Colorectal Cancer

Colorectal Cancer Rate of Growth

10-20 years

Incidence of Colon Cancer

106,180 (3rd most common cancer in American men and women)

Mortality of Colon Cancer

52580; 3rd leading cause of cancer related deaths

Highest risk for CRC

Black communities; 20% most likely to be diagnosed and 40% higher mortality

Modifiable risk factors

• smoking

• Alcohol intake

• High fat diet

• High intake of red and processed meats

• Obesity

• Low fiber diet

• Physical inactivity

Nonmodifiable risk factors

• >50 years old

• Black

• personal or family history of colon CA or IBS (20%of cases)

• Attenuated familial polyposis (combined 5% of cases)

• MUTYH-associated polyposis (combined 5%)

• Lynch syndrome (combined 5%)

• PJS-1, SPS-1, CPUE-1

• Edematous polyp presence

Prevention of CRC

• healthy weight

• Limit red and processed meats

• Increase vegetable and fruit consumption

• Limit alcohol to 2 drinks a day for men, 1 drink a day for women

• Avoid tobacco

• Exercise

• Aspirin, NSAIDs(high risk)

• Dairy & Milk consumption

Screening Age

Age 45-75

Colonoscopy

Gold standard; Q10 years

Flexible Sigmoidoscopy

Q5 years

Air contrast barium enema

Q5 years

Fecal occult blood

Annual

Fecal immunochemical test

Annually

Stool DNA test

Q3 years

percentage of CRC that is adenocarcinoma

95%

Molecular classifications

• KRAS/NRAS(mets)

• BRAF(Mets)

• MMR or MSI when appropriate

Staging

• TNM

• Colectomy w/ minimum of 12 LN for staging

Survival for CRC

65%

Survival for localized CRC

90%

Survival for Stage IV

14%

Percentage of pts diagnosed in early stage

39%

Surgery for respectable disease of colon

Colectomy with en-bloc removal of regional LN

Surgery for removal of resectable disease of rectum

Transanal, transabdominal resection

Neoadjuvant use of radiation

• in colon with bulky disease

• For unresectable disease with chemo

Adjuvant use for radiation

• Rectal cancer due to high recurrence rate

Systemic treatment in colon cancer

Neoadjuvant with radiation for unresectable tumor

Systemic treatment for rectal cancer

• adjuvant: FOLFOX, CAPEOX, capecitabine/5-FU/leucovorin

• Neoadjuvant: capecitabine for unresectable tumor

Systemic treatment for metastasis

• FOLFOX, FOLFIRI ± bevacizumab or cetuximab/panitumumab dependent upon KRA/NRAS status

• Regorafenib: targeted therapy of choice

• Trifluridine/tipiracil

• PD-1 inhibitors pembrolizumab/nivolumab: dMMR/MSI-H

• PD-L1 Inhibitors atezolizumab

• CTLA-4 Inhibitors ipilimumab