This document provides a brief review of colorectal cancer including epidemiology, risk factors, clinical presentation, screening, diagnosis, and treatment options. It notes that globally, colorectal cancer is the third most commonly diagnosed cancer in males and second in females. Screening is recommended for average risk individuals beginning at age 50. Treatment typically involves surgical resection as the only curative option, and may be combined with chemotherapy or radiation therapy depending on the stage of cancer.

1. Colorectal Cancer: A
Brief Review
Joseph A. Di Como MD

2. Colorectal Cancer Education
Topics
 Epidemiology
 Risk Factors
 Clinical Presentation
 Symptoms
 Screening
 Diagnosis
 Treatment Options

3. Epidemiology
 Globally is third most commonly diagnosed cancer in males
and second in females. Rates higher in males
 In United States incidence and mortality steadily decreasing.
Responsible for approximately 8% of all cancer deaths

4. Risk Factors
 Will Influence Screening
 Hereditary CRC syndrome (Familial adenomatous polyposis, Lynch syndrome,
MUTYH-associated polyposis), personal or family history of sporadic CRC or
adenomatous polyps, abdominal radiation, inflammatory bowel disease
(Crohn's and Ulcerative colitis)
 May Influence Screening
 Race, gender, acromegaly, and renal transplant
 Do not alter screening
 Obesity, DM, red and processed consumption, tobacco, alcohol,
cholecystectomy, others.

5. Clinical Presentation
 Suspicious symptoms and/or signs
 70-90% diagnosed after onset of symptoms
 Asymptomatic patient discovered via routine screening
 Emergency admission due to acute intestinal obstruction,
peritonitis, or gastrointestinal bleed

6. Suspicious Symptoms
 Hematochezia, melena, abdominal pain, unexplained iron
deficiency anemia, change in bowel habits
 Less common includes abdominal distension, Nausea, vomiting
(Possible symptoms due to obstruction)
 Metastatic disease
 Uncommon: Perforation, fistula, fever of unknown origin,
abscesses (intra-abdominal, retroperitoneal, abdominal wall or
intrahepatic)

7. Screening
 Average-risk patient screened for CRC at age 50
 Screen until life expectancy less than 10 years (75-85 years old)
 One timed screening colonoscopy at 83 or sigmoidoscopy at
84 for those never screened
 Potential strategies
 Colonoscopy every 10 years
 Computed tomographic colonoscopy every five years
 Flexible sigmoidoscopy every five years
 Fecal occult blood test (FOBT) with immunochemical testing
(iFOBT) annually on single sample
 FOBT with guaiac reagent annually on three samples
 Multitargetstool DNA testing every three years on one sample

8. Screening
 Sufficiently-Increased Risk screened at earlier age (40-45)
 Personal History of CRC or adenomatous polyp
 Genetic syndrome predisposing to CRC (HNPCC or FAP)
 One first-degree relative with CRC or advanced adenoma at age
<60 years old
 Two or more first-degree relatives with CRC or advanced
adenoma at any age
 IBD leading to pancolitis
 Personal history of abdominal radiation therapy

9. Diagnosis
 Colonoscopy: most accurate and versatile
 Flexible sigmoidoscopy
 Barium Enema: diagnostic yield less than that of colonoscopy
 CT Colonography
 PILLCAM 2
 Tumor Markers: (i.e. Carcioembryonic Antigen) Low diagnostic
ability

10. Treatment
 Surgical resection:
 Only curative modality. Goal is complete oncologic resection
 Open versus Laparoscopic-assisted colectomy
 Laparoscopic has comparable oncologic outcomes, perioperative
morbidity, and mortality and faster recovery.
 Surgical specimen should have at least 12 lymph nodes
 En bloc multivisceral resection: For locally advanced (T4) tumors
that involve contiguous organs or structures

11. Treatment
 Chemotherapy
 Postoperative (Adjuvant) chemo eradicates micometastases,
reduces reoccurrence and increases cure rate
 Risk of significant toxicities (mucositis, emesis, diarrhea, febrile
neutropenia, fatigue, hair loss, hand-foot syndrome and
cardiotoxicity

12. Treatment
 Radiation Therapy
 Adjuvant radiation therapy considered for patients with a T4
disease and penetration to a fixed structure.
 Palliative for Advanced Disease:
 For symptomatic patients with un-resectable metastatic disease
 Surgery is meant to manage complications
 Includes Resection with primary anastomosis, diverting end
colostomy w/ mucous fistula, and bypass procedure

13. References
 Doubeni, Chyke, MD, FRCS, MPH. "Screening for Colorectal Cancer:
Strategies in Patients at Average Risk." Screening for Colorectal Cancer:
Strategies in Patients at Average Risk. Ed. J. Thomas Lamont, Joann G.
Elmore, and H. Nancy Sokol. UpToDate, 8 Apr. 2016. Web. 11 July 2016.
 Macrae, Finlay A., MD. "Colorectal Cancer: Epidemiology, Risk Factors, and
Protective Factors." Colorectal Cancer: Epidemiology, Risk Factors, and
Protective Factors. Ed. Richard M. Goldberg, Timothy O. Lipman, and Diane
MF Savarese. UpToDate, 15 Apr. 2016. Web. 11 July 2016.
 Macrae, Finlay A., MD, and Johana Bendell, MD. "Clinical Presentation,
Diagnosis, and Staging of Colorectal Cancer." Clinical Presentation,
Diagnosis, and Staging of Colorectal Cancer. Ed. Kenneth K. Tanabe,
Diane MF Savarese, and Shilpa Grover. UpToDate, 11 Apr. 2016. Web. 11
July 2016.
 Rodriguez-Bigas, Miguel A., MD. "Surgical Resection of Primary Colon
Cancer." Surgical Resection of Primary Colon Cancer. Ed. Martin Weiser
and Wenliang Chen. UpToDate, 16 June 2016. Web. 11 July 2016.

14. Questions?