3. Colorectal Cancer
Sex: incidence equal men/women until age 50;
then becomes higher in men than women
Incidence and mortality greater in men than
women – 35% to 40% overall
Race/ethnicity: incidence & deaths highest in
blacks, lowest in Indian/Alaska Natives &
Hispanics
7. Screening Tests
Goal: detect & remove adenomatous polyps
Begin age 50
Increased surveillance for those at high risk
1st degree relative begin 10yrs prior to dx
Hx of polyps, genetic mutations etc.
Collaborative effort – ACS, ACR, US CRC task
force.
9. Fecal Occult Blood Test
2/3 of colon cancers and some polyps bleed
Avoid foods for 3 days before exam that can alter test
results:
Aspirin
NSAIDs, such as ibuprofen (Advil, Motrin, others)
Anticoagulants, such as warfarin (Coumadin)
Artichokes, fresh broccoli, cabbage, cauliflower,
cucumbers, horseradish, mushrooms, potatoes,
radishes and turnips
Meat and fish
Vitamin C supplements
Iron supplements
10.
11. Colonscopy
Similar equipment and patient
positioning for sigmoidoscopy
Underutilized
Sedation recommended
Full bowel prep required
If heart valve disease – must have
antibiotics before and after
Arrange for transportation
will be dizzy (due to meds)
after procedure
21. Targeted Therapies
Monoclonal Antibody Mab
Large molecules ‐ IV
Extracellular targets
Prevent ligand binding
Stimulate the immune system
Tyrosine kinase inhibitors
Small molecules ‐ Oral
Multiple Targets ‐ outside and inside the cell
Inhibit signaling cascade
22. Signs and Symptoms
Right Sided
Vague, dull pain, dark stools, mass RLQ
Anemia – fatigue, wt loss, weakness
Left Sided
↑gas, pain, cramps, bright red blood,
Change in bowel habit – const/diarr
∆ in caliber of stool – Obstruction
Rectal – fullness, frank blood, tenesmus
23. Pathophysiology
Colon vs Rectal Cancer
Adenocarcinoma; >90%, arising in glandular
epithelial tissue of mucosa
Squamous cell; < 10%
Metastasis
lymphatic, venous,
direct extension, implantation
1° Liver, Lungs, Peritoneal Cavity
also bone, adrenals, ovary, brain
Colon → liver Rectal → lung
24. Colorectal Case Study
52 yr old African American male
Last physical 5yr ago
H&P: occasional blood on stool denies
pain, ∆ in bowel habit, wt loss or fatigue
Family; Dad died 50ish, unknown
25. CRC Case Study
Physical Exam WNL
Non distended, +BS x 4, ‐ pain, HSM or masses, DRE
neg
Differential Dx
Tests : CBC (anemia)
Refer to GI for colonoscopy
Invasive adenoca of sigmoid colon
26. Diagnostic Studies
Staging work up
CBC, CMP, CEA, +/‐ CA19‐9, bili
CT scan of chest, abdomen & pelvis to r/o
metastatic disease
PET scan
Surgical Consult
Medical Oncology Consult
27. Surgical Op>ons
Colon cancer, Goal: Cure
Hemicolectomy
Laparoscopic vs laperotomy
Colostomy: rare, d/t bowel obstructed temporary vs
permanent
Resection of Liver or Lung Metastasis
Intent to cure
May include RFA (radiofrequency ablation)
May need neo‐adjuvent chemo to downstage
28. Surgical Op>ons
Rectal Cancer , Goal: Cure
Prevent local recurrence
Maintain bowel, bladder and sexual function
Maintain & improve pts QOL
20% impotency, sexual dys, urinary retention, bladder
dys, fecal incont & urgency, stoma
29. Surgical Op>ons
Rectal Cancer
TAE: small early stage lesions, 8cm from anal verge
