This webinar discusses rectal cancer. It begins with introducing the speaker and providing objectives for the webinar. It then covers topics such as prevalence and risk factors of rectal cancer, methods of diagnosis, determining the cancer stage, standard treatment options including surgery, radiation, chemotherapy and targeted therapy. Treatment is discussed in relation to cancer stage. The webinar also touches on survivorship issues and future research regarding rectal cancer.
2. • Speaker(s): Mary Mulkerin, RN, OCN
• Archived Webinars: FightColorectalCancer.org/Webinars
• AFTER THE WEBINAR: Expect an email with links to the
material & a survey. If you fill it out, we’ll send you an “I
booty” bracelet.
• Ask a question in the panel on the RIGHT SIDE of your
screen
• Follow along via Twitter – use the hashtag #CRCWebinar
Today’s Webinar:
4. Disclaimer
:
The information and services provided by Fight Colorectal
Cancer are for general informational purposes only. The
information and services are not intended to be substitutes
for professional medical advice, diagnoses or treatment.
If you are ill, or suspect that you are ill, see a doctor
immediately. In an emergency, call 911 or go to the nearest
emergency room.
Fight Colorectal Cancer never recommends or endorses any
specific physicians, products or treatments for any condition.
5. Speaker:
Mary Mulkerin, RN, OCN is the Gastrointestinal
Oncology Nurse Coordinator at University of
Wisconsin Carbone Cancer Center, coordinating multi-
disciplinary patient care and leading a Gilda’s Club
support group. She obtained her BSN from the
University of Wisconsin-Madison and has practiced in
Oncology for the last 31years. She is currently
completing her MS in Nursing Education at Edgewood
College to pursue her research interests in
survivorship and patient and staff education, in
addition to developing a patient education app that
would make patient’s management of their care more
accessible and user-friendly.
6. MARY MULKERIN, RN, BSN, OCN
UNIVERSITY OF WISCONSIN
CARBONE CANCER CENTER
MAY 25, 2016
Rectal Cancer 101
7. Objectives
Discuss:
Prevalence, risk factors and diagnosis of rectal
cancer
Staging of rectal cancer
Types of treatment and treatment by stage
Survivorship
Future research
8. Rectal Cancer
Malignant (cancer cells) form in the tissues of the
rectum
The rectum is about 6 inches – temporary
storehouse for feces
Coccyx
Tumor
Rectum
Bladder
Image retrieved from: aibolita.com
9. Prevalence
Colorectal Cancer (CRC) – 3rd most common
diagnosed cancer
39,220 new cases per year – slightly more prevalent
in men than women
About 5% or 1 in 20 people of the general population
90% of cases are diagnosed over age 50
Rates are decreasing over time
There are more than 1 million CRC survivors!
American Cancer Society, 2016
10. Increased Prevalence in Younger Adults
Incidence increasing in people under age 40
Between 1984-2005, rate increased by 3.8% - doubled
Approximately 18% rectal cancer cases are in people
<50, 11% for colon cancer
Of these, 20% are caused by familial syndromes
Cause unknown, but possibly related to lifestyle
behaviors and environmental factors
Malik, M., 2016
11. Who’s at risk?
Age 40 or older
Certain hereditary conditions
Having a parent, sibling, or child with a history of
colorectal cancer
Behavioral risk factors
Personal history of:
Colorectal cancer
Polyps
Cancer of the ovary, endometrium or breast
Cleveland Clinic, 2016
12. Symptoms
Change in bowel habits
Diarrhea/Constipation
Narrow stools
Feeling like the bowel does not empty completely
Blood in the stool
Abdominal discomfort
Change in appetite
Unintentional weight loss
Fatigue
Anemia
Cleveland Clinic, 2016
13. Detection
Physical exam and history
Digital rectal exam
Proctoscopy
Colonoscopy
Biopsy
Carcinoembryonic antigen (CEA) – tumor marker
Cleveland Clinic, 2016
14. Factors Affecting Prognosis and Treatment
Stage of the cancer
Whether the tumor has spread into or through the
bowel wall
Where the cancer is located in the rectum
Whether the bowel is blocked or has a hole in it
Whether all of the tumor can be removed by surgery
General health of the person
New diagnosis vs. recurrence
Cleveland Clinic, 2016
16. How Does Cancer Spread?
Through tissue – cancer invades the surrounding
normal tissue
Through the lymph system – cancer invades the
lymph nodes then travels
Through the blood – Capillaries and veins are
invaded by cancer
Metastasis – cancer cells spread from the primary
tumor and form another tumor in another site
Cleveland Clinic, 2016
18. Standard Treatment of Rectal Cancer
Surgery
Radiation Therapy
Chemotherapy
Targeted Therapy
Cleveland Clinic, 2016
19. Surgery
Surgery is the most common treatment for all stages
Radiation therapy or chemotherapy may be given
before surgery – neoadjuvant therapy
After surgery, chemotherapy or radiation may be
given – adjuvant therapy
Cleveland Clinic, 2016
20. Types of Surgery
Type of surgery depends on the stage and overall
health of the person
Types
Polypectomy
Cryosurgery
Local excision - TAMIS
Resection
Radiofrequency ablation
Pelvic exenteration
Cleveland Clinic, 2016
21. Surgical Resection
Low Anterior Resection (LAR) – Tumor is in
the upper part of the rectum. May have a temporary
ostomy.
