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Colorecta l Cancer Update

Colorecta l 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. O utline.

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Colorecta l Cancer Update

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  1. 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

  2. Disclosures • No Disclosures

  3. Outline • Facts and Figures • Risk Factors • Clinical Presentation and Management • Screening

  4. 9% Colon & rectum

  5. 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

  6. Risk Factors Sporadic (65%–85%) Familial (10%–30%) Rare CRC syndromes (<0.1%) Hereditary nonpolyposis colorectal cancer (HNPCC) (5%) Familial adenomatous polyposis (FAP) (1%) Adapted from Burt RW et al. Prevention and Early Detection of CRC, 1996

  7. Risk Factors Adenomatous polyps Age Inflammatory Bowel Disease History of Cancer Family History of Colorectal Cancer Physical Inactivity/obesity Smoking NSAIDS Diets/Supplements Race

  8. Cancer Risk in Polyps

  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

  10. Age

  11. Familial Risk 70% Approximate lifetime CRC risk (%) 17% 10% 8% 6% 2% HNPCC mutation One 1° and two 2° One 1° age <45 None One 1° Two 1° 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 Affected family members

  12. Risk of Colorectal Cancer 5% General population Personal history of colorectal neoplasia 15%–20% Inflammatory bowel disease 15%–40% 70%–80% HNPCC mutation >95% FAP 0 20 40 60 80 100 Lifetime risk (%)

  13. Diet dietary fiber vegetables fruits antioxidant vitamins calcium folate (B Vitamin) decreased risk

  14. Diet consumption of red meat animal and saturated fat refined carbohydrates alcohol increased risk

  15. Clinical Presentation

  16. CRC by Site

  17. Stage at Diagnosis Adapted from NCI Cancer Facts and Figures 2010

  18. Staging Workup Endoscopy with biopsy CT Scan CXR ?PET Scan CEA

  19. Stages of Colon Cancer

  20. Sites of Metastasis • Liver • Lung • Brain • Bone

  21. 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

  22. Management Colon Cancer • Stage I • Surgery alone • Stage II • Surgery alone +/- chemotherapy • Stage III • Surgery + Chemotherapy • Stage IV • Chemotherapy alone • Surgery + chemotherapy + metastasectomy

  23. Rectal Cancer • Similar to Colon Cancer • Chemoradiation for Stages II and III

  24. 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

  25. 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

  26. 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

  27. Screening Modalities High sensitivity Fecal occult blood testing q1yr Flexible Sigmoidoscopy q5years +FOBT q3yrs Colonoscopy q10 years CT colonography* Stool DNA/ FIT

  28. 5-year Survival • Stage I 93% • Stage IIA 85% • Stage IIB 72% • Stage IIIA 83% • Stage IIIB 64% • Stage IIIC 44% • Stage IV 8%

  29. 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

  30. Thank you Jonathan A. Laryea, MD jalaryea@uams.edu Clinic Appointments: (501) 686-6211 Office: (501) 686-6757

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