Colorectal Cancer Flashcards
What are risk factors of colorectal cancer?
- PHM of polyps
- IBD
- Family history
- Smoking
- Heavy alcohol use (folic acid stores)
- Physical inactivity
- Genetic predisposition
How many patients with FAP will develop CRC by their early 40’s if left untreated?
100%
Which condition is caused by mutations in DNA mismatch repair?
Hereditary non-polyposis colorectal cancer or Lynch Syndrome
What are risk factors for colorectal cancer?
- Low socioeconomic status
- Age
- Race (black, native)
What are S/S of colorectal cancer?
- Blood in stool
- Change in bowels
- Fatigue
- N/V
What are prevention strategies for colorectal cancer?
- Fiber supplementation
- Dietary fat reduction
- COX2 inhibitors?
What is the gold standard for diagnosis of CRC?
Colonoscopy
Which enzyme do we need to pay attention to before giving 5-FU?
DPD - deficient patients are at higher risk for toxicities
How can we reduce side effects of 5-FU?
Slow infusion over 46 hours
What are considerations of capecitabine that 5-FU does not have?
- Hyperbilirubinemia
- Diarrhea
- Hand-foot syndrome
- Renal dose adjustment
- Can be a radiosensitizer
Which drugs are contraindicated in DPD deficiency?
- 5-FU
- Capecitabine
What are side effects of oxaliplatin?
- Peripheral neuropathy (cumulative dosing)
- Cold intolerance/sensitivity
- Myelosuppression
What are the main side effects of irinotecan?
- Diarrhea*
- Fatigue
- Alopecia
- Myelosuppression/neutropenia
How do you treat the acute (<24h) phase of irinotecan diarrhea?
Atropine
How do you treat the chronic phase of irinotecan diarrhea?
Loperamide
What is the first line targeted adjuvant with chemotherapy for CLC?
Bevacizumab
What are precautions for bevacizumab?
- Contraindicated in uncontrolled HTN
- Avoid <4 weeks of surgery (delayed wound healing)
- Proteinuria
- Hemorrhage
- VTE
What adjuvant VEGFR2 inhibitor can we use with FOLFIRI for refractory disease?
Ramucirumab
Patients must be KRAS _____ in order to use EGFR inhibitors
Wild-type (no mutation)
Which EGFR inhibitor has a lower chance of infusion reactions?
Panitumumab (fully humanized) < cetuximab
How can we prevent skin reactions on EGFR inhibitors?
- Limit sun exposure, use sunscreen
- Avoid over-drying the skin
- Moisturize skin
- Avoid OTC acne products
How can we treat EGFRi rashes?
Steroids and antibiotics
When do we consider holding or discontinuing EGFR inhibitors?
Grade 3 rash (hold)
Grade 4 rash (D/C)
What is the BBW for the last-line CRC therapy, regorafenib?
Hepatotoxicity
What can we use for HER2 expression in CRC?
Trastuzumab based therapies
What is the later-line chemotherapy treatment for CRC that causes major myelosuppression?
Trifluridine + Tipiracil
When can we use immunotherapy for CRC?
MSI-H tumors, typically stage IV
What are the immunotherapy agents we use for CRC?
Pembrolizumab and nivolumab
Which treatment do we use for the BRAF mutation?
Cetuximab + Encorafenib
What is the general first-line treatment for CRC?
Surgery
How do we treat stage 2 CRC requiring adjuvant chemo?
- Single agent capecitabine*
- 5-FU/leucovorin
High risk: - FOLFOX
- CapeOx
What do we give for low risk stage 3 CRC?
3 months CapeOx*
What do we give for high risk stage 3 CRC?
- FOLFOX 6 months
- CapeOx 3-6 months
When can we consider surgery in metastatic patients?
- Resectable liver-only or lung-only metastases
After chemo
What is first-line for unresectable metastatic CRC?
FOLFOX + bevacizumab
