3.5 Colorectal Cancer - Comeau

colorectal cancer is 30% more common in

a. women

b. men

c. Hispanics

d. Caucasians

b

name the 2 most important RF for colorectal cancer

obesity and sedentary lifestyle

name the two germline inherited mutations that can cause colorectal cancer (CRC)

familiar adenomatous polyposis (FAP)

hereditary nonpolyposis CRC

if a pt has polyps it means they have…

CRC

more than 90% of colorectal tumors are

adenocarcinomas

how does CRC spread

lymph nodes and or through the blood

CRC spreads through the lymph nodes and or blood to which areas of the body

liver

lungs

peritoneum

what is the most important method of preventing CRC

physical activity

if a pt has FAP, they can prevent CRC by…

total colectomy or proctocolectomy (removal of the colon)

at what age should ppl begin screening for CRC

45

what age range is indicated for regular CRC screening

50-75

what are the two CRC screening methods that can be done at home?

fecal immunochemical test (FIT)

multitarget stool DNA (Cologard)

fecal immunochemical test:

1. what is it used for

2. how often should it be done

1. CRC screening at home

2. yearly

multitarget stool DNA (cologard):

1. what is it used for

2. how often should it be done

1. CRC screening at home

2. q3yr

what are the 3 CRC screening methods done by a physician?

flexible sigmoidoscopy (FS)

CT colonography

colonoscopy

how often should each of these CRC screening methods be done?

1. flexible sigmoidoscopy (FS)

2. CT colonography

3. colonoscopy

1. q5y

2. q5y

3. q10y

which two CRC screening methods can have a biopsy?

Colonoscopy

Flexible sigmoidoscopy

which CRC screening method canNOT have a biopsy?

CT Colonography

which two CRC screening methods require full bowel cleansing?

colonoscopy and CT colonography

which CRC screening method can visualize the whole colon

colonoscopy

how to diagnose CRC

colonoscopy with biopsy

most common stage of CRC at diagnosis

III (regional Lymph node involvement)

local tx options for CRC

surgery or radiation

T or F:

radiation can ONLY be used for colon cancer, NOT rectal cancer

F

(opposite)

all pts with CRC must be tested for ____ to determine treatment

DNA mismatch repair status

if a pt with CRC and their MMR genes are present and working, they are…

a. pMMR

b. dMMR

a

if a pt with CRC and their MMR genes are missing and not working, they are…

a. pMMR

b. dMMR

b

what are the two types of dMMR

germline

somatic

describe germline dMMR

inherited or “in blood”

causes cancer

describe somatic dMMR

“in tumor”

causes cancer to grow

if a pt is dMMR, they MUST get ____

a. chemotherapy

b. endocrine therapy

c. immunotherapy

d. radiation

c

non-metastatic CRC treatment:

stage I

surgery ONLY

non-metastatic CRC treatment:

stage III

surgery then adjuvant chemotherapy

stage III nonmetastatic CRC adjuvant chemo therapy:

name the two options

FOLFOX

CAPEOX

which is more effective, FOLFOX or CAPEOX?

neither, equal efficacy

what meds are included in FOLFOX

5FU, leucovorin, and oxaliplatin

why is leucovorin included in FOLFOX?

increases efficacy of 5FU

how is FOLFOX given?

continuous infusion over 2 days (pt is sent home with this in a bag)

what meds are included in CAPEOX?

capecitabine and oxaliplatin

how is CAPEOX given?

oral

if a pt has stage III non metastatic CRC and is dMMR, what must be added to their adjuvant chemotherapy?

atezolizumab

bolus 5FU ADE

neutropenia

mucositis

continuous infusion of 5FU and capecitabine ADE

hand foot syndrome

which has a higher incidence of causing more hand foot syndrome, 5FU or capecitabine?

capecitabine

which has a higher incidence of causing more diarhea, 5FU or capecitabine?

neither, same incidence

how to prevent hand foot syndrome while on 5FU or capecitabine?

thick emollient cream (topical)

diclofenac gel

5FU is cytotoxic if it undergoes…

anabolism

5FU and capecitabine are metabolized by..

