskGenetic Testing for Cancer Risk
Genetic Testing for Cancer Risk
 

More from Virginia Mason Internal Medicine Residency

More from Virginia Mason Internal Medicine Residency (20)

Noon conference specialty talk ccu 5-7-19
Noon conference specialty talk   ccu 5-7-19Noon conference specialty talk   ccu 5-7-19
Noon conference specialty talk ccu 5-7-19
 
Jgk noon conference 5.7.19
Jgk noon conference 5.7.19Jgk noon conference 5.7.19
Jgk noon conference 5.7.19
 
Organism potpourri 5 6-2019
Organism potpourri 5 6-2019Organism potpourri 5 6-2019
Organism potpourri 5 6-2019
 
Noon conference 2 caballero
Noon conference 2 caballeroNoon conference 2 caballero
Noon conference 2 caballero
 
Clinical osa evaluation (residents)
Clinical osa evaluation (residents)Clinical osa evaluation (residents)
Clinical osa evaluation (residents)
 
Noon conference opheim 050219
Noon conference opheim 050219Noon conference opheim 050219
Noon conference opheim 050219
 
Tb answer sheet
Tb answer sheetTb answer sheet
Tb answer sheet
 
Latent tb worksheet
Latent tb worksheetLatent tb worksheet
Latent tb worksheet
 
Intro to ct head prr
Intro to ct head   prrIntro to ct head   prr
Intro to ct head prr
 
2019 04-30 noon conference [stephen slade]
2019 04-30 noon conference [stephen slade]2019 04-30 noon conference [stephen slade]
2019 04-30 noon conference [stephen slade]
 
Noon conference banta
Noon conference bantaNoon conference banta
Noon conference banta
 
Mm 4 29-19
Mm 4 29-19Mm 4 29-19
Mm 4 29-19
 
Migraine headache presentation resident
Migraine headache presentation residentMigraine headache presentation resident
Migraine headache presentation resident
 
Noon conference Lobaton
Noon conference LobatonNoon conference Lobaton
Noon conference Lobaton
 
Noon conference kaylee park
Noon conference kaylee parkNoon conference kaylee park
Noon conference kaylee park
 
Uri presentation 4 23-19
Uri presentation 4 23-19Uri presentation 4 23-19
Uri presentation 4 23-19
 
Case report 4 23-19
Case report 4 23-19Case report 4 23-19
Case report 4 23-19
 
Crc talk for residents 2019
Crc talk for residents 2019Crc talk for residents 2019
Crc talk for residents 2019
 
Noon conference mgus
Noon conference   mgusNoon conference   mgus
Noon conference mgus
 
19 im resident future of rectal cancer
19 im resident future of rectal cancer19 im resident future of rectal cancer
19 im resident future of rectal cancer
 

Recently uploaded

Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu Medical University
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisSujoy Dasgupta
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Vaikunthan Rajaratnam
 
Pregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfPregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfMedicoseAcademics
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationMedicoseAcademics
 
World-TB-Day-2023_Presentation_English.pptx
World-TB-Day-2023_Presentation_English.pptxWorld-TB-Day-2023_Presentation_English.pptx
World-TB-Day-2023_Presentation_English.pptxsumanchaulagain3
 
General_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_WellbeingGeneral_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_WellbeingAnonymous
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project reportNARMADAPETROLEUMGAS
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...Shubhanshu Gaurav
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptPradnya Wadekar
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Peter Embi
 
Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...
Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...
Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...bkling
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxkomalt2001
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024EwoutSteyerberg1
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyMedicoseAcademics
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentsaileshpanda05
 
Physiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid ArthritisPhysiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid ArthritisNilofarRasheed1
 

Recently uploaded (20)

Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosis
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.
 
Pregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfPregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdf
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
 
World-TB-Day-2023_Presentation_English.pptx
World-TB-Day-2023_Presentation_English.pptxWorld-TB-Day-2023_Presentation_English.pptx
World-TB-Day-2023_Presentation_English.pptx
 
General_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_WellbeingGeneral_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_Wellbeing
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project report
 
Cone beam CT: concepts and applications.pptx
Cone beam CT: concepts and applications.pptxCone beam CT: concepts and applications.pptx
Cone beam CT: concepts and applications.pptx
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologyppt
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024
 
Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...
Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...
Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptx
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before Pregnancy
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing student
 
Physiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid ArthritisPhysiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid Arthritis
 

