Colon Cancer

Etiology

Prevention

Screening

Symptoms

Treatment

Presenter: Catherine Azar, MD

Disclosure

I have no disclosures

Presenter: Catherine Azar, MD

Learning Objectives Discuss what age should colonoscopy

screenings start.

Discuss lifestyle changes to help prevent colon cancer.

Discuss common side effects can a patient who is receiving chemotherapy present with.

Presenter: Catherine Azar, MD

Risk Factors Age: risk increases as a person gets older

Having had colorectal cancer or premalignant polyps before

Having a history of ulcerative colitis or Crohn’s disease

Family history of colorectal cancer

Race or ethnic background, such as being African American or Ashkenazi

Type 2 diabetes

Certain family syndromes, like familial adenomatous polyposis (FAP) or hereditary non-polyposis colon cancer (HNPCC, also called Lynch syndrome)

Presenter: Catherine Azar, MD

Lynch Syndrome People with Lynch syndrome may experience:

Colon cancer that occurs at a younger age, especially before age 50

A family history of colon cancer that occurs at a young age

A family history of endometrial cancer

Presenter: Catherine Azar, MD

Lynch Syndrome A family history of other related cancers, including ovarian cancer,

kidney cancer, stomach cancer, small intestine cancer, liver cancer, sweat gland cancer (sebaceous carcinoma) and other cancers

Lynch Syndrome is a hereditary disorder caused by a mutation in a mismatch repair gene

The defects in the genes disallow repair of DNA mistakes and as cells divide, errors stack and uncontrollable cell growth may result in cancer.

Presenter: Catherine Azar, MD

Personal Risks Certain types of diets: one that is high in red meats and processed

meats can increase your colorectal cancer risk, nitrate

Cooking meats at very high heat (frying, broiling, or grilling) can create chemicals that might increase cancer risk??? Nitrates

Lack of exercise

Being obese

Smoking

Heavy ETOH use

Presenter: Catherine Azar, MD

Prevention

Low fat, high fiber diet

Exercise

ASA QD, NSAID’s???

Decrease ETOH

Stop smoking

Weight loss

Vitamin D supplementation

Presenter: Catherine Azar, MD

Cancers linked to smoking

Lung

Head & Neck

Bladder

Colorectal

Esophagus

Stomach

AML

?Breast

Presenter: Catherine Azar, MD

SEER DATA

Estimated New Cases in 2015: 132,700

% of All New Cancer Cases: 8.0%

Estimated Deaths in 2015: 49,700

% of All Cancer Deaths: 8.4%

Percent Surviving 5 Years: 64.9% From 2005 to 2011 Presenter: Catherine Azar, MD

SEER DATA Number of New Cases and Deaths per 100,000: The number of new cases

of colon and rectum cancer was 42.4 per 100,000 men and women per year. The number of deaths was 15.5 per 100,000 men and women per year. These rates are age-adjusted and based on 2008-2012 cases and deaths.

Lifetime Risk of Developing Cancer: Approximately 4.5 percent of men and women will be diagnosed with colon and rectum cancer at some point during their lifetime, based on 2010-2012 data.

Prevalence of This Cancer: In 2012, there were an estimated 1,168,929 people living with colon and rectum cancer in the United States.

Presenter: Catherine Azar, MD

CDC Recommendations

High-sensitivity fecal occult blood test (FOBT): should be done every year.

Flexible sigmoidoscopy: should be done every five years with FOBT every three years.

Colonoscopy :

should be done every ten years.

Presenter: Catherine Azar, MD

USPSTF Recommends screening for colorectal cancer using fecal occult blood

testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years.

Recommends against routine screening for colorectal cancer in adults 76 to 85 years of age. There may be considerations that support colorectal cancer screening in an individual patient

Recommends against screening for colorectal cancer in adults older than age 85 years.

