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Workshop with the Experts: Colorectal Cancer Series
- 1. Workshop With the Experts: Colorectal Cancer Series This program is supported by educational grants from Originally posted 3/27/2012 at clinicaloptions.com/ss/CRCVA12
- 2. Workshop With the Experts: Colorectal Cancer Series clinicaloptions.com/oncology About These Slides Users are encouraged to use these slides in their own noncommercial presentations, but we ask that content and attribution not be changed. Users are asked to honor this intent This abbreviated slideset was posted to SlideShare to publicize the availability of the full slideset. These slides may not be published or posted online without permission from CCO (email permissions@clinicaloptions.com) Disclaimer The materials published on the Clinical Care Options Web site reflect the views of the authors of the CCO material, not those of Clinical Care Options, LLC, the CME providers, or the companies providing educational grants. The materials may discuss uses and dosages for therapeutic products that have not been approved by the United States Food and Drug Administration. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or using any therapies described in these materials.
- 3. Workshop With the Experts: Colorectal Cancer Series clinicaloptions.com/oncology Faculty Program Director Edward Chu, MD Herbert Hurwitz, MD Chief Division of Hematology/Oncology Associate Professor of Medicine University of Pittsburgh School of Department of Hematology/Oncology Medicine Duke Cancer Institute Deputy Director Durham, North Carolina University of Pittsburgh Cancer Faculty Institute Pittsburgh, Pennsylvania Al B. Benson III, MD, FACP Professor, Division of Hematology/Oncology George A. Fisher, MD, PhD Feinberg School of Medicine at Associate Professor of Medicine Northwestern University Department of Medicine/Oncology Associate Director for Clinical Stanford Cancer Center Investigations Palo Alto, California Robert H. Lurie Comprehensive Cancer Center Chicago, Illinois
- 4. Workshop With the Experts: Colorectal Cancer Series clinicaloptions.com/oncology Faculty Scott Kopetz, MD, PhD, FACP Muhammad Wasif Saif, MD Assistant Professor Professor of Clinical Medicine Department of Gastrointestinal Medical Department of Medicine Oncology Director, GI Oncology Section University of Texas M. D. Anderson Cancer Herbert Irving Comprehensive Cancer Center Center Houston, Texas Columbia University College of Physicians and Surgeons Mark Kozloff, MD New York, New York Clinical Associate Professor of Medicine Department of Medicine The University of Chicago Medical Center Chicago, Illinois Weijing Sun, MD Associate Professor of Medicine Caio Max S. Rocha-Lima, MD Director, GI Medical Oncology Program Professor of Medicine Abramson Cancer Center Colorectal/Pancreatohepatobiliary Programs University of Pennsylvania Co-Leader, Phase I Unit Philadelphia, Pennsylvania Co-Director, Sylvester Cancer Center University of Miami Sylvester Comprehensive Cancer Center Miami, Florida
- 5. Workshop With the Experts: Colorectal Cancer Series clinicaloptions.com/oncology Faculty Disclosures Al B. Benson III, MD, FACP, has disclosed that he has received research support on behalf of Northwestern University from Amgen, Bayer, Genentech, and Gilead and consulting fees from Abbott, Bayer, Genentech, Genomic Health, Precision Therapeutics, and sanofi-aventis. Edward Chu, MD, has disclosed that he has received consulting fees from Roche. Herbert Hurwitz, MD, has disclosed that he has received research support from Bristol-Myers Squibb, GlaxoSmithKline, Pfizer, and Roche/ Genentech and consulting fees from Roche/Genentech. George A. Fisher, MD, PhD, has disclosed that he has received research support from Amgen, Bristol-Myers Squibb, Exelixis, and Genentech.
- 6. Workshop With the Experts: Colorectal Cancer Series clinicaloptions.com/oncology Faculty Disclosures Scott Kopetz, MD, PhD, FACP, has disclosed that he has received research support from AstraZeneca and Roche and consulting fees from AstraZeneca, Bayer, MedImmune, Roche, and sanofi-aventis. Mark Kozloff, MD, has disclosed that he has received consulting fees from Genentech and fees for non-CME services from Eli Lilly, Genentech, and Roche. Caio Max S. Rocha-Lima, MD, has no significant financial relationships to disclose. Muhammad Wasif Saif, MD, has disclosed that he has received fees for non-CME services from Amgen, Bristol-Myers Squibb, Eli Lilly, and Genentech. Weijing Sun, MD, has no significant financial relationships to disclose.
