Today we will discuss

Understanding colon and rectum cancer

Screening and early detection

Partnering with your medical team

Making treatment decisions

Managing side effects Coping with life after treatment

Understanding Colorectal Cancer

Understanding CRC
Colorectal cancer (CRC) starts in the colon or rectum CRC is the 3rd most common form of cancer diagnosed in men and women in the US (148,000 new cases in 2010) CRC is the 2nd leading cause of cancer deaths in the US. (48,000 deaths in 2010) The number of people dying from CRC has declined over the past 20 years with better screening, diagnosis and treatments Screening for/removing polyps early is the best way to prevent and cure CRC I keep thinking to myself: I may have cancer, but cancer doesnt have me! -Pam

Signs and Symptoms

Symptoms could include: A change in bowel movements (diarrhea, constipation, never feeling relieved, narrower stools) Blood in the stool (dark red) Abdominal discomfort Loss of appetite Weight loss for no known reason Constant fatigue Nausea and vomiting Many people have no symptoms - encourage those close to you to get screened

Colorectal Cancer
80% present with early
Stage at Diagnosis
Distant (Stage IV) 20%
Localized (Stage I/II) 50%

disease
20% present with

metastatic disease.
Among patients

diagnosed with earlystage disease, 40% will suffer recurrence.

Regional (Stage III) 30%

Staging of Colorectal Cancer

Stage
Extent of tumor

A
No deeper than submucosa

B1
Not through bowel wall 8085%

B2
Through bowel wall 7075%

C1
Not through bowel wall: lymph node metastases 5065%

C2
Through bowel wall: lymph node metastases 2545%

D
Distant metastases < 5%

5-year survival

> 90%

Mucosa Muscularis mucosa Submucosa

Muscularis propria Serosa Fat Lymph nodes

5-Year Survival for CRC by Stage

100

70-90% 65% 25-70%

% of patients

80 60 40 20 0

5-10%

All Stages

Localized (Stage I and II)

Regional Stage III

Distant (Stage IV)

Colorectal Cancer (CRC)

Sporadic (average risk) (75-80%)

Family history (10-15%)

Rare syndromes (<0.1%) Familial adenomatous polyposis (FAP) (1-2%)

Hereditary non-polyposis colorectal cancer (HNPCC) (3-5%)

Risk Factors for CRC

Age >50 (average risk) Racial, ethnic factors African-Americans have increased risk Dietary factors high animal fat, low fiber diet Lifestyle Sedentary Obesity Smoking Alcohol

Risk Factors for CRC

Family or personal history of CRC
HNPCC Lynch syndrome I, II Polyposis syndromes FAP, Gardners syndrome, Turcots syndrome, juvenile polyposis Inflammatory bowel disease chronic ulcerative colitis, Crohns disease

Lifestyle Risk Factors for Colorectal Cancer

Decrease Risk Increase Risk

Exercise Folic acid Aspirin Calcium, vitamin D Screening

Obesity Red meat Alcohol Smoking

Natural History

Polyp

Advanced cancer

Age 50, 25% risk of developing polyps Age 75, 50-75% risk of developing polyps

Screening = Prevention & Early Detection

Prevention = polyp removal Decreased Incidence

Early Detection Decreased Mortality

Screening Methods

Annual Fecal Occult Blood Test (FOBT) Flexible Sigmoidoscopy every 5 years Annual FOBT + Flexible Sigmoidoscopy every 5 years Colonoscopy every 10 years

Colonoscopy - gold standard

Factors Associated with CRC Screening

Higher socio-economic status Higher education White Older age (>50 years) Men Married

Issues Related to CRC Screening

Practical barriers System Cost Environment/area Lack of access to healthcare provider Psychological barriers Lower knowledge or awareness Lower perceived risk of CRC Negative attitudes towards screening Higher worry or fear of CRC

Other Screening Tests

Virtual colonoscopy

Pickhardt et al, NEJM, Dec 2003

Sensitivity 94%, Specificity 96% Johnson et al, NEJM, Sept 2008 Sensitivity 90%, Specificity 86% Advantages: no need for sedation, noninvasive, rapid imaging of entire colorectum, low risk of complications Especially useful in patients who can not undergo colonoscopy Stool DNA testing Video capsule

CRC Screening Guideline: Summary

For average risk persons, CRC screening

should begin at age 50 African-Americans should be screened earlier starting at age 45 CRC screening is cost-effective CRC is highly curable when diagnosed at an early stage with 90% 5-year survival

Diagnosing CRC
A colonoscopy looks at the entire colon to identify problems Blood tests help to categorize your overall health
a CEA test is often used to follow the presence of CRC

Imaging tests will identify if cancer exists in other parts of your body
CAT scan, MRI, PET scan

Surgery will remove tumor(s), tissue and lymph nodes which will be tested by a pathologist to determine the type and stage of cancer present

Stages of CRC
Three elements: T = Tumor
How large is the tumor?

