PLWC Slide Deck Series:PLWC Slide Deck Series:

Understanding Colorectal CancerUnderstanding Colorectal Cancer

PresentPresentss

20052005

What is Cancer?

A group of 100 different diseases

The uncontrolled, abnormal growth of cells

Cancer may spread to other parts of the body

What is Colorectal Cancer?

Third most common type of cancer and second most frequent cause of cancer-related death

A disease in which normal cells in the lining of the colon or rectum begin to change, grow without control, and no longer die

Usually begins as a noncancerous polyp that can, over time, become a cancerous tumor

What is the Function of the Colon and Rectum?

The colon and rectum comprise the large intestine (large bowel)

The primary function of the large bowel is to turn liquid stool into formed fecal matter

What Are the Risk FactorsWhat Are the Risk Factors for Colorectal Cancer? for Colorectal Cancer?

Polyps (a noncancerous or precancerous growth Polyps (a noncancerous or precancerous growth associated with aging)associated with aging)

AgeAge

Inflammatory bowel disease (IBD)Inflammatory bowel disease (IBD)

Diet high in saturated fats, such as red meatDiet high in saturated fats, such as red meat

Personal or family history of cancerPersonal or family history of cancer

ObesityObesity

SmokingSmoking

OtherOther

Hereditary Colorectal Cancer Syndromes: HNPCC

Hereditary non-polyposis colorectal cancer (HNPCC), Hereditary non-polyposis colorectal cancer (HNPCC), sometimes called Lynch syndrome, accounts for sometimes called Lynch syndrome, accounts for approximately 5% to 10% of all colorectal cancer casesapproximately 5% to 10% of all colorectal cancer cases

The risk of colorectal cancer in families with HNPCC is The risk of colorectal cancer in families with HNPCC is 70% to 90%, which is several times the risk of the 70% to 90%, which is several times the risk of the general populationgeneral population

People with HNPCC are diagnosed with colorectal People with HNPCC are diagnosed with colorectal cancer at an average age of 45cancer at an average age of 45

Genetic testing for the most common HNPCC genes is Genetic testing for the most common HNPCC genes is available; measures can be taken to prevent available; measures can be taken to prevent development of colorectal cancer development of colorectal cancer

Hereditary Colorectal Cancer Hereditary Colorectal Cancer Syndromes: FAPSyndromes: FAP

Familial adenomatous polyposis (FAP) accounts for 1% of Familial adenomatous polyposis (FAP) accounts for 1% of colorectal cancer casescolorectal cancer casesPeople with FAP typically develop hundreds to thousands People with FAP typically develop hundreds to thousands of colon polyps (small growths); the polyps are initially of colon polyps (small growths); the polyps are initially benign (noncancerous), but there is nearly a 100% chance benign (noncancerous), but there is nearly a 100% chance that the polyps will develop into cancer if left untreatedthat the polyps will develop into cancer if left untreatedColorectal cancer usually occurs by age 40 in people with Colorectal cancer usually occurs by age 40 in people with FAP FAP Mutations (changes) in the APC gene cause FAP; genetic Mutations (changes) in the APC gene cause FAP; genetic testing is availabletesting is availableYearly screening for polyps is recommendedYearly screening for polyps is recommendedAttenuated familial adenomatous polyposis (AFAP) is Attenuated familial adenomatous polyposis (AFAP) is related to FAP; people have fewer polypsrelated to FAP; people have fewer polyps

Hereditary Colorectal Cancer SyndromesHereditary Colorectal Cancer Syndromes

Several other less common syndromes can Several other less common syndromes can increase a person’s risk of colorectal cancerincrease a person’s risk of colorectal cancer

Talk with your doctor about finding a genetic Talk with your doctor about finding a genetic counselor if you have a history of colorectal counselor if you have a history of colorectal cancer in your family and family members cancer in your family and family members developed cancer before age 50developed cancer before age 50

For more information, visit For more information, visit www.plwc.org/geneticswww.plwc.org/genetics

Colorectal Cancer and Early DetectionColorectal Cancer and Early Detection

Colorectal cancer can be prevented through Colorectal cancer can be prevented through regular screening and the removal of polyps regular screening and the removal of polyps

Early diagnosis means a better chance of Early diagnosis means a better chance of successful treatmentsuccessful treatment

