Kembara Xtra - Medicine - Colorectal Cancer

Kembara Xtra - Medicine - Colorectal Cancer 
​Introduction 

Colon and rectal cancers, sometimes known as CRC, are frequently come  together.
linked but are two separate clinical entities that are distinct from one another in the
their diagnosis, presentation, staging, and care are all aspects of their situation.
Colorectal cancer is the most common form of the disease and the second biggest cause of cancer fatalities.
the third most prevalent form of cancer in both men and women in the
United States of America.
Regular screening for colon cancer lowers both the risk of developing and the
cancer of the colon, leading to death.

Epidemiology (Incidence and Prevalence) 
Incidence
It is anticipated that in the United States in the year 2019, there will be a total of
101,420 newly diagnosed cases of colon cancer and 44,180 newly diagnosed cases of breast cancer
according to the statistics provided by the American Cancer Society.
Approximately 51,020 cases of colorectal cancer are anticipated to be diagnosed this year.
deaths that will occur in 2019.
There is not much of a difference in the incidence of the disease between males and women.
The colorectal cancer ranks as the third most prevalent form of the disease worldwide.
and is the second most prevalent kind seen in females.
Recent database research indicates that there is a general tendency toward greater
occurrence within the population older than 50 years.

Prevalence
The likelihood of a person in the United States having colon cancer throughout the course of their lifespan
States is approximately 1 in 22 (4.49%) cases for men and 1 in 24 (1%) cases for women.
(4.15%) in the case of females.
Both the incidence of the disease and the death rate have been on the decline due to
enhanced diagnostic testing, preventative measures, and treatment options.

Pathophysiology 

The progression from the earliest aberrant cells to the latter stages of the disease.
The first symptoms of colon cancer typically show between the ages of 10 and 15.
years, a characteristic of the disease that adds to the
the efficiency of the screening and preventative processes.
Multiple polyps, villous or atypical polyps are examples of high-risk polyp findings.
polyps with a dysplastic appearance as well as bigger polyps. Polyps that are hyperplastic
are less likely to progress into colorectal cancer over time.
There are a number of genetic and environmental factors that have been found to be
connected to the beginning of the CRC project.
Genetics
10 percent of cases of colorectal cancer have been related to an inherited gene.
Patients who present with an early beginning of CRC are more likely to have a larger percentage of
reasons related to genetics, hence the need for genetic counseling and
potentially a colorectal cancer–specific multigene panel
could be advised to patients who were diagnosed with CRC at an early stage.
or members of their immediate or first-degree family.
- A good many of them are passed down in an autosomal dominant fashion.
fashion:
alterations in the tumor suppressor gene APC have been found in familial
adenomatous polyposis (FAP).
Genes that are responsible for DNA mismatch repair (MMR)
Hereditary nonpolyposis has been linked to enzymes in some cases.
colon cancer, often known as high-risk non-polyposis colon cancer or HNPCC,
including but not limited to hMLH1, hMSH2, hMSH6, hPMS1, and hPMS2
others.
○ STK11, a tumor suppressor gene, is mutated in Peutz-
Jeghers syndrome.
– It's possible that just a tiny percentage of patients with hereditary CRC have.
a recessive gene.

MUTYH faults are the root cause of problems with the base excision.
repair gene. The MUTYH-associated polyposis (MAP) is a type of cancer.
may manifest itself as a different form of FAP.
Oncogenes have been associated to sporadic occurrences of colorectal cancer (CRC):
KRAS, C-MYC, C-SRC, HER-2/neu, BRCA1, BRCA2, TP53, and others have been linked to cancer.
others.

factors of danger 
● Age
- More than ninety percent of individuals diagnosed with sporadic colon cancer
are older than fifty years of age.
On the other hand, younger individuals have a greater risk of having
disease in an advanced stage at the time of diagnosis as a result of low
suspicion of cancer and decreased access to care.

