In this presentation, Dr. Deborah Schrag, Medical Oncologist from Dana Farber Cancer Institute covers therapy options, surgery options, and radiation options, that are specific to rectal cancer patients. She also touches on the importance of clinical trials for this population, and highlights a few trials in research that she finds most interesting. More information related to our Webinar Series can be found at http://fightcolorectalcancer.org/about/webinars

1. Welcome!
Advancements in Treating
Rectal Cancer
Part of Fight Colorectal Cancer’s Monthly Patient Webinar Series
Our webinar will begin shortly
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1. Tonight’s speaker: Dr. Deborah Schrag, MD
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Dr. Deborah Schrag, MD, MPH
Dana Farber Cancer Institute
Associate Professor of Medicine, Harvard Medical School

6. Deborah Schrag MD MPH
Dana-Farber Cancer Institute
Boston, MA

7.  American Cancer Society estimates 40,340
new cases of rectal cancer in 2013
 Colon/Rectal cancer is the 3rd leading cause of
cancer-related death in US

8.  The death rate from rectal cancer has been
dropping for 20+ years.
 >1 million colorectal cancer survivors in US
 Advancements:
 Screening & early detection
 Improvements in treatment

9. Detection
Workup
Staging
Treatment
Surveillance

10.  Screening (typically starts at age 50)
 Colonoscopy (camera)
 CT (scan)

11. Procedure What is it? Why do it?
Biopsy & Pathology
Review
Remove tumor tissue &
examine it under a
microscope
To discover the
presence, cause or
extent disease.
Colonoscopy &
Proctoscopy
Examine colon & rectum
with a camera
To discover the
presence, cause or
extent disease.
CT of
chest/abdomen/pelvis
An x-ray scan (image)
To see if the cancer has
spread beyond the
rectum.
CEA Blood test
Carcinoembryonic antigen
(CEA) is a protein
associated with tumors.
ERUS or MRI
Medical imaging that
examines soft tissue
To discover the
presence, cause or
extent disease.

12.  Stage
 describes the extent of the cancer in the body
 how far the main tumor has grown into nearby areas
 extent of spread to nearby lymph nodes
 whether the cancer has spread (metastasized) to other
organs of the body
 is an important factor in determining prognosis &
treatment options
 based on the results of physical exam, biopsies, &
imaging tests

13.  Surgery
 Radiation Therapy
 Chemotherapy

14.  Surgery is usually the main treatment for rectal
cancer, although radiation and chemotherapy
will often be given before and/or after surgery.
 Surgeon removes tumor and surrounding
tissues (extent of resection depends on extent
of tumor)

15.  Advances in techniques, equipment, and
surgical specialization
 More precise excision
 Availability of stapling devices
 J pouch and coloplasty pouch
 Attention to cancer clearance - Total mesorectal
excision has reduced local recurrence following
surgery
 Microsurgery

16.  High-energy rays or particles destroy cancer
cells
 Radiation may
 Lower the risk that the tumor will come back
 Improve operability

17.  External-beam radiation therapy
 Similar experience to getting an x-ray
 Endocavitary radiation therapy
 Small device inserted to deliver radiation
 Brachytherapy (internal radiation therapy)
 Small pellets of radioactive material placed next to
tumor

18.  May be administered before and/or after
surgery
 Drugs used to treat rectal cancer
 5-Fluorouracil
 Capecitabing
 Irinotecan
 Oxaliplatin

19.  Regimens (combinations of drugs) used to
treat rectal cancer
 FOLFOX = 5-FU + leucovorin + oxaliplatin
 FOLFIRI = 5-FU + leucovorin + irinotecan
 FOLFOXIRI = leucovorin + 5-FU + oxali + irinotecan
 CapeOx = capecitabine + oxaliplatin
 Addition of biologic agents
 Bevacizumab
 Cetuximab
 Panitumumab

20.  Periodic screening & tests to see if the cancer
has come back.
 History/Physical
 CT Scan
 Colonoscopy
 Blood Tests

21.  This research study is being done to see if
radiation can be avoided for a select group of
rectal cancer patients who have a good
response to 6 treatments with a chemotherapy
combination regimen known as FOLFOX.
 The proposed study does not use new agents
or procedures, but rather sequences existing
well established treatment strategies in a
different way.

22.  Stage II & III rectal cancer is treated in 3 phases:
1. Chemotherapy and radiation given together over 5.5
weeks –”chemoradiation”
 Why? To prevent the tumor from coming back in the same
location in the pelvis
2. Surgery to remove the tumor
3. Chemotherapy with a drug combination called
“FOLFOX” given every 2 weeks over about 4 months
 Why? To prevent the cancer from coming back in a distant
organ such as the liver

23.  With modern surgical techniques, chemotherapy
advances, and MRIs it is possible that some patients
can avoid radiation to the pelvis
 Because chemoradiation has side effects, it would be
valuable to avoid it for patients who can achieve good
results without it
 Rectal cancer specialists hope that FOLFOX
chemotherapy before surgery will enable some rectal
cancer patients to avoid chemoradiation

24.  Radiation treatment is time consuming….daily visits
 Radiation often has long term effects on bowel bladder
and sexual function
 Radiation in previous clinical trials does not improve
overall survival rates, but does decrease the local
recurrence rates
 Radiation treatment may be unnecessary for some
patients with early stage rectal cancer
 Better imaging techniques, better surgical techniques
have made it easier to carefully stage patients
 We do not know the best way to treat this disease until
we carefully compare these approaches.
 We need your help!

25. Chemotherapy
for 3-4 months
Surgery
5.5 weeks
of radiation
with 5FU
chemotherapy
(5FUCMT)
4-6 weeks
Recovery
4-6 weeks
Recovery

26. Chemo
for 3-4
Months*
Surgery
If tumor
responds to
chemotherapy
If tumor
does not
respond to
chemo
5.5 weeks
of radiation
with 5FU
chemo
(5FUCMT)
Surgery
Chemo
for 3-4
months
Re-
evaluation
3 mo. of
chemo
(6 FOLFOX
treatments)
4-6weeksrecovery
4-6weeksrecovery
4-6weeksrecovery4-6weeksrecovery
*If the pathologist or surgeon find evidence of more extensive disease, it is
possible that postoperative 5FUCMT could also be recommended

27.  The National Cancer Institute at:
 1-800-4-CANCER (1-800-422-6237)
 http://cancer.gov/clinicaltrials/
 http://cancer.gov/cancerinfo/
 For more information about the PROSPECT trial
(N1048):
 http://www.cancer.gov/clinicaltrials/search/view?cdrid=715321&
protocolsearchid=10158136&version=patient
 The lead investigator for this trial, Dr. Deborah Schrag, at
deb_schrag@dfci.harvard.edu
 The protocol coordinator for this trial, John Taylor, at
jtaylor1@uchicago.edu

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