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Today we will discuss… Understanding colon and rectum cancer Screening and early detection Partnering with your medical team Making treatment decisions.

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Presentation on theme: "Today we will discuss… Understanding colon and rectum cancer Screening and early detection Partnering with your medical team Making treatment decisions."— 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  20% present with metastatic disease.  Among patients diagnosed with early- stage disease, 40% will suffer recurrence. Stage at Diagnosis Localized (Stage I/II) 50% Distant (Stage IV) 20% Regional (Stage III) 30%

7 Stage Extent of tumor 5-year survival Mucosa Muscularis mucosa Submucosa Muscularis propria Serosa Fat Lymph nodes A No deeper than submucosa > 90% B 1 Not through bowel wall 80–85% B 2 Through bowel wall 70–75% C 1 Not through bowel wall: lymph node metastases 50–65% C 2 Through bowel wall: lymph node metastases 25–45% D Distant metastases < 5% Staging of Colorectal Cancer

8 5-Year Survival for CRC by Stage 65% 70-90% 25-70% 5-10% All Stages Localized (Stage I and II) Regional Stage III Distant (Stage IV) % of patients

9 Colorectal Cancer (CRC)Sporadic (average risk) (75-80%) Family history (10-15%) Hereditary non-polyposis colorectal cancer (HNPCC) (3-5%) Familial adenomatous polyposis (FAP) (1-2%) Rare syndromes (<0.1%)

10 Risk Factors for CRC 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

11 Risk Factors for CRC 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

12 Lifestyle Risk Factors for Colorectal Cancer  Decrease Risk  Exercise  Folic acid  Aspirin  Calcium, vitamin D  Screening  Increase Risk  Obesity  Red meat  Alcohol  Smoking

13 Natural HistoryPolyp Advanced cancer Age 50, 25% risk of developing polyps Age 75, 50-75% risk of developing polyps

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15 Screening = Prevention & Early Detection Prevention = polyp removal Decreased Incidence Early Detection Decreased Mortality

16 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

17 Factors Associated with CRC Screening  Higher socio-economic status  Higher education  White  Older age (>50 years)  Men  Married

18 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

19 Other Screening Tests  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

20  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 CRC Screening Guideline: Summary

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

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 Agent FDA approval status 5-FU 1962 Irinotecan (CPT-11) 1998 (second-line) 2000 (first-line) Capecitabine (oral 5-FU) 2001 (first-line) Oxaliplatin 2002 (second-line) 2004 (first-line) Chemotherapy of Colorectal Cancer

34 Agent FDA approval status Bevacizumab 2004 (Anti-VEGF Ab) Cetuximab 2004 (Anti-EGFR Ab) Panitumumab 2006 (Anti-EGFR Ab) Targeted Therapy of Colorectal Cancer

35 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 Median Survival (months) ~4-6 mo ~10-12 mo ~ 15 mo 20.3 mo ~20 mo >24-28 mo

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 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 National Cancer Institute 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 1Year 2Year 3Years 4 & 5 Doctor’s VisitEvery 3-6 mo. Every 6 months CEA testEvery 3 months As determined by your doctor CT scan (chest and abdomen) Once per yr., if recommended As determined by your doctor CT scan (pelvis) (rectal cancer only) Once per yr., if recommended As determined by your doctor ColonoscopyOnceAt 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 “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 For suggestions on ways to bring up this topic, see p. 65 in the Frankly Speaking About Colorectal Cancer booklet

57 Genetic Model of Colorectal Cancer Optimum phase for early detection Dwell Time: Many decades 2-5 years 2-5 years Mutation Normal Epithelium Adenoma Late Adenoma Early Cancer Late Cancer APC/β-catenin FAP K-Ras B-Raf 18q p53 SMAD4/SMAD2 PIK3CA/Akt

58 Stool Screening Non-invasive Entire large bowel and rectum reflected No cathartic preparation Off-site collection/mailing Genetic markers identified; better markers needed Non-invasive Entire large bowel and rectum reflected No cathartic preparation Off-site collection/mailing Genetic markers identified; better markers needed


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