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Today we will discuss… Understanding colon and rectum cancer

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Presentation on theme: "Today we will discuss… Understanding colon and rectum cancer"— Presentation transcript:

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2 Today we will discuss… Understanding colon and rectum cancer
Screening and early detection Partnering with your medical team Making treatment decisions Managing side effects Coping with life after treatment

3 Understanding Colorectal Cancer

4 Understanding CRC Colorectal cancer (CRC) starts in the colon or rectum CRC is the 3rd most common form of cancer diagnosed in men and women in the US (148,000 new cases in 2010) CRC is the 2nd leading cause of cancer deaths in the US. (48,000 deaths in 2010) The number of people dying from CRC has declined over the past 20 years with better screening, diagnosis and treatments Screening for/removing polyps early is the best way to prevent and cure CRC “I keep thinking to myself: ‘I may have cancer, but cancer doesn’t have me!’” -Pam

5 Signs and Symptoms Symptoms could include:
A change in bowel movements (diarrhea, constipation, never feeling “relieved”, narrower stools) Blood in the stool (dark red) Abdominal discomfort Loss of appetite Weight loss for no known reason Constant fatigue Nausea and vomiting Many people have no symptoms - encourage those close to you to get screened

6 Colorectal Cancer 80% present with early disease
RCF-10 CRC Slides Section A 4/10/2017 7:40 AM Colorectal Cancer 80% present with early disease 20% present with metastatic disease. Among patients diagnosed with early- stage disease, 40% will suffer recurrence. Stage at Diagnosis Distant (Stage IV) 20% Localized (Stage I/II) 50% Numbers for stage at diagnosis may not add up to 100% due to the presence of unknown stage or unstaged disease in patients at diagnosis.1 Only 39% of CRC cases are diagnosed early in stage I and II. This reflects the often asymptomatic nature of early disease. The majority of CRC cases (57%) are diagnosed in later disease stages. Nineteen percent are diagnosed with distant metastases (stage IV). Among patients with metastatic disease, the median 5-year survival is only ~10%. 1. Jemal A, et al. CA Cancer J Clin. 2007;57;43-66. Regional (Stage III) 30% 6

7 Staging of Colorectal Cancer
RCF-10 CRC Slides Section A 4/10/2017 7:40 AM Stage Extent of tumor 5-year survival Mucosa Muscularis mucosa Submucosa Muscularis propria Serosa Fat Lymph nodes A No deeper than submucosa > 90% B1 Not through bowel wall 80–85% B2 Through bowel wall 70–75% C1 Not through bowel wall: lymph node metastases 50–65% C2 Through bowel wall: lymph node metastases 25–45% D Distant metastases < 5% 7

8 5-Year Survival for CRC by Stage
RCF-10 CRC Slides Section A 4/10/2017 7:40 AM 100 70-90% 80 25-70% 65% % of patients 60 40 5-Year Survival for CRC by Stage The 5-year survival rate for patients with CRC is ~65%. This is dependent on the stage of disease at presentation. While only 37% of all patients with CRC are identified with localized stage I or II disease, year survival for these patients is ~92%. Five-year survival rates drop to ~70% with involvement of adjacent organs or lymph nodes in stage III disease. Five-year survival is as low as ~10% in patients with stage IV disease with both nodal and metastatic involvement. The changing landscape of first- and second-line therapies for metastatic disease offers increased potential for prolongation of survival in such patients. With newer and more sophisticated diagnostic/imaging techniques in CRC, the number of patients diagnosed with early CRC may improve the overall 5-year survival rates for these patients. 20 5-10% All Stages Localized (Stage I and II) Regional Stage III Distant (Stage IV) SEER Cancer Statistics Review, At: Accessed May 2006. 8

9 Colorectal Cancer (CRC)
RCF-10 CRC Slides Section A 4/10/2017 7:40 AM Sporadic (average risk) (75-80%) Family history (10-15%) Rare syndromes (<0.1%) Hereditary non-polyposis colorectal cancer (HNPCC) (3-5%) Familial adenomatous polyposis (FAP) (1-2%) 9

