colorectal cancer wellness talk dr. edwardchu

8/13/2019 Colorectal Cancer Wellness Talk Dr. EdwardChu

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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


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Understanding Colorectal Cancer


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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 toprevent and cure CRC

I keep thinking to myself:

I may have cancer, but cancer doesnt have me!

-Pam


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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


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olorectal ancer 80% present with early

disease

20% present with

metastatic disease.

Among patientsdiagnosed with early-stage disease, 40% will

suffer recurrence.

Stage at Diagnosis

Localized(Stage I/II)

50%

Distant(Stage IV)

20%

Regional(Stage III)

30%


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StageExtent of tumor

5-year survival

Mucosa

Muscularis mucosa

Submucosa

Muscularis propria

Serosa

Fat

Lymph nodes

ANo deeper than

submucosa

> 90%

B1Not throughbowel wall

8085%

B2Through

bowel wall

7075%

C1Not throughbowel wall:lymph nodemetastases

5065%

C2Through bowel

wall: lymph nodemetastases

2545%

DDistant

metastases

< 5%

Staging of Colorectal Cancer


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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)

Regional

Stage III

Distant

(Stage IV)

%o

fpatie

nts


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Colorectal Cancer (CRC)

Sporadic

(average risk)

(75-80%)

Family

history

(10-15%)Hereditary non-polyposis

colorectal cancer

(HNPCC) (3-5%)Familial adenomatous

polyposis (FAP) (1-2%)

Rare

syndromes(


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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


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Risk Factors for CRC

Family or personal history of CRCHNPCCLynch syndrome I, II

Polyposis syndromesFAP, Gardnerssyndrome, Turcots syndrome, juvenile

polyposis

Inflammatory bowel diseasechronic

ulcerative colitis, Crohns disease


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Lifestyle Risk Factors for ColorectalCancer

Decrease Risk

Exercise

Folic acid

Aspirin

Calcium, vitamin D

Screening

Increase Risk

Obesity

Red meat

Alcohol

Smoking


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Natural History

Polyp Advanced cancer

Age 50, 25% risk of developing polyps

Age 75, 50-75% risk of developing polyps


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Screening = Prevention & EarlyDetection

Prevention = polyp removal

Decreased Incidence

Early Detection Decreased Mortality


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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


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Factors Associated with CRC Screening

Higher socio-economic status

Higher education

White

Older age (>50 years)

Men

Married


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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


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Other Screening Tests

Virtual colonoscopy

Pickhardt et al, NEJM, Dec 2003

Sensitivity 94%, Specificity 96%

Johnson et al, NEJM, Sept 2008Sensitivity 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 notundergo colonoscopy

Stool DNA testing

Video capsule


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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


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Diagnosing CRC

A colonoscopylooks at the entire colon to identifyproblems

Blood testshelp to categorize your overall health

a CEA test is often used to follow the presence of CRC

Imaging testswill identify if cancer exists in other parts ofyour body

CAT scan, MRI, PET scan

Surgerywill remove tumor(s), tissue and lymph nodes

which will be tested by a pathologist to determine the typeand stage of cancer present


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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


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Stages of CRC


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Partnering With

Your Medical Team

It is important that you feel respected and listened to.Work with a healthcare team you can trust.


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Your Medical Team

Successful treatmentrequires a multidisciplinaryteam 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 teamdepends on preferences:

Recommendations Expertise

Style of communication Location Type of institution (private

practice, communityhospital, cancer center)

Insurance

B P d f


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Be Prepared for

Appointments.

Keep a list of questions/concerns to bring toappointments

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

C id d


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Consider a second

opinion

You have the rightto get a second, and even a third,

opinion

It is very common and accepted

Its 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 didnt know about


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Making Treatment Decisions


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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


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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

T t d Th i /


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Targeted Therapies/

Biologic Agents

Targeted therapies work through specificpathways 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


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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

T t d Th f C l t l


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Agent FDA approval status

Bevacizumab 2004(Anti-VEGF Ab)

Cetuximab 2004(Anti-EGFR Ab)

Panitumumab 2006(Anti-EGFR Ab)

Targeted Therapy of ColorectalCancer


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Historical Progress of Therapyof 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

~15mo

20.3 mo

~20 mo

>24-28 mo


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Clinical Trials

Clinical trials study promising new drugs andtreatment 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 bythe US FDA

Participants are not guinea pigs

Wh t Aff t


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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 youve had cancer and/or cancer

treatment in the past

Your willingness/ability to tolerate certain side effects

Ease and convenience of treatmentoral vs intravenous Insurance coverage and costs

Making


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Making

Treatment Decisions

You always have time to think about youroptions and ask questions.

The ultimate question:

What will give me the greatest chance ofcure or longer life, and at what price?

- Wendy Schlessel Harpham, M.D.

In the Frankly Speaking About Colorectal Cancerbooklet, see more detailed information about

treatment options in Chapter 4.


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Managing


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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, during, and after cancer treatment will

help you prepare

Goal: take control of side effects before they take

control of you

Side Effects


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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, see p.49 in the Frankly Speaking About

Colorectal Cancerbooklet

If I hadnt had a colostomy, I wouldnt have lived. Its what youhave to do to survive. It doesnt limit me in any way, except for not

wearing extremely tight clothes that I wouldnt wear anyway.

- Pam

Side Effects


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Side Effects

from Chemotherapy

Diarrhea

Mouth sores

Hand-footsyndrome

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.

Managing


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Managing

Bowel 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 systemEver since radiation Ive had adhesions with partial blockage of

the colon. It started 9 months after treatment Id get cramps andthrow up all of a sudden. Now I go to a massage therapist and I

havent had an attack for a few months, so I think its helping.

- Nancy


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Colorectal Cancer Survivorship


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Quality of Life

A colorectal cancer diagnosis raises bothphysical 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


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Talking About CRC

Keep communication open and honest Do not keep fears, embarrassment, worry toyourself

CRC can be awkward to talk about Find people in a similar situation for support

If you dont 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 its such

a burden. Bu t i f you have enough fai th in each other and lov efor each other you can conquer anything.

- Scott

Are you Feeling


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Are you Feeling

Distressed?

If you think you or someone you love is suffering fromdepression: 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?


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Strategies for


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Strategies for

Wellness

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 of


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Fear of

Recurrence

Be informed Talk about it with your medical team

Allow yourself to feel up and downit is healthy to

express negative emotions

Be Patient Active take control of what you can, butknow what you cant control

Do not to let anxiety and fear prevent you from seeking

medical care


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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 isimportant: seek-out support

Try to live each day to the fullest!

No matter how severe the symptoms and treatmentssurvival

from day to d ay, week to w eek, and year to year con st i tutes anenormou s personal and human tr iumph over what might have

been. -A Cancer Survivors Almanac


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Resources

C3: Colorectal Cancer Coalition

877-4CRC-111 www.FightColorectalCancer.org

Colon Cancer Alliance

877-422-2030 www.ccalliance.org

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

American Cancer Society

800-ACS-2345 www.cancer.org

National Cancer Institute

800-4-CANCER www.cancer.gov

More resources can

be found in the

Frankly SpeakingAbout Colorectal

Cancerbooklet
http://www.fightcolorectalcancer.org/http://www.ccalliance.org/http://www.thewellnesscommunity.org/http://www.cancer.org/http://www.cancer.gov/http://www.cancer.gov/http://www.cancer.org/http://www.thewellnesscommunity.org/http://www.ccalliance.org/http://www.fightcolorectalcancer.org/


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