Colorectal cancer is the third most common cancer in men and women in the US, with odds of around 5% of developing it. Screening colonoscopy is recommended every 10 years starting at age 50. Staging involves determining how deep the cancer has invaded the bowel wall (T stage) and if it has spread to lymph nodes (N stage). Treatment involves surgery with chemotherapy or radiation added for more advanced stages. New drugs have improved survival, which is around 65% at 5 years and varies by stage from 90% for local to 12% for distant disease.

1. Colorectal Cancer
Robert Miller MD
www.aboutcancer.com

2. Third Most Common Cancer
in Men and Women

3. Odds of Developing Colorectal
cancer in the US (2007-9)~ 5%
Type Men Women
Any Cancer 45% (1in 2) 38% (1 in 3)
Breast 12% (1 in 8)
Colorectal 5% (1in 19) 4.8% (1 in 21)
Prostate 16% (1in 6)

4. Declining Incidence last 30y

5. Third Most Lethal Cancer in
Men and Women

6. Declining Mortality in Men
US Data 1930 to 2009

7. Declining Mortality in Women
US Data 1930 to 2009

8. Odds of Dying of Colorectal
cancer in the US (2007-9) ~ 2%
Type Men Women
Any Cancer 23% (1in 4) 19% (1 in 5)
Breast 2.8% (1 in 36)
Colorectal 2.11% (1in 47) 1.94% (1 in 52)
Prostate 2.8% (1in 36)

9. Most patients are diagnosed before they have symptoms because of
screening or the findings of rectal blood (hematochezia) or anemia
Abdominal pain — 44 percent
Change in bowel habit — 43 percent
Hematochezia or melena — 40 percent
Weakness — 20 percent
Anemia — 11 percent
Weight loss — 6 percent
Patients who are symptomatic at diagnosis have a somewhat worse
prognosis. In one report, the five-year survival rate for symptomatic (49%)
and asymptomatic patients (71%)
Symptoms

10. Median Age of Patients with
colon and rectal cancer (2005-
2009)
Site Male Female
Colon 69y 73y
Rectum 64y 66y

11. Colon
8% less than
50y
Rectum
14% less than
50y
Age Distribution
from the NCDB
for 2000- 2012

12. Screening
Colonoscopy
every 10 years
starting at the
age of 50 unless
high risk

15. How should family history effect the age
to start screening colonoscopy?
First-degree (share one half genes) = parent, child or sibling
Second-degree (share one quarter genes) = grandparents, uncle,
niece

16. Workup or Evaluation Prior to Deciding
on Treatment for Colon Cancer

17. Pathology Report
• Confirm that it is malignant (usually adenocarcinoma)
• Information about stage: depth in invasion and lymph nodes involved
(look at 12 nodes)
• Surgical margins (to ensure complete removal)
• Other prognostic risk factors: grade, vascular invasion, perineural
invasion
• Genetic risk factors: MSI (microsatellite instability) testing/ MMR protein
to look for Lynch syndrome
• Gene mutation testing: KRAS and BRAF that will determine whether the
patient would benefit from anti EGFR drugs (cetuximab, panitumumab,
regorafenib)

18. Workup or Evaluation Prior to Deciding
on Treatment for Rectal Cancer

19. T2 T3
Nodes
Transrectal Endoscopic Ultrasound

20. Accuracy of Imaging in Staging
Rectal Cancer
Site Ultrasound CT MRI
Tumor 80-95% 65-75% 75-85%
Nodes 70-75% 55-65% 60-65%

21. Staging

22. Staging: T (tumor stage)

23. Stage Depth of Invasion
T1 submucosa
T2 muscularis propria
T3 Pericolorectal tissue
T4a Surface of visceral peritoneum
T4b Into other organs/structures
Staging: T (tumor stage)

24. Staging: N (lymph node stage)

25. Stage Nodes Involved
N0 0
N1a 1
N1b 2, 3
N2a 4, 6
N2b 7 or more
Staging: N (lymph node stage)

27. Colon Cancer Stage Distribution

28. Rectal Cancer Stage Distribution

29. NCCN.org

31. Treatment of colorectal
cancer
• Early stages are treated with surgery
• More advanced stages have surgery followed
by chemotherapy (colon) or radiation and
chemotherapy prior to surgery (rectum)
• Metastatic or recurrent disease treated with
chemotherapy or targeted therapy and
possibly radiation, surgical resection or RF
ablation

32. Survival in Months Drug Regimen
14.8 months bolus 5FU/LV
17.4 months Infusional 5FU/LV
20.1 months irinotecan (Camptosar) +5FU/LV
20.3 months camptosar = 5FU + bevacizumab (Avastin)
21.5 months FOLFIRI then FOLFOX
25.1 months irinotecan/5FU + avastin +oxaliplatin (Eloxatin)
New Drugs for Colorectal Cancer

33. There are now seven different classes of drugs with
significant antitumor activity:
• 5-fluorouracil [5-FU] which is usually given with leucovorin, capecitabine,
(Xeloda) tegafur plus uracil
• Irinotecan (Camptosar)
• Oxaliplatin (Eloxatin)
• Cetuximab (Erbitux) and panitumumab (Vectibix), two monoclonal
antibodies (MoAbs) directed against the epidermal growth factor receptor
(EGFR) if KRAS wild type
• Bevacizumab (Avastin), a MoAb targeting vascular endothelial growth
factor (VEGF)
• Aflibercept, a recombinant fusion protein consisting of vascular
endothelial growth factor (VEGF) binding portions from the human VEGF
receptors 1 and 2 fused to the Fc portion of human immunoglobulin G1,
• Regorafenib, a small molecule inhibitor of multiple kinases

34. 30 Year Trends in 5 Year Survival
Site 1975 2008
Colon 51% 65%
Rectum 48% 68%

35. Stage and 5 Year Survival
US Data 2002- 2008
Stage Incidence Survival
All 100% 64%
Local 39% 90%
Regional 36% 70%
Distant 20% 12%

36. Survival with Colon Cancer

37. Survival with Rectal Cancer

38. 5 Year Survival from NCDB
Stage Colon Rectum
I 77.5% 77.7%
II 66.6% 63.2%
III 54.5% 58.0%
IV 9.6% 9.8%

39. www.adjuvantonline.com

40. Colorectal Cancer
Robert Miller MD
www.aboutcancer.com