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Page 1: Colorectal Cancer Survivorship: Second Primary Cancers Cancer... · Colorectal Cancer Survivorship: Second Primary Cancers ... Colorectal Cancer Survivorship: Second Primary Cancers

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PowerPoint Slides English Text Spanish Translation Colorectal Cancer Survivorship: Second Primary Cancers

VideoTranscript

Supervivencia al cáncer colorrectal: Segundos cánceres

primarios Transcripción del video

Professional Oncology Education

Colorectal Cancer Survivorship: Second Primary Cancers

Time: 7:40

Educación Oncológica Profesional Supervivencia al cáncer colorrectal: Segundos cánceres

primarios Duración: 7:40

Therese B. Bevers, M.D. Professor, Clinical Cancer Prevention Medical Director, Cancer Prevention Center The University of Texas, MD Anderson Cancer Center

Dra. Therese B. Bevers

Profesora de Prevención Clínica del Cáncer Directora Médica del Centro de Prevención del Cáncer MD Anderson Cancer Center de la Universidad de Texas

Colorectal Cancer

Survivorship:

Second Primary Cancers

Therese B. Bevers, M.D.

Professor, Clinical Cancer Prevention

Medical Director, Cancer Prevention Center

I am Dr. Therese Bevers, Professor of Clinical Cancer Prevention and Medical Director of the Cancer Prevention Center at the University of Texas MD Anderson Cancer Center. I’m going to talk today about second primary cancers in colorectal cancer survivors.

Soy la Dra. Therese Bevers, profesora de Prevención Clínica del Cáncer y directora médica del Centro de Prevención del Cáncer en el MD Anderson Cancer Center de la Universidad de Texas. Hoy hablaré sobre los segundos cánceres primarios en los sobrevivientes de cáncer colorrectal.

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Objectives

Upon completion of this lesson, participants will be able to:

• Identify risk of second primary cancers after

colorectal cancer

• Outline mechanisms related to the development of

these second primary cancers

• Discuss risk reduction and screening strategies for

second primary cancers

The objectives of this lesson are to identify the risk of second primary cancers after having had colorectal cancer; outline the mechanisms related to the development of these second primary cancers; and discuss risk reduction and screening strategies for second primary cancers.

Los objetivos de esta lección son: identificar el riesgo de segundos cánceres primarios después del cáncer colorrectal, delinear los mecanismos relacionados con el desarrollo de estos segundos cánceres primarios, y analizar estrategias para reducir los riesgos y detectar segundos cánceres primarios.

Second Primary Cancer (SPC)

• New primary cancer developing in a person with a

history of cancer

• A neoplasm that:

– Arises in a tissue distinct from the first primary

– Develops subsequent to the initial cancer by some

defined time period

Krueger H et al., Prog Exp Tumor Res 2008 40:7-16

Let’s start off with the definition for second primary cancers. This is a new primary cancer developing in a person with a history of cancer. However, upon thinking about that it is somewhat simplistic because the questions begin to arise, “What about a cancer occurring in the same organ as the patient already had a cancer?” So, to be more specific, a second primary cancer is a neoplasm that arises in a tissue that is distinct from the first primary and it develops subsequent to the initial cancer by some time --- defined time period. Typically, this is greater than two months.

Comencemos definiendo qué es un segundo cáncer primario. Es un nuevo cáncer primario que se desarrolla en una persona con historial de cáncer. Esta es una explicación un tanto simplificada, pues surgen preguntas como: “¿Qué hay de un cáncer que aparece en el mismo órgano donde el paciente ya tenía cáncer?”. Más específicamente, un segundo cáncer primario es un neoplasma que se origina en un tejido diferente al del primer cáncer y que se desarrolla con posterioridad al cáncer inicial, generalmente más de dos meses después.

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Metachronous Colorectal Cancer

• By our definition, metachronous colorectal cancer is

not a SPC

• Common, even after controlling for familial patterns

• Occur at higher rate than first primaries of the colorectum

– Genetic factors other than Familial adenomatous polyposis

(FAP)/ Lynch Syndrome have been implicated

Krueger H et al., Prog Exp Tumor Res. 2008 40:85-91

By our definition, metachronous colorectal cancer is not a second primary cancer even after controlling for familial patterns. However, we do see that it occurs at a higher rate than first primaries of the colorectum. This is probably related to genetic factors other than those due to familial adenomatous polyposis or Lynch Syndrome.

Según esta definición, el cáncer colorrectal metacrónico no sería un segundo cáncer primario, pero aun después de hacer un control de patrones familiares, vemos que ocurre a una tasa superior que los primeros cánceres primarios de colon y recto. Esto probablemente esté relacionado con factores genéticos distintos de los de la poliposis adenomatosa familiar o el síndrome de Lynch.

