March is National Colorectal Cancer Awareness Month. Dr. Benjamin Weinberg discusses the importance of increasing public awareness of this disease and encouraging people to reduce their risk of colorectal cancer through screening- earlier and often.
4 Things That Reduce the Risk of CRC
Dr. John Marshall discusses the four major factors that can reduce the risk of developing colon cancer, as well as subsequently reducing the risk of cancer recurrence. A daily regimen including a dose of aspirin, exercise, moderate sun exposure to improve endogenous vitamin D production, and introducing more tree nuts into meals, like almonds and cashews, can reduce both incidence and recurrence of colon cancer.
Rise in Young Onset Colorectal Cancer
Since the mid-90’s, there has been a rise in young patients getting colorectal cancer. Even more recently, we’ve seen death rates in patients under the age of 50 rise. There is no clear understanding of why this is happening. Theories such as diabetes and obesity are potential causes. At Georgetown, research is looking at microbiomes and seeing if there is any correlation.
Tumor Sidedness
Cancers from the colon and rectum can behave very differently. Interestingly, we’re seeing differences with cancers from the left and right side of the colon and are treating these differently. Studies are showing that certain drugs have more effect on cancers depending on what side of the colon they are located.
Colon Cancer & Genetic Testing
Dr. John Marshall explains why genetic testing of colon cancer cells is necessary to determine what variant of colon cancer you have, and how testing will ultimately define the best treatment plan for you as a patient. Mutations of the RAS, HER-2, and BRAF genes require different approaches to treat. Microsatellite instability (MSI) and what side your tumor is on are also important factors that can change what medications your doctor adds or removes from a regimen.
Colorectal Cancer Treatment
Immunotherapy and Colorectal Cancer
Bevacizumab is an anti-VEGF treatment (sometimes called Avastin) given to some patients with advanced colon cancer. It helps block the formation of new blood vessels making it more challenging for cancer cells to migrate throughout the body.
Bevacizumab is an anti-VEGF treatment (sometimes called Avastin) given to some patients with advanced colon cancer. It helps block the formation of new blood vessels making it more challenging for cancer cells to migrate throughout the body.
Side Effects of Bevacizumab
Avastin® (Bevacizumab) is a biolgic cancer drug that binds two growth factors in your body to prevent new blood vessels from forming. Some of the major side effects are vascular, including high blood pressure, nose bleeds, and rarely stroke and heart attack. Bowel perforation is also a possible serious side effect.
Dosing of Capecitabine (Xeloda)
Dosing of Xeloda can have variations that may be more beneficial to different patients. It’s important to consider the right approach for you with your medical team.
Side Effects of Capecitabine (Xeloda)
Xeloda is the pill version of 5-FU and you take it twice a day. A single dose has no side effects, but over time, side effects like hand and foot peeling, diarrhea, fatigue, sensitivity to sun and on rare occasions heart damage can be present.
Cetuximab or Panitumumab
Dr. John Marshall discusses the treatment and potential side effects of Cetuximab and Panitumumab, two chemotherapy drugs used to treat the small subset of colon cancer patients with tumors of the left side of the colon. Cetuximab and Panitumumab may cause adverse skin reactions, however these can be reduced with a regimen of sun avoidance and sunblock, skin moisturizers, hydrocortisone cream, and in certain cases an oral antibiotic may be recommended.
5-FU Infusion
5-FU is a chemotherapy drug that is administered in two ways; either through a mediport which can be done at home or you can get 5-FU with bolus using an IV. Bolus is less common and may have additional side effects.
FOLFOX / XELOX Side Effects
Front line therapy for respected colon cancer or colon cancer that has spread to other parts of the body is often treated with FOLFOX or CAPOX. The 5-FU (a fluoropyrimidine drug) often has various side effects, such as nausea, vomiting, diarrhea, and low blood counts. Oxaliplatin can cause cold hypersensitivity, neuropathy, extravasation, and allergic reactions. It is advised to limit cumulative exposure to oxaliplatin.
Side Effects of Irinotecan
Irinotecan (Camptosar) is a drug commonly used to treat GI Cancers that is administered by IV (often a mediport). This drug can cause some hair loss, tiredness, lower blood counts, and possibly diarrhea.
