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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 doesn‟t 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

40% will suffer recurrence.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. Regional (Stage III) 30% .

Staging of Colorectal Cancer Stage Extent of tumor A No deeper than submucosa B1 Not through bowel wall 80–85% B2 Through bowel wall 70–75% C1 Not through bowel wall: lymph node metastases 50–65% C2 Through bowel wall: lymph node metastases 25–45% 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) .

1%) Familial adenomatous polyposis (FAP) (1-2%) Hereditary non-polyposis colorectal cancer (HNPCC) (3-5%) .Colorectal Cancer (CRC) Sporadic (average risk) (75-80%) Family history (10-15%) Rare syndromes (<0.

ethnic factors – African-Americans have increased risk • Dietary factors – high animal fat.Risk Factors for CRC • Age >50 (average risk) • Racial. low fiber diet • Lifestyle – Sedentary – Obesity – Smoking – Alcohol .

juvenile polyposis • Inflammatory bowel disease – chronic ulcerative colitis. II • Polyposis syndromes – FAP. Turcot’s syndrome. Crohn’s disease . Gardner’s syndrome.Risk Factors for CRC • Family or personal history of CRC • HNPCC – Lynch syndrome I.

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. 50-75% risk of developing polyps . 25% risk of developing polyps • Age 75.

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Screening = Prevention & Early Detection Prevention = polyp removal Decreased Incidence Early Detection Decreased Mortality .

gold standard .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 .

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  .

low risk of complications – Especially useful in patients who can not undergo colonoscopy  Stool DNA testing  Video capsule .Other Screening Tests  Virtual colonoscopy  Pickhardt et al. Specificity 86% – Advantages: no need for sedation. rapid imaging of entire colorectum. NEJM. Specificity 96% – Johnson et al. NEJM. Dec 2003 Sensitivity 94%. Sept 2008 Sensitivity 90%. noninvasive.

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 .

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

spread to other organs .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.

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. .

cancer center) – Insurance .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.

nutritional supplements you may be taking • Learn the best method of on-going communication – Appointments.Be Prepared for Appointments…. phone. • 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. even email • Bring a relative or friend to take notes • Ask for copies of your reports and test results . ―herbs‖.

opinion – It is very common and accepted – It’s 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 didn’t know about . and even a third.Consider a second opinion… • You have the right to get a second.

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! .

combination regimens .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.

e.e.: Cetuximab and Panitumumab) – VEGFR inhibitors (i.Targeted Therapies/ Biologic Agents • Targeted therapies work through specific pathways involved in cancer growth to attack cancer cells directly – EGFR inhibitors (i.: 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 + Oxaliplatin/Irinotecan) 2 Active Drugs + bevacizumab 2/3 Active Drugs + Targeted/Biologic Agents ~4-6 mo ~10-12 mo ~15 mo ~20 mo 20. Capecitabine) 2 Active Drugs (5-FU/LV + Oxaliplatin/Irinotecan.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 you’ve 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 .

D. see more detailed information about treatment options in Chapter 4. . and at what price?” . • The ultimate question: “What will give me the greatest chance of cure or longer life. In the Frankly Speaking About Colorectal Cancer booklet.Wendy Schlessel Harpham. M.Making Treatment Decisions • You always have time to think about your options and ask questions.

Managing Side Effects .

and after cancer treatment will help you prepare • Goal: take control of side effects before they take control of you . during.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.

I wouldn‟t have lived.” . see p. It‟s what you have to do to survive.49 in the Frankly Speaking About Colorectal Cancer booklet “If I hadn‟t had a colostomy.Pam .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. It doesn‟t limit me in any way. except for not wearing extremely tight clothes that I wouldn‟t wear anyway.

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. .

bloating.Nancy . Now I go to a massage therapist and I haven‟t had an attack for a few months.” . constipation or diarrhea.Managing Bowel Issues • Obstruction and/or perforation – Caused by the cancer itself. inability to pass gas. 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 I‟ve had adhesions with partial blockage of the colon. nausea and vomiting. It started 9 months after treatment … I‟d get cramps and throw up all of a sudden. so I think it‟s helping. or treatment • Symptoms include: abdominal pain.

Colorectal Cancer Survivorship .

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

Talking About CRC • Keep communication open and honest • Do not keep fears. worry to yourself • CRC can be awkward to talk about – Find people in a similar situation for support • If you don’t want to talk about it – write it down – Keep a journal and use it to share your emotions with loved ones. embarrassment. yourself.” . But if you have enough faith in each other and love for each other you can conquer anything.Scott . or your doctor “I know cancer can destroy some relationships because it‟s such a burden.

Are you Feeling Distressed? • If you think you or someone you love is suffering from depression: talk to your doctor. 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? . a social worker.

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 . increased zest for life.Find Support • TWC research found that people in support groups report a decrease in depression.

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

Fear of Recurrence • Be informed • Talk about it with your medical team • Allow yourself to feel up and down—it is healthy to express negative emotions • Be ―Patient Active‖ – take control of what you can. but know what you can’t control • Do not to let anxiety and fear prevent you from seeking medical care .

Survivorship • Advances are being made. 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 treatments—survival from day to day. and year to year constitutes an enormous personal and human triumph over what might have been.” . giving more patients the chance for a longer.A Cancer Survivor’s Almanac . week to week. nurses. better quality of life after diagnosis • Doctors.

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

Acknowledgments This program was created by in partnership with and supported through a charitable contribution from .