Colorectal Cancer Update

Jonathan A. Laryea, MD FACS FASCRS FWACSDivision of Colon & Rectal SurgeryDepartment of SurgeryUniversity of Arkansas for Medical SciencesLittle 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

<1 cm 1-2 cm >2 cm

Tubular Adenoma 1.0% 10.2% 34.7%

Tubulovillous 3.9% 7.4% 45.8%

Vilous Adenoma 9.5% 10.3% 52.9%

Adenoma-Cancer Sequence

Normal epithelium

Hyper-proliferativeepithelium

Earlyadenoma

Inter-mediate

adenoma

Lateadenoma Carcinoma Metastasis

Loss ofAPC

Activationof K-ras

Deletion of 18q

Loss ofTP53

Other alterations

Adapted from Fearon ER. Cell 61:759, 1990

Age

Familial Risk

Approximatelifetime

CRC risk (%)

Affected family members

0

20

40

60

80

100

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

0 20 40 60 80 100

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 DiagnosisLocalized

(confined to primary site)

39%

Regional (spread to re-gional lym-phnodes)

37%

Distant (cancer has metasta-

sized)19%

Unknown (unstaged)5%

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

ManagementColon Cancer Stage I

Surgery alone Stage II

Surgery alone +/- chemotherapy Stage III

Surgery + Chemotherapy Stage IV

Chemotherapy aloneSurgery + chemotherapy + metastasectomy

Rectal Cancer

Similar to Colon Cancer

Chemoradiation for Stages II and III

Minimally Invasive Surgery

Laparoscopy/ Robotic-assisted

Oncologically equivalent

Benefits versus costSmaller incisionsLess painShorter length of stayEarlier return to activitiesOverall 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 93% 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, MDjalaryea@uams.edu

Clinic Appointments: (501) 686-6211Office: (501) 686-6757