Screening should begin at age 50 for all “average Screening should begin at age 50 for all “average risk” individuals or sooner if you have a family risk” individuals or sooner if you have a family history of colorectal cancer, symptoms, or a history of colorectal cancer, symptoms, or a personal history of inflammatory bowel diseasepersonal history of inflammatory bowel disease

Screening Methods for Colorectal Screening Methods for Colorectal CancerCancer

Colonoscopy (currently the best way to prevent and Colonoscopy (currently the best way to prevent and detect colorectal cancer) detect colorectal cancer)

Virtual colonographyVirtual colonography

SigmoidoscopySigmoidoscopy

Fecal occult blood testFecal occult blood test

Double contrast barium enemaDouble contrast barium enema

Digital rectal examination Digital rectal examination

What Are the Symptoms ofWhat Are the Symptoms ofColorectal Cancer?Colorectal Cancer?

A change in bowel habits: diarrhea, constipation, or a A change in bowel habits: diarrhea, constipation, or a feeling that the bowel does not empty completelyfeeling that the bowel does not empty completely

Bright red or dark blood in the stoolBright red or dark blood in the stool

Stools that appear narrower or thinner than usualStools that appear narrower or thinner than usual

Discomfort in the abdomen, including frequent gas Discomfort in the abdomen, including frequent gas pains, bloating, fullness, and crampspains, bloating, fullness, and cramps

Unexplained weight loss, constant tiredness, or Unexplained weight loss, constant tiredness, or unexplained anemia (iron deficiency)unexplained anemia (iron deficiency)

How is Colorectal Cancer Evaluated?How is Colorectal Cancer Evaluated?

Diagnosis is confirmed with a biopsyDiagnosis is confirmed with a biopsy

Stage of disease is confirmed by pathologists and Stage of disease is confirmed by pathologists and imaging tests, such as computerized tomography imaging tests, such as computerized tomography (CT or CAT) scans(CT or CAT) scans

Endoscopic ultrasound and magnetic resonance Endoscopic ultrasound and magnetic resonance imaging (MRI) may also be used to stage rectal imaging (MRI) may also be used to stage rectal cancercancer

Cancer Treatment: SurgeryCancer Treatment: Surgery

Foundation of curative therapyFoundation of curative therapy

The tumor, along with the adjacent healthy colon The tumor, along with the adjacent healthy colon or rectum and lymph nodes, is typically removed or rectum and lymph nodes, is typically removed to offer the best chance for cureto offer the best chance for cure

May require temporary or (rarely) permanent May require temporary or (rarely) permanent colostomy (surgical opening in abdomen that colostomy (surgical opening in abdomen that provides a place for waste to exit the body)provides a place for waste to exit the body)

Cancer Treatment: ChemotherapyCancer Treatment: Chemotherapy

Drugs used to kill cancer cellsDrugs used to kill cancer cells

Typical medications include fluorouracil (5-FU), Typical medications include fluorouracil (5-FU), oxaliplatin (Eloxatin), irinotecan (Camptosar), oxaliplatin (Eloxatin), irinotecan (Camptosar), and capecitabine (Xeloda)and capecitabine (Xeloda)

A combination of medications is often used A combination of medications is often used

Types of Chemotherapy

Adjuvant chemotherapy is given after surgery to Adjuvant chemotherapy is given after surgery to maximize a patient’s chance for cure maximize a patient’s chance for cure

Neoadjuvant chemotherapyNeoadjuvant chemotherapy is given before is given before surgerysurgery

Palliative chemotherapy is given to patients Palliative chemotherapy is given to patients whose cancer cannot be removed to delay or whose cancer cannot be removed to delay or reverse cancer-related symptoms and reverse cancer-related symptoms and substantially improve quality and length of lifesubstantially improve quality and length of life

Cancer Treatment: Radiation TherapyCancer Treatment: Radiation Therapy

The use of high-energy x-rays or other particles to The use of high-energy x-rays or other particles to destroy cancer celldestroy cancer cell

Used to treat rectal cancer, either before or after Used to treat rectal cancer, either before or after surgerysurgery

Different methods of deliveryDifferent methods of delivery

External-beam: outside the bodyExternal-beam: outside the body

Intraoperative: one dose during surgeryIntraoperative: one dose during surgery

New Therapies: Antiangiogenesis New Therapies: Antiangiogenesis TherapyTherapy

““Starves” the tumor by disrupting its blood Starves” the tumor by disrupting its blood supplysupply