10 Risk Factors for CRC Age >50 (average risk) Racial, ethnic factors
RCF-10 CRC Slides Section A Risk Factors for CRC 4/10/2017 7:40 AM Age >50 (average risk) Racial, ethnic factors – African-Americans have increased risk Dietary factors – high animal fat, low fiber diet Lifestyle – Sedentary – Obesity – Smoking – Alcohol 10

11 Family or personal history of CRC
RCF-10 CRC Slides Section A Risk Factors for CRC 4/10/2017 7:40 AM Family or personal history of CRC HNPCC – Lynch syndrome I, II Polyposis syndromes – FAP, Gardner’s syndrome, Turcot’s syndrome, juvenile polyposis Inflammatory bowel disease – chronic ulcerative colitis, Crohn’s disease 11

12 Lifestyle Risk Factors for Colorectal Cancer
RCF-10 CRC Slides Section A 4/10/2017 7:40 AM Lifestyle Risk Factors for Colorectal Cancer Decrease Risk Exercise Folic acid Aspirin Calcium, vitamin D Screening Increase Risk Obesity Red meat Alcohol Smoking 12

13 Natural History • Age 50, 25% risk of developing polyps
RCF-10 CRC Slides Section A 4/10/2017 7:40 AM Advanced cancer Polyp • Age 50, 25% risk of developing polyps • Age 75, 50-75% risk of developing polyps 13

14 RCF-10 CRC Slides Section A
4/10/2017 7:40 AM 14

15 Screening = Prevention & Early Detection
RCF-10 CRC Slides Section A 4/10/2017 7:40 AM Prevention = polyp removal Decreased Incidence Early Detection Decreased Mortality 15

16 Screening Methods Annual Fecal Occult Blood Test (FOBT)
RCF-10 CRC Slides Section A 4/10/2017 7:40 AM Screening Methods Annual Fecal Occult Blood Test (FOBT) Flexible Sigmoidoscopy every 5 years Annual FOBT + Flexible Sigmoidoscopy every 5 years Colonoscopy every 10 years Colonoscopy - gold standard 16

17 Factors Associated with CRC Screening
RCF-10 CRC Slides Section A 4/10/2017 7:40 AM Factors Associated with CRC Screening Higher socio-economic status Higher education White Older age (>50 years) Men Married 17

18 Issues Related to CRC Screening
RCF-10 CRC Slides Section A 4/10/2017 7:40 AM Issues Related to CRC Screening Practical barriers System Cost Environment/area Lack of access to healthcare provider Psychological barriers Lower knowledge or awareness Lower perceived risk of CRC Negative attitudes towards screening Higher worry or fear of CRC 18

19 Other Screening Tests Virtual colonoscopy
RCF-10 CRC Slides Section A 4/10/2017 7:40 AM Virtual colonoscopy Pickhardt et al, NEJM, Dec 2003 Sensitivity 94%, Specificity 96% – Johnson et al, NEJM, Sept 2008 Sensitivity 90%, Specificity 86% – Advantages: no need for sedation, non-invasive, rapid imaging of entire colorectum, low risk of complications – Especially useful in patients who can not undergo colonoscopy Stool DNA testing Video capsule 19

20 CRC Screening Guideline: Summary
RCF-10 CRC Slides Section A 4/10/2017 7:40 AM CRC Screening Guideline: Summary For average risk persons, CRC screening should begin at age 50 African-Americans should be screened earlier starting at age 45 CRC screening is cost-effective CRC is highly curable when diagnosed at an early stage with 90% 5-year survival 20

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22 Diagnosing CRC A colonoscopy looks at the entire colon to identify problems Blood tests help to categorize your overall health a CEA test is often used to follow the presence of CRC Imaging tests will identify if cancer exists in other parts of your body CAT scan, MRI, PET scan Surgery will remove tumor(s), tissue and lymph nodes which will be tested by a pathologist to determine the type and stage of cancer present

