1. COLON CANCER A MAJOR ISSUE IN ALASKA

2. A common malignancy 200,000 cases in the U. S. in 2008 200,000 cases in the U. S. in 2008 Greater than 50 new cases each year in Alaska Natives Greater than 50 new cases each year in Alaska Natives

3. RISK FACTORS Age Age Family history Family history –Genetic predisposition Adenomatous polyps Adenomatous polyps History of other gastrointestinal malignancies History of other gastrointestinal malignancies

4. Screening FOBT FOBT –Problematic in our patient population because of H. pylori –Cannot differentiate upper from lower bleeds  A new test being studied possibly can Sigmoidoscopy Sigmoidoscopy Colonoscopy Colonoscopy

5. Diagnosis Tissue biopsy Tissue biopsy

6. Staging I confined to the mucosa I confined to the mucosa II into the muscularis II into the muscularis III involving the lymph nodes III involving the lymph nodes IV distant metastases IV distant metastases

7. Special considerations Colon versus Rectum Colon versus Rectum –A different approach for rectal cancer both before and after surgery

8. Treatment Surgery is the primary curative therapy Surgery is the primary curative therapy Pre-op chemotherapy-radiotherapy for rectal cancer unless the lesion is superficial Pre-op chemotherapy-radiotherapy for rectal cancer unless the lesion is superficial For patients with metastastic disease who are or may soon become obstructed For patients with metastastic disease who are or may soon become obstructed

9. CEA Good to have a baseline CEA, for both follow up and to follow for recurrence or progression Good to have a baseline CEA, for both follow up and to follow for recurrence or progression

10. Chemotherapy Adjuvant Adjuvant –For Stage III –For high risk stage II (T4 N0)  Obstruction  Perforation  circumferential –For pre-op in rectal lesions, then post op

11. Radiation for rectal cancers Pre-Op Pre-Op Stage III Stage III High risk stage II High risk stage II After trans-anal resection of lesions greater than T2 After trans-anal resection of lesions greater than T2

12. Agents FOLFOX FOLFOX XELOX XELOX Irinotecan Irinotecan Avastin Avastin Cetuximab Cetuximab Penitumumab Penitumumab

13. Unusual side effects Hand-Foot syndrome Hand-Foot syndrome Cold-induced neuropathy Cold-induced neuropathy Cholera syndrome Cholera syndrome Skin rash Skin rash Perforation (bowel, lung, wound) Perforation (bowel, lung, wound) Accelerated hypertension Accelerated hypertension