UPDATE IN THE MANAGEMENT AND TREATMENT OF COLORECTAL CANCER Edwin A. Empaynado, MD Advocare Colon and Rectal Surgical Specialists WHAT IS COLON CANCER? WHAT CAUSES COLORECTAL CANCER? WHAT ARE THE RISK FACTORS SYMPTOMS DIAGNOSIS AND SCREENING STAGING OF COLON CANCER MEDICAL AND SURGICAL TREATMENT SURVIVORSHIP AND FOLLOW-UP PREVIEW OF PRESENTATION Common Types Estimated New Estimated Rank HOW COMMON IS of Cancer Cases 2018 Deaths 2018 Breast Cancer COLORECTAL 1. 266,120 40,920 (Female) CANCER? Lung and 2. Bronchus 234,030 154,050 Cancer 3. Prostate Cancer 164,690 29,430 3rd most common cause of Colorectal 4. 140,250 50,630 Cancer cancer in men and women of Melanoma of the U.S. or 8.1% of all new 5. 91,270 9,320 the Skin cancer cases in 2018 6. Bladder Cancer 81,190 17,240 Non-Hodgkin 7. 74,680 19,910 Lymphoma 2nd leading cause of cancer Kidney and 8. Renal Pelvis 65,340 14,970 death among men and Cancer women of the U.S. or 8.3% of all 9. Uterine Cancer 63,230 11,350 cancer deaths in 2018 10. Leukemia 60,300 24,370 1 National Cancer Institute WHAT AGE GROUP GETS COLORECTAL CANCER? Median age at diagnosis is 67 NCI, SEER 18 2011-2015 WHO DIES FROM COLORECTAL CANER? Median age at death 73 Rates of newly diagnosed cases of CRC have been decreasing 2.6% per year over past 10 years Rates of death from CRC cases have been decreasing 2.4% per year over past 10 years TRENDS IN NEW CASES OF COLORECTAL CANCER AND DEATH RATES NCI, SEER 9 1975-2015 TRENDS IN SURVIVAL RATES FOR COLORECTAL CANCER Percent surviving past 5 years from diagnosis of CRC 64.5 NCI, SEER 1975-2010 Population Health Data from 2013-2015 34.4/100,000 new cases diagnosed per year 14.5/100,000 number of deaths per year 4.5% lifetime risk of being diagnosed with colorectal cancer 1,332,085 people diagnosed with CRC in U.S. in 2015 PREVALENCE OF COLORECTAL CANCER 1 National Cancer Institute WHAT IS COLON CANCER? • Carcinoid tumors • Gastrointestinal stromal tumors (GIST) • Lymphomas • Sarcomas • Metestatic tumors (ie – endometrial, ovarian, melanoma, etc.) • Adenocarcinoma – 96% of all colorectal cancers Cancer cells that arise from adenomatous polyps of mucous producing cells that normally help lubricate the inside lining of the colon and rectum Cancers can be caused by changes in the DNA inside our cells called DNA mutations These mutations leads to uncontrolled cell growth and the development of cancerous tumors Inherited gene mutations occurs in about 10% cases Acquired gene mutations most common cause of CRC where a person acquires a mutation during a lifetime rather than inherited. WHAT CAUSES COLORECTAL CANCER? SYMPTOMS OF A change in bowel habits COLORECTAL CANCER Rectal bleeding or blood in your stool Abdominal discomfort and/or fullness that persists or recurs Feelings of incomplete evacuation Progressive weakness or fatigue Unexplained weight loss Anemia on recent bloodwork STOOL-BASED TESTS SCREENING FOR COLORECTAL CANCER Highly sensitive fecal immunochemical test (FIT) every year Highly sensitive guaiac-based fecal American Cancer Society (ACS) occult blood test (gFOBT) every year recommends average risk screening for CRC to start at age 45 through to Multi-targeted stool DNA test (MT-sDNA) age 75 at 10 year intervals every 3 years Ages 76 through 85 screening is based VISUAL EXAMS OF THE COLON AND RECTUM on overall medical health and patient preferences Colonoscopy every 10 years CT colonoscopy (virtual colonoscopy) People over 85 should no longer get every 5 years colorectal screening Flexible sigmoidoscopy (FSIG) every 5 years 2 American Cancer Society Average risk patients DO NOT have the following Personal history of colorectal cancer or colon polyps Family history of colorectal cancer Personal history of inflammatory bowel WHAT IS AVERAGE RISK disease SCREENING? A confirmed hereditary colorectal cancer syndrome Personal history of abdominal and/or pelvic radiation to treat prior cancer WHAT ARE THE RISK Older age FACTORS FOR COLORECTAL CANCER? African-American race Personal history of colorectal cancer or polyps Crohn’s Disease Inflammatory intestinal conditions Ulcerative Colitis Inherited syndromes Lynch Syndrome Family history of colon cancer Familial Adenomatous Polyposis (FAP) Low-fiber, high fat diet Sedentary lifestyle Diabetes Obesity Smoking Alcohol Radiation therapy for cancer Patients at increased risk for SCREENING FOR PEOPLE colorectal cancer may need WHO ARE AT HIGHER RISK? screening prior to age 45 and screened at more frequent intervals with colonoscopy Strong family history of colon cancer or Start screening prior to age 45 polyps Personal history of colon cancer and/or Consider more frequent polyps screening, ie- every 3 to 5 years Personal history of inflammatory bowel Screening