Killing Colon Cancer Cells

Fighting and Killing Colon Cancer Cells Prepared by: Prof. Ped Salvador March 11, 2009

Good News: Survivor Experience

Terry – Colon Cancer • Hearing the words "you have cancer" is bad enough, but after the operation that removed the tumor and part of my colon, I was informed that they also removed a small tumor from my liver, which meant the cancer had metastasized. The oncologist did not look too happy when he told me I was in stage 4. I must have been in total denial because I really didn't believe this was happening to me. I had it all - a good marriage two great kids – a job I liked - good friends and about to become a grandmother. Maybe life was a little too good. The chemotherapy that was selected for my cancer was infused through a port-acath. I received about a teaspoon daily for 4 months. • The side effects were minimal – no hair loss or nausea but other small inconveniences which were bearable. You can imagine the anxiety I felt when I went for my first CT scan but the news was good and it has been good for the past 14 years. I had one doctor tell me he did not believe that I had this type of cancer and was still living until he saw the reports. Why am I a survivor? I ask myself that question everyday when I thank God. Maybe I needed to see my first granddaughter who was born later that year, or her sister born 4 years later - or to see my two little grandsons, one of which was just born or maybe I am still needed. I don't know the answer but if I did I would wish it for all the cancer patients. It's been 14 years - I still think about it everyday and am so grateful to the doctors who treated me and my family for their support. Courage and hope to all the cancer patients. You are in my thoughts and prayers.

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Good News: Survivor Experience

Scott Hamilton – A survivor! • I remember I was tired. I thought I was just overworked, I mean I was on tour, skating, traveling, doing a million things. But then I had trouble standing up straight. I have to say I was in pain, but I still thought it was from indigestion or something minor. I never imagined what was in store for me. I went to a physician in Peoria, Illinois, and suddenly I was having all these tests, scary tests. It all happened really fast, but one thing I remember so clearly. I'll never forget when I first heard the words "You have cancer." At first, I was petrified. I was in shock. I couldn't believe it. A lot of things go through your mind, and sometimes all the thoughts aren't so good. But then, I made up my mind that I would fight and that I could do it. That's when I first said, "The only disability in life is a bad attitude." I really believe that. I had so much support from my friends and family and the great folks at The Cleveland Clinic. There were some tough times, but the chemotherapy wasn't as bad as I thought it was going to be. I was able to manage it and make it and I know that other people can too. I have learned a lot from my experience going through testicular cancer, but I guess what I want to say is that the experience wasn't as bad as what I feared. The fear was worse. If people can get information, they can overcome their fear and make it through. I did it and you can too.

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Good News: Survivor Experience Greg - 6 Lessons I learned from my cancer • Lesson #1: Many more people genuinely care about you than you can possibly know - and they are ready to do everything in their power to help you through your treatment. • Lesson #2: God is NOT mean - sometimes bad things happen to good people. • Lesson #3: All big words have simple explanations - you just have to keep asking until you get it. • Lesson #4: Not all doctors are very good; but some doctors are outstanding; and personally dedicated to making you get well again. The same can be said for Nurses, Radiation Techs, and Receptionists. Take the time to find the really good ones. • Lesson #5: It's OK to have a bad day. You're sick; you don't have to happy about it. • Lesson #6: You're a LOT tougher than you think you are - you CAN DO this.

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Good News: Survivor Experience Benjamin - Lung Cancer I am 76 years old and I have one foot in the grave and the other is on a banana peel, but life is a ball. In 1998 when I was a young man of 70, I was informed that I had a growth in my left lung. After a few examinations and a needle biopsy, I was informed it was a cancerous growth. After consultation with an Internist, a Pulmonologist, a Cardiothoracic Sugeon and an Oncologist (here I would like to wish that you all would have as wonderful a group of doctors and nurses as I had), it was decided that chemotherapy and surgery would be our course of action. This was accomplished. In January of 2002, it was discovered that I had a tumor in the upper portion of my left lung. A biopsy indicated it was cancerous. This time chemo and radiation was the prescribed treatment and it was successful in eliminating the tumor. I mention this only to indicate I know of what I speak. Do no let Cancer end your Life. Wade in with Faith, Humor, and Resolve to survive and enjoy what ever length of time you have left on this green earth. We will all die at some point, it is the living that we must face, conquer and manage. Faith is a strong ally and is never to be overlooked. Humor is the lubricant for an enjoyable Life, both for you and those around you. Resolve is the determination to fight for every moment of enjoyment life has to offer. Let no one "rain on your parade."

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What is cancer? • Cancer is a group of more than 100 different diseases. • They affect the body's basic unit, the cell. • Cancer occurs when cells become abnormal and divide without control or order.

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Colon and Rectum • Like all other organs of the body, the colon and rectum are made up of many types of cells. Normally, cells divide to produce more cells only when the body needs them. This orderly process helps keep the body healthy.

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What is cancer? • If cells keep dividing when new cells are not needed, a mass of tissue forms. This mass of extra tissue, called a growth or tumor, can be benign or malignant. • Benign tumors are not cancer. They can usually be removed and, in most cases, they do not come back. Most important, cells from benign tumors do not spread to other parts of the body. Benign tumors are rarely a threat to life. 8

What is cancer? • Malignant tumors are cancer. Cancer cells can invade and damage tissues and organs near the tumor. Also, cancer cells can break away from a malignant tumor and enter the bloodstream or lymphatic system. This is how cancer spreads from the original (primary) tumor to form new tumors in other parts of the body. The spread of cancer is called metastasis. • When cancer spreads to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the primary tumor. For example, if colon cancer spreads to the liver, the cancer cells in the liver are colon cancer cells. The disease is metastatic colon cancer (it is not liver cancer).

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What is cancer of the colon ? • The colon is the part of the digestive system where the waste material is stored. The rectum is the end of the colon adjacent to the anus. • Together, they form a long, muscular tube called the large intestine (also known as the large bowel). • Tumors of the colon and rectum are growths arising from the inner wall of the large intestine. • Benign tumors of the large intestine are called polyps. Malignant tumors of the large intestine are called cancers. • Benign polyps do not invade nearby tissue or spread to other parts of the body.

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What is cancer of the colon ? • Benign polyps can be easily removed during colonoscopy and are not life-threatening. If benign polyps are not removed from the large intestine, they can become malignant (cancerous) over time. • Most of the cancers of the large intestine are believed to have developed from polyps. Cancer of the colon and rectum (also referred to as colorectal cancer) can invade and damage adjacent tissues and organs. • Cancer cells can also break away and spread to other parts of the body (such as liver and lung) where new tumors form. The spread of colon cancer to distant organs is called metastasis of the colon cancer. Once metastasis has occurred in colorectal cancer, a complete cure of the cancer is unlikely.

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Colon Anatomy • The colon is the last portion of the digestive system in most vertebrates; it extracts water and salt from solid wastes before they are eliminated from the body.

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Colon Sections • The colon consists of four sections: the ascending colon, the transverse colon, the descending colon, and the sigmoid colon.