DPD

5FU and capecitabine have a BBW for…

myelosuppression, diarrhea, mucositis, hand foot syndrome, and neurotoxicity

what is DPYD

gene that encodes for DPD

polymorphisms of DPYD can lead to _____ metabolism of 5FU

decreased

if a pt is an intermediate or poor DPYD metabolizer, then they require…

dosing adjustments for 5FU

all pts that are indicated for 5FU products must be tested for DPYD metabolism status UNLESS…

immediate treatment is needed

oxaliplatin can lead to acute neurotoxicity in _

a. </= 3 days

b. </= 6 days

c. </= 10 days

d. </= 14 days

d

oxaliplatin acute neurotoxicity presentation

cold sens, peripheral neuropathy, muscle cramps and pain

oxaliplatin can cause cumulative sensory neurotoxicity after _____ of treatment

>14 days

how to prevent / treat oxaliplatin neurotoxicity

reduce dose

d/c med

duloxetine for the pain

how to prevent / treat oxaliplatin neurotoxicity

a. give duloxetine for the numbness

b. give gabapentin for the tingling

c. give duloxetine for pain

d. give pregabalin for the cold sensitivity

c

goal of rectal cancer treatment

cure and maintaining function of the anal sphincter

if a pt with rectal cancer is dMMR, which drug should be used?

pembrolizumab

which of the following is true regarding rectal cancer?

a. long course RT has the same efficacy as short course RT

b. long course RT is more efficacious than short course RT

c. short course RT is more efficacious than long course RT

a

long course RT for rectal cancer:

1. duration

2. chemo therapy or no?

1. 25-28 days

2. chemotherapy needed

short course RT for rectal cancer:

1. duration

2. chemo therapy or no?

1. 5 days

2. no

long course RT for rectal cancer is given with chemotherapy. name the two options of chemotherapy

single agent 5FU or single agent capecitabine

neoadjuvant treatment with chemoradiation is indicated for pts with rectal cancer if…

cannot spare the anal sphincter with initial surgery

chemotherapy options for rectal cancer include…

FOLFOX CAPEOX

duration of chemotherapy for rectal cancer

12-16 weeks

order of treatment for non-dMMR rectal cancer:

1. option 1

2. option 2

1. RT —> chemo —> surgery

2. chemo —> RT —> surgery

non-dMMR rectal cancer treatmentn always ends with…

surgery

stage IV CRC:

goal

palliative

stage IV CRC:

most pts are indicated for

5-FU/Capecitabine based chemotherapy

stage IV CRC:

pts should receive chemotherapy until…

progression or intolerable ADE

stage IV CRC:

name the 4 5FU treatment options

FOLFOX

CAPEOX

FOLFIRI

FOLFIRINOX

most common ADE of irinotecan

diarrhea

irinotecan can cause early onset diarrhea, how do you treat/ prevent this ADE

atropine (IV or subq)

irinotecan can cause late onset diarrhea, how do you treat/ prevent this ADE

loperamide

irinotecan is metabolized by…

carboxyl esterase

irinotecan is metabolized by carboyl esterase into…

active metabolite SN38

what is Sn38

active metabolite of irinotecan

SN38 is metabolized to its inactive form by which enzyme

UGT1A1

pts with UGT1A1 polymorphisms on irinotecan have an increased risk of which toxicities?

neutropenia and diarrhea

T or F:

immunotherapy must be given if a pt is pMMR

F (it doesnt work on those pts)

if a pt has pmh of peripheral neuropathy, they should NEVER which drug?

oxaliplatin

dMMR + stage IV CRC:

first line treatment

pembrolizumab

pembrolizumab is indicated for any pt with …

any stage IV cancer with a dMMR tumor