A history of colorectal polyps in one's own family - The likelihood of developing polyps increases with age
numerous polyps, villous polyps, bigger polyps (>1 cm), and
dysplasia was found to be present.

Personal experience with the disease
- A thirty percent increased likelihood of acquiring a metachronous (new) condition
primary cancers that are unrelated to any of the patients' past conditions
malignancies) colon cancer - 2–4% incidence of local
colon cancer recurrence, a three to five percent incidence of
radiation therapy's long and complicated history with synchronous colon cancer
to the belly and the pelvic

Personal experience with inflammatory bowel disease (also known as IBD) –
Prevalence of colorectal cancer in patients with Crohn disease and ulcerative colitis
is less than 3%, while the cumulative chance of developing colorectal cancer after ten years is 2%.
8% during the first 20 years, and 18% after the first 30 years.
– Ulcerative colitis with pancolitis can increase the risk of colon cancer by up to 10 times.
CRC, eight to ten years following the original diagnosis.
A history of CRC in the family
— The presence of even a single first-degree relative who has a history of
The CRC roughly multiplies the risk by 1.7.
Those with a previous history of the condition have a risk that is more than two times as high.
CRC or polyps in any first-degree relative who is younger than fifty years old
of age
Two relatives within the first degree, regardless of their age
One relative within the first degree and one within the second degree

● Inherited syndromes
— HNPCC
○ Often develops in young age (Average age at
average age at diagnosis of colorectal cancer is 48 years.) Frequently appears with
lesions on the right side of the body and cancer are likely to come again.
risk of colorectal cancer ranges from 52 to 69%; also related with
endometrial and other malignancies account for less than three percent of the total.
all CRC
– FAP
Those that are afflicted can get anything from hundreds to thousands of
polyps in the colon and rectum, generally appearing as symptoms of colon cancer
while they were younger.
CRC is typically present in untreated patients by the age of 40 years.
individuals; nevertheless, the majority are taking preventative medication
colectomies.
Represents less than one percent of the CRC
Gardner syndrome and Turcot syndrome are two examples of variants of this condition.
as well as attenuated forms of influenza A (AFAP).
– Peutz-Jeghers syndrome
It's possible that some people have hyperpigmented skin.
lesions of the mucocutaneous tract (mouth, hands, and feet) as well as big
Adolescent discovery of polyps in the gastrointestinal tract.
an increased risk of CRC and other cancers ranging from 81–93%
- BRCA1 and BRCA2 disorders
a number of pieces of evidence point to the possibility that those who carry the BRCA1 gene
increased risk for early-stage cancer of the colon; nonetheless, there is more evidence
is required in order to make a recommendation for early screening.

racial and ethnic categories
— The incidence of colorectal cancer is higher among African Americans, and
rates of death that occur in the United States. These significant differences
require further investigation, however there may be a connection to diet,
factors such as pressures, falling insurance coverage, and perceptions
concerning colorectal cancer screening, bias on the part of providers and systemic
racism, complications following the removal of polyps, and lack of faith in clinical
trials, as well as a decline in chances for physician referrals.
Aspects of one's way of life
- Cigarette smoking, being overweight, engaging in sedentary behavior, insulin resistance,
diet heavy in fat and low in fiber, as well as perhaps the microbiota