This therapy is given along with chemotherapyThis therapy is given along with chemotherapy

Bevacizumab (Avastin) was approved by the U.S. Bevacizumab (Avastin) was approved by the U.S. Food and Drug Administration (FDA) in 2004 for Food and Drug Administration (FDA) in 2004 for the treatment of stage IV colorectal cancerthe treatment of stage IV colorectal cancer

New Therapies: Targeted TherapyNew Therapies: Targeted Therapy

Treatment designed to target cancer cells while Treatment designed to target cancer cells while minimizing damage to healthy cellsminimizing damage to healthy cells

Cetuximab (Erbitux) was approved by the FDA in Cetuximab (Erbitux) was approved by the FDA in 2004 for the treatment of advanced colorectal 2004 for the treatment of advanced colorectal cancercancer

Colorectal Cancer StagingColorectal Cancer Staging

Staging is a way of describing a cancer, such as Staging is a way of describing a cancer, such as the depth of the tumor and where it has spreadthe depth of the tumor and where it has spreadStaging is the most important tool doctors have Staging is the most important tool doctors have to determine a patient’s prognosis to determine a patient’s prognosis Staging is described by the TNM system: the size Staging is described by the TNM system: the size (the depth of penetration of the (the depth of penetration of the TTumor into the umor into the wall of the bowel), whether cancer has spread to wall of the bowel), whether cancer has spread to nearby lymph nearby lymph NNodes, and whether the cancer odes, and whether the cancer has has MMetastasized (spread to organs such as the etastasized (spread to organs such as the liver or lung)liver or lung)The type of treatment a person receives depends The type of treatment a person receives depends on the stage of the canceron the stage of the cancer

Stage Stage 00 Colorectal Cancer Colorectal Cancer

Known as “cancer in Known as “cancer in situ,” meaning the situ,” meaning the cancer is located in cancer is located in the mucosa (moist the mucosa (moist tissue lining the colon tissue lining the colon or rectum)or rectum)

Removal of the polyp Removal of the polyp (polypectomy) is the (polypectomy) is the usual treatmentusual treatment

Stage I Colorectal CancerStage I Colorectal Cancer

The cancer has grown The cancer has grown through the mucosa through the mucosa and invaded the and invaded the muscularis (muscular muscularis (muscular coat)coat)

Treatment is surgery Treatment is surgery to remove the tumor to remove the tumor and some surrounding and some surrounding lymph nodeslymph nodes

Stage II Colorectal CancerStage II Colorectal CancerThe cancer has grown The cancer has grown beyond the muscularis beyond the muscularis of of the colon or rectum but has the colon or rectum but has not spread to the lymph not spread to the lymph nodesnodes

Stage II colon cancer is Stage II colon cancer is treated with surgery and, treated with surgery and, in some cases, in some cases, chemotherapy after surgerychemotherapy after surgery

Stage II rectal cancer is Stage II rectal cancer is treated with surgery, treated with surgery, radiation therapy, and radiation therapy, and chemotherapychemotherapy

Stage III Colorectal CancerStage III Colorectal CancerThe cancer has spread to The cancer has spread to the regional lymph nodes the regional lymph nodes (lymph nodes near the (lymph nodes near the colon and rectum)colon and rectum)

Stage III colon cancer is Stage III colon cancer is treated with surgery and treated with surgery and chemotherapychemotherapy

Stage III rectal cancer is Stage III rectal cancer is treated with surgery, treated with surgery, radiation therapy, and radiation therapy, and chemotherapychemotherapy

Stage IV Colorectal CancerStage IV Colorectal CancerThe cancer has spread The cancer has spread outside of the colon or outside of the colon or rectum to other areas of rectum to other areas of the bodythe bodyStage IV cancer is treated Stage IV cancer is treated with chemotherapy. with chemotherapy. Surgery to remove the Surgery to remove the colon or rectal tumor may colon or rectal tumor may or may not be doneor may not be doneAdditional surgery to Additional surgery to remove metastases may remove metastases may also be done in carefully also be done in carefully selected patientsselected patients

The Role of Clinical Trials for the The Role of Clinical Trials for the Treatment of Colorectal CancerTreatment of Colorectal Cancer

Clinical trials are research studies involving peopleClinical trials are research studies involving people

They test new treatment and prevention methods They test new treatment and prevention methods to determine whether they are safe, effective, and to determine whether they are safe, effective, and better than the best known treatmentbetter than the best known treatment

