Oncology Update in GI Cancer Tiffany Sipe FNP-BC, MSN,OCN
Oncology Nurse Practitioner Tennova Physicians Services Slide 2
Disclosures Tiffany is on the speakers bureau for Alexion
Pharmaceuticals and IMER. Slide 3 Outcomes at the end of the
presentation the participant will: Better understand the most
recent data regarding digestive tract cancer rates in the U.S.
Recognize new treatment options for GI cancers Identify at least
two unique side effects related to new agents used to treat
digestive tract cancers Understand the role of targeted therapies
in Digestive Tract Cancers Slide 4 Estimated New Cancer Cases 2011
All Sites- Both Sexes 1,596,670 Females Breast 230,480 Lung 106,070
Colon & Rectum 69,360 Uterine 46,470 Pancreas 21,980 (3%)
Cancer Statistics, 2011, A Cancer Journal for Clinicians, Vol.61
(4). Males Prostate 240,890 Lung 115,060 Colon & Rectum 71,850
Urinary Bladder 52,020 Pancreas 22,050 (3%) Slide 5 Estimated
Deaths 2011 All Sites-Both Sexes 571,950 Females Lung 71,340 (26%)
Breast 39,520 (15%) Colon & Rectum 24,130 (9%) Pancreas 18,300
(7%) Cancer Statistics, 2011, A Cancer Journal for Clinicians,
Vol.61 (4). Males Lung 85,600 (28%) Prostate 33,720 (11%) Colon
& Rectum 25,250 (8%) Pancreas 19,360 (6%) Slide 6 Rocky Top
Youll Always Be Home Sweet Home to Me??
TennesseeAlabamaFloridaOregon All Sites: 34,750All Sites:25,530All
Sites: 113,400All Sites: 21,180 CRC: 3,170CRC: 2,310CRC:
10,180CRC:1,730 Lung: 5,870Lung: 4,240Lung: 17,150Lung: 2,860 Slide
7 Digestive Tract Statistics 2011 Esophagus New Cases: Male: 13,450
Female: 3,530 Deaths: Male: 11,910 Female: 2,800 Cancer Statistics,
2011, A Cancer Journal for Clinicians, Vol.61 (4). Stomach New
Cases: M ale: 13,120 Female: 8,400 Deaths: Male: 6,260 Female:
4,080 Slide 8 Gastric Cancer Highest incidence occurs in eastern
Asia, Andean regions of South America and Eastern Europe Overall
incidence of gastric cancer is declining but there is an increase
in cancer of the GE junction No routine screening for GC Often
asymptomatic- patients are often diagnosed with regional or
distance metastasis leading to poor overall prognosis Slide 9
Colorectal cancer is the third most commonly diagnosed cancer in
men and the second in women worldwide. Prostate, Breast, Lung and
Colon Cancer are the most commonly diagnosed cancers in men and
women Lung Cancer is the leading cause of cancer death in men and
women. Colo-rectal cancer is the third leading cause of cancer
death in men and women Pancreatic is fourth leading cause of cancer
death in men and women Slide 10 Treatment options for colon cancer
Surgery Radiation-more likely used in rectal cancer or for
palliative treatment Chemotherapy Targeted Therapy Best Supportive
Care Slide 11 Staging of Colon Cancer Stage O-carcinoma in
situ-abnormal cells are found in the mucosa of the colon wall.
Stage I- formed in the mucosa and spread to the submucosa. May have
spread to the muscle layer of the colon wall. Stage II-( A,B,C).
Spread through the muscle layer of the colon wall to the serosa,
through the serosa or through the serosa and nearby organ. Stage
III-(A,B,C)spread through serosa to nearby lymph nodes Stage
IV-Spread to distant lymph nodes and other organs. Most common site
of metastasis is liver and lung. 2011, www.cancer.gov,
NCIwww.cancer Slide 12 Oncotype DX Colon Cancer Assay First
Commercial Test to provide a quantitative Recurrence Score for
patient with Stage II Colon Cancer Requires either 1- fixed
paraffin-embedded tumor block or 15 unstained slides Incorporates
number of nodes examined, tumor size, micro- metastatic lymph or
vascular invasion, tumor grade and MMR status Written report
available in 10 days with a recurrence score, 5 yr vs 3 yr colon
cancer recurrence estimations and relevance for chemotherapy
benefit 2011, Oncotype DX Insert Slide 13 Oncology Terminology
Neoadjuvant Treatment Adjuvant Treatment 1 st line, 2 nd line,
salvage treatment Palliative Treatment Best Supportive Care Hospice
ONS NCCN Guidelines Slide 14 Chemotherapy 101 Traditional
chemotherapy side effects: 1. Neutropenia 2. Anemia 3.
