Colon Cancer

Question 1

What is important to know about Colon Cancer?

Answer 1

• 3rd most common cause and death in men and women
• 91% suvival - caught early

Question 2

What are some of the risk factors for Colon Cancer?

Answer 2

• Age
• Family Hx [HNPCC]
• Diet/Lifestyle
• Polyps [FAP]
• Colitis or Crohns

Question 3

What is the reason that Colitis or Crohns may have an impact of Colon Cancer?

Answer 3

• The CONSTANT inflammation

Question 4

What is the importance of polyps within Colon Cancer?

Answer 4

• Familial Adenomatous Polyposis [FAP]
• When there is a lot of polyps = 100% of Colon Cancer

Question 5

What is Hereditary Nonpolyposis Colorectal Cancer [HNPCC]?

Answer 5

• 80% of getting Colon Cancer
• INCREASED risk of getting endometrial, stomach or ovaran cancers too

Question 6

What is the pathophysiology of Colon Cancer?

Answer 6

• Polyps will grow in the membrane [can spread]
• ADENOCARCINOMAS

Question 7

What are some of the warning signs and symptoms of Colon Cancer?

Answer 7

• Constipation or Diarrhea
• Bloody stools
• Tender belly
• Weight loss
• Fatigue

Question 8

What is one work up strategy that is used to help determine the treatment in Colon Cancer?

Answer 8

• DNA Mismatch Repair [dMMR] –> Test for Mircosatellite Instability [MSI]
• MSS, MSI-L, MSI-H, pMMR, dMMR

Question 9

What are the goals of treatment for EARLY stage [I, II, III] Colon Cancer?

Answer 9

• Curable
• Surgery [WANT to do] & Chemo [no Rads - helps pain]

Question 10

Which EARLY stages and MMR of Colon Cancer is Chemo used in?

Answer 10

• Stage II WITH MSI-H: Decreased benefit from Chemo
• Stage III WITH MSI-H: Increase benefit from Chemo

Question 11

What is the localized treatment therapy for EARLY stage Colon Cancer?

Answer 11

• Surgery is the definitive therapy
• Chemo can be used in High risk patients

Question 12

What are the chemo regimens that are used in EARLY stage [II] Colon Cancer/

Answer 12

• FOLFOX
• CapeOX

Question 13

What is FOLFOX?

Answer 13

• 5-FU, Leucovorin, Oxaliplatin

Question 14

What is CapeOX?

Answer 14

• Capectiabine, Oxaliplatin

Question 15

What is the treatment for EARLY Stage [III] Colon Cancer?

Answer 15

• Chemo is indicated [Bevacizumab, Cetuximab, Panitumumab, Irinotecan are ONLY used in Stage IV]

Question 16

What was the trial that gave us the recommendations on Chemotherapy in Colon Cancer?

Answer 16

• IDEA: CapeOX for 3 months was good & FOLFOX for 6 months was good

Question 17

If your a LOW RISK patient in Stage III Colon Cancer was is the preferred treatment?

Answer 17

• CapeOX for 3 months [FOLFOX for 6 months]

Question 18

If your HIGH RISK patient in Stage II Colon Cancer was is the perferred treatment?

Answer 18

• FOLFOX for 6 months [CapeOX for 6 months]

Question 19

What are some fo the main differences between FOLFOX and CapeOX in Colon Cancar?

Answer 19

• FOLFOX: Port, Increased Myelosuppression
• CapeOX: NO Port, Increased Hand Foot syndrome, $$$

Question 20

What are the treatments options that could be used in Metastatic [Stage IV] Colon Cancer?

Answer 20

• Chemo [main]
• Surgery and Rads not really used

Question 21

What is important to remember when starting a patient on Chemo in Metastatic Colon Cancer?

Answer 21

• Co-Morbidities?
• If neuropathy: NO platins
• If UGT1A1 issues: NO tecan

Question 22

When might PD-L1 [Immunotherapy] be used in Metastatic Colon Cancer?

Answer 22

• Used in BOTH Unresectable or Metastatic WITH MSI-H after FOLFOX or FOLFIRI
• Pembrolizumab and Nivolumab

Question 23

What are some of the predictive biomarkers that we should look at for Metastatic Colon Cancer?

Answer 23

• EGFR: dosent matter
• KRAS: Mutation = NO cetuximab or panitumumab
• BRAF: Test all in metastatic

Question 24

What are some of the 1st line treatments that are used in Metastatic Colon Cancer?

Answer 24

• FOLFOX [+/- Bevacizumab or Cetuximab or Pantiumumab]
• CapeOX [+/- Bevacizumab or Cetuximab or Pantiumumab]
• FOLFIRI [+/- Bevacizumab or Cetuximab or Pantiumumab]

Question 25

What is in FOFIRI?

Answer 25

• Irinotecan + Leucovorin + 5-FU

Question 26

When someone can not tolerate Chemo, what is the 1st line treatment in Metastatic Colon Cancer for them?

Answer 26

• Remove the Chemo: 5-FU + Leucovorin

Question 27

What would be the 2nd line treatment for Metastatic Colon Cancer?

Answer 27

• If failed FOLFOX, switch to FOLFIRI and vice versa

Question 28

What is the 3rd line treatment for Metastatic Colon Cancer?

Answer 28

• ORAL agents: Regorafenib or Trifluridine
• LOTS of side effects

Question 29

What is 5-FU?

Answer 29

• converts into FUTP & FdUMP –> binds to thymidylate synthase [TS] and reduces DNA synthesis, replication and repair
• Metabolized by DPD: deficiency in DPD = toxicities [diarrhea, fatigue]

Question 30

What is Leucovorin?

Answer 30

• Used in Combo with 5-FU
• Helps increase the efficacy of 5-FU by acting as a folate = more TS

Question 31

What is Irinotecan?

Answer 31

• Prodrug of SN38 –> Inhibits topo I
• Metabolized by UGT1A1: deficiency in UGT1A1 will increase tocixities –> DIARRHEA [give atropine]

Question 32

What is Oxaliplatin?

Answer 32

• 3rd gen Platinum that inhibits DNA replication via cross-links
• Part of FOLFOX
• COLD INTOLERANCE

Question 33

What is Capecitabine?

Answer 33

• Prodrug of 5-FU
• Hand-Foot syndrome and diarrhea

Question 34

What is Cetuximab & Panitumuab?

Answer 34

• Binds to EGFR
• ONLY used in NORMAL KRAS
• Acne rash and Hypomagnesemia

Question 35

What is Beveacizumab?

Answer 35

• Binds to VEGF and decreases angiogenesis
• Given with FOLFIRI
• BLACKBOX WARNINGS

Question 36

What is Regorafenib?

Answer 36

• Mutli-kinase inhibitor that targets angiogenesis [VEGF, BRAF…]
• Can cause Squamous cell carcinoma
• 3A4