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Colorectal Cancer • Colorectal cancer, also called colon cancer or large bowel cancer, includes cancerous growths in the colon, rectum and appendix. • It is the third most common form of cancer and the second leading cause of cancer-related disease in the Western world. 14

Colorectal Cancer • Many colorectal cancers are thought to arise from adenomatous polyps in the colon. These mushroom-like growths are usually benign, but some may develop into cancer over time. • The majority of the time, the diagnosis of localized colon cancer is through colonoscopy. • Therapy is usually through surgery, which in many cases is followed by chemotherapy.

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Causes • In general, cancer occurs when healthy cells become altered. Healthy cells grow and divide in an orderly way to keep your body functioning normally. • But sometimes this growth gets out of control — cells continue dividing even when new cells aren't needed. In the colon and rectum, this exaggerated growth may cause precancerous cells to form in the lining of your intestine. • Over a long period of time — spanning up to several years — some of these areas of abnormal cells may become cancerous. • In later stages of the disease, colon cancer may penetrate the colon walls and spread (metastasize) to nearby lymph nodes or other organs.

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Precancerous growths in the colon • Precancerous cells can occur anywhere in your large intestine, the muscular tube that forms the last part of your gastrointestinal tract. The colon comprises the upper 4 to 5 feet of your large intestine, and the rectum makes up the lower 6 inches. • Precancerous growths most commonly occur as clumps of cells (polyps) that extend from the wall of the colon. Polyps can appear mushroom-shaped. Precancerous growths can also be flat or recessed into the wall of the colon (nonpolypoid lesions). Nonpolypoid lesions are more difficult to detect, but are less common.

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Polyps

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Several types of colon polyps Among the most common are: • Adenomas. These polyps have the potential to become cancerous and are usually removed during screening tests such as flexible sigmoidoscopy or colonoscopy. • Hyperplastic polyps. These polyps are rarely, if ever, a risk factor for colorectal cancer. • Inflammatory polyps. These polyps may follow a bout of ulcerative colitis. Some inflammatory polyps may become cancerous, so having ulcerative colitis increases your overall risk of colon cancer

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Polyps

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Symptons • Colon cancer can be present for several years before symptoms develop. • Colon cancer often causes no symptoms until it has reached a relatively advanced stage. Thus, many organizations recommend periodic screening for the disease with fecal occult blood testing and colonoscopy 22

Symptons • Symptoms vary according to where in the large bowel the tumor is located. The right colon is spacious, and cancers of the right colon can grow to large sizes before they cause any abdominal symptoms. • Typically, right-sided cancers cause iron deficiency anemia due to the slow loss of blood over a long period of time. Iron deficiency anemia causes fatigue, weakness, and shortness of breath. The left colon is narrower than the right colon. Therefore, cancers of the left colon are more likely to cause partial or complete bowel obstruction. • Cancers causing partial bowel obstruction can cause symptoms of constipation, narrowed stool, diarrhea, abdominal pains, cramps, and bloating. Bright red blood in the stool may also indicate a growth near the end of the left colon or rectum.

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Bowel Symptoms Details Change in bowel habits – change in frequency (constipation and/or diarrhea), – change in the quality of stools – change in consistency of stools

Bloody stools or rectal bleeding Stools with mucus Tarry stools (melena) (more likely related to upper gastrointestinal i.e. stomach or duodenal disease) • Feeling of incomplete defecation (tenesmus) (usually associated with rectal cancer) • Reduction in diameter of feces • Bowel obstruction (rare) • • •

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Constitutional Symptoms Details • Especially in the cases of cancer in the ascending colon, sometimes only the less specific constitutional symptoms will be found: • Anemia, with symptoms such as dizziness, malaise and palpitations. Clinically there will be pallor and a complete blood picture will confirm the low hemoglobin level. • Anorexia • Asthenia, weakness • Unexplained weight loss.

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Metastatic Symptoms Details • There may also be symptoms attributed to distant metastasis: • Shortness of breath as in lung metastasis • Epigastric or right upper quadrant pain, as in liver metastasis. Rarely there can be jaundice if the outflow of bile is blocked. Clinically there might be liver enlargement .

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Tumor • The term tumor is derived from the Latin term tumor or "swelling". It originally meant an abnormal swelling of the flesh. In contemporary English, tumor is synonymous with solid neoplasm (abnormal proliferation of cells), while all other forms of swelling are called swelling. • Furthermore, this usage is common in medical literature where the nouns tumefaction and tumescence derived from the adjective tumefied. These nouns are also the current medical terms for non-neoplastic swelling.

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Diagnosis • Specific and correct diagnosis can only be rendered by a biopsy or skin biopsy. The biopsy is submitted to a laboratory and a pathology report is generated. • Clinical diagnosis is by clinical history, visual diagnosis often with dermatoscopy, and palpation. But clinical diagnosis can only be confirmed by a biopsy.

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Cause • A neoplasm is an abnormal proliferation of tissues, usually caused by genetic mutations. Most neoplasms cause a tumor, with a few exceptions like leukemia or carcinoma in situ. • Other causes of tumor development include exposure to chemicals and toxins like benzene, excessive alcohol and tobacco consumption, excessive exposure to sunlight and/or radiation, or an inactive sedentary lifestyle and obesity. • Certain viruses can also play a role in the development of tumors, such as cervical cancer (human papillomavirus) and hepatocellular carcinoma (hepatitis B virus). • Tumors may be benign, pre-malignant or malignant. The nature of the tumor is determined by a pathologist after examination of the tumor tissues from a biopsy or a surgical excision specimen

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Infectiousness of tumor cells • Tumor cells are generally not infective to individuals other than the host. • The reason behind this is the presence of MHC proteins which are host-specific and help the immune system distinguish between the self and non-self. • These proteins are present on the surface of the cells and produces vigorous immune response if a foreign cell is found in the body. • However, tumor can be transplanted in an individual if its immune system is compromised.

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Treatment • Treatment depends on the size and type of the tumor, the initial location of the tumor, and the general health of the person. The goals of treatment may be relief of symptoms, improved comfort or functioning. • Tumor treatment also varies based on whether it is in benign or malignant condition. If the tumor is benign (has no potential to spread) and is located in a area where it will not cause any symptoms or disrupt the proper functioning of the organ, most often no treatment is needed. • However, benign tumors may be removed for cosmetic reasons. If a tumor is malignant, possible treatments include surgery, chemotherapy, radiation, or a combination of these procedures.

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Treatment • If the cancer is confined to only one location, the purpose of treatment is usually surgical removal of the malignant tumor and treatment. • In some circumstances, if the malignant tumor has spread only to local lymph nodes, these may also be removed. • If all of the cancer cannot be removed with surgery, the options for treatment include radiation and chemotherapy, or combination of these methods. • In contrast, lymphoma usually is not treated with surgery and chemotherapy; and radiation therapy may be the possible treatment [

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Pathology • The pathology of the tumor is usually reported from the analysis of tissue taken from a biopsy or surgery. • A pathology report will usually contain a description of cell type and grade. • The most common colon cancer cell type is adenocarcinoma which accounts for 95% of cases. • Other, rarer types include lymphoma and squamous cell carcinoma.

• Histopathologic image of colonic carcinoid stained by hematoxylin and eosin.