TME: resects node bearing mesorectum, ↓ local recurrence
from 30% to <10%
Low ant resection: proximal lesions, >6cm from anal verge
AP resection: <6cm from anal verge, colostomy
30. Colorectal Case Study
Surgical consult
CT CAP w & w/out contrast
CMP, CEA, PT, PTT, EKG, CXR
L hemicolectomy w/anastomosis
6cm moderately differentiated invasive
adenocarcinoma
Pathology pending
31. Staging Criteria
Pathologic/histologic stage
T: depth of tumor penetration into &
through the intestinal wall
N: regional lymph node involvement
M: absence or presence of distant
metastases
G: Grading 1‐4, degree of differentiation
AJCC 7th Edition
34. TNM Stages for CRC
STAGE T N M
I T1 or T2 NO MO
IIA T3 NO MO
IIB T4a NO MO
IIC T4b NO MO
IIIA T1‐T2 N1 MO
T1 N2a MO
IIIB T3‐T4a N1 MO
T2‐T3 N2a MO
T1‐T2 N2b MO
IIIC T4a N2a MO
T3‐T4a N2b MO
T4b N1‐N2 MO
46. Stage IV Colon Ca
Single Met in Liver or Lung
Surg: resect colon and met lesion
Adj chemo: Avastin + Folfox x 6mth
Restage and surveillance
Multiple Mets
Adj chemo: Avastin + Folfox or other
Restage in 2mths for surg resection and efficacy of
chemotherapy
48. Rectal Caner
Stage IV – widely metastatic
Combination chemo + Avastin may be given to control
disease prior to starting chemo/radiation
Avastin is not given during XRT
49. NP Role
H&P
Assess physical and mental health
Assess pts knowledge of dz and dx
Staging
Path review for staging
Review CT/PET, labs: CEA, CBC, CMP, LFT’s
50. NP Role
Treatment Planning
Baseline labs/scans, +/‐ port‐a‐cath
Educate: tx, schedule, side effects
Write chemo orders, prescriptions
Tx plan to billing/authorization
Management
Tolerance, side effects, response
Complications
52. Treatment Plan
Labs: CBC, CMP, CEA
PET scan ‐ baseline
FOLFOX6 q2wks x 12 cycles
Education
Schedule of tx, chemo s/e, pump
Who and when to call
Rx for anti‐nausea
60. EGFR Inhibitors
Hypomagnesia
Cause: renal wasting
↑ likelihood with ongoing tx, 50%
Monitor Mg q mth
Replace orally at least 400mgs QD
IV replacement
61. NP role in Management
Tolerance to therapy
Management of side effects
Adjustment to chemo regimen
Coping with dz and therapy
Supportive therapy/Advocate for pt
Advanced disease
Restaging PET/CT
Monitor markers
62. Colorectal Case Study
S/P FOLFOX x 6 cyles
Mild nausea x 2d,
Neuropathy: fingertips to nailbed, resolves
w/in 10d
Plts 75k
PE – WNL
Plan ?
66. Reference List
ACS (2012), Colorectal Facts & Figures 2011
ACS (2008), Colorectal Facts & Figures 2008‐2010.
Davies, L. & Goldberg, R., (2008). First‐Line Therapeutic Strategies in
Metastatic Colorectal Cancer. Oncology.
Dotan, E., Browner, I., Hurria, A & Denlinger, C. (2012) Challenges in
the Management of Older Patients with Cancer.
Lindsetmo, R.O., Yong & Delaney, (2009), Surgical treatment for
Rectal Cancer: An International Perspective
Meyerhardt, J. & Mayer, R. (2009). Drug Therapy; Systemic Therapy
for Colorectal Cancer. NEJM.
67. Reference List
Morse, M. (2006), Supportive Care in the Management of Colon
Cancer, Supportive Cancer Therapy
NCCN (2012), Clinical Practice Guidelines in Oncology, Colorectal
Cancer.
http://www.cancer.gov/flash/targetedtherapies/flex/main.
html
http://www.cancerstaging.org/staging/posters/colon8.5x11.
pdf