Johns Hopkins Colon Cancer Whitepaper

J O H N S H O P K I N S M E D I C I N E B A L T I M O R E , M A R Y L A N D T H E J O H N S H O P K I N S W H I T E P A P E R S 2 0 0 8 C O L O N C A N C E R Ross C. Donehower, M.D., F.A.C.P. http://www.johnshopkinshealthalerts.com/white_papers/colon_cancer_wp/digital08_landing.html?st=link&s=DCW_080101_001 Ross C. Donehower, M.D., F.A.C.P. Virginia and D.K. Ludwig Professor in Clinical Investigation of Cancer Director, Division of Medical Oncology Johns Hopkins University School of Medicine P. S. Don’t forget to visit www.HopkinsColonCancer.com for the latest news on colon cancer and other information that will complement your Johns Hopkins White Paper. Dear Reader: Welcome to the 2008 Colon Cancer White Paper—your Johns Hopkins guide to the preventtion diagnosis, andmanagement of colon and rectal cancers. This year’s highlights include: • Action plan for handling the emotional aftershocks of a colorectal cancer diagnosis. (page 6) • Beyond colonoscopy: Promising new state-of-the-art screening tests for colorectal cancer. (page 10) • Should you be concerned about coffee and colon cancer? (page 13) • How soon should you get a colonoscopy after polyp removal? (page 17) • New research reveals what factors make one colonoscopy more effective than another. (page 20) • Does everyone need regular colonoscopies after age 50, or is there a point when you can safely stop? (page 24) • Can you be “too old” for colorectal cancer surgery? How to improve the outcome in your 70s, 80s, and beyond. (page 34) • Can massage and acupuncture relieve pain after colon cancer surgery? (page 37) • Coping strategies for “chemo brain,” the mental fuzziness after chemotherapy. (page 52) • Focus on your diet to help keep polyps and colon cancer from returning. (page 58) • Seven key strategies for preventing a recurrence of colorectal cancer. (page 64) You’ll also find a new “Ask the Doctor” column on pages 29, 33, 49, 61, and 63. This year’s questions came from my patients, but next year I’d like to answer a few of yours. If you have any colorectal cancer-related queries you want answered in the White Papers or comments about the White Papers in general, please e-mail the editors at whitepapers@johnshopkinshealthalerts.com. Wishing you the best of health in 2008, http://www.johnshopkinshealthalerts.com/white_papers/colon_cancer_wp/digital08_landing.html?st=link&s=DCW_080101_001 Ross C. Donehower, M.D., F.A.C.P., is Director of the Division of Medical Oncoloog and the Medical Oncology Fellowship Training Program at the Johns Hopkiin University School of Medicine and the Sidney Kimmel Comprehensive Cancce Center. He is a Professor of Medicine and Oncology and the Virginia and D.K. Ludwig Professor in Clinical Investigation of Cancer at that institution. His professional activities have included membership on the American Board of Internal Medicine Medical Oncology Examination Committee and several positions with the American Society of Clinical Oncology, including the board of directors and chairmanship of the grant awards committee and the scientific progrra committee for the national meeting. Dr. Donehower is a graduate of the University of Minnesota Medical School. He completed his internal medicine training at Johns Hopkins and his medical oncology training at the National Cancer Institute. He has been on the faculty at Johns Hopkins since 1980. His research and clinical activities relate to gastrointesttina malignancies and the development of new anticancer therapies. T H E A U T HOR http://www.johnshopkinshealthalerts.com/white_papers/colon_cancer_wp/digital08_landing.html?st=link&s=DCW_080101_001 CON T E N T S What Is Colorectal Cancer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 The Gastrointestinal Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 How Colorectal Cancer Begins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Screening and Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Diagnosis and Pretreatment Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 Issues Immediately After Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 Treatment Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 Treatment of Colon Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 Treatment of Rectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45 Advanced, Recurrent, or Metastatic Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . .50 Treating Metastasized or Recurrent Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Living With Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 Follow-Up and Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 Chart: Screening and Diagnostic Tests by Risk Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Chart: Staging Systems for Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Chart: Common Chemotherapy Drugs for Colorectal Cancer . . . . . . . . . . . . . . . . . . . . .42 Chart: Colorectal Cancer Chemotherapy Regimens . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 Health Information Organizations and Support Groups . . . . . . . . . . . . . . . . . . . . . . . . .70 Leading Hospitals for Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72 http://www.johnshopkinshealthalerts.com/white_papers/colon_cancer_wp/digital08_landing.html?st=link&s=DCW_080101_001 1 COLON CANCER Although colon cancer is a more familiar term, doctors commonly refer to cancer that arises in the large intestine as colorectal cancer, a term that includes cancers of both the colon and the rectum. The American Cancer Society ranks colorectal cancer as the third most common cause of cancer (excluding skin cancer) and the second leading cause of cancer-related deaths among both men and women in the United States. Yet when diagnosed and treated in the early stages, it is among the most curable of all cancers. The five-year survival rate for people whose colon or rectal cancer is discovered and treated in the early stages is more than 90%. In some cases, regular screening reveals precancerous growths that can be removed, thereby preventing cancce from developing in the first place. This White Paper discusses the way colorectal cancer develops, how it can be detected early, and how you can reduce your risk. It will also describe new developments in screening, diagnosis, treatmeen options, and research, and ways in which people who have already been treated for colon cancer can lower their risk of having a recurrence.What Is Colorectal Cancer? Colorectal cancer occurs