23 Stages of CRC Three elements: T = Tumor N = Node M = Metastases
How large is the tumor? N = Node Are cancer cells in the lymph nodes? M = Metastases Has the cancer spread to other organs? Four stages: Stage I Spread to the middle layers of the colon or rectum Stage II Stage III Stage IV Advanced disease, spread to other organs

24 Stages of CRC

25 Partnering With Your Medical Team
It is important that you feel respected and listened to. Work with a healthcare team you can trust.

26 Your Medical Team Successful treatment requires a multidisciplinary team of CRC specialists: Surgical Oncologist Medical Oncologist Radiation Oncologist Radiologist Pathologist Oncology Nurse Specialist Social Worker Nutritionist Patient Navigator Pharmacist YOU and your team! Your choice of a medical team depends on preferences: Recommendations Expertise Style of communication Location Type of institution (private practice, community hospital, cancer center) Insurance

27 Be Prepared for Appointments….
Keep a list of questions/concerns to bring to appointments ALWAYS tell your doctor about side effects or symptoms that interfere with your life ALWAYS tell your doctor about other medications, “herbs”, nutritional supplements you may be taking Learn the best method of on-going communication Appointments, phone, even Bring a relative or friend to take notes Ask for copies of your reports and test results

28 Consider a second opinion…
You have the right to get a second, and even a third, opinion It is very common and accepted It’s never too late to get another opinion There is no one “right” way to treat CRC Talking with different experts can help you feel more confident in your course of action A second opinion might introduce you to a clinical trial or targeted treatment you didn’t know about

29 Making Treatment Decisions

30 Goals of Treatment Treatment is defined by stage and type of cancer present Goals of Treatment for Early Disease Remove cancer cells Kill cancer cells Keep the cancer cells from returning Goals of Treatment for Advanced Disease Slow or stop the growth of cancer cells Manage quality of life concerns Every person responds differently to treatment, so communication is key!

31 Types of Treatments Surgery Laparoscopy vs. open surgical resection
Colostomy: temporary or permanent Chemotherapy Adjuvant, neoadjuvant, and palliative Oral versus intravenous Targeted agents EGFR inhibitors VEGFR inhibitors Chemoradiation (rectal cancer) Clinical trials New agents, combination regimens

32 Targeted Therapies/ Biologic Agents
Targeted therapies work through specific pathways involved in cancer growth to attack cancer cells directly EGFR inhibitors (i.e.: Cetuximab and Panitumumab) VEGFR inhibitors (i.e.: Bevacizumab) Targeted therapies cause fewer side-effects since they attack cancer cells more specifically Talk to your doctor about new treatments in development

33 Chemotherapy of Colorectal Cancer
RCF-10 CRC Slides Section A 4/10/2017 7:40 AM Agent FDA approval status 5-FU Irinotecan (CPT-11) (second-line) 2000 (first-line) Capecitabine (oral 5-FU) (first-line) Oxaliplatin (second-line) 2004 (first-line) 33

34 Targeted Therapy of Colorectal Cancer
RCF-10 CRC Slides Section A 4/10/2017 7:40 AM Agent FDA approval status Bevacizumab (Anti-VEGF Ab) Cetuximab (Anti-EGFR Ab) Panitumumab 2006 34

35 Historical Progress of Therapy of Advanced CRC
RCF-10 CRC Slides Section A 4/10/2017 7:40 AM Historical Progress of Therapy of Advanced CRC Supportive Care 1 Active Drug (5-FU/LV, Capecitabine) 2 Active Drugs (5-FU/LV + Oxaliplatin/Irinotecan; Capecitabine + Oxaliplatin/Irinotecan) 2 Active Drugs + bevacizumab 2/3 Active Drugs + Targeted/Biologic Agents ~4-6 mo ~10-12 mo ~15 mo ~20 mo 20.3 mo >24-28 mo 6 12 18 24 Median Survival (months) 35 35

