1. Gastrointestinal Cancers 1

2. Pancreatic Cancer 2

3. Breast Cancer New diagnoses each year in the US: 246,660 Women 2,600 Men 40,450 estimated deaths from breast cancer in 2016 3

4. Pancreatic Cancer New diagnoses in 2015 (US): 48,960 40,560 died of pancreatic cancer in 2015 6.9% of all cancer deaths, and the 4 th leading cause of cancer deaths in the U.S. 4

5. Incidence by Race & Gender 5

6. Breast Cancer Lifetime Risk: 1/8.1 Women Median age of diagnosis = 61 YOA Median age of death = 68 YOA 5 year survival = 89.4% 6

7. Pancreatic Cancer Lifetime Risk: 1/67 Median age of diagnosis = 71 YOA Median age of death = 73 YOA 5 year survival = 7.2% 7

8. 8

9. The most common (~95%) type of pancreatic cancer is exocrine—i.e., adenocarcinoma. Endocrine function: Islet cells secrete glucose-regulating hormones Exocrine function (98%): Acinar cells secrete digestive enzymes 9

10. Risk Factors Diabetes Smoking Obesity Chronic Pancreatitis Family History Heritable disorders e.g., HNPCC; von Hippel-Lindau syndrome, Peutz-Jeghers syndrome. 10

11. Symptoms Early: None Later in the disease: Dark urine/pale stool Stool that floats Jaundice Upper abdominal pain Continual middle back pain Fatigue/weakness Loss of appetite/unexplained weight loss 11

12. Staging Stage 1: Tumor confined to the pancreas. IA: < 2cm IB: > 2cm Stage 2: Cancer has spread to nearby organs, (via lymphatics or shedding) but not to the local blood vessels. IIA: spread to local organs but NOT lymph nodes IIB: spread to regional lymph nodes; maybe to local organs Stage 3: Cancer has invaded to local blood vessels (e.g., superior mesenteric artery, celiac axis, common hepatic artery, and portal vein). Lymph nodes may be involved. Stage 4: Cancer is found at distant sites. 12

13. 13

14. Diagnosis Physical Exam CT Ultrasound Endoscopy (EUS, ERCP, PCT) MRI PET Scan Blood Tests (chemistry, CA 19-9, CEA) Needle Biopsy Laparoscopy 14

15. Surgical Treatment Whipple : (Body/tail left intact, head, part of stomach, part of small intestine, gallbladder removed) Pancreatectomy (pancreas along with part of stomach, part of small intestine, spleen, gallbladder removed) Distal pancreatectomy (Head left intact, body/tail/spleen removed) 15

16. Whipple Procedure Operative mortality = 1-16% 2-3 week hospital stay 1-3 months’ rest at home 4-6 weeks of difficulty digesting food (full and bloated feeling) Digestion problems should dissipate after 3 months 5 year survival: 18-24% 16

17. Other Treatment Chemotherapy Radiation Therapy Targeted Therapy (EGF-R kinase inhibitor [Tarceva]) Pain Control (pharmaceutical, epidural, acupuncture/hypnosis) 17

18. Colorectal Cancer 18

19. Colorectal Cancer New diagnoses in 2015 (US): 132, 700 49,700 died of colorectal cancer in 2015 2 nd leading cause of cancer deaths in the U.S. 19

20. Incidence by Race & Gender 20

21. Colorectal Cancer Lifetime Risk: 1/22 (4 th most common) Median age of diagnosis = 68 YOA Median age of death = 73 YOA 5 year survival = 64.9% 21

22. 22

23. Risk Factors Age > 50 Smoking IBD (ulcerative colitis) HNPCC (hereditary non-polyposis colon cancer (2%)) Familial adenomatous polyposis (<1%) Other solid tumors (breast, ovarian) High fat, low fiber diet Personal History of polyps Family History 23

24. Family History Relative Risk for CRC Absolute Risk of CRC by Age 79 yoa No family history 14% One first-degree relative with CRC2.39% More than one first-degree relative with CRC4.316% One affected first-degree relative diagnosed with CRC before age 45 y3.915% One first-degree relative with colorectal adenoma2.08% 24

25. Symptoms Early: None Later in the disease: Bloody stool ‘Narrow’ stool Diarrhea or Constipation Gas Pains/bloated feeling Fatigue/weakness Nausea or vomiting Loss of appetite/unexplained weight loss 25

26. Staging 26

27. Stage 0: Carcinoma in situ 27

28. Stage 1: Tumor is confined to the inner colon wall. 28

29. Stage 2: Tumor has invaded deeper into the colon wall, and possibly nearby tissues, but has not disseminated to the lymph nodes. 29

30. Stage 3: Cancer has disseminated to local lymph nodes but not to distant sites. 30

31. Stage 4: Cancer is found at distant sites. 31

32. Survival 32

33. Screening/Diagnosis Physical Exam Fecal Occult Blood Test Sigmoidoscopy Colonoscopy X-rays (Barium) Digital Rectal Exam “Virtual Colonoscopy” (CT) Camera Capsule 33

34. Carcinoembryonic Antigen (CEA) CEA is elevated in patients with colorectal cancer, but clinical trials show that there are too many false positives. Therefore, this test should not be the sole indicator used to diagnose cancer. 34

35. Surgical Treatment 35

36. Treatment Surgery Cryosurgery Radiofrequency Ablation Chemotherapy Radiation Therapy Biological Therapy (e.g., Avastatin—anti-angiogenic agent) Targeted Therapy (e.g., Regorafinib—multi kinase inhibitor) (e.g., anti EGF-R, VEGF-R2 monoclonal antibodies) 36