all over the world, with the highest rates in industrialized countries such as the United States, Canada, Australia, New Zealand, and the nations of western Europe. About 5% of the U.S. population will develop colorectal cancer. The lowest rates are found in developing countries in Africa and Asia. In the United States, the death rate from colorectal cancer has been declining steadily over the past 20 years. Today, there are more than one million colorectal cancer survivors in the United States alone. A major factor has been greater use of improved screening tests to detect cancer early, when it is treated best—and an increase in the number of people willing to have these tests, especially colonoscopy. Perhaps 80–90% of colorectal cancers could be prevented if everyoon were screened and polyps identified and removed. http://www.johnshopkinshealthalerts.com/white_papers/colon_cancer_wp/digital08_landing.html?st=link&s=DCW_080101_001 2 2 0 0 8 H o p k i n s C o l o n C a n c e r . c o m § Many Reasons for Optimism Colon cancer screening did not appear often in the news before the year 2000, when television personality Katie Couric had a colonoscoop that was broadcast on national television. Couric’s husband, Jay Monahan, died of advanced colon cancer two years earlier, at the age of 42. After Couric publicized the importance of screening for early detection, colonoscopy rates rose by 20%. Many improved treatments have also contributed to better surviiva and cure rates. Precancerous polyps and even small cancerous polyps can be removed during a colonoscopy. Cancers may be remoove with laparoscopic surgery, which requires only a few small incisions rather than one very large abdominal incision. Cancers that have moved beyond the very early stage may be treated with a combination of surgery and chemotherapy to reduce the chance of recurrence. Presurgical radiation may shrink some rectal cancers, allowing the surgeon to perform a less radical operatiion Colorectal cancer that has metastasized (spread to other organs) or that comes back (recurs) locally is more serious. Yet even in these cases, there are newer treatments, such as bevacizzuma (Avastin), which can starve tumors of their blood supply. And techniques such as radiofrequency ablation (RFA) can pinpoint and destroy previously inoperable cancer that has invaded the liver. In the past, some people feared screening because they believed that if colon or rectal cancer were discovered the consequence would be either bowel incontinence or a colostomy. (In a permaneen colostomy, the rectum and anus are removed or bypassed and feces are eliminated through an opening created surgically through the abdomen. Bowel incontinence can result when a cancer that occurs low in the rectum or anus invades the sphincter muscles.) Today, those concerns are less of an issue. Advances in surgical techniques and preoperative radiation have greatly decreased the need for colostomy. Newer imaging techniques such as rectal ultrasooun can localize cancers in the rectum or anus precisely, so that surgeons can operate more carefully and preserve muscle function. There is no question that colorectal cancer is a serious conditiion But it is important to remember that there are treatment optiion at all stages. How Does Colorectal Cancer Develop? Because colorectal cancer may arise anywhere in the large intestine, cancers of the colon and the rectum are discussed together in the next few sections; but the treatment sections discuss themseparately. http://www.johnshopkinshealthalerts.com/white_papers/colon_cancer_wp/digital08_landing.html?st=link&s=DCW_080101_001 3 C O L O N C A N C E R 2 0 0 8 § Your colon, or large intestine, is the last stop in the digestion process. The primary function of the colon is to absorb water. The rectum is a 5-to 10-inch canal at the end of the colon, where a ring of muscles holds undigested material in place before it is expelled. The anatomy of your colon. Shaped like an upside-down letter “U”, the large intestine is made up of six sections: • The cecum, a small pouch about 2–3 inches long, located where the small intestine joins the colon • The ascending colon, or right colon, which rises from the cecum up along the right side of the abdomen and makes a left turn at the hepatic flexure • The transverse colon, which crosses the abdomen toward your left, and turns downward at the splenic flexure • The descending colon, or left colon, which goes down the left side of your abdomen • The short sigmoid colon, which looks like the lettte “S” • The rectum, where feces are stored before being expelled, and the anus, the opening at the end of the rectum. How polyps become cancerous. The insets show: (1) the appearance of a normal colon during a colonoscopy; (2) a section of colon containing a polyp; and (3) a malignant cancer. Polyps, which are benign (not cancerous), establiis themselves in the upper (mucosal) layer of the colon and might not invade the underlying muscle or deeper layers of the wall of the colon. Malignant cancers penetrate the wall of the intestine. In advanced cancers, some tumor cells enter the bloodstream and have established secondary canceer elsewhere in the body. The Colon and Rectum: From Healthy to Cancer transverse colon stomach normal colon Parts of the colon Views during colonoscopy benign polyp adenocarcinoma splenic flexure descending colon sigmoid colon rectum hepatic flexure ascending colon small intestine cecum appendix http://www.johnshopkinshealthalerts.com/white_papers/colon_cancer_wp/digital08_landing.html?st=link&s=DCW_080101_001 Copyright © 2008 Medletter Associates, LLC. All rights reserved. No part of this White Paper may be reproduced or transmitted in any form or by any means electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Please address inquiries on bulk subscriptions and permission to reproduce selections from this White Paper to Medletter Associates, LLC, 6 Trowbridge Drive, Bethel, CT 06801. The editors are interested in receiving your comments at whitepapers@johnshopkinshealthalerts.com or the above address but regret that they cannot answer letters of any sort personally. ISBN 978-1-933087-59-7 1-933087-59-5 Printed in the United States of America The information contained in this White Paper is not intended as a substitute for the advice of a physician. Readers who suspect they may have specific medical problems should consult a physician about any suggestions made. 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