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Pathology • Cancers on the right side (ascending colon and cecum) tend to be exophytic, that is, the tumor grows outwards from one location in the bowel wall. • This very rarely causes obstruction of feces, and presents with symptoms such as anemia. • Left-sided tumors tend to be circumferential, and can obstruct the bowel much like a napkin ring. 34

Histopathology: • Adenocarcinoma is a malignant epithelial tumor, originating from glandular epithelium of the colorectal mucosa. • It invades the wall, infiltrating the muscularis mucosae, the submucosa and thence the muscularis propria. • Tumor cells describe irregular tubular structures, harboring pluristratification, multiple lumens, reduced stroma ("back to back" aspect). 35

Histopathology: • Sometimes, tumor cells are discohesive and secrete mucus, which invades the interstitium producing large pools of mucus/colloid (optically "empty" spaces) mucinous (colloid) adenocarcinoma, poorly differentiated. • If the mucus remains inside the tumor cell, it pushes the nucleus at the periphery - "signet-ring cell." • Depending on glandular architecture, cellular pleomorphism, and mucosecretion of the predominant pattern, adenocarcinoma may present three degrees of differentiation: well, moderately, and poorly differentiated.

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Tumor Growth

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Colorectal Cancer

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Colon polyps and colon cancer • Doctors believe that most colon cancers develop in colon polyps. Therefore, removing benign colon polyps can prevent colorectal cancer. • Colon polyps develop when chromosome damage occurs in cells of the inner lining of the colon. Chromosomes contain genetic information inherited from each parent. • Normally, healthy chromosomes control the growth of cells in an orderly manner. When chromosomes are damaged, cell growth becomes uncontrolled, resulting in masses of extra tissue (polyps). Colon polyps are initially benign. • Over years, benign colon polyps can acquire additional chromosome damage to become cancerous.

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Risk Factor: Growing Polyps • Adenomatous polyps, are a risk factor for colon cancer. The removal of colon polyps at the time of colonoscopy reduces the subsequent risk of colon cancer. • This polyps carries a near 100% risk of developing colorectal cancer by the age of 40 if untreated.

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Risk Factor: Diet

• Studies show that a diet high in red meat and low in fresh fruit, vegetables, poultry and fish increases the risk of colorectal cancer. In June 2005, a study by the European Prospective Investigation into Cancer and an suggested that diets high in red and processed meat, as well as those low in fiber, are associated with an increased risk of colorectal cancer. • Individuals who frequently ate fish showed a decreased risk. 41

Diet and colon cancer • Diets high in fat are believed to predispose humans to colorectal cancer. In countries with high colorectal cancer rates, the fat intake by the population is much higher than in countries with low cancer rates. • It is believed that the breakdown products of fat metabolism lead to the formation of cancercausing chemicals (carcinogens). • Diets high in vegetables and high-fiber foods such as whole-grain breads and cereals may rid the bowel of these carcinogens and help reduce the risk of cancer. 42

Risk Factor: Ulcerative colitis and colon cancer • Chronic ulcerative colitis causes inflammation of the inner lining of the colon. Colon cancer is a recognized complication of chronic ulcerative colitis. The risk for cancer begins to rise after eight to 10 years of colitis. The risk of developing colon cancer in a patient with ulcerative colitis also is related to the location and the extent of his or her disease. • Current estimates of the cumulative incidence of colon cancer associated with ulcerative colitis are 2.5% at 10 years, 7.6% at 30 years, and 10.8% at 50 years. Patients at higher risk of cancer are those with a family history of colon cancer, a long duration of colitis, extensive colon involvement, and those with primary sclerosing cholangitis (PSC).

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Ulcerative colitis and colon cancer • Since the cancers associated with ulcerative colitis have a more favorable outcome when caught at an earlier stage, yearly examinations of the colon often are recommended after eight years of known extensive disease. • During these examinations, samples of tissue (biopsies) can be taken to search for precancerous changes in the lining cells of the colon. When precancerous changes are found, removal of the colon may be necessary to prevent colon cancer.

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Risk Factor: Genetics and colon cancer • A person's genetic background is an important factor in colon cancer risk. Among first-degree relatives of colon cancer patients, the lifetime risk of developing colon cancer is 18% (a threefold increase over the general population in the United States). • Even though family history of colon cancer is an important risk factor, majority (80%) of colon cancers occur sporadically in patients with no family history of colon cancer. Approximately 20% of cancers are associated with a family history of colon cancer. • And 5 % of colon cancers are due to hereditary colon cancer syndromes. Hereditary colon cancer syndromes are disorders where affected family members have inherited cancer-causing genetic defects from one or both of the parents.

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Genetics and colon cancer • Chromosomes contain genetic information, and

chromosome damages cause genetic defects that lead to the formation of colon polyps and later colon cancer. • In sporadic polyps and cancers (polyps and cancers that develop in the absence of family history), the chromosome damages are acquired (develop in a cell during adult life). • The damaged chromosomes can only be found in the polyps and the cancers that develop from that cell. But in hereditary colon cancer syndromes, the chromosome defects are inherited at birth and are present in every cell in the body. • Patients who have inherited the hereditary colon cancer syndrome genes are at risk of developing large number of colon polyps, usually at young ages, and are at very high risk of developing colon cancer early in life, and also are at risk of developing cancers in other organs.

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Genetics and colon cancer • FAP (familial adenomatous polyposis) is a hereditary colon cancer syndrome where the affected family members will develop countless numbers (hundreds, sometimes thousands) of colon polyps starting during the teens. • Unless the condition is detected and treated (treatment involves removal of the colon) early, a person affected by familial polyposis syndrome is almost sure to develop colon cancer from these polyps. • Cancers usually develop in the 40s. These patients are also at risk of developing other cancers such as cancers in the thyroid gland, stomach, and the ampulla (the part where the bile ducts drain into the duodenum just beyond the stomach).

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Genetics and colon cancer • AFAP (attenuated familial adenomatous polyposis) is a milder version of FAP. Affected members develop less than 100 colon polyps. Nevertheless, they are still at very high risk of developing colon cancers at young ages. They are also at risk of having gastric polyps and duodenal polyps. • HNPCC (hereditary nonpolyposis colon cancer) is a hereditary colon cancer syndrome where affected family members can develop colon polyps and cancers, usually in the right colon, in their 30s to 40s. Certain HNPCC patients are also at risk of developing uterine cancer, stomach cancer, ovarian cancer, and cancers of the ureters (the tubes that connect the kidneys to the bladder), and the biliary tract (the ducts that drain bile from the liver to the intestines). • MYH polyposis syndrome is a recently discovered hereditary colon cancer syndrome. Affected members typically develop 10-100 polyps occurring at around 40 years of age, and are at high risk of developing colon cancer.

