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

Colorectal Cancer

80% present with early 80% present with early diseasedisease

20% present with 20% present with metastatic disease.metastatic disease.

Among patients Among patients diagnosed with early-diagnosed with early-stage disease, 40% will stage disease, 40% will suffer recurrence.suffer recurrence.

Stage at Diagnosis

Localized(Stage I/II)

50%

Distant(Stage IV)

20%

Regional(Stage III)

30%

StageExtent of tumor

5-year survival

Mucosa

Muscularis mucosa

Submucosa

Muscularis propria

SerosaFat

Lymph nodes

ANo deeper than

submucosa

> 90%

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%

DDistant

metastases

< 5%

Staging of Colorectal Cancer

5-Year Survival for CRC by Stage

65%

70-90%

25-70%

5-10%

0

20

40

60

80

100

All Stages Localized(Stage I and II)

RegionalStage III

Distant(Stage IV)

% o

f p

atie

nts

Colorectal Cancer (CRC)

Sporadic Sporadic (average risk) (average risk) (75-80%)(75-80%)

FamilyFamilyhistoryhistory(10-15%)(10-15%)

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

polyposis (FAP) (1-2%)polyposis (FAP) (1-2%)

Rare Rare syndromes syndromes

(<0.1%)(<0.1%)

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, Gardner’s syndrome, Turcot’s syndrome, juvenile polyposis

• Inflammatory bowel disease – chronic ulcerative colitis, Crohn’s disease

Lifestyle Risk Factors for Colorectal Cancer

Decrease Risk Exercise Folic acid Aspirin Calcium, vitamin D Screening

Increase Risk Obesity Red meat Alcohol Smoking

Natural History

PolypPolyp Advanced cancerAdvanced 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, non-

invasive, rapid imaging of entire colorectum, low risk of complications

– Especially useful in patients who can not undergo colonoscopy

Stool DNA testing Video capsule

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

CRC Screening Guideline: Summary

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?

• N = Node– Are cancer cells in the

lymph nodes?

• M = Metastases – Has the cancer spread to

other organs?

Four stages:• Stage I

– Spread to the middle layers of the colon or rectum

• 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

– 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

Making Treatment Decisions

Goals of Treatment

Goals of Treatment for Early Disease

• Remove cancer cells

• Kill cancer cells

• Keep the cancer cells from returning

Treatment is defined by stage and type of cancer present

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

Goals of Treatment for Advanced Disease

• Slow or stop the growth of cancer cells

• Manage quality of life concerns

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

Agent FDA approval status

5-FU 1962

Irinotecan (CPT-11) 1998 (second-line)

2000 (first-line)

Capecitabine (oral 5-FU) 2001 (first-line)

Oxaliplatin 2002 (second-line)

2004 (first-line)

Chemotherapy of Colorectal Cancer

Agent FDA approval status

Bevacizumab 2004

(Anti-VEGF Ab)

Cetuximab 2004 (Anti-EGFR Ab)

Panitumumab 2006(Anti-EGFR Ab)

Targeted Therapy of Colorectal Cancer

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

0 6 12 18 24

Median Survival (months)

~4-6 mo

~10-12 mo

~15 mo

20.3 mo

~20 mo

>24-28 mo

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 AffectsTreatment 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

MakingTreatment 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

ManagingSide 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 Effectsfrom 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 hadn’t had a colostomy, I wouldn’t have lived. It’s what you have to do to survive. It doesn’t limit me in any way, except for not

wearing extremely tight clothes that I wouldn’t wear anyway.”

- Pam

Side Effectsfrom 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.

ManagingBowel 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 I’ve had adhesions with partial blockage of

the colon. It started 9 months after treatment … I’d get cramps and throw up all of a sudden. Now I go to a massage therapist and I haven’t had an attack for a few months, so I think it’s 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 don’t 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 it’s such a burden. But if you have enough faith in each other and love

for each other you can conquer anything.”- Scott

Are you FeelingDistressed?

• 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 forWellness• 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 ofRecurrence• 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, 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 treatments—survival 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 Survivor’s Almanac

Resources

• C3: Colorectal Cancer Coalition877-4CRC-111 www.FightColorectalCancer.org

• Colon Cancer Alliance877-422-2030 www.ccalliance.org

• The Wellness Community888-793-WELL www.thewellnesscommunity.org

• American Cancer Society800-ACS-2345 www.cancer.org

• National Cancer Institute800-4-CANCER www.cancer.gov

More resources can be found in the

Frankly Speaking About Colorectal Cancer booklet

Acknowledgments

This program was created by

in partnership with

and supported through a

charitable contribution from