Colon cancer 2018 - Dr Lin

  • 1. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center What You Should Know About Colorectal Cancer Bruce Lin, M.D. November 29, 2018 Hematology-Oncology Virginia Mason Medical Center
  • 2. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Learning Objectives • Epidemiology of colorectal cancer • Rick factors • Colon cancer screening • Management of colon cancer based on stage • Management of rectal cancer • Surveillance for colorectal cancer survivors
  • 3. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center medicinenet.co m
  • 4. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center chemotherapyadvices.com
  • 5. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Epidemiology • 4th most frequent cancer in the US  95,270 new cases of colon cancer estimated in 2018  43,030 new cases of rectal cancer  25% higher incidence in men than women  20% higher incidence in African Americans than in whites
  • 6. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center • Incidence higher in developed countries • 75% occurs as “sporadic cancer” • Remaining cases occur in high risk populations  Inherited conditions, inflammatory bowel disease
  • 7. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center • 2nd leading cause of cancer death in US  50,630 will die of colorectal cancer  25% higher mortality in men  20% higher mortality in African Americans • Decreasing incidence and mortality  Incidence rates have declined about 4% per year  Mortality has decreased by 35% from 1990 to 2007 • Increasing incidence in patients younger than 50  Incidence rates will increase by 90.0% for colon cancer and 124.2% for rectal cancer in patients 20-34 y/o by 2030
  • 8. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Jemal A et al: Cancer statistics, 2007
  • 9. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Colorectal Cancer Incidence Trends by Age and Sex, 1992-2007 American Cancer Society
  • 10. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Risk Factors  Familial syndromes  Familial adenomatous polyposis (FAP) • 0.5 – 1% of all colorectal cancer • Mutation of APC tumor suppressor gene key in the wnt-signaling pathway – APC mutations also found in 80-85% of sporadic colorectal cancers • Hundreds to thousands of polyps • Extracolonic manifestations – Small-bowel adenoma or adenocarcinoma, gastric adenoma and cancer, fundic gland polyps, adrenal adenomas and cancers, thyroid cancer, and desmoid tumor • 95% have polyps by age 35, without colectomy, almost 100% will develop colon cancer at mean age of 39
  • 11. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Modern Pathology
  • 12. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center  Hereditary nonpolyposis colorectal cancer (HNPCC, Lynch Syndrome) • 5% of all colorectal cancers • Caused by mutations in DNA mismatch repair enzymes, MSH-2, MLH-1, PMS-1, PMS-2, and MSH-6 – Also occurs in 10-15% of sporadic colon cancer • Extracolonic manifestations including ovarian, pancreatic, breast, biliary, endometrial, gastric, genitourinary, and small bowel cancers • Can have up to 10 polyps • 80% lifetime risk of colorectal cancer, mean age of diagnosis is 44 • Two-thirds occur in the proximal colon
  • 13. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center • Inflammatory bowel disease  Ulcerative colitis • 5-10% increased risk of colon cancer by 20 years after time of diagnosis  Crohn’s disease • May have a role in colon cancer in the ileocolic region • No increased risk if no colonic involvement
  • 14. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center • Adenomatous polyps Tubular Adenoma 5% risk of cancer Tubulovillous adenoma 20% risk of cancer Villous Adenoma 40% risk of cancer  Size of polyp  <1 cm - <1% risk of cancer  1 cm – 10% risk of cancer  2 cm – 15% risk of cancer Wikipedia.org
  • 15. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center • Personal history of colorectal cancer  1.5 – 3% risk of second colorectal cancer in first 5 years after resection of first one • Family history in first-degree relative (parent, sibling, or child)  Two times the risk of general population  Risk further increased if two first-degree relatives with colorectal cancer or diagnosed below 50-60 years of age
  • 16. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center • Sporadic cancer  Age - 90% of cases in patients older than 50  Environmental and lifestyle factors • Based on observational studies, causal relationship unproven • Associated with a small or uncertain increased risk Risk Factor Comments Diabetes mellitus - Up to 38% increased risk Alcohol - 2-3 drinks per day – 21% increased risk - ≥4 drinks per day – 52% increased risk Obesity (BMI ≥ 25 kg/m2) - 1.5-fold increased risk - 12% increased in CRC mortality Cigarette smoking - 18% increased risk - 25% increase in CRC mortality Red meat or processed meat - Increased risk of left sided tumors - Counterbalanced by benefits such as iron and vitamin B12
