1. Colorectal Cancer Treatment Susan Rein, BSN RN CCRC

2. Colorectal Cancer Diagnosis Colorectal cancer includes malignant or cancerous tumors of the colon and/or the rectum.

3. Anatomy Anus Rectum Sigmoid Descending Transverse Ascending Cecum

4. Staging When you’re diagnosed with colorectal cancer, your doctor needs to find how advanced the disease is, or how far it has spread. This important part of your colorectal cancer diagnosis is known as staging.

5. Tests used to determine the stage of your colorectal cancer Blood Tests: The level of certain substances in your blood is checked. If you have colorectal cancer, you may have a high carcinoembryonic antigen (CEA) level. Endoscopic Ultrasound (EUS): An ultrasound probe that sends out sound waves is inserted into your rectum. A computer-generated picture, created from the echoes of the sound waves, shows how deep the rectal tumor has grown and whether the cancer has spread (or metastasized) to lymph nodes or other nearby tissues. Chest X-Ray: X-rays of your chest can show whether the cancer has spread to your lungs.

6. Tests… CT Scan: An X-ray machine linked to a computer gives doctors a detailed picture of areas inside your body. Tumors in your liver, lungs, and other areas will show up on the CT scan. PET Scan: positron emission tomography – An imaging test used to light up cancer in different parts of the body. You get an injection of a short-lived radioactive substance before having the scan. Cancerous tissue will build up more of the substance and appear brighter than normal tissue on the PET images. Other non-cancerous tissues, such as areas of inflammation, can also sometimes “light up.”

7. How is colorectal cancer treated? Surgery Radiation Oncology Chemotherapy Biological Therapy

8. The Team Medical Oncologists – Oncologists are doctors who study and treat cancer Radiation Oncologists – Radiation oncologists use X-rays and other types of medical radiation to control or kill cancer cells in the body Surgical Oncologists – Surgical oncologists are part of the multidisciplinary cancer team who specialize in operations that remove cancer from different areas of the body Gastroenterologists - Doctors who specialize in the digestive system Oncology social workers, who help you manage the stresses associated with cancer diagnosis and treatment and help the patient find needed resources Alternative therapists who provide massage, acupuncture, biofeedback and other therapies as an optional part of the treatment program

9. Surgery(Primary Treatment) Laparoscopy: Early colon cancer may be removed with the aid of a thin, lighted tube (laparoscope). Three or four tiny cuts are made into your abdomen. The surgeon sees inside your abdomen with the laparoscope. The tumor and part of the healthy colon are removed. Nearby lymph nodes also may be removed. The surgeon checks the rest of your intestine and your liver to see if the cancer has spread. Open surgery: The surgeon makes a large cut into your abdomen to remove the tumor and part of the healthy colon or rectum. Some nearby lymph nodes are also removed. The surgeon checks the rest of your intestine and your liver to see if the cancer has spread.

10. Common types of ostomies in intestinal surgery Ileostomy –connecting the ileal (where the small and large bowel meet) part of the small intestine to the abdominal wall Colostomy –connecting the colon, or, large intestine to the abdominal wall

11. Radiation Therapy Radiation therapy involves using X-rays and other types of medical radiation aimed at specific parts of the body to: –Kill cancer cells –Prevent cancer cells from developing or recurring –Improve many of the symptoms caused by cancer

12. Radiation Therapy Radiation therapy can be: Used before surgery to make the operation easier (this is called “neoadjuvant” treatment) Used after surgery to reduce the chances of the cancer coming back (this is called “adjuvant treatment”) Almost as effective as surgery in people who are not fit enough for an operation

13. External Beam Radiation Therapy External beam radiation therapy involves a series of daily outpatient treatments to accurately deliver radiation to the area at risk. –Before beginning treatment, you will be scheduled for a simulation to map out the area being treated. This will involve having X-rays and/or a CT scan. You will also receive tiny tattoo marks on your skin to help the therapists precisely position you for daily treatment. Treatment is given once a day, Monday through Friday, for about four to six weeks.

14. Rectal Cancers Radiation can be given either before or after surgery treated by low anterior resection or abdominoperineal resection chemotherapy before surgery (neoadjuvant treatment), as well as giving adjuvant chemotherapy after surgery

15. Chemotherapy Chemotherapy uses anticancer drugs to kill cancer cells. The drugs enter the bloodstream and can affect cancer cells all over the body. Anticancer drugs are usually given through a vein, but some may be given by mouth. You may be treated in an outpatient part of the hospital, at the doctor's office, or at home. Rarely, a hospital stay may be needed. The side effects of chemotherapy depend mainly on the specific drugs and the dose. The drugs can harm normal cells that divide rapidly: –Blood cells: These cells fight infection, help blood to clot, and carry oxygen to all parts of your body. When drugs affect your blood cells, you are more likely to get infections, bruise or bleed easily, and feel very weak and tired. –Cells in hair roots: Chemotherapy can cause hair loss. Your hair will grow back, but it may be somewhat different in color and texture. –Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores.

16. Chemotherapy Drugs Used for Colorectal Cancer 5-Fluorouracil (5-FU) has been the first choice chemotherapy drug for colorectal cancer for many years. It is used in combination with leucovorin (a vitamin), which makes 5-FU more effective. 5-FU is given intravenously. Recently, a pill form of 5-FU has been developed, called Xeloda, which is used for colorectal cancer that has spread to other organs.

17. FOLFOX FOLFOX is a chemotherapy regime for treatment of colorectal cancer, made up of the drugs FOL– Folinic acid (Leucovorin) F – Fluororacil (5-FU) OX – Oxaliplatin (Eloxatin)

18. Monoclonal Antibodies These are substances produced in the laboratory that can locate and bind to cancer cells wherever they are in the body. These antibodies can be used to see where the tumor is in the body (detection of cancer), or as therapy to deliver drugs, toxins, or radioactive material directly to a tumor. In February 2004, the U.S. Food and Drug Administration approved the first monoclonal antibody to treat metastatic colorectal cancer, Erbitux (Cetuximab). Also in February 2004, the FDA approved another first of its kind monoclonal antibody called Avastin (Bevacizumab). This drug works by shutting down a process called angiogenesis - the process whereby tumors grow new blood vessels to help them receive the nutrients needed to survive. It's approved to treat advanced colorectal cancer that has spread to other organs. A third drug, Vectibix (Panitumumab), was approved in 2007.

19. Chemotherapy Agents Several new chemotherapy drugs also are used for the treatment of colorectal cancer that has spread. These include: Camptosar (Irinotecan HCL) Eloxatin (Oxaliplatin) Avastin (Bevacizumab) Erbitux (Cetuximab)

20. Other Treatment Funding Sources Pharmaceutical Drug Replacement Genentech Access to Care Foundation –Avastin (Bevacizumab) PACT+ Sanofi Aventis –Oxaliplatin (Eloxatin) Roche Patient Assistant Foundation –Xeloda (Capecitabine)

21. Contact Information Susan Rein BSN RN CCRC University of Colorado Denver 303-724-1272 303-724-0964 Fax susan.rein@ucdenver.edu