• Age > 50
• Polyps
• Family history (colorectal cancer syndromes, polyps)
• Geography
• Diet
• Inflammatory Bowel Disease
• Previous colorectal cancer or pelvic irradiation
• Obesity
• Smoking EtOH
• Previous Non-Cancer Surgery?

• Hundreds to Thousands of tiny adenomatous polyps, evident by age 25
• 3x more common in women
• Autosomal dominant
• Adenomatous Polyposis Coli gene on chromosome #5
• Total colectomy recommended

• Also called Lynch syndrome
• Type 1=no extracolonioc involvement
• Type 2=extracolonic malignancies including ovary, breast, uterus, stomach, or bile duct
• Autosomal dominant -- mismatch repair gene mutations
• Right sided cancers
• Early age of onset
• Should be screened for other malignancies

• Aspirin/NSAID use
• HRT in women
• MVI w/ folic acid
• Ca2+ supplements
• High fiber diet

• Early tumors may be asymptomatic
• General signs -- rectal bleeding, abdominal pain, change in bowel habits, abdominal distention

• Less symptomatic
• Ulcerative lesions can result in blood loss --> anemia

• Hematochezia
• Sense of incomplete evacuation
• Painful defecation
• Narrowing of stool shape

• Complete history and physical exam
• Endoscopy, barium enema
• CBC
• Blood chemistry
• LFTs
• CEA (tumor marker) -- nl < 2.5 ng/mL
• Chest X-ray
• Abdominal CT scan

Beginning at age 50 for men and women, the following tests should be performed:

• Sigmoidoscopy every 5 yrs
• Double-contrast barium enema every 5 yrs
• CT colonoscopy (virtual colonoscopy) every 5 yrs
• Colonoscopy every 10 yrs
• Yearly fecal occult blood tests -- however, does not find polyps

• FH of colorectal cancer in first degree relative < 60 yrs old or 2 or more first degree relatives any age -- colonoscopy every 10 yrs starting at 40
• FAP: should have colectomy (no screening)
• HNPCC: colonoscopy every 1-2 yrs from 21-40 then annually thereafter
• IBDs (including UC and Crohn's): colonoscopy yearly

• Repeat screening is more stringnent
• Colonoscopy in 3-6 yrs -- if normal, go back to regular schedule

• Red meat
• Turnips, broccoli, cauliflower, and radishes
• Iron supplementation
• Rectal penetration (of ANY sort)

Surgery

• resection of primary tumor and regional mesenteric lymph nodes
• Surgery results in a partial colectomy
• Patients frequently will require colostomy bag

• Surgery THEN Adjuvant Chemotherapy
• 5-FU/Leucovorin for 6 months

Locally Advanced Disease

• Surgery THEN Adjuvant Chemotherapy
• FOLFOX-4 for 6 months

NOT CURATIVE

• Surgery (palliation)
• Chemotherapy + Bevacizumab

FOLFOX-4 + bevacizumab

OR

FOLFIRI + bevacizumab

• Liver mets --> systemic chemo + hepatic artery infusion of floxuridine

Quick

Hypersensitivity

Short Term

• NV
• Myelosuppression
• Alopecia
• Hand-foot syndrome
• Stomatitis
• Diarrhea

Quick

Hypersensitivity

Short Term

• NV
• Myelosuppression
• Alopecia
• Hand-foot syndrome
• Stomatitis
• Diarrhea
• Neuropathies -- oxaliplatin

Quick

Hypersensitivity

Short Term

• NVD
• Myelosuppression
• Alopecia
• Hand-foot syndrome
• Stomatitis
• Neuropathies
• VTEs
• Bowel perforation
• Proteinuria

Quick

Hypersensitivity

Short Term

• NV
• DIARRHEA
• Myelosuppression
• Alopecia
• Hand-foot syndrome
• Stomatitis
• VTEs
• Bowel perforation
• Proteinuria

Surgery

• resection of primary tumor and regional mesenteric lymph nodes
• Surgery results in a partial colectomy
• Patients frequently will require colostomy bag

• Surgery THEN:
• Adjuvant XRT with continuous infusion 5-FU THEN:
• Chemotherapy with 5-FU/Leucovorin

• Neoadjuvant XRT with 5-FU THEN
• Surgery THEN
• Adjuvant chemo for 6 months with FOLFOX-4

NOT CURATIVE

• Surgery
• Radiation
• Chemoterapy:

FOLFOX-4 + Bevacizumab

OR

FOLFIRI + Bevacizumab

• Liver mets --> surgery + chemo + hepatic artery infusion of floxuridine

• History and Physical every 3 months for 2 yrs, then every 6 months for total of 5 yrs
• CEA every 3 months for 2 yrs then every 6 months for 2-5 yrs
• Colonoscopy one year after treatment, repeat in 3 yrs, then every 5 year schedule

Combo Therapy

• FOLFOX or FOLFIRI with bevacizumab
• CAPOX (capecitabine + oxaliplatin)
• IROX (irinotecan + oxaliplatin)
• Cetuximab + irinotecan

Single Agent

• Capecitabine
• Irinotecan
• Cetuximab