Transcript Document
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
Sporadic (65 % – 85%) Familial (10 % – 30%) Rare CRC syndromes (<0.1%) Familial adenomatous polyposis (FAP) (1%) Hereditary nonpolyposis colorectal cancer (HNPCC) (5%) Adapted from Burt RW et al.
Prevention and Early Detection of CRC
, 1996
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 <1 cm 1-2 cm >2 cm Tubular Adenoma 1.0% 10.2% 34.7% Tubulovillous Vilous Adenoma 3.9% 7.4% 45.8% 9.5% 10.3% 52.9%
Adenoma-Cancer Sequence
Loss of
APC
Activation of
K-ras
Deletion of 18q Loss of
TP53
Other alterations
Normal epithelium Hyper proliferative epithelium Early adenoma Inter mediate adenoma Late adenoma Carcinoma Metastasis
Adapted from Fearon ER.
Cell
61:759, 1990
Age
Familial Risk
100
70%
80
Approximate lifetime CRC risk (%)
60 40
17%
20
6% 8% 10% 2%
0
Aarnio M et al.
Int J Cancer
Houlston RS et al.
Br Med J
None One 1 ° One 1° and two 2 ° 64:430, 1995 301:366, 1990 1 One ° age <45 Two 1 Affected family members ° HNPCC mutation 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
0
5% 15% –20% 15% –40%
20 40 60
Lifetime risk (%)
80
70% –80%
100
>95%
Diet
decreased risk dietary fiber vegetables fruits antioxidant vitamins calcium folate (B Vitamin)
Diet
increased risk consumption of red meat animal and saturated fat refined carbohydrates alcohol
Clinical Presentation
CRC by Site
Stage at Diagnosis
Distant (cancer has metastasized) 19% Unknown (unstaged) 5% Localized (confined to primary site) 39% Adapted from NCI Cancer Facts and Figures 2010 Regional (spread to regional lymphnodes) 37%
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 I Stage IIA Stage IIB Stage IIIA Stage IIIB Stage IIIC Stage IV 93% 85% 72% 83% 64% 44% 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 [email protected]
Clinic Appointments: (501) 686-6211 Office: (501) 686-6757