- 7. Workshop With the Experts: Colorectal Cancer Series clinicaloptions.com/oncology Outline Epidemiology of CRC Current Screening Modalities and Guidelines Early-Stage CRC – CRC Staging – Adjuvant Therapy Options – Guidelines and Risk Assessment for Stage II CRC Patients Metastatic CRC – Initial and Salvage Therapy Options – Therapy and Adverse Effect Management – Continuum of Care
- 8. Workshop With the Experts: Colorectal Cancer Series clinicaloptions.com/oncology CRC: Epidemiology in 2012 Third most common cancer Third leading cause of cancer diagnosis in US[1] deaths in 2011 (estimated 49,380 deaths)[1] – Estimated 143,460 new cases in 2012; 1:1 male:female ratio[2] Race/Ethnicity Death Rates in 2008, per 100,000[3] At diagnosis, 39% localized All races 16.4 (stage 0-II), 37% regional (stage White 15.8 III), 20% metastatic (stage IV)[3] African American 23.0 Steady decrease in age- Asian/Pacific Islander 11.5 adjusted incidence rates of distal American Indian/ 19.1 colon, proximal colon, and rectal Alaska Native cancers in 1976-2005[4] Hispanic 12.1 1. American Cancer Society. Colorectal cancer facts & figures. 2011-2013. 2. Siegel R, et al. CA Cancer J Clin. 2012;62:10-29. 3. SEER. Stat fact sheets: colon and rectum. 4. Cheng L, et al. Am Clin Oncol. 2011;34:573-580.
- 9. Current Screening Modalities and Guidelines
- 10. Workshop With the Experts: Colorectal Cancer Series clinicaloptions.com/oncology Major Risk Factors for CRC Factors That Increase Risk Relative Risk* Heredity and Medical History Family history • 1 first-degree relative 2.2 • More than 1 relative 4.0 • Relative with diagnosis before 45 yrs of age 3.9 Inflammatory bowel disease • Crohn’s disease 2.6 • Ulcerative colitis (colon) 2.8 Diabetes 1.2 Smoking 1.2 * Relative risk compares risk of disease in people with “exposure” to risk of people without exposure. Factors that decrease risk are physical activity (in colon cancer), calcium, and consumption of milk American Cancer Society. Colorectal cancer facts & figures. 2011-2013.
- 11. Workshop With the Experts: Colorectal Cancer Series clinicaloptions.com/oncology Impact of Personal and Family History in CRC ≈ 20% of patients with CRC have close relative with CRC ≈ 5% of CRC cases are associated with genetic syndrome – Lynch syndrome (HNPCC) most common, accounting for 2% to 4% of all cases – Higher risk of other cancers (eg, endometrial, ovarian, pancreatic) – Familial adenomatous polyposis, second most common and associated with nearly 100% lifetime risk of CRC without intervention – BRCA associated with increased risk of CRC Previous history of localized CRC associated with increased risk of new CRC tumors American Cancer Society. Colorectal cancer facts & figures. 2011-2013.
- 12. Workshop With the Experts: Colorectal Cancer Series clinicaloptions.com/oncology CRC Screening Alternatives Tests That Are Likely to Detect Both Adenomatous Polyps and Cancer Test Some Benefits Some Limitations Rapid, few complications, minimal bowel Views only 1/3 of colon, no removal of large Flexible sigmoidoscopy prep, no sedation polyps, low risk of infection/tear Permits examination of entire colon and Full bowel prep, sedation, high expense, higher Colonoscopy removal of polyps risk of bowel tears or infection vs other tests Can miss small polyps and cancers, full bowel Can usually view entire colon, few Double-contrast barium enema prep, unable to remove polyps, exposure to complications, no sedation required low-dose radiation Noninvasive, permits examination of entire Can miss some polyps and cancers, full bowel CT colonography colon, few complications, no sedation prep, unable to remove polyps, exposure to (virtual colonoscopy) needed low-dose radiation Tests That Are Primarily Effective for Detection of Cancer Test Some Benefits Some Limitations Will miss most polyps and some cancers, may No bowel prep, sampling done at home, Fecal occult blood test require multiple samples, higher false-positive noninvasive rate than other tests Will miss most polyps and some cancers, No bowel prep, sampling done at home, Stool DNA test new technology with uncertain test intervals, noninvasive high cost vs other stool tests American Cancer Society. Colorectal cancer facts & figures. 2011-2013. Levin B, et al. CA Cancer J Clin. 2008;58:130-160.
