1 / 71

Colon & Rectal Cancers

Colon & Rectal Cancers. Imran Ahmad, MD., Clinical Assistant Professor. Medical Oncology, Saskatoon Cancer Centre. Faculty Declaration. Will discuss an unapproved/investigative use of a commercial product/device

salena
Download Presentation

Colon & Rectal Cancers

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Colon & Rectal Cancers Imran Ahmad, MD., Clinical Assistant Professor. Medical Oncology, Saskatoon Cancer Centre.

  2. Faculty Declaration • Will discuss an unapproved/investigative use of a commercial product/device • I have/had a financial arrangement or affiliation with one or more organizations Research Support – Hoffman La-Roche

  3. Colon & rectal cancers Objectives: - Colon and rectal ca statistics in Canada. - Prevention and screening. - Medical management of localized and advanced stage cancer.

  4. Colon & rectal cancers Statistics: - An estimated 153,000 new cases & 70,000 deaths from cancer will occur in 2006 in Canada1. - An estimated 20,000 new cases & 8,500 deaths from colorectal cancer will occur in 2006 in Canada1. 1Canadian cancer statistics, 2006.

  5. Percentage Distribution of Estimated New Cases for Selected Cancer Sites, Males, Canada, 2006.

  6. Percentage Distribution of Estimated Deaths for Selected Cancer Sites, Males, Canada, 2006

  7. Percentage Distribution of Estimated New Cases for Selected Cancer Sites, Females, Canada, 2006

  8. Percentage Distribution of Estimated Deaths for Selected Cancer Sites, Females, Canada, 2006

  9. Age-Standardized Incidence Rates (ASIR) for Selected Cancer Sites, Males, Canada, 1977-2006

  10. Age-Standardized Mortality Rates (ASMR) for Selected Cancer Sites, Males, Canada, 1977-2006

  11. Age-Standardized Incidence Rates (ASIR) for Selected Cancer Sites, Females, Canada, 1977-2006

  12. Age-Standardized Mortality Rates (ASMR) for Selected Cancer Sites, Females, Canada, 1977-2006

  13. Selected Causes of Potential Years of Life Lost (PYLL), Canada, 2002

  14. Actual Data for New Cases for the Most Common Cancer Sites by Sex And Geographic Region, Most Recent Year1, Canada 1 2001 for Canada, Quebec; 2002 for Ontario; 2003 for Newfoundland, Prince Edward Island, Nova Scotia, New Brunswick, Manitoba, Saskatchewan, Alberta, British Columbia; 199-2003 average for Yukon, Northwest Territories, Nunavut

  15. Canadian Cancer Stats 2004

  16. Colon & rectal cancers Risk factors: (I) Sporadic (70%): - Age: Risk increases significantly b/w ages of 40 and 50, & in each succeeding decade thereafter1. - Lifetime incidence is about 5%. 1Eddy, DM et al. Ann Intern Med 1990.

  17. Colon & rectal cancers Risk factors (Sporadic): - Inflammatory bowel disease (Pancolitis ,5-15 fold increased risk )1 - Alcohol - Diabetes mellitus - Cigarette smoking. 1Ekbom,A et al. NEJM 1990.

  18. Colon & rectal cancers (II) Risk factors, inherited (5-10%): (a) Germ line mutations. (1) Polyposis syndromes: - Familial adenomatous polyposis. - Less than 1% of CRC. - Germ line mutations in APC gene on ch 51. 1Burt, RW et al. Ann Rev Med 1995.

  19. Colon & rectal cancers (II) Risk factors, inherited (5-10%): (a) Germ line mutations. (2) Non Polyposis syndromes - Hereditary nonpolyposis CRC. - Autosomal dominant. - More common than FAP1. 1Lynch, HT et al. Gastroenterology 1993.

  20. Colon & rectal cancers (III) Risk factors, familial (20-25%): - Affected pts have family history, but pattern is different from inherited one. - Having an affected 10 relative increases the risk 1.7 fold. - Genetic abnormalities: ? Mutated APC gene, ? loss of DNA, ?mismatch repair genes.

  21. Adenoma carcinoma sequence

  22. Genetic model of CRC carcinogenesis

  23. Colon & rectal cancers Protective factors: - Diet high in fruits and vegetables.1 (? Fiber, antioxidants, FA, Selenium) - ASA / NSAID’S2. - HMG-CoA reductase inhibitors3. 1Kim et al. Nutr Rev 1996. 2Giovannucci et al. NEJM 1999 3Sacks et al. NEJM 1996.

  24. Colon & rectal cancers • CASE #1 • 63 yr old asymptomatic man with no family h/o colorectal ca, presented for first annual physical exam, by family MD. • Physical exams including rectal exam was normal. Fecal occult blood testing was negative. • What should be further recommendations for colorectal cancer screening in future?

  25. Colon & rectal cancers Screening: “Canadian Association of Gastroenterology &Canadian Digestive Foundation. Guidelines on Colon Ca Screening. 2004.” - Begin screening at age 40 if; One 10 relative >60 yrs has CRC or AP, or > one 20 relative has CRC or AP. • Otherwise begin screening at age 50. • www.cag-acg.org/www.screencolons.ca

  26. Colon & rectal cancers Choices of screening methods include1: - FOB atleast every 2 years. - Flex sig (w/wo FOB) every 5 yrs. - Double contrast BE every 5 yrs. - Colonoscopy every 10 yrs. “Screening method should be determined by its availability & after discussion b/w pt & physician” 1Leddin et al. Can J Gastroenterol 2004.