  • 17. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Protective Factors Comments Physical activity, exercise -27% risk reduction of proximal colon cancer -26% risk reduction of distal colon cancer - Exercise 150 minutes per week Fruits and vegetable - Mixed data, benefit limited to distal colon cancer - Little benefit associated with > 100 g/day of intake Fiber - Controversial - Fiber from unprocessed wheat bran better than processed forms Folate/folic acid - Controversial, benefit might be limited to dietary rather than supplemental intake Vitamin B6 (pyridoxine) - 10-20% risk reduction of colorectal cancer Calcium - Recommended for prevention of colonic adenomas by American college of Gastroenterology Vitamin D - Poor vitamin D status associated with increased colon cancer risk
  • 18. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Protective Factors Comments Magnesium - Associated with 40% risk reduction of colorectal cancer in women in a Swedish study Garlic - Controversial, listed as probable protective factor by American Institute of Cancer Research, but very limited credible evidence per FDA. Fish/omega-3 fatty acids - Modest 12% risk reduction of colorectal cancer Aspirin/NSAIDs -20 – 40% risk reduction of colonic adenomas and colorectal cancer incidence - Protective effect in patients with Lynch syndrome - Newer data suggests mortality benefit might be limited to small subset of patients with specific mutation - Can cause GI ulcers, NSAIDs use may also cause cardiovascular side effect - USPSTF recommends against routine use of aspirin and NSAIDs to prevent colorectal cancer in average risk individuals
  • 19. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Carcinogenesis Gastroenterology, vol. 138, issue 6, p. 2059-2072
  • 20. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Screening Recommendations USPSTF Recommendation Statement 2016 JAMA. 2016;315(23):2564-2575. doi:10.1001/jama.2016.5989
  • 21. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center JAMA. 2016;315(23):2564-2575. doi:10.1001/jama.2016.5989
  • 22. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center ACS Guideline for CRC Screening • 2018 guideline update recommends starting screening at 45 years and older  Average risk of CRC  High-sensitivity stool-based test or visual exams such as colonoscopy, CT colonography, or flexible sigmoidoscopy  May not be covered by most insurance
  • 23. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Screening for High Risk Patients • HNPCC  Colonoscopy every 1-3 years starting at ages 20-25 • FAP  Screening colonoscopies as early as age 10 • IBD  AGA • Colonoscopy should start after 8 years in patients with pancolitis, 15 years in patients with colitis limited to left colon • Repeated every one to two years • Recommendation similar for both ulcerative colitis and Crohn’s disease
  • 24. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Workup • Pathology review • Colonoscopy • CBC, platelets, chemistry profile, CEA • Chest/abdominal/pelvic CT with contrast • PET-CT not routinely indicated
  • 25. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Staging National Cancer Institute
  • 26. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Staging, Incidence, and Treatment Stage I Stage II Stage III Stage IV Staging T1, N0, M0 T2, N0, M0 A: T3, N0, M0 B: T4, N0, M0 A: T1-2, N1, M0 B: T3-4, N1, M0 C: Any T, N2, M0 Any T, Any N, M1 Definition Invades submucosa (T1) or muscular propria (T2) Invades subserosa, nonperitonealized pericolic/perirectal tissues (T3) or invades other organs/structures/ visceral peritoneum (T4) Involves 1 to 3 (N1) or more (N2) lymph nodes Involves distant metastases Incidence 15% 25% 35% 25% Usual treatment Surgery Surgery with or without chemotherapy Surgery adjuvant chemotherapy Chemotherapy with or without surgery AJCC Staging Manual, Sixth Edition
  • 27. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center AJCC Staging Manual, Seventh Edition
  • 28. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center AJCC Staging Manual, Seventh Edition
  • 29. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Treatment • Stage 0  Cured by endoscopic resection alone • Stage I  Surgery alone is curative for more than 85% of patients • Stage II  Benefit of adjuvant chemotherapy only 3% in 3-year disease-free and overall survivals  Adjuvant chemotherapy in patients with T4 disease or high risk features • Grade 3-4, lymphatic/vascular invasion, bowel obstruction, < 12 lymph nodes examined, perineural invasion, localized perforation, or close, indeterminate or positive margins  Multi-gene assay panels (Oncotype DX Colon Cancer, ColoPrint) not yet standard
  • 30. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center  Stage III ◦ 5-year survival rate is 30-50% with surgery only ◦ Adjuvant chemotherapy for 6 months is standard of care  Stage IV ◦ Without therapy, median survival only 5-6 months ◦ Systemic combination chemotherapy