- 13. Workshop With the Experts: Colorectal Cancer Series clinicaloptions.com/oncology CRC Screening Guidelines Begin at 50 yrs of age – Earlier in higher-risk groups (family history, IBD, African American patients, etc) Frequency – Colonoscopy: 10 yrs – Flexible sigmoidoscopy: 5 yrs – CT colonography and FOBT variable recommendations ACG recommends “split dosing” for bowel preparation (at least one half of the preparation is taken on the day of the test) Rex DK, et al. Am J Gastroenterol. 2009;104:739-750. NCCN. Clinical practice guidelines in oncology: colorectal cancer screening. v.2.2011. US Preventive Services Task Force. Ann Intern Med. 2008;149: 627-637.
- 14. Early-Stage CRC
- 15. Workshop With the Experts: Colorectal Cancer Series clinicaloptions.com/oncology CRC Staging Stage Description 0 Intraepithelial; lamina propria invasion I Submucosa (T1) or muscularis propria (T2) invasion A: pericolorectal tissue invasion (T3) II B: penetration to visceral peritoneum surface (T4a) C: invasion/adherence to other organs/structures (T4b) A: T1-T2 + 1-3 regional LN; T1 + 4-6 regional LN B: T3-T4a + 1-3 regional LN; T2-T3 + 4-6 regional LN; T1-T2 + ≥ 7 III regional LN C: T4a + 4-6 regional LN; T3-T4a + ≥ 7 regional LN; T4b + any regional LN A: metastasis to 1 organ/site IV B: metastases to multiple organs/sites or peritoneum Edge SB, et al. AJCC cancer staging manual, 7th ed. New York, NY: Springer; 2010.
- 16. Workshop With the Experts: Colorectal Cancer Series clinicaloptions.com/oncology 5-Yr Survival Rates by Colon Cancer Stage Stage Observed 5-Yr Survival,% I 74.3-78.7 IIA 66.7 IIB 60.6 IIC 45.7 IIIA 64.7-73.7 IIIB 42.1-58.2 IIIC 12.9-32.5 IV 19.2* *2001-2003 SEER data. Gunderson LL, et al. J Clin Oncol. 2010;28:264-271. Kopetz S, et al. J Clin Oncol. 2009;27:3677-3683.
- 17. Workshop With the Experts: Colorectal Cancer Series clinicaloptions.com/oncology For the rest of this presentation… Epidemiology of CRC Current Screening Modalities and Guidelines Early-Stage CRC – CRC Staging – Adjuvant Therapy Options – Guidelines and Risk Assessment for Stage II CRC Patients Metastatic CRC – Initial and Salvage Therapy Options – Therapy and Adverse Effect Management – Continuum of Care
- 18. …download the full PowerPoint slideset for self-study or use in your own educational presentations at: clinicaloptions.com/ss/CRCVA12 Go online for more from CCO Oncology, including: Expert Analysis panel discussions exploring the clinical implications of all the key data from recent conferences Treatment Updates: review clinical issues and choices from our experts on disease management More ways to connect with CCO:
Editor's Notes
- This slide lists the faculty who were involved in the production of these slides.
- This slide lists the faculty who were involved in the production of these slides.
- This slide lists the disclosure information of the faculty involved in the development of these slides.
- This slide lists the disclosure information of the faculty involved in the development of these slides.
- CRC, colorectal cancer.