Prevention 

There are several different screening methods available for colon cancer. Stoolbased
examinations like the guaiac fecal occult blood test
(gFOBT) as well as the fecal immunochemical test (FIT) or the FIT-DNA.
tests are less intrusive, but endoscopic testing (more flexible) is still the gold standard.
sigmoidoscopy or colonoscopy) has the opportunity to provide information on potential
intervention in the event that a polyp is found.
Factors related to one's way of life that could lower one's risk: – No study has
proof that is convincing enough to affect risk
screening and categorization depending on the presence of protective variables.
- A healthy diet rich in fiber, consistent physical activity, and
There is a lack of consensus regarding the folic acid content in fruits and vegetables.
acid, calcium, vitamin D, magnesium, NSAIDs, fish oil,
as well as statins.
ALERT
The United States Preventive Services Task Force (USPSTF) has issued a strong recommendation that
suggests beginning colorectal cancer screening between the ages of 50 and 75
years (A) and reports that there is a fair amount of confidence that
There is a moderate benefit to screening between the ages of 45 and 50.
(B). The American Cancer Society and a few other organizations, in addition, recommend
screenings will begin at the age of 45. For those between the ages of 76 and 85
screening should be based on the individual's overall health, regardless of age.
status and life expectancy, as well as the shared responsibility for
patient participation in decision-making with health care providers
provider.
● Screening methods:
— Assessments based on visualization:
— A colonoscopy once every ten years
sigmoidoscopy with flexible endoscope once every five years
Flexible sigmoidoscopy once every ten years in addition to FIT testing once each year
– Tests that are based on stool:
FIT once every year
fecal occult blood tests with a high level of sensitivity should be performed annually
FIT-DNA (sDNA) test between once every 1 and 3 years
– Tests that rely on imaging:
a colonoscopy with CT scan once every 5 years
- For individuals who have either a positive FIT or FOBT as well as a positive stool DNA test
test, a colonoscopy is strongly suggested as the next step.
Cancer detection by screening in high-risk populations: – The American College of
The field of gastroenterology advises screening for people of African descent.
beginning when the person is 45 years old.
Those with a family history of polyps should have frequent colonoscopies.
screening colonoscopy, with the time between examinations based on
the number of polyps, their size, and their histology (1).
— Individuals who have a relative inside the first degree or two within the second degree
family history of colorectal cancer or adenomatous polyps
Before the age of 60 years old, one should start having colonoscopies around the age of 40.
or ten years younger than the age of the relative with the youngest child.
whenever the cancer is diagnosed, whichever comes first.
Patients diagnosed with IBD ought to get surveillance colonoscopies.
8 to 10 years following the diagnosis, once every one to two years.
- Patients who have had abdominal or pelvic radiation in the past should be
screened; nevertheless, suggestions tend to differ from case to case.
beginning between the ages of 30 and 40 years and repeating every 5 years
to a period of ten years following that.
- Individuals suspected of having a genetic condition may benefit from undergoing genetic testing.
a significant family history of colorectal cancer or polyps: 
The family and friends of a patient with HNPCC should get started.
a colonoscopy at the age of 25.
Individuals who have a history of symptoms consistent with FAP should have yearly
sigmoidoscopy with a flexible scope starting between the ages of 10 and 12
years; if polyps are found, a colonoscopy is need to be performed.
recommended.
How often should polyps be followed up on: – Less than one year:
Having to Do It Piece by Piece (You Can't Remove It All at Once)
loop) excision of a big polyp that is greater than 15 mm in size 
With Sharp Edges
polyposis syndrome; one of the following conditions must be met.
the presence of at least five polyps with serrated edges proximal to the
sigmoid, having at least two 10 mm thicknesses 
Any polyps with serrated edges
proximal to the sigmoid with a history of serrated tumors in the family
polyposis syndrome 
Twenty polyps with serrations of any size
across the whole of the colon
– 1 year:
Known case of FAP or at risk due to a history in the family
- From one to two years:
Irritable bowel disease, such as Crohn's or ulcerative colitis
– <3 years:
○ >10 adenomatous polyps
– 3 years:
○ 3 to 10 tubular adenomas
○ Tubular adenoma 10 mm or greater
Sessile polyp with serrations that are 10 mm or greater
○ Villous adenomatous polyp
Serrated polyp or high-grade dysplastic adenoma on the
pathology
a sessile serrated polyp that demonstrates signs of dysplasia
adenoma with serrations
– 5 years:
1 sessile serrated polyp less than 10 millimeters in size and free of dysplasia;
Prior history of colon cancer surgery if the starting period was less than one year
Normal follow-up will occur One relative within the first degree with
Having a diagnosis of CRC or advanced adenoma before the age of 60
Two relatives within the first degree who have been diagnosed at any age
age
– 10 years:
— A colonoscopy screening that was normal and revealed no polyps
Polyps of hyperplastic differentiation in the rectum or sigmoid colon, 10
mm
On pathology, there were three tubular adenomatous polyps, all of which were ten
mm in size (with the potential to recur every 5 years depending on risk factors) 
One relative within the first degree with colorectal cancer or advanced
an adenoma was identified at the age of sixty, and it was of the second degree.
relatives that have colon cancer