Four stages: Stage I

Spread to the middle layers of the colon or rectum

N = Node
Are cancer cells in the lymph nodes?

M = Metastases
Has the cancer spread to other organs?

Stage II Stage III Stage IV

Advanced disease, spread to other organs

Stages of CRC

Partnering With Your Medical Team

It is important that you feel respected and listened to. Work with a healthcare team you can trust.

Your Medical Team

Successful treatment requires a multidisciplinary team of CRC specialists: Surgical Oncologist Medical Oncologist Radiation Oncologist Radiologist Pathologist Oncology Nurse Specialist Social Worker Nutritionist Patient Navigator Pharmacist YOU and your team! Your choice of a medical team depends on preferences: Recommendations Expertise Style of communication Location Type of institution (private practice, community hospital, cancer center) Insurance

Be Prepared for Appointments.

Keep a list of questions/concerns to bring to appointments ALWAYS tell your doctor about side effects or symptoms that interfere with your life ALWAYS tell your doctor about other medications, herbs, nutritional supplements you may be taking Learn the best method of on-going communication
Appointments, phone, even email

Bring a relative or friend to take notes Ask for copies of your reports and test results

Consider a second opinion

You have the right to get a second, and even a third, opinion
It is very common and accepted Its never too late to get another opinion

There is no one right way to treat CRC

Talking with different experts can help you feel more confident in your course of action

A second opinion might introduce you to a clinical trial or targeted treatment you didnt know about

Making Treatment Decisions

Goals of Treatment
Treatment is defined by stage and type of cancer present
Goals of Treatment for Early Disease
Remove cancer cells Kill cancer cells Keep the cancer cells from returning

Goals of Treatment for Advanced Disease

Slow or stop the growth of cancer cells Manage quality of life concerns

Every person responds differently to treatment, so communication is key!

Types of Treatments
Surgery Laparoscopy vs. open surgical resection Colostomy: temporary or permanent Chemotherapy Adjuvant, neoadjuvant, and palliative Oral versus intravenous Targeted agents EGFR inhibitors VEGFR inhibitors Chemoradiation (rectal cancer) Clinical trials New agents, combination regimens

Targeted Therapies/ Biologic Agents

Targeted therapies work through specific pathways involved in cancer growth to attack cancer cells directly
EGFR inhibitors (i.e.: Cetuximab and Panitumumab) VEGFR inhibitors (i.e.: Bevacizumab)

Targeted therapies cause fewer side-effects since they attack cancer cells more specifically

Talk to your doctor about new treatments in development

Chemotherapy of Colorectal Cancer

Agent 5-FU Irinotecan (CPT-11) FDA approval status 1962 1998 (second-line)

2000 (first-line)
Capecitabine (oral 5-FU) 2001 (first-line) Oxaliplatin 2002 (second-line) 2004 (first-line)

Targeted Therapy of Colorectal Cancer

Agent Bevacizumab FDA approval status 2004 2004 2006

(Anti-VEGF Ab)
Cetuximab (Anti-EGFR Ab) Panitumumab (Anti-EGFR Ab)

Historical Progress of Therapy of Advanced CRC

Supportive Care 1 Active Drug (5-FU/LV, Capecitabine) 2 Active Drugs (5-FU/LV + Oxaliplatin/Irinotecan; Capecitabine + Oxaliplatin/Irinotecan) 2 Active Drugs + bevacizumab 2/3 Active Drugs + Targeted/Biologic Agents

~4-6 mo
~10-12 mo ~15 mo

~20 mo
20.3 mo
>24-28 mo
0 6 12 18 24

Median Survival (months)

Clinical Trials
Clinical trials study promising new drugs and treatment regimens
Every CRC treatment regimen that is now standard was first developed through a clinical trial

Phases I-IV Remember that all standard cancer drugs used to treat CRC and other cancer types were studied in clinical trials before being approved by the US FDA Participants are not guinea pigs

What Affects Treatment Decisions?

The type and stage of your disease The specific genetic make-up of your colon cancer Your age and overall health Other medical conditions Whether or not youve had cancer and/or cancer treatment in the past Your willingness/ability to tolerate certain side effects Ease and convenience of treatment oral vs intravenous Insurance coverage and costs

Making Treatment Decisions

You always have time to think about your options and ask questions. The ultimate question: What will give me the greatest chance of cure or longer life, and at what price?
- Wendy Schlessel Harpham, M.D.