Presenter: Catherine Azar, MD

COLON CANCER SYMPTOMS No signs or symptoms at all

A change of bowel habits

Blood (either bright red or very dark) in the stool

Diarrhea, constipation, or feeling that the bowel does not empty completely

Stools that are narrower than usual

Frequent gas pains, bloating, fullness, or cramps

Weight loss for no known reason

Feeling very tired

Presenter: Catherine Azar, MD

Treatment Surgery even if there is metastatic disease

For quality of life so that patient can eat

To avoid infection

To avoid perforation

To avoid bleeding

Presenter: Catherine Azar, MD

Chemotherapy

Almost all agents cause diarrhea-dehydration and electrolyte abnormalities

5-FU

Xeloda

Oxaliplatin

Irinotecan

Presenter: Catherine Azar, MD

Side Effects

Mucositis

Hand-foot syndrome

Low counts

Presenter: Catherine Azar, MD

Biological agents Erbitux

Patients must be KRAS wild type not mutant to use these agents

The most reliable way to predict whether a colorectal cancer patient will respond to one of the EGFR-inhibiting drugs is to test for certain “activating” mutations in the gene that encodes KRAS, which occurs in 30%-50% of colorectal cancers. Studies show patients whose tumors express the mutated version of the KRAS gene will not respond to Erbitux or Vectibix

Approved only for MCRC

Vectibix

Presenter: Catherine Azar, MD

KRAS-MUTANT

V-Ki-ras2 Kirsten rat sarcoma viral oncogene homolog

30%-50% of colorectal cancers

More aggressive disease

Less treatment options

Presenter: Catherine Azar, MD

Side effects Rash

Hypomagnesaemia

Hypercoagulability

Allergic reaction

Cardiopulmonary Arrest-Erbitux

Pulmonary fibrosis, interstitial disease

Presenter: Catherine Azar, MD

Other biologic agents

Avastin, 1st LINE

Zaltrap, 2nd LINE

Stivarga, 2nd LINE

All block VEGF receptors- vascular endothelial growth factor

Presenter: Catherine Azar, MD

Side Effects Bleeding

Poor healing

Hypertension

Hypercoagulability

Perforation

Worsens toxicity of chemotherapy in combination

Presenter: Catherine Azar, MD

PD-1 Inhibitors Programmed death-1 (PD-1) is expressed on the surface of activated

Tcells. Programmed death ligand-1 (PD-L1) is expressed on cancer cells. When PD-1 and PD-L1 bind, they form a biochemical response suppressing the immune system from recognizing tumor cells.

PD-1 inhibitors are monoclonal antibodies that inhibit PD-1 and may enhance the ability of the body’s immune system to recognize cancer cells. Once recognized, they may stimulate the body’s immune system

to fight the cancer.

Presenter: Catherine Azar, MD

PD-1 Inhibitors They are currently approved in some countries for unresectable and

metastatic melanoma, and in the United States for metastatic squamous non-small cell lung cancer (NSCLC) with progression on or after platinumbased chemotherapy.

Some agents in development are associated with a biomarker test for PDL1 expression to identify patients more likely to benefit from therapy.

PD-1 inhibitors are administered as an intravenous infusion over 30-60 minutes every 2-3 weeks (ranges due to differences between specific PD-1 agents).

Presenter: Catherine Azar, MD

PD-1 Inhibitors

Keytruda, Pembrolizumab

Opdivo, nivolumab

Multiple other agents by different manufacturers in development

Presenter: Catherine Azar, MD

Side Effects

Fatigue

Anorexia

Pruritus

Infusion related reactions

Immune‐mediated pneumonitis, colitis, hepatitis, nephritis, hypo/hyperthyrodism

Presenter: Catherine Azar, MD

QUESTIONS

At what age should colonoscopy start?

Name lifestyle changes to prevent colon cancer.

What common side effects can a patient who is receiving chemotherapy present with?

Presenter: Catherine Azar, MD

How to contact me:

Green Valley Office: 520-625-6600

River Road Office: (520) 529-2031

Cell Phone: 520-599-0812

Presenter: Catherine Azar, MD