Colorectal Cancer Update Jonathan A. Laryea, MD FACS FASCRS FWACS Division of Colon & Rectal Surgery Department of Surgery University of Arkansas for Medical Sciences Little Rock, Arkansas Arkansas Cancer Coalition Summit XV March 11, 2014
Disclosures No Disclosures
Outline Facts and Figures Risk Factors Clinical Presentation and Management Screening
9% Colon & rectum
Facts 2014 Estimates New cases: 96,830 (colon); 40,000 (rectal) Deaths: 50,310 (colon and rectal combined) Death rate over last 20 years declining Screening and improvements in treatment
Risk Factors Adapted from Burt RW et al. Prevention and Early Detection of CRC, 1996 Sporadic (65 %– 85%) Familial (10 %– 30%) Hereditary nonpolyposis colorectal cancer (HNPCC) (5%) Familial adenomatous polyposis (FAP) (1%) Rare CRC syndromes (<0.1%)
Risk Factors Adenomatous polyps Age Inflammatory Bowel Disease History of Cancer Family History of Colorectal Cancer Physical Inactivity/obesity Smoking NSAIDS Diets/Supplements Race
Cancer Risk in Polyps
Adenoma-Cancer Sequence NormalepitheliumHyper-proliferativeepitheliumEarlyadenomaInter-mediateadenomaLateadenomaCarcinomaMetastasis Loss of APCActivation of K-ras Deletion of 18q Loss of TP53Otheralterations Adapted from Fearon ER. Cell 61:759, 1990
Age
Familial Risk Approximatelifetime CRC risk (%) Affected family members None One 1° One 1° and two 2° One 1° age <45 Two 1° HNPCC mutation 2% 6% 8% 10% 17% 70% Aarnio M et al. Int J Cancer 64:430, 1995 Houlston RS et al. Br Med J 301:366, 1990 St John DJ et al. Ann Intern Med 118:785, 1993
Risk of Colorectal Cancer General population Personal history of colorectal neoplasia Inflammatory bowel disease HNPCC mutation FAP 5% 15%–20% 15%–40% 70%–80% >95% Lifetime risk (%)
dietary fiber vegetables fruits antioxidant vitamins calcium folate (B Vitamin) decreased risk Diet
consumption of red meat animal and saturated fat refined carbohydrates alcohol increased risk Diet
Clinical Presentation
CRC by Site
Stage at Diagnosis Adapted from NCI Cancer Facts and Figures 2010
Staging Workup Endoscopy with biopsy CT Scan CXR ?PET Scan CEA
STAGES OF COLON CANCER
Sites of Metastasis Liver Lung Brain Bone
Principles of Management Surgery is the mainstay of treatment Complete removal of tumor with negative margins Removal of involved node-bearing tissue Avoid spillage or disruption of tumor Assess for evidence of metastasis Personalized treatment based on molecular profiling
Management Colon Cancer Stage I Surgery alone Stage II Surgery alone +/- chemotherapy Stage III Surgery + Chemotherapy Stage IV Chemotherapy alone Surgery + chemotherapy + metastasectomy
Rectal Cancer Similar to Colon Cancer Chemoradiation for Stages II and III
Minimally Invasive Surgery Laparoscopy/ Robotic-assisted Oncologically equivalent Benefits versus cost Smaller incisions Less pain Shorter length of stay Earlier return to activities Overall cost-effective
Screening Prevents cancer by removing precancerous polyps Early identification of cancer Misconceptions and ignorance abound regarding screening PCP recommendation has most significant impact Screening fully covered with no out of pocket expenses under ACA
Screening Average Risk Start at age 50 Family History Start at age 40 or 10 years earlier than youngest family member with cancer High Risk Based on risk factors Familial Adenomatous Polyposis; start at age10-12y and yearly Lynch Syndrome; start at age 20y and q2y till 45y then yearly
Screening Modalities High sensitivity Fecal occult blood testing q1yr Flexible Sigmoidoscopy q5years +FOBT q3yrs Colonoscopy q10 years CT colonography* Stool DNA/ FIT
5-year Survival Stage I93% Stage IIA 85% Stage IIB 72% Stage IIIA 83% Stage IIIB 64% Stage IIIC 44% Stage IV 8%
Take home message Incidence and death rates are declining Eat right, exercise and avoid smoking Screening saves lives Most people get screened because their doctor told them to Advances in treatment have led to improved survival Advances in molecular profiling of cancers has led to personalized treatments
Thank you Jonathan A. Laryea, MD Clinic Appointments: (501) Office: (501)