Fifth Most Common Type of Cancer*

• Colorectal

• Lung

• Breast

• Prostate

• Second primary cancer

*Excluding non-melanoma skin cancers

Rheingold SR et al., Holland-Frei Cancer Medicine. 6th edition. Bast, RC et al. (eds)

Hamilton: BC Decker 2000, pps 2399-2406

You may be surprised to find out that collectively second primary cancers are the fifth most common type of cancer after excluding for non-melanoma skin cancers.

Puede resultar sorprendente descubrir que, colectivamente, los segundos cánceres primarios son el quinto tipo de cáncer más común, si excluimos los cánceres de piel distintos del melanoma.

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Incidence of Second Primary Cancer:

Colorectal Cancer

• Higher for individuals with early onset colorectal cancer

– Related to genetic syndromes

• Higher for females –

– Female survivors live longer than male survivors

– Related to second primary cancer of breast and

gynecologic organs

• Possibly genetic in origin

Krueger H et al., Prog Exp Tumor Res. 2008 40:85-91

In looking at the incidence of second primary cancers after having had colorectal cancer, we see it is higher for individuals with early onset colorectal cancer. And, this is likely related to genetic syndromes. It’s also higher for females who live longer than their male counterparts. And, also, related to the fact that there are more s --- cancers that can occur in females such as breast, cervical, uterine, and ovarian than can occur in males, such as testicular or prostate.

Al analizar la incidencia de los segundos cánceres primarios después del cáncer colorrectal, vemos que es mayor en las personas con cáncer colorrectal temprano. Esto tal vez esté relacionado con síndromes genéticos. También es mayor en las mujeres que viven más que sus contrapartes masculinas. Asimismo, se relaciona con el hecho de que existen más tipos de cáncer en las mujeres (cáncer de mama, cervical, de útero y de ovarios) que en los hombres (cáncer testicular o de próstata).

Second Primary Cancer in Colon Cancer

Cumulative incidence of developing a second cancer among

patients with cancer of the colon, both sexes, SEER 1973-2000

Mysliwiec PA et al., NIH Publ. No. 05-5302. Bethesda, MD 2006

If we look at the cumulative incidence of developing a second cancer among patients with a history of colon cancer that cumulative incidence is about 15%. We see that the vast majority of the cancers are in the digestive tract. And, there is a substantial percentage of metachronous colorectal cancers. It, however, is this constellation of cancers those that are not in the colon or rectum that we need to pay attention to, because if we did not identify these risks, we would not pick them up through routine surveillance of the patient for their colon cancer.

La incidencia acumulativa de desarrollar un segundo cáncer en los pacientes con historial de cáncer de colon es del 15%, aproximadamente. La gran mayoría de los cánceres se encuentran en el tracto digestivo y hay un porcentaje considerable de cánceres colorrectales metacrónicos. Debemos prestar atención a los numerosos tipos de cáncer que no ocurren en el colon o el recto. Si no identificamos estos riesgos, no los detectaremos en los controles de rutina de los pacientes con cáncer de colon.

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Second Primary Cancer in Colon Cancer

• Increased risk of:

– Tongue

– Oropharyngeal

– Stomach

– Small intestine

– Bile ducts

– Uterus

– Kidney

– Ureter

Mysliwiec PA et al., NIH Publ. No. 05-5302. Bethesda, MD 2006

Individuals with a history of colon cancer have an increased risk of the cancers listed on this screen. You will see that many of them in fact do arise in the GI tract.

Las personas con historial de cáncer de colon tienen mayor riesgo de sufrir estos cánceres y muchos de ellos se producen en el tracto gastrointestinal.

Second Primary Cancer in Rectal Cancer

Overall, risk for SPC not increased in rectal cancer patients

• Rectal cancer at younger age associated with 51%

increased risk of SPC

- Small intestine, bile ducts, uterus

- Tumors associated with genetic predisposition

• Risk lower in patients diagnosed at older ages

Risk of SPC increased in rectal patients treated with radiation

• Uterus, bladder

Mysliwiec PA et al., NIH Publ. No. 05-5302. Bethesda, MD 2006

Individuals with a pri --- history of rectal cancer overall are not at increased risk for a second primary cancer. However, if their rectal cancer occurred at a younger age, they actually do have a 51% increased risk of an SPC. This includes cancers of the small intestine, bile ducts, and uterus. And, again, these tumors often are associated with a genetic predisposition. Not surprisingly then, the risk would be lower in patients diagnosed with rectal cancer at an older age. Now, rectal cancer patients who were treated with radiation actually have an increased risk of second primary cancers occurring in the radiation field, such as the uterus or the bladder.