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What tests can be done to detect colon cancer? • When colon cancer is suspected, either a lower GI series (barium enema x-ray) or colonoscopy is performed to confirm the diagnosis and to localize the tumor. • A barium enema involves taking x-rays of the colon and the rectum after the patient is given an enema with a white, chalky liquid containing barium. The barium outlines the large intestines on the x-rays. Tumors and other abnormalities appear as dark shadows on the x-rays. 49

What tests can be done to detect colon cancer? • Colonoscopy is a procedure whereby a doctor inserts a long, flexible viewing tube into the rectum for the purpose of inspecting the inside of the entire colon. • Colonoscopy is generally considered more accurate than barium enema x-rays, especially in detecting small polyps. If colon polyps are found, they are usually removed through the colonoscope and sent to the pathologist. • The pathologist examines the polyps under the microscope to check for cancer. While the majority of the polyps removed through the colonoscopes are benign, many are precancerous. Removal of precancerous polyps prevents the future development of colon cancer from these polyps. For more information, please read the Colonoscopy article. 50

What tests can be done to detect colon cancer? • If cancerous growths are found during colonoscopy, small tissue samples (biopsies) can be obtained and examined under the microscope to confirm the diagnosis. • If colon cancer is confirmed by a biopsy, staging examinations are performed to determine whether the cancer has already spread to other organs. Since colorectal cancer tends to spread to the lungs and the liver, staging tests usually include chest x-rays, ultrasonography, or a CAT scan of the lungs, liver, and abdomen. • Sometimes, the doctor may obtain a blood test for CEA (carcinoembyonic antigen). CEA is a substance produced by some cancer cells. It is sometimes found in high levels in patients with colorectal cancer, especially when the disease has spread.

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Colonoscopy • A lighted probe called a colonoscope is inserted into the rectum and the entire colon to look for polyps and other abnormalities that may be caused by cancer. A colonoscopy has the advantage that if polyps are found during the procedure they can be immediately removed. Tissue can also be taken for biopsy.

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Grown Polyps

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Full Grown Tumor

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Staging • Colon cancer staging is an estimate of the amount of penetration of a particular cancer. • It is performed for diagnostic and research purposes, and to determine the best method of treatment. • The systems for staging colorectal cancers largely depend on the extent of local invasion, the degree of lymph node involvement and whether there is distant metastasis. 55

Tumor Stages

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Staging • Definitive staging can only be done after surgery has been performed and pathology reports reviewed. • An exception to this principle would be after a colonoscopic polypectomy of a malignant pedunculated polyp with minimal invasion. • Preoperative staging of rectal cancers may be done with endoscopic ultrasound. • Adjuncts to staging of metastasis include Abdominal Ultrasound, CT, PET Scanning, and other imaging studies. 57

Dukes' system • Dukes' classification, first proposed by Dr Cuthbert E. Dukes in 1932, identifies the stages as: • A - Tumor confined to the intestinal wall • B - Tumor invading through the intestinal wall • C - With lymph node(s) involvement • D - With distant metastasis

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TNM system • The most common current staging system is the TNM (for tumors/nodes/metastases) system, though many doctors still use the older Dukes system. The TNM system assigns a number: • T - The degree of invasion of the intestinal wall

– T0 - no evidence of tumor – Tis- cancer in situ (tumor present, but no invasion) – T1 - invasion through submucosa into lamina propria (basement membrane invaded) – T2 - invasion into the muscularis propria (i.e. proper muscle of the bowel wall) – T3 - invasion through the subserosa – T4 - invasion of surrounding structures (e.g. bladder) or with tumor cells on the free external surface of the bowel

• N - the degree of lymphatic node involvement – – –

N0 - no lymph nodes involved N1 - one to three nodes involved N2 - four or more nodes involved

• M - the degree of metastasis – M0 - no metastasis – M1 - metastasis present

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Pathogenesis • Colorectal cancer is a disease originating from the epithelial cells lining the gastrointestinal tract. Hereditary or somatic mutations in specific DNA sequences, among which are included DNA replication or DNA repair genes, and also the APC, K-Ras, NOD2 and p53 genes, lead to unrestricted cell division. • The exact reason why (and whether) a diet high in fiber might prevent colorectal cancer remains uncertain. • Chronic inflammation, as in inflammatory bowel disease, may predispose patients to malignancy.

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What are the treatments and survival for colon cancer? • The treatment depends on the staging of the cancer. When colorectal cancer is caught at early stages (with little spread) it can be curable. However when it is detected at later stages (when distant metastases are present) it is more difficult to cure. • Surgery remains the primary treatment while chemotherapy and/or radiotherapy may be recommended depending on the individual patient's staging and other medical factors.

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What are the treatments and survival for colon cancer? • Surgery is the most common treatment for colorectal cancer. During surgery, the tumor, a small margin of the surrounding healthy bowel, and adjacent lymph nodes are removed. • The surgeon then reconnects the healthy sections of the bowel. In patients with rectal cancer, the rectum is permanently removed. • The surgeon then creates an opening (colostomy) on the abdomen wall through which solid waste in the colon is excreted. Specially trained nurses (enterostomal therapists) can help patients adjust to colostomies, and most patients with colostomies return to a normal lifestyle 62

Treatment: Surgery • Surgeries can be categorized into curative, palliative, bypass, fecal diversion, or open-and-close. • Curative Surgical treatment can be offered if the tumor is localized. • Very early cancer that develops within a polyp can often be cured by removing the polyp (i.e., polypectomy) at the time of colonoscopy. • In colon cancer, a more advanced tumor typically requires surgical removal of the section of colon containing the tumor with sufficient margins, and radical en-bloc resection of mesentery and lymph nodes to reduce local recurrence (i.e., colectomy). If possible, the remaining parts of colon are anastomosed together to create a functioning colon. In cases when anastomosis is not possible, a stoma (artificial orifice) is created.

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Curative and Non Curative Surgery • Curative surgery on rectal cancer includes total mesorectal excision (lower anterior resection) or abdominoperineal excision. • In case of multiple metastases, palliative (non curative) resection of the primary tumor is still offered in order to reduce further morbidity caused by tumor bleeding, invasion, and its catabolic effect. Surgical removal of isolated liver metastases is, however, common and may be curative in selected patients; improved chemotherapy has increased the number of patients who are offered surgical removal of isolated liver metastases. • If the tumor invaded into adjacent vital structures which makes excision technically difficult, the surgeons may prefer to bypass the tumor (ileotransverse bypass) or to do a proximal fecal diversion through a stoma.

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Colon Prognosis • The long-term prognosis after surgery depends on whether the cancer has spread to other organs (metastasis). • The risk of metastasis is proportional to the depth of penetration of the cancer into the bowel wall. In patients with early colon cancer which is limited to the superficial layer of the bowel wall, surgery is often the only treatment needed. • These patients can experience long-term survival in excess of 80%. • In patients with advanced colon cancer, wherein the tumor has penetrated beyond the bowel wall and there is evidence of metastasis to distant organs, curing will be more than difficult. 65

Treatment: Chemotherapy • Chemotherapy is used to reduce the likelihood of metastasis developing, shrink tumor size, or slow tumor growth. • Chemotherapy is often applied after surgery (adjuvant), before surgery (neo-adjuvant), or as the primary therapy if surgery is not indicated (palliative). • The treatments listed here have been shown in clinical trials to improve survival and/or reduce mortality rate and have been approved for use by the US Food and Drug Administration. 66

Chemotherapy • In some patients, there is no evidence of distant metastasis at the time of surgery, but the cancer has penetrated deeply into the colon wall or reached adjacent lymph nodes. These patients are at risk of tumor recurrence either locally or in distant organs. • Chemotherapy in these patients may delay tumor recurrence and improve survival. • Chemotherapy is the use of medications to kill cancer cells. It is a systemic therapy, meaning that the medication travels throughout the body to destroy cancer cells. After colon cancer surgery, some patients may harbor microscopic metastasis (small foci of cancer cells that will hardly be detected).