  27. Colon & rectal cancers CRC Screening: Practices & opinions of primary care physicians1. • < 42% of physicians were familiar with guidelines. • Only 35.6% of physicians offered screening to at least 75% of their average risk pts. 1McGregor et al. Preventive Medicine 2004.

  28. Colorectal Cancer Screening: Percentage of Men and Women Aged 50 Years and Over Reporting a Screening Fecal Occult Blood Test (FOBT Within the Last 2 Years, by Province. Regions (Within SK, ON)*, 2003 * Based on selected sampling units (regions) where relevant data were collected: 7 of 11 units in Saskatchewan (63% of SK population) and 14 of 37 units in Ontario (27% of ON population; Toronto not included)

  29. Colon & rectal cancers Diagnosis: *Presenting symptoms 1(resectable cancer): - Abdominal pain (44%) - Change in bowel habit (43%) - Haematochezia or melena (40%) - Fe def anemia, w/o other GI symp (11%) - Weight loss (6%) 1Steinberg et al. Cancer 1986.

  30. Colon & rectal cancers Diagnosis: * Presentation of metastatic disease: - 15-20% of pts have metastatic disease on presentation. - Common sites are LN, liver, lungs and peritoneum.

  31. Mesenteric Lymphadenopathy in a pt with colon ca

  32. Liver mets in a pt with colon cancer

  33. Colon & rectal cancers Diagnostic procedures: - Colonoscopy. - Double contrast barium enema.

  34. Colon & rectal cancers • CASE #2 • 65 yr old woman, with no significant medical history presented to family doctor with h/o tiredness and easy fatigue. • Blood studies showed evidence of hypochrmic microcytic anemia secondary to iron deficiency. • What inv will be needed to r/o colorectal ca as the cause of problem?

  35. Colon & rectal cancers Stages of disease at presentation: “Duke’s classification & AJCC staging” - Localized to mucosa and submucosa (Dukes A or TNM stage I) 23%. - Extending through muscle layer without LN involvement (Dukes B or TNM stage II) 31%. - LN involvement (Dukes C or TNM stage III) 26%. - Distant mets (Dukes D or TNM stage IV) 20%.

  36. Colon & rectal cancers Pre op staging: - Essential workup: H & P, CT scan of abd & pelvis. Chest xray, Serum CEA. - Other tests LFT’s, PET scan, EUS.

  37. Five yr survival rates for rectal cancer

  38. Colon & rectal cancers Other prognostic features: - Lymphovascular invasion. - Pre op CEA Level. - Presence of microsatellite instability & loss of the Deleted in Colon Cancer (DCC) gene.

  39. Colon & rectal cancers Adjuvant therapy for colon cancer: * Monotherapy. 5 Fluorouracil. (no improvement in 5 yr survival)1 * Combination chemo (NSABP C-01 trial)2. - 1166 pts. - Arm A: Surgery, Arm B: BCG, Arm C: MOF - Result: Significant improvement in 5 yr OS with MOF. 1Buyse et al, JAMA 1988. 2Wolmark et al, JNCI 1988

  40. Colon & rectal cancers • CASE #3: • Lady in case #2 underwent colonoscopy followed by laparotomy for cecal cancer. • She was found out to have a 5 cm mod differentiated adenocarcinoma, with one out of 11 lymph node positive. • She is 3 wks out of surgery, and asking for further recommendations?

  41. Colon & rectal cancers Adjuvant therapy for colon cancer: (NCCTG trial)1 - 5 FU & levamisole vs surgery alone. - 40 % reduction in risk of recurrence. - OS benefit only in lymph nodes positive disease. 1Laurie et al; JCO 1989.

  42. Colon & rectal cancers Adjuvant therapy for colon cancer: * Trials using combination of 5FU & leucovorin. (NSABP C-03, IMPACT report1, NCCTG trial2) - 5 FU & leucovorin for at least 6 mo. - Approx 20% reduction in death, 5% benefit in 3 yr OS. - Benefit limited to node positive disease. 1Impact investigators; Lancet 1995. 2O’Connell et al; JCO 1997

  43. Colon & rectal cancers Adjuvant therapy for colon cancer: 1990 NIH consensus conference1, “Adjuvant 5 FU containing chemotherapy is the standard of care for resected node positive (stage III) colon cancer”. 1NIH consensus conf; JAMA 1990.

  44. Colon & rectal cancers New developments in adjuvant therapy: Oxaliplatin containing regimens. (MOSAIC trial)1 - 2246 pts. - 5FU and Leucovorin +/- Oxaliplatin. - 3 yr DFS 78% vs 73 % (p< 0.05). - OS was similar. 1Andre T et al. NEJM 2004.

  45. Colon & rectal cancers New developments in adjuvant therapy: Use of oral Capecitabine (X-ACT study)1 - 1987 pts. - 5FU and LV vs oral Capecitabine - Capecitabine was at least as effective as 5FU and LV, but better tolerable. 1Scheithauer W et al. Ann Oncol 2003.

  46. Colon & rectal cancers Current options for adjuvant therapy for colon ca: • Oxaliplatin based regimen. - Oral capecitabine.

More Related