The purpose of a clinical trial is to answer a The purpose of a clinical trial is to answer a specific medical question in a highly structured, specific medical question in a highly structured, controlled processcontrolled process

Clinical trials can evaluate methods of cancer Clinical trials can evaluate methods of cancer prevention, screening, diagnosis, treatment, and/or prevention, screening, diagnosis, treatment, and/or quality of lifequality of life

Clinical Trials: Patient SafetyClinical Trials: Patient Safety

Informed consent: Participants should Informed consent: Participants should understand why they are being offered entry into understand why they are being offered entry into a clinical trial and the potential benefits and a clinical trial and the potential benefits and risks; informed consent is an ongoing processrisks; informed consent is an ongoing process

Participation is always voluntary, and patients Participation is always voluntary, and patients can leave the trial at any timecan leave the trial at any time

Other safeguards exist to ensure ongoing patient Other safeguards exist to ensure ongoing patient safetysafety

Clinical Trials: PhasesClinical Trials: Phases

Phase I trials determine safety and dose of a new Phase I trials determine safety and dose of a new treatment in a small group of peopletreatment in a small group of people

Phase II trials provide more detail about the Phase II trials provide more detail about the safety of the new treatment and determine how safety of the new treatment and determine how well it works for treating a given form of cancerwell it works for treating a given form of cancer

Phase III trials take a new treatment that has Phase III trials take a new treatment that has shown promising results when used to treat a shown promising results when used to treat a small number of patients with cancer and small number of patients with cancer and compare it with the current, standard treatment compare it with the current, standard treatment for that disease; phase III trials involve a large for that disease; phase III trials involve a large number of patientsnumber of patients

Clinical Trials ResourcesClinical Trials Resources

Coalition of Cancer Cooperative Groups Coalition of Cancer Cooperative Groups (www.CancerTrialsHelp.org)(www.CancerTrialsHelp.org)

CenterWatch (www.centerwatch.com)CenterWatch (www.centerwatch.com)

National Cancer Institute National Cancer Institute (www.cancer.gov/clinical_trials)(www.cancer.gov/clinical_trials)

Coping With the Side Effects of CancerCoping With the Side Effects of Cancerand its Treatmentand its Treatment

Side effects are treatable; talk with the doctor or Side effects are treatable; talk with the doctor or nursenurse

Fatigue is a common, treatable side effectFatigue is a common, treatable side effect

Pain is treatable; non-narcotic pain relievers are Pain is treatable; non-narcotic pain relievers are availableavailable

Antiemetic drugs can reduce or prevent nausea Antiemetic drugs can reduce or prevent nausea and vomitingand vomiting

For more information, visit For more information, visit www.plwc.org/sideeffectswww.plwc.org/sideeffects

Follow-Up CareFollow-Up Care

Doctor’s visitsDoctor’s visits

Serial carcinoembryonic antigen (CEA) Serial carcinoembryonic antigen (CEA) measurements are recommendedmeasurements are recommended

Colonoscopy one year after removal of colorectal Colonoscopy one year after removal of colorectal cancercancer

Surveillance colonoscopy every three to five Surveillance colonoscopy every three to five years to identify new polyps and/or cancersyears to identify new polyps and/or cancers

More information can be found in the More information can be found in the ASCO ASCO Patient Guide: Follow-Up Care for Colorectal Patient Guide: Follow-Up Care for Colorectal CancerCancer

Where to Find More Information: PLWC Guide to Colorectal Cancer

(www.plwc.org/colorectal)

OverviewOverviewMedical IllustrationsMedical IllustrationsRisk Factors and Risk Factors and PreventionPreventionSymptomsSymptomsDiagnosisDiagnosisStaging With Staging With IllustrationsIllustrationsTreatmentTreatment

Side Effects of Cancer Side Effects of Cancer and Cancer Treatmentand Cancer TreatmentAfter TreatmentAfter TreatmentQuestions to Ask the Questions to Ask the DoctorDoctorCurrent ResearchCurrent ResearchPatient Information Patient Information ResourcesResourcesClinical Trials Clinical Trials ResourcesResources

People Living With Cancer People Living With Cancer (www.plwc.org)(www.plwc.org)

PLWC is the cornerstone of ASCO’s patient resources PLWC is the cornerstone of ASCO’s patient resources programprogram

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