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Chemotherapy • Chemotherapy is given shortly after surgery to destroy these microscopic cells. • Chemotherapy given in this manner is called adjuvant chemotherapy. Recent studies have shown increased survival and delay of tumor recurrence in some patients treated with adjuvant chemotherapy within five weeks of surgery. • Most drug regimens have included the use of 5-flourauracil (5-FU). • On the other hand, however, chemotherapy for shrinking or controlling the growth of metastatic tumors has been disappointing. • Improvement in the overall survival for patients with widespread metastasis has not been convincingly demonstrated.

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Chemotherapy • Chemotherapy is usually given in a doctor's office, in the hospital as a outpatient, or at home. • Chemotherapy is usually given in cycles of treatment periods followed by recovery periods. Side effects of chemotherapy vary from person to person, and also depend on the agents given. Modern chemotherapy agents are usually well tolerated, and side effects are manageable. • In general, anti-cancer medications destroy cells that are rapidly growing and dividing. Therefore, red blood cells, platelets, and white blood cells are frequently affected by chemotherapy. • Common side effects include anemia, loss of energy, easy bruising, and a low resistance to infections. Cells in the hair roots and intestines also divide rapidly. Therefore, chemotherapy can cause hair loss, mouth sores, nausea, vomiting, and diarrhea.

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Chemotherapy Drugs •

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Adjuvant (after surgery) chemotherapy. One regimen involves the combination of infusional 5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX) – 5-fluorouracil (5-FU) or Capecitabine (Xeloda®) – Leucovorin (LV, Folinic Acid) – Oxaliplatin (Eloxatin®) Chemotherapy for metastatic disease. Commonly used first line chemotherapy regimens involve the combination of infusional 5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX) with bevacizumab or infusional 5-fluorouracil, leucovorin, and irinotecan (FOLFIRI) with bevacizumab – 5-fluorouracil (5-FU) or Capecitabine – Leucovorin (LV, Folinic Acid) – Irinotecan (Camptosar®) – Oxaliplatin (Eloxatin®) – Bevacizumab (Avastin®) – Cetuximab (Erbitux®) – Panitumumab (Vectibix) In clinical trials for treated/untreated metastatic disease. [2] – Bortezomib (Velcade®) – Oblimersen (Genasense®, G3139) – Gefitinib and Erlotinib (Tarceva®) – Topotecan (Hycamtin®)

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Chemotherapy using Drug C225 • Miracle Drug Thus it was with considerable delight that cancer researchers

at the meeting of the American Society of Clinical Oncology in New Orleans learned last Monday of a patient who had done the seemingly impossible. Shannon Kellum, a 30 year old accountant from Fort Myers, Florida, learned in 1998 that she had terminal colon cancer, and could not expect to live long. The cancer had already spread to her liver, with tumors the size of grapefruits, far too large to remove. Her life expectancy was nil. Today she is tumor-free, and not at all dead . The drug C225 was administered to Kellum once a week intravenously, with chemotherapy to aid in knocking out any tumor cells weakened but not killed by lack of EGF. Her liver tumors shrank by 80% in four months. Four months later, the tumors were small enough to be removed surgically. Today she is tumor-free. Only time will tell if she is cured -- some cancer cells may remain that could restart tumors. But there is no denying the fact that she is very much alive and leading a normal life, a year after she should have died. 71

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Treatment: Radiation therapy

• Radiotherapy is not used routinely in colon cancer, as it could lead to radiation enteritis, and it is difficult to target specific portions of the colon. It is more common for radiation to be used in rectal cancer, since the rectum does not move as much as the colon and is thus easier to target. Indications include: • Colon cancer – pain relief and palliation - targeted at metastatic tumor deposits if they compress vital structures and/or cause pain • Rectal cancer – neoadjuvant - given before surgery in patients with tumors that extend outside the rectum or have spread to regional lymph nodes, in order to decrease the risk of recurrence following surgery or to allow for less invasive surgical approaches (such as a low anterior resection instead of an abdomino-perineal resection) – adjuvant - where a tumor perforates the rectum or involves regional lymph nodes (AJCC T3 or T4 tumors or Duke's B or C tumors) – palliative - to decrease the tumor burden in order to relieve or prevent symptoms

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Radiation Therapy • Radiation therapy in colorectal cancer has been limited to treating cancer of the rectum. There is a decreased local recurrence of rectal cancer in patients receiving radiation either prior to or after surgery. • Without radiation, the risk of rectal cancer recurrence is close to 50%. With radiation, the risk is lowered to approximately 7%. • Side effects of radiation treatment include fatigue, temporary or permanent pelvic hair loss, and skin irritation in the treated areas. • Other treatments have included the use of localized infusion of chemotherapeutic agents into the liver, the most common site of metastasis.

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Radiation Therapy • This involves the insertion of a pump into the blood supply of the liver which can deliver high doses of medicine directly to the liver tumor. • Response rates for these treatments have been reported to be as high as eighty percent. Side effects, however, can be serious. • Additional experimental agents considered for the treatment of colon cancer include the use of cancerseeking antibodies bound to cancer-fighting drugs. • Such combinations can specifically seek and destroy tumor tissues in the body.

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Radiation Therapy • Other treatments attempt to boost the immune system, the bodies' own defense system, in an effort to more effectively attack and control colon cancer. • In patients who are poor surgical risks, but who have large tumors which are causing obstruction or bleeding, laser treatment can be used to destroy cancerous tissue and relieve associated symptoms. • Still other experimental agents include the use of photodynamic therapy. In this treatment, a light sensitive agent is taken up by the tumor which can then be activated to cause tumor destruction.

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Others Treatment Immunotherapy • Bacillus Calmette-Guérin (BCG) is being investigated as an adjuvant mixed with autologous tumor cells in immunotherapy for colorectal cancer. Vaccine • In November 2006, it was announced that a vaccine had been developed and tested with very promising results. • The new vaccine, called TroVax, works in a totally different way to existing treatments by harnessing the patient's own immune system to fight the disease. • Experts say this suggests that gene therapy vaccines could prove an effective treatment for a whole range of cancers. Oxford BioMedica is a British spin-out from Oxford University specializing in the development of . • Phase III trials are underway for renal cancers and planned for colon cancers. 77

Treatment of colorectal cancer metastasis to the liver • According to the American Cancer Society statistics in 2006 greater than 20% of patients present with metastatic (stage IV) colorectal cancer at the time of diagnosis, and up to 25% of this group will have isolated liver metastasis that is potentially resectable. • Lesions which undergo curative resection have demonstrated 5-year survival outcomes now exceeding 50%.