36 Clinical Trials Clinical trials study promising new drugs and treatment regimens Every CRC treatment regimen that is now “standard” was first developed through a clinical trial Phases I-IV Remember that all standard cancer drugs used to treat CRC and other cancer types were studied in clinical trials before being approved by the US FDA Participants are not “guinea pigs”

37 What Affects Treatment Decisions?
The type and stage of your disease The specific genetic make-up of your colon cancer Your age and overall health Other medical conditions Whether or not you’ve had cancer and/or cancer treatment in the past Your willingness/ability to tolerate certain side effects Ease and convenience of treatment – oral vs intravenous Insurance coverage and costs

38 Making Treatment Decisions
You always have time to think about your options and ask questions. The ultimate question: “What will give me the greatest chance of cure or longer life, and at what price?” - Wendy Schlessel Harpham, M.D. In the Frankly Speaking About Colorectal Cancer booklet, see more detailed information about treatment options in Chapter 4.

39 Managing Side Effects

40 Managing Side Effects You may not experience common side effects
Ask about preventing side effects before treatment Having information about short and long term side effects before, during, and after cancer treatment will help you prepare Goal: take control of side effects before they take control of you

41 Side Effects from Surgery
Initial pain and risk of infections Scarring and adhesions Fecal incontinence Ostomy: a procedure to make a new path for stool An ostomy pouch is adhered to your skin to collect waste For more information, see p.49 in the Frankly Speaking About Colorectal Cancer booklet “If I hadn’t had a colostomy, I wouldn’t have lived. It’s what you have to do to survive. It doesn’t limit me in any way, except for not wearing extremely tight clothes that I wouldn’t wear anyway.” - Pam

42 Side Effects from Chemotherapy
Diarrhea Mouth sores Hand-foot syndrome Neuropathy High blood pressure Skin rash Bowel perforation Allergic reaction The Frankly Speaking About Colorectal Cancer booklet includes tips for managing these side effects on pp

43 Managing Bowel Issues Obstruction and/or perforation
Caused by the cancer itself, or treatment Symptoms include: abdominal pain, nausea and vomiting, bloating, inability to pass gas, constipation or diarrhea, loss of appetite Get suggestions from your medical team for diet and lifestyle changes to help lessen pain and motivate your digestive system “Ever since radiation I’ve had adhesions with partial blockage of the colon. It started 9 months after treatment … I’d get cramps and throw up all of a sudden. Now I go to a massage therapist and I haven’t had an attack for a few months, so I think it’s helping.” - Nancy

44 Colorectal Cancer Survivorship

45 Quality of Life A colorectal cancer diagnosis raises both physical and emotional issues to manage Feeling sad, alone, angry, anxious, overwhelmed or distressed is very common Know that it is possible to find a balance between medical concerns, relationships, work, finances, and other responsibilities Here are some suggestions …

46 Talking About CRC Keep communication open and honest
Do not keep fears, embarrassment, worry to yourself CRC can be awkward to talk about Find people in a similar situation for support If you don’t want to talk about it – write it down Keep a journal and use it to share your emotions with loved ones, yourself, or your doctor “I know cancer can destroy some relationships because it’s such a burden. But if you have enough faith in each other and love for each other you can conquer anything.” - Scott

47 Are you Feeling Distressed?
If you think you or someone you love is suffering from depression: talk to your doctor, a social worker, or professional counselor Some questions to ask yourself: Do you cry often or uncontrollably? Have you lost interest in things that used to give you pleasure? Have you stopped looking forward to “fun” events and occasions? Are you eating and/or sleeping more or less than you used to?

