1. PLWC Slide Deck Series: Understanding Colorectal Cancer Presents 2005

2. What is Cancer? A group of 100 different diseases The uncontrolled, abnormal growth of cells Cancer may spread to other parts of the body

3. What is Colorectal Cancer? Third most common type of cancer and second most frequent cause of cancer-related death A disease in which normal cells in the lining of the colon or rectum begin to change, grow without control, and no longer die Usually begins as a noncancerous polyp that can, over time, become a cancerous tumor

4. What is the Function of the Colon and Rectum? The colon and rectum comprise the large intestine (large bowel) The primary function of the large bowel is to turn liquid stool into formed fecal matter

5. What Are the Risk Factors for Colorectal Cancer? Polyps (a noncancerous or precancerous growth associated with aging) Age Inflammatory bowel disease (IBD) Diet high in saturated fats, such as red meat Personal or family history of cancer ObesitySmokingOther

6. Hereditary Colorectal Cancer Syndromes: HNPCC Hereditary non-polyposis colorectal cancer (HNPCC), sometimes called Lynch syndrome, accounts for approximately 5% to 10% of all colorectal cancer cases The risk of colorectal cancer in families with HNPCC is 70% to 90%, which is several times the risk of the general population People with HNPCC are diagnosed with colorectal cancer at an average age of 45 Genetic testing for the most common HNPCC genes is available; measures can be taken to prevent development of colorectal cancer

7. Hereditary Colorectal Cancer Syndromes: FAP Familial adenomatous polyposis (FAP) accounts for 1% of colorectal cancer cases People with FAP typically develop hundreds to thousands of colon polyps (small growths); the polyps are initially benign (noncancerous), but there is nearly a 100% chance that the polyps will develop into cancer if left untreated Colorectal cancer usually occurs by age 40 in people with FAP Mutations (changes) in the APC gene cause FAP; genetic testing is available Yearly screening for polyps is recommended Attenuated familial adenomatous polyposis (AFAP) is related to FAP; people have fewer polyps

8. Hereditary Colorectal Cancer Syndromes Several other less common syndromes can increase a person’s risk of colorectal cancer Talk with your doctor about finding a genetic counselor if you have a history of colorectal cancer in your family and family members developed cancer before age 50 For more information, visit www.plwc.org/genetics

9. Colorectal Cancer and Early Detection Colorectal cancer can be prevented through regular screening and the removal of polyps Early diagnosis means a better chance of successful treatment Screening should begin at age 50 for all “average risk” individuals or sooner if you have a family history of colorectal cancer, symptoms, or a personal history of inflammatory bowel disease

10. Screening Methods for Colorectal Cancer Colonoscopy (currently the best way to prevent and detect colorectal cancer) Virtual colonography Sigmoidoscopy Fecal occult blood test Double contrast barium enema Digital rectal examination

11. What Are the Symptoms of Colorectal Cancer? A change in bowel habits: diarrhea, constipation, or a feeling that the bowel does not empty completely Bright red or dark blood in the stool Stools that appear narrower or thinner than usual Discomfort in the abdomen, including frequent gas pains, bloating, fullness, and cramps Unexplained weight loss, constant tiredness, or unexplained anemia (iron deficiency)

12. How is Colorectal Cancer Evaluated? Diagnosis is confirmed with a biopsy Stage of disease is confirmed by pathologists and imaging tests, such as computerized tomography (CT or CAT) scans Endoscopic ultrasound and magnetic resonance imaging (MRI) may also be used to stage rectal cancer

13. Cancer Treatment: Surgery Foundation of curative therapy The tumor, along with the adjacent healthy colon or rectum and lymph nodes, is typically removed to offer the best chance for cure May require temporary or (rarely) permanent colostomy (surgical opening in abdomen that provides a place for waste to exit the body)

14. Cancer Treatment: Chemotherapy Drugs used to kill cancer cells Typical medications include fluorouracil (5-FU), oxaliplatin (Eloxatin), irinotecan (Camptosar), and capecitabine (Xeloda) A combination of medications is often used

15. Types of Chemotherapy Adjuvant chemotherapy is given after surgery to maximize a patient’s chance for cure Neoadjuvant chemotherapy is given before surgery Palliative chemotherapy is given to patients whose cancer cannot be removed to delay or reverse cancer- related symptoms and substantially improve quality and length of life

16. Cancer Treatment: Radiation Therapy The use of high-energy x-rays or other particles to destroy cancer cell Used to treat rectal cancer, either before or after surgery Different methods of delivery External-beam: outside the body Intraoperative: one dose during surgery