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Metastasis to the liver • Resectability of a liver met is determined using preoperative imaging studies (Ct or MRI), intraoperative ultrasound, and by direct palpation and visualization during resection. • Lesions confined to the right lobe are amenable to en bloc removal with a right hepatectomy (liver resection) surgery. Smaller lesions of the central or left liver lobe may sometimes be resected in anatomic "segments", while large lesions of left hepatic lobe are resected by a procedure called hepatic trisegmentectomy. • Treatment of lesions by smaller, non-anatomic "wedge" resections is associated with higher recurrence rates. Some lesions which are not initially amenable to surgical resection may become candidates if they have significant responses to preoperative chemotherapy or immunotherapy regimines. Lesions which are not amenable to surgical resection for cure can be treated with modalities including radio-frequency ablation (RFA), cryoablation, and chemoembolization.

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Metastasis to the liver • Patients with colon cancer and metastatic disease to the liver may be treated in either a single surgery or in staged surgeries (with the colon tumor traditionally removed first) depending upon the fitness of the patient for prolonged surgery, the difficulty expected with the procedure with either the colon or liver resection, and the comfort of the surgery performing potentially complex hepatic surgery. • Poor pronostic factors of patients with liver metastasis include • Synchronous (diagnosed simultaneously) liver and primary colorectal tumors • A short time between detecting the primary cancer and subsequent development of liver mets • Multiple metastatic lesions • High blood levels of the tumor marker, carcino -embryonic antigen (CEA), in the patient prior to resection • Larger size metastatic lesions

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What is the follow-up care for colon cancer? • Follow-up exams are important after treatment for colon cancer. The cancer can recur near the original site or in a distant organ such as the liver or lung. Follow-up exams include a physical examination by the doctor, blood tests of liver enzymes, chest xrays, CAT scans of the abdomen and pelvis, colonoscopies, and blood CEA levels. • Abnormal liver enzymes may indicate growth of liver metastasis. CEA levels may be elevated before surgery and become normal shortly after the cancer is removed. Slowly rising CEA level may indicate cancer recurrence. A CAT scan of the abdomen and pelvis can show tumor recurrence in the liver, pelvis, or other areas. Colonoscopy can show recurrence of polyps or cancer in the large intestine. • In addition to checking for cancer recurrence, patients who have had colon cancer may have an increased risk of cancer of the prostate, breast, and ovary. Therefore, follow-up examinations should include these areas.

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Follow-up • The aims of follow-up are to diagnose in the earliest possible stage any metastasis or tumors that develop later but did not originate from the original cancer (metachronous lesions). • The U.S. National Comprehensive Cancer Network and American Society of Clinical Oncology provide guidelines for the follow-up of colon cancer. A medical history and physical examination are recommended every 3 to 6 months for 2 years, then every 6 months for 5 years. Carcinoembryonic antigen blood level measurements follow the same timing, but are only advised for patients with T2 or greater lesions who are candidates for intervention. • A CT-scan of the chest, abdomen and pelvis can be considered annually for the first 3 years for patients who are at high risk of recurrence (for example, patients who had poorly differentiated tumors or venous or lymphatic invasion) and are candidates for curative surgery (with the aim to cure). • A colonoscopy can be done after 1 year, except if it could not be done during the initial staging because of an obstructing mass, in which case it should be performed after 3 to 6 months. If a villous polyp, polyp >1 centimeter or high grade dysplasia is found, it can be repeated after 3 years, then every 5 years. For other abnormalities, the colonoscopy can be repeated after 1 year.

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How can colon cancer be prevented? • Unfortunately, colon cancers can be well advanced before they are detected. The most effective prevention of colon cancer is early detection and removal of precancerous colon polyps before they turn cancerous. • Even in cases where cancer has already developed, early detection still significantly improves the chances of a cure by surgically removing the cancer before the disease spreads to other organs. Multiple world health organizations have suggested general screening guidelines. • Digital rectal examination and stool occult blood testing • It is recommended that all individuals over the age of 40 have yearly digital examinations of the rectum and their stool tested for hidden or "occult" blood. During digital examination of the rectum, the doctor inserts a gloved finger into the rectum to feel for abnormal growths. Stool samples can be obtained to test for occult blood (see below). The prostate gland can be examined at the same time.

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How can colon cancer be prevented? • Most colorectal cancers should be preventable, through increased surveillance, improved lifestyle, and, probably, the use of dietary chemopreventative agents. Surveillance • Most colorectal cancer arise from adenomatous polyps. These lesions can be detected and removed during colonoscopy. Studies show this procedure would decrease by > 80% the risk of cancer death, provided it is started by the age of 50, and repeated every 5 or 10 years. • As per current guidelines under National Comprehensive Cancer Network, in average risk individuals with negative family history of colon cancer and personal history negative for adenomas or Inflammatory Bowel diseases, flexible sigmoidoscopy every 5 years with fecal occult blood testing annually or double contrast barium enema are other options acceptable for screening rather than colonoscopy every 10 years (which is currently the GoldStandard of care). 84

How can colon cancer be prevented? • An important screening test for colorectal cancers and polyps is the stool occult blood test. Tumors of the colon and rectum tend to bleed slowly into the stool. • The small amount of blood mixed into the stool is usually not visible to the naked eye. The commonly used stool occult blood tests rely on chemical color conversions to detect microscopic amounts of blood. • These tests are both convenient and inexpensive. A small amount of stool sample is smeared on a special card for occult blood testing. Usually, three consecutive stool cards are collected. • A person who tests positive for stool occult blood has a 30% to 45% chance of having a colon polyp and a 3% to 5% chance of having a colon cancer. • Colon cancers found under these circumstances tend to be early and have a better long-term prognosis.

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How can colon cancer be prevented? • It is important to remember that having stool tested positive for occult blood does not necessarily mean the person has colon cancer. Many other conditions can cause occult blood in the stool. • However, patients with a positive stool occult blood should undergo further evaluations involving barium enema x-rays, colonoscopies, and other tests to exclude colon cancer, and to explain the source of the bleeding. • It is also important to realize that stool which has tested negative for occult blood does not mean the absence of colorectal cancer or polyps. Even under ideal testing conditions, at least 20% of colon cancers can be missed by stool occult blood screening. • Many patients with colon polyps are tested negative for stool occult blood. In patients suspected of having colon tumors, and in those with high risk factors for developing colorectal polyps and cancer, flexible sigmoidoscopies or screening colonoscopies are performed even if the stool occult blood tests are negative.

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How can colon cancer be prevented? • Flexible sigmoidoscopy and colonoscopy • Beginning at age 50, a flexible sigmoidoscopy screening tests is recommended every three to five years. Flexible sigmoidoscopy is an exam of the rectum and the lower colon using a viewing tube (a short version of colonoscopy). • Recent studies have shown that the use of screening flexible sigmoidoscopy can reduce mortality from colon cancer. This is a result of the detection of polyps or early cancers in people with no symptoms. If a polyp or cancer is found, a complete colonoscopy is recommended. • The majority of colon polyps can be completely removed by colonoscopy without open surgery. Recently doctors are recommending screening colonoscopies instead of screening flexible sigmoidoscopies for healthy individuals starting at ages 50-55.