Conditions That Often Occur Together 
Syndromes associated with polyposis that have a greater correlation with
colorectal cancer, including HNPCC, Gardner, and Crail (Turcot), as well as other variants of the disease
FAP, Peutz-Jeghers, and juvenile polyposis syndromes 
●
inflammatory bowel diseases (IBDs), including Crohn disease and in particular ulcerative
pancolitis accompanied with colitis


Providing an Account of History 
The majority of people who have colon cancer do not have any symptoms.
Microcytic anemia of iron deficiency in men of any age and women of any age in men
CRC is presumed to exist in postmenopausal women until proven otherwise;
diagnostic colonoscopy.
There is a possibility that symptoms point to an advanced condition.
- Aching or cramping in the abdominal region
- Alterations in bowel habits or in the consistency of the stool
(tenesmus, constipation, diarrhea) Rectal hemorrhage, tenesmus, constipation, diarrhea
black stools, or blood in stool
- Weakness and/or exhaustion
- Loss of weight for no apparent reason

The Patient's Clinical Examination 
Symptoms of anemia, such as a pale complexion and systolic flow murmurs, etc. 
●
Loss of weight
● Palpable abdominal mass (late presentation) 
● Must
include digital rectal exam

Differential Diagnosis 
>95% of colon malignancies are adenocarcinomas. Different colonic
Carcinoid tumors, lymphomas, and Kaposi's sarcoma are all types of tumors.
sarcoma in HIV.

Results From the Laboratory 
Initial Tests (lab, imaging)
In the event that any screening technique identifies an increased risk,
The colonoscopy needs to be done because it has the potential to both
both in terms of diagnosis and treatment.
Obtain the following tests if you have a biopsy that confirms you have colorectal cancer: CBC,
ferritin accompanied with an iron panel
- CEA—most frequently utilized for the diagnosis of chronic or
illness recurrence in the years to come

Tests to Follow, in Addition to Special
Considerations
a contrast-enhanced CT scan of the chest, abdomen, and pelvis to look for
metastatic disease; if found, MRI of the brain will be performed 
● Intraoperative
An example of a solid organ that can be evaluated with ultrasonography is the liver.
liver) following the removal of the tumor.
Positron emission tomography, or PET, may be used in certain circumstances.
may be utilized to detect metastatic disease, especially if the patient has a history of smoking.
It is not possible to employ contrast.
The many stages of colon cancer
- The AJCC tumornode, which stands for the American Joint Committee on Cancer
The staging of the metastases is recommended.
○ Stage 0: restricted to the mucosa (carcinoma in situ or
intramucosal cancer) (Tis, N0, M0) 
○ Stage I:
invades mucosa (T1) or muscularis propria (T2); no
lymph node involvement or invasion at distant places (grade T1, N0, M0 or higher)
T2, N0, M0) 
Invades the pericolorectal stage at Stage IIA
tissues; no lymph nodes or distant places (T3, N0, M0)
Penetration to the surface of the visceral layer in Stage IIB
peritoneum; no lymph nodes or distant sites (T4a, N0,
M0) 
Stage IIC: directly invades other tissue or adheres to it
tissues or anatomical structures (T4b, N0, M0) 
○ Stage IIIA:
spreads across the submucosa as well as the muscularis propria.
between one and three lymph nodes; there were no distant locations (T1, N1, or M0).
T2, N1, M0) 
○ Stage IIIB: invades pericolorectal
tissues or the surface of the visceral peritoneum, with further spread to
1 to 3 lymph nodes; there are no distant sites (T3, N1, M0, etc).
T4a, N1, M0) 
Invades the pericolorectal stage at Stage IIIC
tissues, the peritoneum, or any of the other organs, in addition to 4
lymph nodes in the immediate area; no distant sites (either T3 or T4,
N2, M0) 
Any level of invasion with spread is considered to be Stage IVA.
pertaining to a single organ or place (any T, any N, M1a). 
○ Stage IVB:
any degree of invasion that has extended to more than one location
peritoneum or organ or any other place (any T, any N, M1b).

