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COLORECTAL CANCER
| Question | Answer | |||
|---|---|---|---|---|
| CRC Risk factors | - age -gender -race/ethnicity - genetic predisposition (FAP/HNPCC) - ulcerative colitis -diabetes - polyps - sedentary lifestyle - overweight - high fat low fiber diet - moderate to heavy use of alc | |||
| Prevention of colon cancer | - diet - smoking cessation recommended - physical activity - colectomy (removal of colon) - ASA, NSAIDs, COX2 inhibitors | |||
| Screening for CRC | GOLD STANDARD: ≥45 y/o = colonoscopy Q 10 years Other options: - CT colonography q 5 yrs - Flex sig q 5-10 yrs | STOOL BASED TESTING FIT: yearly FOBT (fecal occult blood testing): yearly Multi-targeted Stool DNA: Q3 yr | ||
| FECAL OCCULT BLOOD TESTING | AVOID FALSE POSITIVES: - no red meat and veggies with peri-oxidase activity x 3 days - Avoid iron products x 3 days - Avoid NSAIDs x 7 days | AVOID FALSE NEGATIVES: - avoid Vit C x 3 days - Avoid testing dehydrated samples | ||
| SCREENING FOR HIGH RISK | FAM HX: screening at 40 or 10 years before family member was dx HNPCC: screening at 30 FAP: screening at age 10-12 Ulcerative colitis: Screening as early as 8 years after onset | |||
| CLINICAL PRESENTATION of CRC | EARLY: no s/sx LATE: pencil like stools blood in stool anorexia/weight loss ab pain weakness | |||
| TYPES OF COLON POLYPS | Flat - sessile "look like hill" - Pedunculated "look like mushroom" | |||
| CRC WORKUP | 1. confirm dx: biopsy, CBC & labs, CEA level, CT chest 2. Test for MMR/MS: If dMMR/MSI-H = MMR def and MS instable ; if pMMR/MSS = proficient in MMR and MS stable 3. if mets test for: BRAF, V600E, KRAS, NRAS | |||
| CRC STAGE + TREATMENT | STAGE I & II: SURGERY STAGE III LN+: SURGEY, XRT, CHEMO STAGE IV: MAYBE SURGERY, DEF CHEMO | |||
| TREATMENT OF EARLY STAGE COLON CANCER | STAGE I = OBSERVATION | STAGE II = OBSERVATION or consider 5FU/Leucovorin or capecitabine or FOLFOX or CAPEOX for 3-6 mos | STAGE III= pMMR/MMS = FOLFOX or CAPEOX 3-6 mos ; if dMMR/MSI-H treat with FOLFOXor CAPEOX + Atezolizumab for 3-6 mos then just Atezolizumab | If PIK3CA mutation ADD ASPIRIN 100-162 mg PO daily for 3 years |
| FOLFOX | folinic acid (leucovorin) Fluorouracil (5-FU) Oxaliplatin | TOXICITIES: diarrhea, mouth sores if SEVERE, early onset toxicities pt might be DPD def | ||
| CAPEOX | Capecitabine Oxaliplatin | TOXICITIES: Hand foot syndrome (palmar-plantar erythrodysesthesia) | COUNSELING: take capeox with food, don't take PPIs (reduces capeox efficacy) | OXALIPLATIN DOSE LIMITING TOX: SENSORY NEUROPATHY |
| LEUCOVORIN | a rescue agent for MTX toxicity BUT it does INCREASE toxicity of 5-FU since it increases its effectiveness | |||
| METASTATIC CRC | most common site of mets = liver | determine KRAS/NRAS/BRAF and HER2 | ||
| LIVER ONLY OR LUNG ONLY METs | if resectable, localized resection is treatment of choice | other options: chemoembolization and radiation therapy | ||
| Preoperative chemo w/ possible resection | pMMR/MSS = FOLFOX or CapeOx dMMR/MSI-H give neoadjuvant nivolumab + Ipilimumab, pembrolizumab | Reassess every 2 months for resection. Give 6 months of neoadjuvant therapy total. Assess until tumor becomes resectable | ||
| Metastatic Colon Cancer dMMR/MSI-H Treatment 1st line | 1st line: CHECKPOINT INHIBITORS (pick one) 1. nivolumab +/- ipilimumab 2. pembrolizumab 3. dostarlimab | 2nd line: pMMR/MSS treatment (if they progressed while on checkpoint inhibitor) | ||
| Mets CRC pMMR/MSS INTENSIVE 1st line treatment | - FOLFOX +/- bevacizumab - CAPEOX +/- bevacizumab - FOLFIRI +/- bevacizumab -FOLFIRINOX +/- bevacizumab | KRAS/NRAS/BRAF Wild type and left sided tumors only: - FOLFOX + (cetuximab or panitumumab) - CAPEOX +(cetuximab or panitumumab) - FOLFIRI +(cetuximab or panitumumab) | BRAF V600E + - Encorafenib +(cetuximab or panitumumab) + FOLFOX | |
| Mets CRC pMMR/MSS NOT Intensive 1st line treatment | * 5-FU +/- Leucovorin +/- bevacizumab *Capecitabine +/- bevacizumab | KRAS/NRAS?BRAF Wild Type and left sided tumor: Cetuximab or Panitumumab | HER2 amplified and RAS and BRAF wild type: Trastuzumab + (pertuzumab or lapatinib or tucatnib) | |
| Choosing between mAbs | Cetuximab or Panitumumab: KRAS wildtype NRAS wildtype and BRAF wildtype AND left sided tumors ALL have to be present | Bevacizumab: Everyone | ||
| ADRs Fluorouracil | - mouth sores - diarrhea - hand/foot syndrome | DOSE LIMITING: Myelosuppression | ||
| ADRs Oxaliplatin | - neuropathy - N/V - fatigue | DOSE LIMITING: neuropathy | ||
| ADRs Irinotecan | - Early/Late Onset Diarrhea - Alopecia | DOSE LIMITING: Late onset diarrhea | ||
| ADRs Pembrolizumab | - Fatigue - Immune mediated pneumonitis/colitis/hepatitis/endocrinopathies/nephritis/skin disorders | |||
| ADRs Bevacizumab | - Wound dehiscence - Bleeding - VTE | |||
| ADRs Cetuximab/Panitumumab | - Acneiform Rash (means drug is working) | TO PREVENT: moisturize twice daily and minimize sun exposure | EGFR Induced Diarrhea: Loperamide if it doesn't work then Octreotide. If grade 3 or higher diarrhea then consider dose reduction or DC |
Created by:
texantaco