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How can colon cancer be prevented? • Patients with a high risk of developing colorectal cancer may undergo colonoscopies starting at earlier ages than 50. For example, patients with family history of colon cancer are recommended to start screening colonoscopies at an age 10 years before the earliest colon caner diagnosed in a first-degree relative, or five years earlier than the earliest precancerous colon polyp discovered in a first-degree relative. • Patients with hereditary colon cancer syndromes such as FAP, AFAP, HNPCC, and MYH are recommended to begin colonoscopies early. The recommendations differ depending on the genetic defect, for example in FAP; colonoscopies may begin during teenage years to look for the development of colon polyps. • Patients with a prior history of polyps or colon cancer may also undergo colonoscopies to exclude recurrence. Patients with a long history (greater than 10 years) of chronic ulcerative colitis have an increased risk of colon cancer, and should have regular colonoscopies to look for precancerous changes in the colon lining.

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How can colon cancer be prevented? • Genetic counseling and testing • Blood tests are now available to test for FAP, AFAP, MYH, and HNPCC hereditary colon cancer syndromes. Families with multiple members having colon cancers, members with multiple colon polyps, members having cancers at young ages, and having other cancers such as cancers of the ureters, uterus, duodenum, etc., should be referred for genetic counseling followed possibly by genetic testing. • Genetic testing without prior counseling is discouraged because of the extensive family education that is involved and the complicated nature of interpreting the test results. • The advantages of genetic counseling followed by genetic testing include: (1) identifying family members at high risk of developing colon cancer to begin colonoscopies early; (2) identifying high risk members so that screening may begin to prevent other cancers such as ultrasound tests for uterine cancer, urine examinations for ureter cancer, and upper endoscopies for stomach and duodenal cancers; and (3) alleviating concern for members who test negative for the hereditary genetic defects.

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How can colon cancer be prevented? Lifestyle • The comparison of colorectal cancer incidence in various countries strongly suggests that sedentarity, overeating (i.e., high caloric intake), and perhaps a diet high in meat (red or processed) could increase the risk of colorectal cancer. • In contrast, physical exercise, and eating plenty of fruits and vegetables would decrease cancer risk, probably because they contain protective phytochemicals. • Accordingly, lifestyle changes could decrease the risk of colorectal cancer as much as 60-80%. 90

How can colon cancer be prevented? Chemoprevention • More than 200 agents, including the above cited phytochemicals, and other food components like calcium or folic acid (a B vitamin), and NSAIDs like aspirin, are able to decrease carcinogenesis in preclinical models: Some studies show full inhibition of carcinogen-induced tumors in the colon of rats. • Other studies show strong inhibition of spontaneous intestinal polyps in mutated mice (Min mice). Chemoprevention clinical trials in human volunteers have shown smaller prevention, but few intervention studies have been completed today. • Calcium, aspirin and celecoxib supplements, given for 3 to 5 years after the removal of a polyp, decreased the recurrence of polyps in volunteers (by 15-40%).The "chemoprevention database" shows the results of all published scientific studies of chemopreventive agents, in people and in animals.

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How can colon cancer be prevented? Aspirin chemoprophylaxis • Aspirin should not be taken routinely to prevent colorectal cancer, even in people with a family history of the disease, because the risk of bleeding and kidney failure from high dose aspirin (300mg or more) outweigh the possible benefits. • A clinical practice guideline by the U.S. Preventive Services Task Force (USPSTF) recommended against taking aspirin (grade D recommendation).The Task Force acknowledged that aspirin may reduce the incidence of colorectal cancer, but "concluded that harms outweigh the benefits of aspirin and NSAID use for the prevention of colorectal cancer". A subsequent meta-analysis concluded "300 mg or more of aspirin a day for about 5 years is effective in primary prevention of colorectal cancer in randomised controlled trials, with a latency of about 10 years". However, long-term doses over 81 mg per day may increase bleeding events.

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How can colon cancer be prevented? Calcium • A meta-analysis by the Cochrane Collaboration of randomized controlled trials published through 2002 concluded "Although the evidence from two RCTs suggests that calcium supplementation might contribute to a moderate degree to the prevention of colorectal adenomatous polyps, this does not constitute sufficient evidence to recommend the general use of calcium supplements to prevent colorectal cancer.". • Subsequently, one randomized controlled trial by the Women's Health Initiative (WHI) reported negative results. • A second randomized controlled trial reported reduction in all cancers, but had insufficient colorectal cancers for analysis.

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What does the future hold for patients with colorectal cancer? • Colon cancer remains a major cause of death and disease, especially in the western world. A clear understanding of the causes and course of the disease is emerging. This has allowed for recommendations regarding screening for and prevention of this disease. • The removal of colon polyps helps prevent colon cancer. Early detection of colon cancer can improve the chances of a cure and overall survival. Treatment remains unsatisfactory for advanced disease, but research in this area remains strong and newer treatments continue to emerge. • New and exciting preventive measures have recently focused on the possible beneficial effects of aspirin or other anti-inflammatory agents. In trials, the use of these agents has markedly limited colon cancer formation in several experimental models. • Other agents being evaluated to prevent colon cancer include calcium, selenium, and vitamins A, C, and E. More studies are needed before these agents can be recommended for widespread use by the public to prevent colon cancer.

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DIETARY MANAGEMENT

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Objectives • Recognize the special nutritional needs of cancer survivors during active cancer treatment • Advise cancer survivors about nutrition and physical activity during the recovery phase and beyond • Resolve controversial nutritional issues facing cancer survivors 96

Challenges of Cancer Survivors • Highly motivated to seek information about diet and lifestyle changes. • Often receive conflicting dietary advice. • Claims abound on the use of dietary alternatives. • Currently there are many gaps and inconsistencies in the scientific evidence.

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NUTRITIONAL DEFICIENCIES There are several factors that may contribute to the type and degree of nutrient deficiencies:

• The primary organ where the malignancy occurs. • The severity of the cancer at the time of diagnosis. • The symptoms experienced by the person with cancer. • The type and frequency of the cancer treatment being used and the side effects associated with that treatment (surgery, radiation, or chemotherapy). • The effect of the malignancy or disease on food and nutrient ingestion, tolerance, and utilization. 98

Body Weight Changes • Intentional weight loss during cancer treatment is not recommended • Some cancer survivors may gain weight during and after treatments • During treatment, a healthy eating plan that meets but does not exceed caloric needs (along with physical activity) is advisable • Healthy weight loss is best initiated after the recovery phase • Obesity is associated with increased risk and poorer prognosis of breast and colon cancers

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The Phases of Cancer Survival • Phase 1: Active Treatment • Phase 2: Recovery from Treatment • Phase 3: Preventing Cancer Recurrence, Second Primary Cancers. • Phase 4: Living with Advanced Cancer – Dietary management 100

Phase 1: Nutritional Issues During Active Treatment • Energy balance is the most important goal •ENERGY INTAKE •ENERGY EXPENDITURE •NUTRITIONAL SUPPLEMENTS

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ENERGY INTAKE – The need for caloric intake is usually increased during cancer treatments – Nausea, vomiting, taste changes, loss of appetite, bowel changes all interfere with the usual eating patterns. – Food choices at this time should be easy to chew, swallow, digest and absorb and should also be appealing. – Adjust usual food choices and usual food patterns.