at earlier age disease and every 1 to 2 years Known family history of hereditary colorectal Start as early as teenage years with cancer syndrome more frequent intervals Personal history of abdominal and/or pelvic radiation for treatment of prior cancer Earlier age of screening and every 3 to 5 years PROS SCREENING MODALITIES • Stool collection can done at home Highly sensitive fecal immunochemical test (FIT) • No prep required • No need for sedation CONS • Fails to detect some polyps and cancers • Certain foods and medications may need to be avoided • If positive, additional tests are needed to determine the source • False-positive results Check stool samples for hidden (occult) blood. Test is done annually PROS SCREENING MODALITIES • Does not require a bowel prep Multi-targeted stool DNA test • You can eat, drink and take your (MT-sDNA) medications as usual before the test • Stool collection done at home to avoid disruption of your daily routine CONS • DNA stool test is less sensitive than colonoscopy at detecting precancerous polyps • If abnormal, additional tests would be needed Stool sample is used to look for DNA • False-positive rates as high as 10-15% changes that would suggest the presence of colon cancer or precancerous conditions. Repeated every 3 years. PROS • Sedation is not required • Less extensive bowel prep requirement SCREENING MODALITIES Flexible sigmoidoscopy (FSIG) • Biopsies and/or other therapies can be performed through the scope CONS • Upper colon abnormalities are not seen • An enema prep is usually required • You may need to change your diet and/or medication prior to test • Rare complication of bowel injury and/or bleeding can occur • Cramping and bloating after exam Tiny video camera that allows visualization of the rectum and lower part of the colon (sigmoid colon). Repeated every 5 years PROS • Test does not require sedation or insertion of SCREENING MODALITIES a scope into the rectum CT colonoscopy (virtual colonoscopy) CONS • Requires a thorough bowel cleansing before the test • May not detect small polyps or cancers • Dietary and/or medication changes would be required • Radiation exposure • Purely diagnostic procedure; abormal findings would need colonoscopy follow-up • Cramping and bloating CT scan produces initial cross-section images of abdominal organs that can be reconstructed in 3D images by a computer to detect abnormalities. Repeated every 5 years. PROS • The most sensitive test currently available for SCREENING colon cancer screening. MODALITIES • Visualize the entire colon Colonoscopy • Abnormal tissues can be biopsied and/or removed through the scope CONS • Thorough bowel cleansing is required before the test • Diet changes are required and medications may need to altered • Sedation is usually required and would require someone to take you home • Rare complication of bowel injury and/or bleeding from therapeutic sites • Cramping and bloating after procedure Flexible tube with fiberoptic video camera is inserted into the rectum to detect abnormalities. Repeated every 10 years. SHAPE o PEDUCULATED o SESSILE o SEMI-PEDUCULATED CELL PATTERN TUBULAR VILLOUS TUBULOVILLOUS HYPERPLASTIC DYSPLASIA SERRATED LOW-GRADE DYSPLASIA HIGH-GRADE ADENOMATOUS POLYPS DYSPLSIA Polyps are tissue growth from the inner lining of the colon that can be benign (non-cancerous) or grow into cancers (precancerous). Adenomatous feature is a description of a cell when viewed under a microscope that is different from normal cell appearance. DIFFERENTIATION WELL DIFFERENTIATED MODERTELY DIFFERENTIATED POORLY DIFFERENTIATED HISTOLOGY INVASION MUCIN PRODUCING SIGNET-CELL VASCULAR LYMPHATIC LYMPHOVASCUALR INVASIVE ADENOCARCINOMA Adenocarinoma is a type of cancer from cells that form mucous producing glands lining the colonic wall. Invasive is a cell description suggesting spread beyond the inner lining of the colon. PRE-OP o < 5ng/mL STAGING TESTS o Can be higher in smokers Radiographic staging of tumor Helps determine chemotherapy and/or radiation treatment plans Assess tumor resectability Carcinoembryonic Antigen Test (CEA) CT scan 3T MRI TransRectal UltraSound (TRUS) PET/CT Scan 85% of patients who present with colonic obstruction have CRC Only 40% of patients with obstructing left-sided colon cancer can be resected without the need of a colostomy Stent placement provides an effective solution to acute colonic obstruction Allows for bridge to elective and more favorable operative conditions Palliative treatment for advanced stage colon cancer TREATMENTS ENDOSCOPY AND COLONIC STENTING Open Segmental colon resection Proximal diverting colostomy Laparoscopic colon resection Robotic colon resection Transanal full-thickness excision Transanal Endoscopic Microsurgery