In the Frankly Speaking About Colorectal Cancer booklet, see more detailed information about treatment options in Chapter 4.

Managing Side Effects

Managing Side Effects

You may not experience common side effects

Ask about preventing side effects before treatment

Having information about short and long term side effects before, during, and after cancer treatment will help you prepare Goal: take control of side effects before they take control of you

Side Effects from Surgery

Initial pain and risk of infections Scarring and adhesions Fecal incontinence Ostomy: a procedure to make a new path for stool
An ostomy pouch is adhered to your skin to collect waste

For more information, see p.49 in the Frankly Speaking About Colorectal Cancer booklet
If I hadnt had a colostomy, I wouldnt have lived. Its what you have to do to survive. It doesnt limit me in any way, except for not wearing extremely tight clothes that I wouldnt wear anyway. - Pam

Side Effects from Chemotherapy

Diarrhea Mouth sores Hand-foot syndrome Neuropathy High blood pressure Skin rash Bowel perforation Allergic reaction

The Frankly Speaking About Colorectal Cancer booklet includes tips for managing these side effects on pp. 50-56.

Managing Bowel Issues

Obstruction and/or perforation
Caused by the cancer itself, or treatment

Symptoms include: abdominal pain, nausea and vomiting, bloating, inability to pass gas, constipation or diarrhea, loss of appetite Get suggestions from your medical team for diet and lifestyle changes to help lessen pain and motivate your digestive system
Ever since radiation Ive had adhesions with partial blockage of the colon. It started 9 months after treatment Id get cramps and throw up all of a sudden. Now I go to a massage therapist and I havent had an attack for a few months, so I think its helping. - Nancy

Colorectal Cancer Survivorship

Quality of Life
A colorectal cancer diagnosis raises both physical and emotional issues to manage Feeling sad, alone, angry, anxious, overwhelmed or distressed is very common Know that it is possible to find a balance between medical concerns, relationships, work, finances, and other responsibilities

Here are some suggestions

Talking About CRC

Keep communication open and honest Do not keep fears, embarrassment, worry to yourself CRC can be awkward to talk about
Find people in a similar situation for support

If you dont want to talk about it write it down

Keep a journal and use it to share your emotions with loved ones, yourself, or your doctor
I know cancer can destroy some relationships because its such a burden. But if you have enough faith in each other and love for each other you can conquer anything. - Scott

Are you Feeling Distressed?

If you think you or someone you love is suffering from depression: talk to your doctor, a social worker, or professional counselor Some questions to ask yourself: Do you cry often or uncontrollably? Have you lost interest in things that used to give you pleasure? Have you stopped looking forward to fun events and occasions? Are you eating and/or sleeping more or less than you used to?

Find Support
TWC research found that people in support groups report a decrease in depression, increased zest for life, and a new attitude toward their illness There are different types of support groups and counseling services available just ask Support groups can help you:
Learn from others with similar challenges Share concerns and learn coping strategies Feel less alone Manage side effects and anxiety Learn about resources

Strategies for Wellness

Physical Activity elevates mood, combats fatigue, maintains function, promotes rest Healthy Foods maintains energy, strengthens immune system, avoids/limits symptoms, provides comfort Drink Plenty of Fluids avoids dehydration, promotes regularity, combats fatigue Pamper Yourself find time to relax, seek spirituality, enjoy each day Create a personalized care plan set goals, find resources, use support

Fear of Recurrence
Be informed Talk about it with your medical team Allow yourself to feel up and downit is healthy to express negative emotions Be Patient Active take control of what you can, but know what you cant control Do not to let anxiety and fear prevent you from seeking medical care

Survivorship
Advances are being made, giving more patients the chance for a longer, better quality of life after diagnosis

Doctors, nurses, social workers and other survivors can help patients and families cope with the diagnosis
Emotional support through treatment and beyond is important: seek-out support Try to live each day to the fullest!
No matter how severe the symptoms and treatmentssurvival from day to day, week to week, and year to year constitutes an enormous personal and human triumph over what might have been. - A Cancer Survivors Almanac

Resources
C3: Colorectal Cancer Coalition 877-4CRC-111 www.FightColorectalCancer.org Colon Cancer Alliance 877-422-2030 www.ccalliance.org The Wellness Community 888-793-WELL www.thewellnesscommunity.org American Cancer Society 800-ACS-2345 www.cancer.org More resources can be found in the Frankly Speaking About Colorectal Cancer booklet

National Cancer Institute 800-4-CANCER www.cancer.gov

Acknowledgments
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