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ENERGY EXPENDITURE – cancer treatment can cause fatigue – light regular physical activity during treatment should be encouraged to improve appetite, stimulate digestion, prevent constipation. – Helps to maintain energy level and muscle mass and provide relaxation or stress reduction

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NUTRITIONAL SUPPLEMENTS  Nutritional products such as Boost, Ensure

etc… can be helpful on a temporary basis to assist with intake of calories and nutrients.  Other supplements is quite controversial. For example, it is counterproductive for patients to take vitamin supplements that contain high levels of folic acid or to eat foods fortified with high amount of folic acid, when on Methotrexate. (metho interferes with folate metabolism).

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NUTRITIONAL SUPPLEMENTS  Antioxidants(Vitamins C, E and phytochemicals or antioxidant minerals), may reduce the effectiveness of RT or CX. May help protect normal cells from treatment collateral damage  No good answer or evidence at this time there fore it would be prudent to advise patients not to exceed the upper intake limits for vitamins and to avoid other nutritional supplements that contain antioxidant compounds.

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Phase 2: Nutritional Issues After Treatment is Completed • Most important goal and correct problems.

Rebuild muscle strength

•Adequate food intake •Physical activity

– Required to rebuild muscle strength. – Consultation required for elder patients.

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Benefits of Moderate Regular Physical Activity for Cancer Survivors • • • • • •

reduce anxiety reduce depression improve mood boost self esteem reduce symptoms of fatigue, beneficial effects on heart rate, lean body mass and respiratory capacity

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Diet and Cancer The American Cancer Society recommends 4 rules of thumb for cancer prevention • Choose most of the foods you eat from plant sources. 5 or more servings • Limit intake of high fat foods, particularly from animal sources. • Be physically active. • Limit alcohol intake. 108

Dietary Components Associated with Cancer

THE BAD GUYS!!!

Excesses of Certain substances such as: • Fat- the end products of metabolism have been found to be carcinogenic. • Alcohol- has been connected with liver, colorectal, and breast cancers.

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Dietary Components Associated with Cancer

THE BAD GUYS!!!

• Pickled and Smoked Foods- related to cancers of the esophagus and stomach. that may increase the risk. • Cooking methods have also been found to have a role in cancer. Frying or charcoal-broiling meats at very high temperatures creates chemicals 110

Protective Dietary Components

THE HEROES

• Certain foods and nutrients have been shown to protect against certain types of cancers. • Vitamin C - has been shown to protect against cancer of stomach, esophagus, and oral cavity. • Antioxidants- these are certain protective substances found in fruits and vegetables. 111

Protective Dietary Components

THE HEROES

• Fruits and Veggies- contain vitamins, fiber and phytochemicals. • Vitamin E and selenium- both antioxidants that protect cells against breakdown. • Calcium- Calcium reduces cell turnover rates. • Water- drinking more than 5 glasses a day has been associated with a lower risk of cancer. 112

Diet and Cancer • Fiber- Insoluble fiber is connected to decreased risk of colon cancer. • Beans, vegetables, whole grains and fruit are good sources. • Salt- some evidence links diets containing large amounts of foods preserved by pickling and salting to increased cancers of the stomach, nose and throat. 113

Diet and the Cancer Patient • Nutrition is an important part of treatment. • Eating the right kinds of food before, during and after treatment can help the patient feel better and stay stronger. • Treatments can have an affect on appetite. 114

Diet and the Cancer Patient • People with cancer have unique nutrition needs. • Eating enough food is usually not a problem. Treatment can have an adverse effect on appetite. • Nutrition suggestions often emphasize eating high calorie, high protein foods. 115

Diet and the Cancer Patient Side Effects Treatments kill cancer cells but they also kill healthy cells. This can cause side effects such as: • Loss of appetite • sore mouth or throat • dry mouth • dental and gum problems • changes in taste or smell • Nausea • Diarrhea • Constipation • fatigue • depression. 116

Diet and the Cancer Patient • It is very important to have good nutrition to minimize the side effects of cancer, prevent or reverse nutritional deficiencies, and to maximize the quality of life. • The best method of calorie intake is by mouth. Sometimes this is not possible. 117

Diet and the Cancer Patient Other options of intake are: • Feeding Tube • TPN or total parental nutritionthis is nutrition directly through a vein.

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FIVE FOR CANCER Five things you should remember about preventing cancer. • Eat lots of fruits, vegetables, and whole grains. • Discover the pleasure of physical activity. • Stay tobacco free • Enjoy a low-fat diet • Protect yourself from the sun between 10:00 am and 4:00 pm.

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COMMON DIET THERAPIES • FULL FLUID DIET • SOFT DIET

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FULL FLUID DIET • Initial diet. • Administered alongside or immediately after therapy. • Predominant diet for oral, pharyngeal, oesophagal and GI tract cancer. • Administered at regular intervals (Every 2 hours).

FOOD

VEGETARIAN

NON-VEGETARIAN

Corn flour

50 mg

50 mg

Dhal flour

30 mg

---

Milk

1000 ml

800 ml

Meat

---

50mg

Egg

---

One

Fruit juice

800ml

850ml

Butter

2 Tbsps

2 Tbsps

Sugar

100 mg

100 mg

The above table shows amount of food to be consumed per 121 day

SOFT DIET • Secondary diet. • Administered following a period of full fluid diet. • Enriched with nutrients. • Supplementation of essential vitamins like folate and Vit C lost during drug therapy. • Meats can be avoided as far as possible as it results in the formation of nitrosamines in stomach. • This can be countered by administration of Vit C

FOOD

VEGETARIAN

NON-VEGETARIAN

Milled cereals

300 mg

300 mg

Dhal

50 mg

30 mg

Milk

1000 ml

600 ml

Meat, fish, sausages---

100 mg

Egg

30 mg

---

Tender vegetables 50 mg

50 mg

Potatoes

100 mg

100 mg

Tender leafy vegetables

100 mg

100 mg

Fruits (Apples & Oranges)

100 mg

100 mg

Fats and Oils

30 mg

30 mg

Sugar

80 mg

80 mg

The above table shows amount of food to be consumed per 122 day

Conclusion • Cancer is a preventable disease in most cases. • Lead a healthy lifestyle. • Be aware of your body.

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Summary • Colorectal cancer is a malignant tumor arising from the inner wall of the large intestine. • Colorectal cancer is the third leading cause of cancer in males and fourth in females in the U.S. • Risk factors for colorectal cancer include heredity, colon polyps, and long-standing ulcerative colitis. • Most colorectal cancers develop from polyps. Removal of colon polyps can prevent colorectal cancer. • Colon polyps and early cancer can have no symptoms. Therefore regular screening is important. • Diagnosis of colorectal cancer can be made by barium enema or by colonoscopy with biopsy confirmation of cancer tissue. • Treatment of colorectal cancer depends on the location, size, and extent of cancer spread, as well as the age and health of the patient. • Surgery is the most common treatment for colorectal cancer. • Effective Nutrition Management is a necessity to alleviate cancer cells.

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References • • • • • • • • •

Microsoft Encarta 2006 Wikipedia 2009 MedicineNet.com MayoClinic.com Chemocare.com Inquirer.net Scribd.com http://www.cancer.gov http://www.cancer.org http://muextension.missouri.edu

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Do our Best and GOD will do the Rest !!

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