- CRC, colorectal cancer. Colorectal cancer is the third most common cancer diagnosed in the United States and the third leading cause of death According to an annual National Cancer Institute Surveillance Epidemiology and End Results (SEER) Registries Review, 71,850 men and 69,360 women were expected to receive a new diagnosis of colon or rectal cancer in 2011, at a median age of 70 years. At diagnosis, about 39% of CRCs are localized; 37% are regional; and 20% are metastatic. In a study of CRC incidence trends based upon 9 SEER registry data, between 1976 and 2005, the age-adjusted incidence of proximal and distal colon, and rectal cancers steadily decreased. The greatest decline was in the incidence of distal colon cancers, and the least change in incidence rates was among proximal colon cancers. A steady increase in proximal CRC subsites occurred in both men and women beginning at age 50. Women experienced a greater increase than men.
- CRC, colorectal cancer. Individuals with a first-degree relative (parent, sibling, or offspring) who was diagnosed with CRC have a 2 to 3 times the risk of developing the disease than do people without the same family history. The relative risk of acquiring CRC increases when more than one relative has been diagnosed, and when a relative is diagnosed before age 45. Other factors that increase risk of CRC are forms of Inflammatory bowel disease, diabetes, smoking, and no prior screening. Factors that are associated with a decrease in the risk of CRC include physical activity for both men and women (in colon cancer), intake of calcium, and consumption of milk.
- CRC, colorectal cancer; FAP, familial adenomatous polyposis. Approximately 20% of colorectal cancer patients have a close relative with the disease, and about 5% of colorectal cancers are linked to a known genetic syndrome. Lynch syndrome—or hereditary nonpolyposis colorectal cancer– is the most common genetic form of the disease, accounting for from 2 to 4 percent of all cases. The second most common known genetic form of colorectal cancer is familial adenomatous polyposis, or FAP. Without identification and intervention, persons with this form of the disease have an almost 100% lifetime risk of colorectal cancer. Individuals with BRCA mutations also appear to be at an increased risk for colon cancer.
- CRC, colorectal cancer. In 2008, the American Cancer Society collaborated with the American College of Radiology and U.S. Multi-Society Task Force on Colorectal Cancer (a consortium that included the American College of Gastroenterology, American Society of Gastrointestinal Endoscopy, the American Gastroenterological Association, and the American College of Physicians). The goal was to develop consensus guidelines for CRC screening. The resulting guidelines drew a distinction between screening tests that primarily detect cancer—that is, stool tests—and those tests that can detect both cancer and precancerous growths. Recommendations, which did not point to one preferred test, instead emphasized that cancer prevention should be the primary goal of screening and that screening tests should be selected on the basis of their ability to both detect and prevent CRC.
- ACG, American College of Gastroenterology ; CRC, colorectal cancer; CT, computed tomography; FOBT, fecal occult blood test; IBD, inflammatory bowel disease. The American College of Gastroenterology recommends colonoscopy screening every 10 years beginning at age 50. African Americans, because of a higher risk for CRC, should begin regular screening earlier, at the suggested age of 45. Note that the increased risk in this population may reflect lower access to care and screening rather than a genetic predisposition. Barium enema is not recommended, but the ACG indicates that CT colonography every 5 years is an alternative to colonoscopy. The ACG also recommends that the pre-test preparation include a split dosing strategy, with at least one-half of the bowel prep solution being taken on the same day as the CRC screening test. The most recent guidelines for colorectal cancer (CRC) screening from the NCCN include a recommendation for colonoscopy every 10 year; flexible sigmoidoscopy every 5 years; or CT colonography every 5 years. For people of average risk for CRC, an annual immunohistochemical (IHC)-based stool testing, with or without flexible sigmoidscopy, is a primary screening option. No current consensus has been developed for use of CT colonography—known as “virtual colonoscopy.” Expert consensus is currently evolved on frequency of screening and the minimal polyp size for referral to colonoscopy. The U.S. Preventive Services Task Force (USPSTF) recommends CRC screening using fecal occult blood testing, sigmoidoscopy, or colonoscopy, beginning at age 50 and continuing at suggested intervals until age 75. Higher-risk individuals (ie, those with a family history of CRC) should be screened beginning at an earlier age. The USPSTF recommends consulting a physician for advice on CRC screening after age 75.
- CRC, colorectal cancer; LN, lymph node
- Notably 5-year survival for patients with stage IIC CRC is poorer than for those with SIIIA indicating more concerning with locally aggressive disease compared to involvement of a few nodes.
- CRC, colorectal cancer.