Dosing and Side Effects of Lonsurf
Lonsurf (trifluridine and tipiracil) is a drug treatment option for 3rd line Metastatic Colon Cancer. This is pill therapy often used when the disease progresses after chemotherapy and other treatments. There are notable side effects such as low white blood cell count. It can also cause nasuea, vomiting, diarrhea, decreased appetite, and abdominal pain.
Side Effects of Oxaliplatin
Oxaliplatin is a common chemotherapy drug often administered via a mediport. Side effects include nausea, possible lower blood counts, and sensitivity to cold things (touch and drinking). Over many cycles of the medicine, you may have nerve sensitivity.
Dosing of STIVARGA
Recently, doctors are considering a new dosing strategy for STIVARGA® (Regorafenib). The ReDOS (Bekaii-Saab) Trial suggests starting with a lower dose and appears to be having a positive impact for some patients.
Side Effects of STIVARGA
STIVARGA (Regorafenib) can have some serious side effects. Minimize the side effects by taking pills after a meal, using Urea cream, having regular blood tests, and meeting with your team regularly.
Side Effects of Liver Directed Therapies – CRC
Post-embolization syndrome can result from liver-directed therapy. It can cause fever, nausea, vomiting and right upper quadrant pain. Usually, these side effects can be managed at home.
Frontline Treatments Metastatic Colon Cancer
The most important base medication is called 5FU (Fluorouracil), a drug that can be taken by either an IV drip or pill form. Two additional chemotherapy medications are later added; oxaliplatin and irinotecan. Although Oxaliplatin and Irinotecan are beneficial to patients, they may introduce symptoms of neuropathy, hair loss, diarrhea, and nausea. Avastin (bevacizumab) is usually the third and last medication added to a treatment regimen for colorectal cancer patients, and works by cutting off blood supply to cancerous tumors. In cases depending on specific genetics, a fourth medication may be added if your doctor thinks it would benefit your treatment.
Second Line and Later Therapies – mCRC
Dr. Ben Weinberg discusses second and later line treatment for Metastatic Colorectal Cancer. Common treatment for 1st and 2nd line is FOLFOX — FOLFIRI, but with a deeper understanding of where the tumor or a patient’s genetic markers may indicate the need for other treatments (e.g. bevacizumab). For 3rd line treatments, trifluridine/tipiracil and Regorafenib are sometimes used.
Patient’s response to the drug Pembrolizumab.
One of the newest things that’s come out of the GI cancer world in the last year or so, is that for the rare subset of patients that have microsatellite instability, high metastatic colorectal cancer, which has only about 4% of patients with advanced colorectal cancer, they seem to benefit much more from immunotherapy than traditional chemotherapy.
Immunotherapies and GI Cancer
Building on the data from Keynote 1-77, which showed that immunotherapy with an anti PD one monoclonal antibody, Pembrolizumab was superior to standard of choice or standard of care chemotherapy.
Maintenance Therapy for Chemotherapy
Your doctor may have recommend something called maintenance therapy, which is nothing to be nervous about, and can be a good sign that a less aggressive treatment approach is needed to maintain progress. Three drugs are typically used in maintenance therapy for colon cancer: 5-FU, Oxaliplatin, Irinotecan, and sometimes Avastin. In an effort to reduce negative symptoms and improve quality of life, your doctor may only use two medications instead of three.
Circulating Tumor DNA (ctDNA) and liquid biopsy
One of the questions we ask is if patients should get chemotherapy, how much chemotherapy and for how long? Newer technologies are hoping to answer this question, and one of them is circulating tumor DNA. This is a test of what we call minimal residual disease. Can we detect the presence of cancer after a curative surgery when it shouldn’t be there?
Disclaimer: These videos are produced and broadcast by the Ruesch Center for the Cure of GI Cancers solely for educational purposes. The information included in it is not intended to replace the advice and recommendations of your healthcare team. Medicine is an ever-changing field; the dose and method of administration for any administered drug should be confirmed before use. These videos are not intended to recommend any measures, techniques, procedures or products, or give advice, and is not a substitute for medical training or your own clinical judgment as a healthcare professional.