Management 

Treatment 
It is abundantly established that adjuvant chemotherapy is advantageous for stage
III (node-positive) illness, when improvements of 30% are seen in patients
can be accomplished in terms of the reoccurrence of the disease as well as the overall
survival when compared to those who did not get any treatment.
Chemotherapeutic methods for diseases that have spread to other organs may
increase the average survival time from six months to two years. Often
Therapies such as FOLFOX (folinic acid, 5-fluorouracil, and oxaliplatin) are utilized.
oxaliplatin), FOLFIRI (folinic acid, leucovorin, 5-fluorouracil,
irinotecan) or CAPEOX (capecitabine, oxaliplatin). Additional
Depending on the genetics of the tumor, other drugs might be administered.
includes bevacizumab, encorafenib, pembrolizumab,
panitumumab, entrectinib, regorafenib, ramucirumab,
cetuximab, nivolumab, and ziv-aflibercept.

Surgical Methods and Operations 
Cancer that is localized
- Operation is the primary treatment, which frequently is required.
Additionally, regional lymph node excision was performed.
- Primary anastomosis can be performed without any major difficulties.
can be a possibility for malignancies found locally.
Resections with the use of drainage tubes are typically necessary for obstructions.
diversion, then colectomy, followed by regional anesthesia
lymphadenectomy.
- Laparoscopic surgery, often known as minimally invasive surgery, has a smaller number of incisions.
complication rates, lower blood loss, shorter hospital stays, and lower overall healthcare costs.
time until the first bowel movement and decreased death rate after 30 days
when contrasted with conventional open surgery involving equal
clinical oncologic results.

Cancers that have progressed locally
-Frequently necessitate the removal of many organs
● Metastatic cancer
Depending on the comorbidities of the patient and the care goals for that patient, it
It sometimes makes sense to resect metastatic disease aggressively.
lesions confined to the liver and lungs in addition to those affecting the
primary tumors.

Keep in Touch 
Monitoring of the Patient
The first four years after treatment are associated with the highest risk of a cancer recurrence; in the first year, 80
2.5
H&P and CEA assessments once every three to six months for the next five years 
● Annual
chest, abdominal, and pelvic CT scans every three years 
● Surveillance
colonoscopy one year after the initial surgical procedure, and then every five years after that.
years, if everything is average 
The CEA is utilized in the process of recurrence detection following
a procedure to remove the main tumor of the colon. CEA levels fall
and return to normal within four to six weeks following surgical intervention.

Prognosis 

Rate of relative survival over 5 years following surgical:
● Stage I: 85–95%
● Stage II: 60–80%
● Stage III: 30–60%
Stage IV: 25–40% after hepatic resection (after hepatic resection)
metastases that have unobscured margins

Complications 
Side effects of chemotherapy include alopecia, nausea, vomiting, and bruises.
drowsiness, a higher possibility of contracting infections 
• Radiotherapy lead to 
inflammation of the skin, nausea, rectal pain, bladder and bowel incontinence, and incontinence
irritability, exhaustion, and sexual dysfunction are all symptoms.