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risk factors for CRC
age- increases after age 40, 90% are 50+
IBD- 30x risk (risk is small during first 10 yrs of disease, longer duration IBD increases risk)
family hx of CRC- 1st degree relative increase risk by 2-2.5x
lifestyle factors- increased risk: alcohol, T2DM, obesity, western diet, smoking
personal Hx of CRC
hereditary- heriditary nonpolyposis colorectal cancer (HNPCC), familial adenomatous poylposis (FAP)
presentation of CRC
hematochezia (blood in stool), melana (black tarry stool), abd pain, and/or change in bowel habits
CRC metastases locations
liver, lungs, peritoneum
if CRC is in colon where is first metastases usually
liver
if CRC starts in rectum where is initial metastases
lungs
major screening tests to detect polyps or CRC
fecal immunochemical tests (FIT)
sigmoidoscopy
barium enema
colonscopy
who are considered average risk individuals for screening purposes
people aged 50-74
no personal or fam Hx of colon cancer
have not had a colonscopy in last 5 years or are currently scheduled for one
no personal Hx of inflammatory colitis or crohns
what screening test is used for average risk individuals
Fecal immunochemical test (FIT)
who needs a colonscopy for screening
1st degree relative (parent, child, sibling) diagnosed with colon cancer under age of 60
2 1st degree relatives (and not necessarily under 60
list all people who get screened with FIT kit
age 50-74 and no personal/fam Hx of CRC, no colonscopy in last 5yrs or one scheduled, no personal Hx of crohns/colitis
one family member diagnosed with CRC over age of 60
more distant relatives (aunts, uncles, cousins, grandparents)
stage I CRC
tumor confined to bowel mucosa
does not extent thru bowel wall
stage II CRC
may extend thru bowel wall to adjacent structures, but no LN involvement
stage III CRC
any LN involvement
stage IV CRC
distant metastases
prognostic factors for CRC
stage of tumor (most reliable prognostic factor)
histologic grade (high- poor prognosis)
CEA levels increased (poor prognosis)
degree of tumor penetration thru bowel well for any given stage
extent of LN involvement (1-3 vs 4+)
rectal cancer has poorer prognosis than colon
lymphovascular invasion predicts an increased risk of local and distant recurrence
stage I colon cancer treatment
Surgery
stage II colon cancer treamtnet
surgery
may consider adjuvant chemo if tumor adherence or fixation to adjacent structures or otherwise poor prognosis
stage III colon cancer treatment
surgery
adjuvant chemo x 6mo
stage IV colon cancer treatment
palliative surgery for obstructive lesions, palliative chemo
recurrent colon cancer treatment
similiar to stage IV: palliative surgery for obstructive lesions, palliative chemo
difference in treatment of rectal and chemo cancer
rectal cancer is similar treatment to colon except adjuvant is used in both stage II and III
why is treatment of rectal cancer slightly different than colon
rectums location in the pelvis and it’s close proximity to other pelvic organs
the absense of outer covering layer (serosa) that is present in colon
what decreases the incidence of local (pelvic) recurrences in rectal cancer
radiation
When is adjuvant therapy given in colon and rectal cancer
in patients who have undergone potentially curative surgery who are considered high risk for relapse
in colon and rectal cancer when should adjuvant Tx commence
within 8 weeks of surgery
standard adjuvant regimen for colon and rectal cancer (stage III and high risk stage II)
Folfox (oxaliplatin, folinic acid (leucovorin), flourouracil bolus and IV infusion)
repeat q 14 days for 12 cycles (6mo)
how long to treat metastatic stage IV CRC
indefinite
first line Tx for metastatic colorectal cancer
Folfiri and Bevacizumab repeat q 14 days
(ironetecan, folinic acid (leucovorin), flourourical bolus, bevacizumab, flourouracil infusion)
second line metastatic CRC treatment
Folfox repeat q 14 days (oxaliplatin, folinic acid (leucovorin), flourouracil bolus then IV)
third line metastatic CRC treatment
panitumumab repeat q 2wks
requirement for panitunumab
wild type RAS
other metastatic Tx option
Regorafenib (multikinase inhibitor inhibiting VEGF, PDGF, and others)
Regorafenib ae
increased LFTs, fatigue, htn
flourouracil AE
bone marrow suppresion, mucositis, diarrhea
capecitabine AE
flourourical toxicities, hand-foot rash
oxaliplatin AE
acute cold sensitivity, cumulative peripheral neuropathy, hypersensitivity rxns
irinotecan AE
early and late diarrhea, dehydration, severe neutropenia
bevacizumab AE
bleeding, ATE, impaired wound healing, GI perforations
cetuximab AE
infusion rxns, skin rash, electrolyte wasting (ex: hypoMg)
panitumumab AE
infusion rxns, skin rash, electrolyte wasting