cancer of the colon and rectum
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Colorectal CancerRobert Miller MD
www.aboutcancer.com
Third Most Common Cancer in Men and Women
Odds of Developing Colorectal cancer in the US (2007-9)~ 5%
Type Men Women
Any Cancer 45% (1in 2) 38% (1 in 3)
Breast 12% (1 in 8)
Colorectal 5% (1in 19) 4.8% (1 in 21)
Prostate 16% (1in 6)
Declining Incidence last 30y
Third Most Lethal Cancer in Men and Women
Declining Mortality in Men US Data 1930 to 2009
Declining Mortality in Women US Data 1930 to 2009
Odds of Dying of Colorectal cancer in the US (2007-9) ~ 2%
Type Men Women
Any Cancer 23% (1in 4) 19% (1 in 5)
Breast 2.8% (1 in 36)
Colorectal 2.11% (1in 47)
1.94% (1 in 52)
Prostate 2.8% (1in 36)
Most patients are diagnosed before they have symptoms because of screening or the findings of rectal blood (hematochezia) or anemia
Abdominal pain — 44 percentChange in bowel habit — 43 percentHematochezia or melena — 40 percentWeakness — 20 percentAnemia — 11 percentWeight loss — 6 percent
Patients who are symptomatic at diagnosis have a somewhat worse prognosis. In one report, the five-year survival rate for symptomatic (49%) and asymptomatic patients (71%)
Symptoms
Median Age of Patients with colon and rectal cancer (2005-2009)
Site Male Female
Colon 69y 73y
Rectum 64y 66y
Colon
8% less than 50y
Rectum
14% less than 50y
Age Distribution from the NCDB for 2000- 2012
Screening
Colonoscopy every 10 years starting at the age of 50 unless high risk
How should family history effect the age to start screening colonoscopy?
First-degree (share one half genes) = parent, child or siblingSecond-degree (share one quarter genes) = grandparents, uncle, niece
Workup or Evaluation Prior to Deciding on Treatment for Colon Cancer
Pathology Report• Confirm that it is malignant (usually adenocarcinoma)• Information about stage: depth in invasion and lymph nodes
involved (look at 12 nodes)• Surgical margins (to ensure complete removal)• Other prognostic risk factors: grade, vascular invasion,
perineural invasion• Genetic risk factors: MSI (microsatellite instability) testing/
MMR protein to look for Lynch syndrome• Gene mutation testing: KRAS and BRAF that will determine
whether the patient would benefit from anti EGFR drugs (cetuximab, panitumumab, regorafenib)
Workup or Evaluation Prior to Deciding on Treatment for Rectal Cancer
T2 T3
Nodes
Transrectal Endoscopic Ultrasound
Accuracy of Imaging in Staging Rectal Cancer
Site Ultrasound
CT MRI
Tumor 80-95% 65-75% 75-85%
Nodes 70-75% 55-65% 60-65%
Staging
Staging: T (tumor stage)
Stage Depth of Invasion
T1 submucosa
T2 muscularis propria
T3 Pericolorectal tissue
T4a Surface of visceral peritoneum
T4b Into other organs/structures
Staging: T (tumor stage)
Staging: N (lymph node stage)
Stage Nodes Involved
N0 0
N1a 1
N1b 2, 3
N2a 4, 6
N2b 7 or more
Staging: N (lymph node stage)
Colon Cancer Stage Distribution
Rectal Cancer Stage Distribution
NCCN.org
Treatment of colorectal cancer
• Early stages are treated with surgery• More advanced stages have surgery
followed by chemotherapy (colon) or radiation and chemotherapy prior to surgery (rectum)
• Metastatic or recurrent disease treated with chemotherapy or targeted therapy and possibly radiation, surgical resection or RF ablation
Survival in Months Drug Regimen
14.8 months bolus 5FU/LV17.4 months Infusional 5FU/LV20.1 months irinotecan (Camptosar) +5FU/LV20.3 months camptosar = 5FU + bevacizumab (Avastin)21.5 months FOLFIRI then FOLFOX25.1 months irinotecan/5FU + avastin +oxaliplatin (Eloxatin)
New Drugs for Colorectal Cancer
There are now seven different classes of drugs with significant antitumor activity:
• 5-fluorouracil [5-FU] which is usually given with leucovorin, capecitabine, (Xeloda) tegafur plus uracil
• Irinotecan (Camptosar)• Oxaliplatin (Eloxatin)• Cetuximab (Erbitux) and panitumumab (Vectibix), two
monoclonal antibodies (MoAbs) directed against the epidermal growth factor receptor (EGFR) if KRAS wild type
• Bevacizumab (Avastin), a MoAb targeting vascular endothelial growth factor (VEGF)
• Aflibercept, a recombinant fusion protein consisting of vascular endothelial growth factor (VEGF) binding portions from the human VEGF receptors 1 and 2 fused to the Fc portion of human immunoglobulin G1,
• Regorafenib, a small molecule inhibitor of multiple kinases
30 Year Trends in 5 Year Survival
Site 1975 2008
Colon 51% 65%
Rectum 48% 68%
Stage and 5 Year Survival US Data 2002- 2008
Stage Incidence Survival
All 100% 64%
Local 39% 90%
Regional 36% 70%
Distant 20% 12%
Survival with Colon Cancer
Survival with Rectal Cancer
5 Year Survival from NCDB
Stage Colon Rectum
I 77.5% 77.7%
II 66.6% 63.2%
III 54.5% 58.0%
IV 9.6% 9.8%
www.adjuvantonline.com
Colorectal CancerRobert Miller MD
www.aboutcancer.com