Thrombocytopenia 4. Nausea/Vomiting 5. Diarrhea 6. Mouth Sores 7.
Fatigue 8. Alopecia Slide 15 Commonly used cytotoxic agents for GI
cancer Esophageal/Gastric: Taxotere, Carboplatin, Xeloda,
Herceptin*,Adriamycin Colo-rectal: Oxaliplatin, Leucovorin, 5FU,
Xeloda, CPT-11, Erbitux*,Vectibex,Avastin Slide 16 Capecitabine
(Xeloda) Oral tablet used in breast, stage III adjuvant and
metastatic CRC Can be used as single agent or in combination with
radiation or chemotherapy. Sensitizing agent Taken with a full
glass of water with meals twice daily- cycle length dependent on
physician/ mode of administration Vitamin B6 helps prevent hand and
foot syndrome Similar to 5FU Slide 17 Eloxatin (Oxaliplatin) First
approved in 2003 for metastatic treatment of CRC Approved in 2004
for first line treatment in Stage IIICRC Given with Leucovorin Cold
Sensitivity for 48 hours post treatment Peripheral Neuropathy Given
every 2 weeks for 6 months as adjuvant treatment in Colon cancer
stage II and III -FOLFOX Given every 2 weeks for 4-6 months as
adjuvant treatment in rectal cancer Eloxatin Package Insert, 2011
Slide 18 Targeted Therapies..The New Frontier Slide 19 Epidermal
Growth Factor Receptor Slide 20 K-Ras Slide 21 Cetuximab (Erbitux)
EGFR wild type, metastatic CRC Binds Epidermal Growth Factor
Receptor inhibiting cell growth and survival Squamous cell Head and
Neck Ca in combo with XRT Requires a loading dose then weekly
maintenance dose Premedicate with antihistamines Post reaction
transfusion related hypotension- usually one to two hour post
infusion observation No renal or hepatic dosing decrease required
Slide 22 Panitumumab (Vectibix) Approved for EGFR expressing
metastatic CRC Resistance to therapy if there is a K-RAS mutation
in codon 12 or 13 6mg/kg IV every 14 days Acneform Rash Infusion
Reactions Slide 23 Acneform Rash Maculopapular rash that occurs
primarily on the face and chest. See handout for photo for examples
Slide 24 Her 2-Neu http://www.youtube.com/watch?v=nXtKboH2S38H
Human epidermal growth factor receptor 2 Approximately 20% of
gastric cancers Normally 20,000 receptors on cell. Her-2 Neu gene
amplification can lead to overexpression of Her-2 Neu- 2,000,000.
Overexpression means the cancer cell will have excellarated
proliferation, survival, motility and adhesion. It is thought that
Her-2 positive status in GC is associated with poor outcomes and
aggressive disease-conflicting data Slide 25 Testing for Her-2 Neu
Immunohistochemistry (IHC) A sample of tissue is stained and read
by a pathologist. According to how much of the tissue takes up the
stain is the grading it will receive. Grade 2-equivocal, 3 or 4=Her
2 neu + Fluorescense in situ hybridization (FISH) Probes specific
for Her-2 neu & a control are placed in the tissue. Ration of
Her 2 to control are recorded.>2.2 is Her 2 Neu+ Slide 26 IHC
Staining Slide 27 Trastuzumab (Herceptin) Monoclonal Antibody
Approved for Her-2 Neu over expressing Metastatic Gastric Cancer
(Esophagus to stomach) ECHO prior to first dose then periodically
throughout treatment. Caution in cardiac disease Loading dose
(8mg/kg IV X 1) then 6mg/kg/IV every 3 weeks with chemotherapy
Infusion Reactions Slide 28 Vascular Endothelial Growth Factor
Slide 29 Bevacizumab (Avastin) Metastatic CRC,(Breast-but now no
longer FDA approved),met.Renal,progressive GBM,NSCLC Antiangiogenic
agent Given IV 28 days AFTER a surgical procedure due to poor wound
healing Nosebleeds/Hemorrhage Proteinuria Hypertension Infusion
Reactions GI Perforation Slide 30 Prognosis of metastatic CRC has
significantly improved with the addition of targeted therapies to
new and existing chemotherapy treatments Newer targeted therapies
have different side effect than we usually expect-i.e. transfusion
related reactions, acneform rash The GI associate can be a pivotal
player in getting the appropriate sample sent for testing for the
newer targeted agents