17. New Therapies: Antiangiogenesis Therapy “Starves” the tumor by disrupting its blood supply This therapy is given along with chemotherapy Bevacizumab (Avastin) was approved by the U.S. Food and Drug Administration (FDA) in 2004 for the treatment of stage IV colorectal cancer

18. New Therapies: Targeted Therapy Treatment designed to target cancer cells while minimizing damage to healthy cells Cetuximab (Erbitux) was approved by the FDA in 2004 for the treatment of advanced colorectal cancer

19. Colorectal Cancer Staging Staging is a way of describing a cancer, such as the depth of the tumor and where it has spread Staging is the most important tool doctors have to determine a patient’s prognosis Staging is described by the TNM system: the size (the depth of penetration of the Tumor into the wall of the bowel), whether cancer has spread to nearby lymph Nodes, and whether the cancer has Metastasized (spread to organs such as the liver or lung) The type of treatment a person receives depends on the stage of the cancer

20. Stage 0 Colorectal Cancer Known as “cancer in situ,” meaning the cancer is located in the mucosa (moist tissue lining the colon or rectum) Removal of the polyp (polypectomy) is the usual treatment

21. Stage I Colorectal Cancer The cancer has grown through the mucosa and invaded the muscularis (muscular coat) Treatment is surgery to remove the tumor and some surrounding lymph nodes

22. Stage II Colorectal Cancer The cancer has grown beyond the muscularis of the colon or rectum but has not spread to the lymph nodes Stage II colon cancer is treated with surgery and, in some cases, chemotherapy after surgery Stage II rectal cancer is treated with surgery, radiation therapy, and chemotherapy

23. Stage III Colorectal Cancer The cancer has spread to the regional lymph nodes (lymph nodes near the colon and rectum) Stage III colon cancer is treated with surgery and chemotherapy Stage III rectal cancer is treated with surgery, radiation therapy, and chemotherapy

24. Stage IV Colorectal Cancer The cancer has spread outside of the colon or rectum to other areas of the body Stage IV cancer is treated with chemotherapy. Surgery to remove the colon or rectal tumor may or may not be done Additional surgery to remove metastases may also be done in carefully selected patients

25. The Role of Clinical Trials for the Treatment of Colorectal Cancer Clinical trials are research studies involving people They test new treatment and prevention methods to determine whether they are safe, effective, and better than the best known treatment The purpose of a clinical trial is to answer a specific medical question in a highly structured, controlled process Clinical trials can evaluate methods of cancer prevention, screening, diagnosis, treatment, and/or quality of life

26. Clinical Trials: Patient Safety Informed consent: Participants should understand why they are being offered entry into a clinical trial and the potential benefits and risks; informed consent is an ongoing process Participation is always voluntary, and patients can leave the trial at any time Other safeguards exist to ensure ongoing patient safety

27. Clinical Trials: Phases Phase I trials determine safety and dose of a new treatment in a small group of people Phase II trials provide more detail about the safety of the new treatment and determine how well it works for treating a given form of cancer Phase III trials take a new treatment that has shown promising results when used to treat a small number of patients with cancer and compare it with the current, standard treatment for that disease; phase III trials involve a large number of patients

28. Clinical Trials Resources Coalition of Cancer Cooperative Groups (www.CancerTrialsHelp.org) CenterWatch (www.centerwatch.com) National Cancer Institute (www.cancer.gov/clinical_trials)

29. Coping With the Side Effects of Cancer and its Treatment Side effects are treatable; talk with the doctor or nurse Fatigue is a common, treatable side effect Pain is treatable; non-narcotic pain relievers are available Antiemetic drugs can reduce or prevent nausea and vomiting For more information, visit www.plwc.org/sideeffects

30. Follow-Up Care Doctor’s visits Serial carcinoembryonic antigen (CEA) measurements are recommended Colonoscopy one year after removal of colorectal cancer Surveillance colonoscopy every three to five years to identify new polyps and/or cancers More information can be found in the ASCO Patient Guide: Follow-Up Care for Colorectal Cancer

31. Where to Find More Information: PLWC Guide to Colorectal Cancer (www.plwc.org/colorectal) Overview Medical Illustrations Risk Factors and Prevention SymptomsDiagnosis Staging With Illustrations Treatment Side Effects of Cancer and Cancer Treatment After Treatment Questions to Ask the Doctor Current Research Patient Information Resources Clinical Trials Resources

32. People Living With Cancer (www.plwc.org) PLWC is the cornerstone of ASCO’s patient resources program Visitors to PLWC will find:  PLWC Guides to more than 90 types of cancer  Coping resources  Ask the ASCO Expert Series, including chats, Q&A forums, and event transcripts  Cancer information in Spanish  The latest cancer news For patient information resources, please call 888-651-3038