  • 31. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center ◦ Limited hepatic or pulmonary metastasis  Resection of metastatic disease significantly increases survival  Evaluation by multidisciplinary team regarding resectability  Upfront systemic chemotherapy for conversion to resectability, only 10-15% of patients are converted to truly resectable ◦ Resection of primary tumor not necessary unless obstructed or perforated
  • 32. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Rectal Cancer • Stage I  Excision/surgery • Stage II, Stage III  Neo-adjuvant chemo/XRT (5-6 weeks) followed by surgery and 4 months of adjuvant chemotherapy • Lower rate of local recurrence, toxicities, and higher rate of sphincter preservation • Stage IV  Management similar to colon cancer
  • 33. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Surveillance • H&P every 3-6 months for 2 years then every 6 months for a total of 5 years • CEA every 3-6 months for 2 years, then every 6 months for a total of 5 years • C/A/P CT annually x 3-5 years for patients at high risk • Colonoscopy in 1 year except if no preoperative colonoscopy due to obstructing lesion, colonoscopy in 3- 6 months  If advanced adenoma, repeat in 1 year  If no advanced adenoma, repeat in 3 years, then every 5 years. • PET-CT not routinely recommended
  • 34. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center THANK YOU!
  • 35. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Question 1 A 47-year-old woman is evaluated for abdominal discomfort of 3 months’ duration accompanied by a change in stool caliber. Her medical history is otherwise noncontributory, and her family history is unremarkable. Physical examination, including rectal examination, is normal. Results of fecal occult blood testing are positive. Colonoscopy reveals a 3-cm sigmoid tumor confirmed as adenocarcinoma on biopsy. On resection of the mass, tumor invasion of the muscularis propria is identified, in addition to metastases in one regional lymph node. The postoperative recovery is uneventful, and the patient presents for a follow-up office visit. Which of the following is the most appropriate next step in management? (A) Adjuvant chemotherapy (B) Radiation therapy (C)Observation (D)Immunohistochemical staining of the tumor
  • 36. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Question 2 A 50-year-old woman is evaluated for a routine follow-up visit. Her history includes a diagnosis of stage II colon cancer 2 years ago for which she underwent a surgical resection and received no adjuvant therapy. On physical examination, she appears healthy. Cardiopulmonary and abdominal examinations are normal. Laboratory studies include a serum CEA concentration that has increased from a recent baseline measurement of < 5 ng/mL to 41 ng/mL. At CT scan of the abdomen shows six hepatic lesions measuring from 2 to 7 cm. Multiple pulmonary nodules of < 1 cm are noted on CT scan of the lung. On biopsy, the liver lesions are confirmed as adenocarcinoma consistent with the initial primary tumor. Which of the following is the most appropriate next step in management? (A) Abdominal and chest PET (B) Hepatic resection (C)Systemic chemotherapy (D)Colonoscopy (E) Pulmonary nodule biopsy
  • 37. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Question 3 A 78-year-old woman is evaluated for worsening symptoms of metastatic colorectal cancer. At diagnosis 5 months ago, she had an 11-cm liver lesion, extensive large pulmonary nodules, and a 5-cm sigmoid mass. She underwent resection of the primary tumor to relieve obstructive symptoms but developed multiple pulmonary emboli postoperatively. Her initial treatment regimen consisted of 5-fluorouracil and oxaliplatin but resulted in disease progression after 8 weeks of therapy. Currently, she cannot care for herself because of cancer-related symptoms and is mostly bedbound. Which of the following is the most appropriate next step in management? (A) Irinotecan chemotherapy (B) Palliative care (C)Cryotherapy (D)Radiotherapy
  • 38. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Question 4 A 61-year-old woman is evaluated after a 2-month history of bright red blood on defecation and a change in stool caliber. The medical history is otherwise noncontributory, and the family history is unremarkable. On physical examination, a tumor is palpated just above the anal sphincter. Laboratory studies indicated a hemoglobin of 11.1 g/dL. Liver chemistry studies are normal. CT of the abdomen reveals a distal rectal mass. Adenocarcinoma of the rectum is confirmed by biopsy. Which of the following is the most appropriate next step in management? (A) Preoperative radiation therapy plus chemotherapy (B) Preoperative chemotherapy (C)Abdominoperitoneal resection (D)Preoperative radiation therapy
  • 39. © 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center Answers • 1. A • 2. C • 3. B • 4. A