48 Find Support TWC research found that people in support groups report a decrease in depression, increased zest for life, and a new attitude toward their illness There are different types of support groups and counseling services available – just ask Support groups can help you: Learn from others with similar challenges Share concerns and learn coping strategies Feel less alone Manage side effects and anxiety Learn about resources

49 Strategies for Wellness
Physical Activity… elevates mood, combats fatigue, maintains function, promotes rest Healthy Foods… maintains energy, strengthens immune system, avoids/limits symptoms, provides comfort Drink Plenty of Fluids… avoids dehydration, promotes regularity, combats fatigue Pamper Yourself… find time to relax, seek spirituality, enjoy each day Create a personalized care plan… set goals, find resources, use support

50 Fear of Recurrence Be informed Talk about it with your medical team
Allow yourself to feel up and down—it is healthy to express negative emotions Be “Patient Active” – take control of what you can, but know what you can’t control Do not to let anxiety and fear prevent you from seeking medical care

51 Survivorship Advances are being made, giving more patients the chance for a longer, better quality of life after diagnosis Doctors, nurses, social workers and other survivors can help patients and families cope with the diagnosis Emotional support through treatment and beyond is important: seek-out support Try to live each day to the fullest! “No matter how severe the symptoms and treatments—survival from day to day, week to week, and year to year constitutes an enormous personal and human triumph over what might have been.” - A Cancer Survivor’s Almanac

52 Resources C3: Colorectal Cancer Coalition
877-4CRC-111 Colon Cancer Alliance The Wellness Community WELL American Cancer Society 800-ACS-2345 National Cancer Institute 800-4-CANCER More resources can be found in the Frankly Speaking About Colorectal Cancer booklet

53 Acknowledgments This program was created by in partnership with
and supported through a charitable contribution from

54 Follow-up Care Follow-Up Care Recommendation Year 1 Year 2 Year 3
Years 4 & 5 Doctor’s Visit Every 3-6 mo. Every 6 months CEA test Every 3 months As determined by your doctor CT scan (chest and abdomen) Once per yr., if recommended CT scan (pelvis) (rectal cancer only) Colonoscopy Once At 3 years Proctosigmoidoscopy (rectal cancer only) Every 6 months (for patients who did not have pelvic radiation treatment) for 5 years

55 Side Effects from Radiation
Burn-like skin irritations and a higher risk for infection Pain and swelling Scarring or blockage of areas around the pelvis Incontinence Inability to control urination and/or bowel movements Sexual side effects Dryness, discomfort, erectile dysfunction “Make sure to let the doctors know your comfort zone. If you’re experiencing pain, tell them how intense it is, because if you’re in pain, you can’t concentrate on the sickness and on getting better. The doctors don’t want us to be in pain, if we don’t have to be.” - Ken

56 Sexuality Many people are reluctant to talk about problems with sexuality, including some healthcare professionals Remember: you have the right to get all your questions answered and to get help For suggestions on ways to bring up this topic, see p. 65 in the Frankly Speaking About Colorectal Cancer booklet “Because of my treatment I can’t get an erection. My wife and I talk about it and about other ways to please each other, like just holding each other and watching a good movie … There are times I want it, but I try to focus on being with my wife in other ways and just being alive.” - Ken

57 Genetic Model of Colorectal Cancer
RCF-10 CRC Slides Section A 4/10/2017 7:40 AM Mutation APC/β-catenin FAP K-Ras B-Raf 18q p53 SMAD4/SMAD2 PIK3CA/Akt Normal Epithelium Adenoma Late Adenoma Early Cancer Late Cancer Groundbreaking work Defines the cause of colorectal cancer Note Bert! Call it the Vogelgram—play it up more Optimum phase for early detection Dwell Time: Many decades years years 57

58 Stool Screening Non-invasive Entire large bowel and rectum reflected
RCF-10 CRC Slides Section A 4/10/2017 7:40 AM Stool Screening Non-invasive Entire large bowel and rectum reflected No cathartic preparation Off-site collection/mailing Genetic markers identified; better markers needed 58


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