Colorectal Cancer

Front 1

Where is the incidence of CC most common?

Back 1

Industrialized nations such as North America, Western Europe, Australia and New Zealand

Front 2

Colorectal cancer is the ____ leading incidence of cancer and cancer death in the USA.

Back 2

3rd

Front 3

Why has there been a decrease in the incidence of colorectal cancer in the past decade?

Back 3

The decrease of white females

Front 4

What are general risk factors for Colorectal Cancer?

Back 4

Age >40, Family history, Diet (Fat, low fiber), obesity, alcohol/tobacco use (nicotine reduces risk)

Front 5

Heriditary nonpolyposis colon cancer (HNPCC) is also known as ____________.

Back 5

Lynch syndrome

Front 6

Describe Lynch Syndrome

Back 6

Autosomal Dominant, Accounts for 5-10%, early onset <40yo, occurs predominantly in proximal colon with less than 100 polyps.

Front 7

Describe FAP/Familial adenomatous polyposis

Back 7

Autosomal dominant trait, 0.5% of cases, Mutation of adenomatous polyposis coli (APC) gene on chromosone 9.
100% of developing malignancy, screening starts at age 12 and surgical colectomy occurs when polyps are detected.

Front 8

What pre-existing conditions can act as risk factors for Colorectal Cancer?

Back 8

IBD: Chronic UC, Crohn's disease

Front 9

Describe 6 Primary Prevention strategies for Colorectal Cancer

Back 9

1. Dietary Fiber
2. Reduction of dietary fat
3. Calcium rich diet
4. Diet high in antioxidant fruits/vegetables (folic acid)
5. ASA/NSAIDs
6. COX-2 Inhibitors, Celecoxib 400mg BID in FAP reduces polyp number significantly

Front 10

How do COX-2 inhibitors help prevent colorectal cancer?

Back 10

COX inhibition decreases COX-2 mediated free radical formation and probably inhibits growth factor synthesis in response to tumor promotors.

Front 11

Describe Secondary Prevention for Colorectal Cancer

Back 11

Polypectomy via conoloscopy or total colectomy for FAP or high risk patients.

Front 12

Describe some techniques for screening/dx of colorectal cancer

Back 12

1. Fecal occult blood test
2. Digital Rectal Screening
3. Sigmoidoscopy (rigid vs flexible)
4. Colonoscopy
5. Barium Enema
6. Serum markers (CEA, CA19-9)

Front 13

What are some important points about the Fecal occult blood test?

Back 13

Has a high false negative rate, decreases mortality by one third and increased sensitivity/specificity when used in combination with other methods.

Front 14

Describe screening guidelines for average risk patients

Back 14

1.Annual DRE + FOBT after age 50 years.
2.Sigmoidoscopy q 5 years
3.Colonoscopy q 10 years
4.Barium enema q 5-10years

Front 15

When does screening begin for patients with a family history of colorectal cancer?

Back 15

35-40 years

Front 16

When does screening begin for patients with HNPCC?

Back 16

30 yo

Front 17

When does screening begin for patients with FAP?

Back 17

12 yo

Front 18

What Signs/Sx would exist for early stage colorectal disease?

Back 18

Asx, Abdominal pain, Changes in bowel habits, flatulence, blood in stool, anemia

Front 19

Describe Signs/Sx of Left sided colon (descending) Late stage disease

Back 19

Constipation, abdominal pain, obstructive Sx (NV)

Front 20

Describe Sign/Sx of Right sided colon (ascending) late stage disease?

Back 20

Vague abdominal aching, anemia (Elderly, Fe deficiency), Weakness, Weight loss

Front 21

Use for surgery for Colorectal cancer

Back 21

Treatment of choice for primary tumor removal and for debulking in metastatic disease

Front 22

Describe surgery for colorectal cancer

Back 22

Complete resection of tumor and regional lymphadenectomy. <1/3 require permanent colostomy but temporary may be used.

Front 23

What are some complications of colorectal cancer surgery?

Back 23

Infection, bowel obstruction, anastmotic leakage, incontinence, impotence, locoregional recurrence.

Front 24

For what type of colorectal cancer is radiation predominantly used?

Back 24

Rectal, not colon

Front 25

What are the acute effects of radiation?

Back 25

Bone marrow suppression, dysuria, diarrhea, abdominal cramping and proctitis

Front 26

What are the acute effects of rectal irradiation?

Back 26

Bone marrow suppression, dysuria, diarrhea, abdominal cramping and proctitis

Front 27

What are the chronic effects of rectal irradiation?

Back 27

Persistent diarrhea, proctitis, enteritis, small bowel obstruction, perineal tenderness and impaired wound healing

Front 28

What enzyme affects metabolism and toxicity of 5-FU?

Back 28

Dihydropyrimidine dehydrogenase. Deficiency will result in severe toxicity

Front 29

Describe the impact a person with Dihydropyrimidine dehydrogenase will have on their chemo therapy for cholorectal cancer?