37. Stomach Cancer 37

38. Stomach Cancer New diagnoses in 2015 (US): 24, 590 10,720 died of colorectal cancer in 2015 38

39. Incidence by Race & Gender 39

40. Stomach Cancer Lifetime Risk: 1/111 Median age of diagnosis = 69 YOA Median age of death = 72 YOA 5 year survival = 29.3% 40

41. Risk Factors Helicobactor pylori infection Chronic gastritis Intestinal metaplasia (reflux) Familial adenomatous polyposis Diet high in salted & smoked foods, low in fruits & vegetables Eating improperly cooked or stored foods Smoking Family History 41

42. Symptoms Early: Indigestion and stomach discomfort A bloated feeling after eating Mild nausea Loss of appetite Heartburn Later in the disease: Blood in the stool Vomiting Unexplained weight loss Stomach pain Jaundice Abdominal Ascites Difficulty swallowing 42

43. Diagnosis History and Physical Examination Blood tests (e.g., CBC, CEA) Endoscopy (upper, EUS) X-ray (Barium swallow) CT PET Scan Biopsy 43

44. Staging Stage 0: Carcinoma in situ Stage 1: Minimally-invasive mucosal tumor Stage IA: mucosal and submucosal involvement Stage IB: mucosal, submucosal and 1-2 lymph nodes OR muscle layer involvement, 44

45. Staging (cont’d) Stage 2: Invasive Mucosal tumor Stage IIA: Submucosal layer involvement and 3-6 lymph nodes OR Muscle layer involvement and 1-2 lymph nodes OR Involvement of the sub-serosa Stage IIB: Submucosal layer involvement and 7+ lymph nodes OR Involvement of the sub-serosa and 1-2 lymph nodes OR Serosal involvement Stage 3: Cancer has disseminated to local lymph nodes but not to distant sites. Stage IIIA: Muscle layer involvement and 7+ lymph nodes OR Serosal involvement and 1-2 lymph nodes OR Involvement of the sub-serosa and 3-6 lymph nodes Stage IIIB: Serosal involvement and 3-6 lymph nodes OR Involvement of the sub-serosa and 7+ lymph nodes OR Tumor has spread to nearby organs (e.g., kidney, spleen, pancreas) and 1-2 lymph nodes Stage IIIC: Serosal involvement and 7+ lymph nodes OR Tumor has spread to nearby organs and 3+ lymph nodes Stage 4: Cancer is found at distant sites. 45

46. Survival 46

47. Treatment Surgery (gastrectomy [partial or total], endoluminal stent or laser therapy) Chemotherapy Radiation therapy Targeted therapy (e.g., anti Her-2, VEGF-R2 monoclonal antibodies) 47

48. Gastrointestinal Stromal Tumors (GISTs) May be malignant or benign Tumors anywhere in the GI tract, but most common in the stomach and small intestine May originate in Interstitial Cells of Cajal (ICC) Small GISTs are very common Hereditary predilection (NF-1 gene mutation) Signs of gastrointestinal stromal tumors include blood in the stool or vomit. Diagnosis via CT, MRI or endoscopy Biopsy determines “mitotic rate” Surgical treatment + Gleevec (c-kit kinase inhibitor) 48

49. Liver Cancer 49

50. Hepatocellular & Bile Duct Cancer New diagnoses in 2015 (US): 35, 660 24,550 died of liver and intrahepatic bile duct cancer in 2015 Although Hepatocellular cancer ranks 13 th in the U.S. for cancer- related deaths, it is the 3 rd leading cause world wide. 50

51. Incidence by Race & Gender 51

52. Hepatocellular and Bile Duct Cancer Lifetime Risk: 1/111 Median age of diagnosis = 63 YOA Median age of death = 67 YOA 5 year survival = 17.2% 52

53. Risk Factors Hepatitis infection Cirrhosis Consumption of Aflatoxin Hemochromatosis 53

54. Symptoms A hard lump on the right side just below the rib cage Discomfort in the upper abdomen on the right side A swollen abdomen Referred pain near the right shoulder blade or in the back Jaundice Easy bruising or bleeding Weakness or fatigue Nausea and vomiting Loss of appetite or feelings of fullness after eating a small meal. Unexplained weight loss Pale, chalky bowel movements and dark urine Fever 54

55. Diagnosis History and physical exam Serum alpha-fetoprotein (AFP) (Other cancers and certain noncancerous conditions, including cirrhosis and hepatitis, may also increase AFP levels. Sometimes the AFP level is normal even when there is liver cancer.) Liver function tests CT scan MRI Ultrasound Biopsy (Fine- or Core-needle aspiration biopsy or biopsy by Laparoscopy) 55

56. The Barcelona Clinic Liver Cancer Staging System Stage 0: Very early Stage A: Early Stage B: Intermediate Stage C: Advanced Stage D: End-stage 56

57. 57

58. Treatment Depends upon Stage BCLC stages 0, A, and B : Treatment goal is to cure the cancer. BCLC stages C and D: Treatment goal is to relieve the symptoms caused by liver cancer and improve the patient's quality of life Treatments are not likely, nor are intended to cure the cancer. 58

59. Treatment Surveillance Surgery (e.g., partial hepatectomy or Liver transplant) Chemotherapy Radiation Therapy Ablation therapy (e.g., Radiofrequency ablation, percutaneous ethanol injection, cryoablation, microwave therapy) Embolization therapy (e.g., Trans-arterial embolization, trans-arterial chemoembolization) Targeted therapy (e.g., Sorafenib [kinase inhibitor]) 59