1. Colorectal Cancer Update Jonathan A. Laryea, MD FACS FASCRS FWACS Division of Colon & Rectal Surgery Department of Surgery University of Arkansas for Medical Sciences Little Rock, Arkansas Arkansas Cancer Coalition Summit XV March 11, 2014

2. Disclosures  No Disclosures

3. Outline  Facts and Figures  Risk Factors  Clinical Presentation and Management  Screening

5. 9% Colon & rectum

6. Facts  2014 Estimates  New cases: 96,830 (colon); 40,000 (rectal)  Deaths: 50,310 (colon and rectal combined)  Death rate over last 20 years declining  Screening and improvements in treatment

19. Risk Factors Adapted from Burt RW et al. Prevention and Early Detection of CRC, 1996 Sporadic (65 %– 85%) Familial (10 %– 30%) Hereditary nonpolyposis colorectal cancer (HNPCC) (5%) Familial adenomatous polyposis (FAP) (1%) Rare CRC syndromes (<0.1%)

20. Risk Factors  Adenomatous polyps  Age  Inflammatory Bowel Disease  History of Cancer  Family History of Colorectal Cancer  Physical Inactivity/obesity  Smoking  NSAIDS  Diets/Supplements  Race

21. Cancer Risk in Polyps

22. Adenoma-Cancer Sequence NormalepitheliumHyper-proliferativeepitheliumEarlyadenomaInter-mediateadenomaLateadenomaCarcinomaMetastasis Loss of APCActivation of K-ras Deletion of 18q Loss of TP53Otheralterations Adapted from Fearon ER. Cell 61:759, 1990

23. Age

24. Familial Risk Approximatelifetime CRC risk (%) Affected family members None One 1° One 1° and two 2° One 1° age <45 Two 1° HNPCC mutation 2% 6% 8% 10% 17% 70% Aarnio M et al. Int J Cancer 64:430, 1995 Houlston RS et al. Br Med J 301:366, 1990 St John DJ et al. Ann Intern Med 118:785, 1993

25. Risk of Colorectal Cancer 020406080100 General population Personal history of colorectal neoplasia Inflammatory bowel disease HNPCC mutation FAP 5% 15%–20% 15%–40% 70%–80% >95% Lifetime risk (%)

26. dietary fiber vegetables fruits antioxidant vitamins calcium folate (B Vitamin) decreased risk Diet

27. consumption of red meat animal and saturated fat refined carbohydrates alcohol increased risk Diet

28. Clinical Presentation

29. CRC by Site

30. Stage at Diagnosis Adapted from NCI Cancer Facts and Figures 2010

31. Staging Workup  Endoscopy with biopsy  CT Scan  CXR  ?PET Scan  CEA

32. STAGES OF COLON CANCER

33. Sites of Metastasis  Liver  Lung  Brain  Bone

34. Principles of Management  Surgery is the mainstay of treatment  Complete removal of tumor with negative margins  Removal of involved node-bearing tissue  Avoid spillage or disruption of tumor  Assess for evidence of metastasis  Personalized treatment based on molecular profiling

35. Management Colon Cancer  Stage I  Surgery alone  Stage II  Surgery alone +/- chemotherapy  Stage III  Surgery + Chemotherapy  Stage IV  Chemotherapy alone  Surgery + chemotherapy + metastasectomy

36. Rectal Cancer  Similar to Colon Cancer  Chemoradiation for Stages II and III

37. Minimally Invasive Surgery  Laparoscopy/ Robotic-assisted  Oncologically equivalent  Benefits versus cost  Smaller incisions  Less pain  Shorter length of stay  Earlier return to activities  Overall cost-effective

39. Screening  Prevents cancer by removing precancerous polyps  Early identification of cancer  Misconceptions and ignorance abound regarding screening  PCP recommendation has most significant impact  Screening fully covered with no out of pocket expenses under ACA

40. Screening  Average Risk  Start at age 50  Family History  Start at age 40 or  10 years earlier than youngest family member with cancer  High Risk  Based on risk factors  Familial Adenomatous Polyposis; start at age10-12y and yearly  Lynch Syndrome; start at age 20y and q2y till 45y then yearly

41. Screening Modalities  High sensitivity Fecal occult blood testing q1yr  Flexible Sigmoidoscopy q5years +FOBT q3yrs  Colonoscopy q10 years  CT colonography*  Stool DNA/ FIT

42. 5-year Survival  Stage I93%  Stage IIA 85%  Stage IIB 72%  Stage IIIA 83%  Stage IIIB 64%  Stage IIIC 44%  Stage IV 8%

43. Take home message  Incidence and death rates are declining  Eat right, exercise and avoid smoking  Screening saves lives  Most people get screened because their doctor told them to  Advances in treatment have led to improved survival  Advances in molecular profiling of cancers has led to personalized treatments

44. Thank you Jonathan A. Laryea, MD jalaryea@uams.edu Clinic Appointments: (501) 686-6211 Office: (501) 686-6757