En general, un historial de cáncer de recto no conlleva un mayor riesgo de segundo cáncer primario, pero si el cáncer de recto ocurrió a una edad temprana, el riesgo aumenta un 51%. Esto incluye los cánceres de intestino delgado, conductos biliares y útero. Estos tumores a menudo están asociados con una predisposición genética. El riesgo es menor en los pacientes diagnosticados con cáncer de recto a una edad mayor. Los pacientes con cáncer de recto tratados con radiación tienen mayor riesgo de segundo cáncer primario en el campo irradiado, como el útero o la vejiga.

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Three Second Primary Cancer

Carcinogenic Pathways

• Common lifestyle/environmental factors

• Common genetic pathway

• Iatrogenic effect of treatment

Krueger H et al., Prog Exp Tumor Res. 2008 40:1-6

I would like to review the three carcinogenic pathways for the development of second primary cancer. These are common lifestyle or environmental factors, common genetic pathway, and iatrogenic effect of treatment.

Veamos las tres vías cancerígenas para el desarrollo de un segundo cáncer primario: los factores comunes de estilo de vida o ambientales, la vía genética común, y el efecto iatrogénico del tratamiento.

Common Lifestyle/Environmental Factors

Obesity

• Known risk factor for colorectal cancer

• Increases risk for other cancers

WCRF/AICR, Nutrition, Physical Activity, and the Prevention of Cancer:

a Global Perspective. Washington, DC: AICR 2007

We see that obesity is a known risk factor for colorectal cancer, but it has been well identified that obesity increases the risk for other cancers. So this is a common lifestyle factor that puts an obese colorectal cancer patient at increased risk for second primaries.

La obesidad es un factor de riesgo conocido del cáncer colorrectal y también aumenta el riesgo de otros cánceres. Es un factor común de estilo de vida que en los pacientes obesos con cáncer colorrectal aumenta el riesgo de un segundo cáncer primario.

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Obesity and Cancer

Convincing increased risk:

• Breast (among postmenopausal women)

• Colon

• Endometrium

• Esophagus

• Kidney

• Pancreas

Probable increased risk:

• Gallbladder

Limited-suggestive

increased risk:

• Liver

WCRF/AICR, Nutrition, Physical Activity, and the Prevention of Cancer:

a Global Perspective. Washington, DC: AICR 2007

We see that there’s convincing risk for obesity being linked to the development of colon cancer. It also has convincing evidence regarding the link to endometrial cancer and kidney cancer, both of which are increased in colon cancer survivors.

Hay un riesgo convincente de que la obesidad está relacionada con el cáncer de colon. También hay pruebas convincentes en su relación con el cáncer de endometrio y riñón, con mayor riesgo para los sobrevivientes de cáncer de colon.

Common Genetic Pathway

Lynch Syndrome

• Uterus- May be “sentinel cancer”

in women with Lynch Syndrome

• Small intestine

• Stomach

• Bile ducts

• Ovary

• Kidney

• Ureter

• Brain

FAP

• Stomach

• Small intestine

• Thyroid

• Brain

Watson P and Lynch HT. Cancer 1993 71(3):677

Burt RW. Gastroenterology 2000 119(3):837Lu KH, et al., Obstet Gynecol 2005 105(3):569

Now, there are common genetic pathways both Lynch Syndrome and Familial Adenomatous Polyposis. These are the cancers that can be seen with either of these syndromes and the ones highlighted in red are the ones that are more commonly seen in patients with a history of colorectal cancer.

Existen vías genéticas comunes para el síndrome de Lynch y la poliposis adenomatosa familiar. Estos cánceres pueden ocurrir con cualquiera de estos síndromes y los resaltados en rojo son más comunes en los pacientes con historial de cáncer colorrectal.

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Iatrogenic Effects of Treatment

• Excess risk for SPC related to treatment seen only in

rectal cancer patients treated with radiation therapy

– Uterus, bladder

• Decreased risk of prostate cancer

– “Nascent but quiescent” prostate cancers “cured”

by spillover radiation

Mysliwiec PA et al., NIH Publ. No. 05-5302. Bethesda, MD 2006

Iatrogenic effects of treatment are those that are related to the treatment we actually use to bring about the full treatment of the cancer and, thus, making the colorectal cancer patient a survivor. There is an excess risk of second primary cancers for those rectal cancer patients who received radiation and that risk is confined to the radiation field so thus it would be the uterus or the bladder. Interestingly enough in men, there is a decreased risk of prostate cancer. It’s been suggested that possibly nascent but quiescent, prostate cancers are cured by the spillover radiation for the rectal cancer treatment.

