Transcript Document

Colorectal
Cancer
Update
Jonathan A. Laryea, MD FACS FASCRS FWACS
Division of Colon & Rectal Surgery
Department of Surgery
University of Arkansas for Medical Sciences
Little Rock, Arkansas
Arkansas Cancer Coalition Summit XV March 11, 2014
Disclosures
No Disclosures
Outline
 Facts and Figures
 Risk Factors
 Clinical Presentation and Management
 Screening
9%
Colon & rectum
Facts
 2014 Estimates
 New cases: 96,830 (colon); 40,000 (rectal)
 Deaths: 50,310 (colon and rectal combined)
 Death rate over last 20 years declining
 Screening and improvements in treatment
Risk Factors
Sporadic
(65%–
85%)
Rare CRC
syndromes
(<0.1%)
Familial adenomatous
polyposis (FAP) (1%)
Familial
(10%–30%)
Hereditary
nonpolyposis
colorectal cancer
(HNPCC) (5%)
Adapted from Burt RW et al. Prevention and Early Detection of CRC, 1996
Risk Factors
 Adenomatous polyps
 Physical
Inactivity/obesity
 Age
 Inflammatory Bowel
Disease
 History of Cancer
 Family History of
Colorectal Cancer
 Smoking
 NSAIDS
 Diets/Supplements
 Race
Cancer Risk in Polyps
<1 cm 1-2 cm >2 cm
Tubular Adenoma
1.0% 10.2%
34.7%
Tubulovillous
3.9%
7.4%
45.8%
Vilous Adenoma
9.5% 10.3%
52.9%
Adenoma-Cancer Sequence
Loss of
APC
Normal
epithelium
Hyperproliferative
epithelium
Activation Deletion of Loss of
of K-ras
18q
TP53
Early
adenoma
Intermediate
adenoma
Adapted from Fearon ER. Cell 61:759, 1990
Late
adenoma
Other
alterations
Carcinoma
Metastasis
Age
Familial Risk
100
70%
80
Approximate
60
lifetime
CRC risk
(%)
40
20
2%
6%
8%
10%
17%
0
None
One Two 1° HNPCC
One 1° One 1°
and two 1° age
mutation
2°
<45
Aarnio M et al. Int J Cancer 64:430, 1995
Houlston RS et al. Br Med J 301:366, 1990
St John DJ et al. Ann Intern Med 118:785, 1993
Affected family members
Risk of Colorectal Cancer
5%
General population
Personal history of
colorectal neoplasia
15%–20%
Inflammatory
bowel disease
15%–40%
70%–80%
HNPCC mutation
>95%
FAP
0
20
40
60
Lifetime risk (%)
80
100
Diet
dietary fiber
vegetables
fruits
decreased risk
antioxidant vitamins
calcium
folate (B Vitamin)
Diet
consumption of red meat
animal and saturated fat
increased risk
refined carbohydrates
alcohol
Clinical Presentation
CRC by Site
Stage at Diagnosis
Distant (cancer has
metastasized)
19%
Regional (spread to
regional
lymphnodes)
37%
Adapted from NCI Cancer Facts and
Figures 2010
Unknown
(unstaged)
5%
Localized (confined
to primary site)
39%
Staging Workup
 Endoscopy with biopsy
 CT Scan
 CXR
 ?PET Scan
 CEA
STAGES OF COLON CANCER
Sites of Metastasis
 Liver
 Lung
 Brain
 Bone
Principles of Management
 Surgery is the mainstay of treatment
 Complete removal of tumor with negative margins
 Removal of involved node-bearing tissue
 Avoid spillage or disruption of tumor
 Assess for evidence of metastasis
 Personalized treatment based on molecular profiling
Management
Colon Cancer
 Stage I
 Surgery alone
 Stage II
 Surgery alone +/- chemotherapy
 Stage III
 Surgery + Chemotherapy
 Stage IV
Chemotherapy alone
Surgery + chemotherapy +
metastasectomy
Rectal Cancer
 Similar to Colon Cancer
 Chemoradiation for Stages II and III
Minimally Invasive Surgery
 Laparoscopy/ Robotic-assisted
 Oncologically equivalent
 Benefits versus cost
 Smaller incisions
 Less pain
 Shorter length of stay
 Earlier return to activities
 Overall cost-effective
Screening
 Prevents cancer by removing precancerous polyps
 Early identification of cancer
 Misconceptions and ignorance abound regarding screening
 PCP recommendation has most significant impact
 Screening fully covered with no out of pocket expenses
under ACA
Screening
 Average Risk
 Start at age 50
 Family History
 Start at age 40 or
 10 years earlier than youngest family member with
cancer
 High Risk
 Based on risk factors
 Familial Adenomatous Polyposis; start at age10-12y and
yearly
 Lynch Syndrome; start at age 20y and q2y till 45y then
yearly
Screening Modalities
 High sensitivity Fecal occult blood testing q1yr
 Flexible Sigmoidoscopy q5years +FOBT q3yrs
 Colonoscopy q10 years
 CT colonography*
 Stool DNA/ FIT
5-year Survival
 Stage I
 Stage IIA
 Stage IIB
 Stage IIIA
 Stage IIIB
 Stage IIIC
 Stage IV
93%
85%
72%
83%
64%
44%
8%
Take home message
 Incidence and death rates are declining
 Eat right, exercise and avoid smoking
 Screening saves lives
 Most people get screened because their doctor told them to
 Advances in treatment have led to improved survival
 Advances in molecular profiling of cancers has led to personalized
treatments
Thank you
Jonathan A. Laryea, MD
[email protected]
Clinic Appointments: (501) 686-6211
Office: (501) 686-6757