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