Los efectos iatrogénicos son aquellos relacionados con el tratamiento completo utilizado para combatir el cáncer, que hacen del paciente con cáncer colorrectal un sobreviviente. Existe un gran riesgo de un segundo cáncer primario en los pacientes con cáncer de recto que recibieron radioterapia, pero se limita al campo irradiado, es decir, el útero o la vejiga. Curiosamente, en los hombres reduce el riesgo de cáncer de próstata. Se ha sugerido que los cánceres de próstata incipientes, pero quiescentes, se curan con la radiación indirecta del tratamiento del cáncer de recto.

Managing Risk of Second Primary Cancers

• Controlling obesity through energy balance

– Calories in (diet) = calories out (exercise)

– Maintain BMI between 18-25

• Identify patients with BMI > 25

– Offer resources and support for weight reduction

– Offer exercise prescription

In managing the risk of second primary cancers, it’s important to understand those carcinogenic pathways and then target those risks that are identified. If we identify that someone is obese or overweight, we want to work at controlling the obesity through energy balance. That means calories in, what you consume, is --- equals calories out or exercise. We would like to maintain the BMI or body mass index between 18 and 25. It is important to identify patients with a BMI greater than 25 and offer them resources and support for weight reduction and offer an appropriate exercise prescription.

Para controlar el riesgo de un segundo cáncer primario es importante comprender estas vías cancerígenas y luego concentrarse en los riesgos identificados. Si identificamos que una persona es obesa o tiene sobrepeso, debemos controlar la obesidad a través del equilibrio de energía. Las calorías consumidas deben quemarse con el ejercicio. Queremos mantener el índice de masa corporal entre 18 y 25. Es importante identificar a los pacientes con un IMC mayor que 25 y ofrecerles recursos y apoyo para bajar de peso, así como una receta de ejercicio adecuada.

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Early Detection of Second Primary Cancers

• Follow current screening recommendations

– Women: breast, cervical

– Men: prostate

– Screening guidelines available at:http://utm-ext01a.mdacc.tmc.edu/mda/cm/cwtguide.nsf/luhtml/sidebar1

• For individuals with Lynch Syndrome or FAP

– Management guidelines can be found within this lecture series in

Dr. Lynch’s presentation on Cancer Screening for Patients with

Inherited Colorectal Cancer

– Consider referral to specialist in Lynch Syndrome or FAP

It’s also important that colorectal cancer [survivors] follow current cancer screening recommendations. They are not immune to developing a cancer that would otherwise have developed had they not had colorectal cancer. For women, they should screen for breast and cervical cancer and men, if they so elect after counseling, screen for prostate cancer. MD Answer has --- MD Anderson has cancer screening guidelines available at the URL on this slide. For individuals with Lynch Syndrome or FAP, management guidelines will be discussed by Dr. Patrick Lynch in his presentation on Cancer Screening for Patients with Inherited Colorectal Cancer. These individuals are appropriate for referral to a specialist in Lynch Syndrome or FAP.

También es importante que los sobrevivientes sigan las recomendaciones de detección actuales, pues no son inmunes a desarrollar un cáncer que se hubiera desarrollado aun sin cáncer colorrectal. Las mujeres deben hacerse exámenes de detección de cáncer de mama y cervical, y los hombres de cáncer de próstata, tras recibir asesoramiento. El MD Anderson dispone de recomendaciones para la detección de cáncer en el URL indicado aquí. Para los pacientes con síndrome de Lynch o poliposis, las pautas serán analizadas por el Dr. Patrick Lynch en su presentación sobre la detección para los pacientes con cáncer colorrectal heredado, pero deben ser referidos a un especialista en síndrome de Lynch o poliposis.

Summary

• Colorectal cancer survivors are at increased risk of SPC

• Managing risk of second primary cancers involves:

– Identify risks for SPC

– Modify risks for SPC

– Implement appropriate screening to detect SPC early

In summary, colorectal cancer survivors are at increased risk of a second primary cancer. The risk can be managed by identifying that risk, modifying it by offering risk reduction strategies, such as weight management, and implementing appropriate screening to detect second primary cancers early. I hope you have enjoyed this lecture. We welcome your feedback.

En resumen, los sobrevivientes de cáncer colorrectal tienen un mayor riesgo de un segundo cáncer primario, que puede controlarse identificándolo y modificándolo con estrategias de reducción, como el control de peso, y con un examen adecuado para detectar un segundo cáncer primario de manera temprana. Espero que hayan disfrutado de esta disertación. Agradeceremos sus comentarios.