colorectal cancer

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