Back 29

It will result in severe 5-FU toxicity since this enzyme is responsible for its metabolism.

Front 30

IV Bolus/Push 5-FU is associated with __________.

Back 30

Neutropenia (Jen, this doesn't contradict Stockwell's notes)

Front 31

IV Infusion of 5-FU is associated with _______________.

Back 31

Hand-foot syndrome and stomatitis.

Front 32

What is another name for hand-foot syndrome?

Back 32

Palmar-plantar erythrodysthesia

Front 33

Why is leucovorin used with 5-FU?

Back 33

to stabilize the fdUMP and TS complex resulting in greater cytotoxicity of 5-FU

Front 34

What are the 1st line agent for Colorectal cancer chemo-wise?

Back 34

5-FU and leucovorin + Irinotecan

Front 35

Describe the overall dosing pattern of 5-FU/Leucovorin in terms of Colorectal cancer

Back 35

5-FU bolus x 5 days every four weeks with low or high dose leucovorin

Front 36

Describe the Mayo Clinic regimen for 5-FU/Leucovorin for colorectal cancer.

Back 36

5-FU 425mg/m2 IVP + Leucovorin 20mg/m2 IVP weekly

Front 37

Describe the Roswell Park regimen for 5-FU/Leucovorin for colorectal cancer.

Back 37

Leucovorin 500mg/m2 over 2 hours + 5-FU 500mg/m2 IVP given at midpoint of infusion weekly.

Front 38

Describe how Capecitabine/Xeloda is similar to 5-FU

Back 38

It is an oral prodrug that requires three enzymatic steps for activation.

Front 39

Describe Capecitabine dosing

Back 39

1250mg/m2 BID for 14 days then 1 week rest for 8 cycles.

Front 40

Predominant toxicity associated with Capecitabine/Xeloda

Back 40

Hand-foot syndrome/Stomatitis

Front 41

IFL

Back 41

Irinotecan, 5-FU, Leucovorin (Bolus)
1st line regimen

Front 42

FOLFIRI

Back 42

Irino, infusion of 5-fu/Leucovorin
1st line regimen

Front 43

FOLFOX

Back 43

Oxaliplat, infusion FU/LEUC
1st/2nd line regimen

Front 44

IV FU/Bevacizumab, regimen line?

Back 44

Also a 1 st line regimen

Front 45

Indication for Irinotecan/Cetuximab

Back 45

Refractory disease

Front 46

How (regimen-wise) is Oxaliplatin used for colorectal cancer?

Back 46

It is used incombinations such as FOLFOX and sequentially in metastatic disease

Front 47

What is the dose limiting side effect of Oxaliplatin

Back 47

Peripheral neuropathy. Temperature sensitive dysethesia occurs, usually with cold

Front 48

Describe what test must be done before administering Irinotecan and its ramifications.

Back 48

Must detect UGT1A1 deficiency. To do this give rifampin 900mg, measure bilirubin 4 hours later, if >1.8--> deficiency.

Front 49

Those with UGT1A1 deficiency will experience what toxicities from Irinotecan

Back 49

Diarrhea, mucositis, hemat. tox

Front 50

Can you still use Irinotecan in patients with UGT1A1 deficiency?

Back 50

Yes, simply reduce the dose by 20%

Front 51

What are the dose limiting side effects associated with Irinotecan?

Back 51

Diarrhea/Stomatitis. Remember the acute/delayed Tx for Diarrhea... early would be atropine later will be loperamide.

Front 52

Irinotecan is typically used in the ___________ regimen or the ___________ regimen.

Back 52

FOLFIRI --> FU/Leuc Infusion + Irinotecan
IFL can use as well, Bolus FU/Leuc + Irinotecan

Front 53

Two major treatment categories for METASTATIC colorectal cancer

Back 53

Surgery + Chemotherapy

Front 54

What organ is typically affected by metastatic colorectal disease. Hint: Not the colon or rectum...

Back 54

Liver, thus resection of isolated hepatic metastases can improve survival but no cure.

Front 55

2 Major Chemotherapy agents used for Metastatic colorectal cancer.

Back 55

Bevacizumab/Avastin or Cetxuimab

Front 56

Describe MOA of Bevacizumab

Back 56

MAB directed at VEGF. Can be combined with FOLFOX or FOLFIRI

Front 57

Regimens containing which agent are bumped to second line?

Back 57

Oxaliplatin

Front 58

ADR associated with Bevacizumab

Back 58

Gastric perforation, hemorrhage, arterial thromboembolic disease, HTN, asthenia, pain and proteinuria.

Front 59

What regimens can bevacizumab be used with?

Back 59

FOLFIRI or FOLFOX

Front 60

Of all those wonderful regimen abbreviations, which one is the only BOLUS one...?

Back 60

IFL, the shorter name!

Front 61

Cetuximab MOA

Back 61

MAB directed at EGFR.

Front 62

According to Shane Scott, what do you need to premedicate cetuximab patients with?

Back 62

Diphenhydramine