Proctectomy with colo-anal anastomosis –
Tumor is in the mid to lower third. Entire rectum
removed and colon is attached to the anus
Abdominoperineal resection (APR) – Tumor is
in the lower rectum. Permanent ostomy
American Cancer Society, 2016
22. Radiation Therapy
High-energy x-rays or other types of radiation is
used to kill cancer cells
2 types of radiation:
External beam
Internal radiation – uses needles seeds, wires or catheters
Type of treatment chosen and length of treatment
depends on stage
Cleveland Clinic, 2016
23. Chemotherapy – Anti-Cancer Drugs
Chemotherapy is give at different times during
treatment – before or after surgery and for stage IV
cancer
Chemotherapy is given is different ways:
Systemic chemotherapy – IV or orally
Regional chemotherapy – given directly into an
artery that leads to a part of the body with a
tumor. Examples: Hepatic artery infusion,
Chemoembolization
American Cancer Society, 2016
24. Embolization
Substances are injected into the hepatic artery to try
and block or reduce the blood flow to cancer cells in
the liver
3 main types of embolization:
Arterial embolization
Chemoembolization (TACE)
Radioembolization
American Cancer Society, 2016
25. Targeted Therapy
Drugs that attack specific genes or proteins in a
cancer
Often have different and less severe side effects
May be given alone or with chemotherapy
Examples:
Drugs that target blood vessel formation
Drugs that target Epidermal Growth Factor Receptor –
Test tumor for KRAS Mutation/Molecular Profiling
Kinase inhibitors – block signals to the cancer cell’s
control center
American Cancer Society, 2016
26. Treatment of Rectal Cancer by Stage
Stage 0 – Removal of the polyp only
Stage I
Local excision
Resection
Resection with radiation therapy and chemotherapy
usually before surgery but may be after
Stage II
Resection plus chemotherapy and radiation
Resection with or without chemotherapy after surgery
Cleveland Clinic, 2016
27. Treatment of Rectal Cancer by Stage
Stage III
Resection plus chemotherapy and radiation usually
before surgery
Resection with or without chemotherapy after surgery
Stage IV and Recurrent Rectal Cancer
Resection with or without chemoradiation before surgery
Resection or pelvic exenteration as palliation
Palliative radiation and/or chemotherapy
Chemotherapy with or without targeted therapy
Placement of a rectal stent/diverting ostomy
Tumor Molecular Profiling
Cleveland Clinic, 2016
28. Treatment of Rectal Cancer by Stage
Treatment of liver metastasis
Cryosurgery of Radiofrequency Ablation
Chemoembolization or systemic chemotherapy
Internal radiation therapy
Surgery to remove the tumor
Treatment of lung metastasis
Cryosurgery or Radiofrequency Ablation
Surgery
Cleveland Clinic, 2016
29. Living as a Rectal Cancer Survivor
A cancer survivor is anyone who has been diagnosed
with cancer – from the time of diagnosis and for the
balance of his or her life
Survivorship Care Plan
Treatment summary
Suggested schedule for follow-up exams and tests
Long-term effects from treatment – management and
when to call the doctor
Surveillance for recurrence and secondary cancers
Healthy lifestyle suggestions
American Cancer Society, 2016
30. Survivorship
Follow-up
Doctor visits
Colonoscopy
CT Scans or other imaging
CEA
Some side effects linger after treatment or may
develop months or years later
American Cancer Society, 2016
31. Long-Term Treatment Effects
Fatigue
Keep a diary for 1 week and use the diary to plan your
schedule
Make a daily schedule with rest breaks
Keep naps to < 30 minutes
Be active
3 Ps: Prioritize, Plan and Pace
Neuropathy
Take practical steps to make your environment safer
May take months or years to improve
Full recovery sometimes is not possible
32. Long Term Treatment Effects
Changes in bowel function
Imodium, Stool bulking agents
Pelvic floor exercises
Diet
Phantom rectal sensation/pain – common, resolves
spontaneously in most cases
Ice packs/warm baths
Anti-depressant medications
Pelvic floor exercises, yoga
Relaxation techniques
33. Emotional Challenges
Sense of relief
Sadness, sense of loss
Worry, irritability and
anxiety
Fear of recurrence
Unexpected emotions
Losing the “safety net”
Role changes
Changes in social
support
Changes in relationships
with family, friends &
coworkers
Unmet expectations
about returning to
normal, “new normal”
34. Additional Concerns
Changes in sexual function
Infertility
Returning to work
Financial issues
Genetic counseling
35. Lowering Risk of Recurrence
Healthy weight
Being active
Eating a healthy diet
Aspirin
Alcohol
Quitting smoking
American Cancer Society, 2016
36. What’s New in Rectal Cancer Research
Prospect Clinical Trial – awaiting data analysis. 4
months of IV chemotherapy is given prior to surgery
instead of chemotherapy and radiation
TNT – Total neoadjuvant therapy. IV chemotherapy
followed by chemotherapy and radiation, then
surgery. No further treatment after surgery.
Traditionally, only 68% of patients complete all of
their adjuvant therapy
37. References
American Cancer Society. (2016). Retrieved from
http://www.cancer.org/cancer/colonandrectumcanc
er/detailed guide
Cleveland Clinic. (2016). Retrieved from
http://my.clevelandclinic.org/health/diseases_condi
tions/hic-colorectal-cancer
Malik, M., (2015). Rising rates of sporadic colorectal
cancer in young adults: a possible environmental
link. Retrieved from http://am.asco.org/rising-rates-
sporadic-colorectal-cancer-young adults-possible-
environmental-link
38. Question & Answer:
SNAP A
#STRONGARMSELFIE
Bayer HealthCare will donate $1 for every
photo posted (up to $25,000).
Flex a “strong arm” & post it to Twitter or
Instagram! (Use the hashtag!)
Biopsy – may check for gene mutations, Lynch syndrome, special immunohistochemical stains
Stage 0 – Carcinoma in situ – abnormal cell are found in the innermost (mucosa) lining of the rectum
Stage I – cancer formed in the mucosa of the rectal wall and has spread to the submucosa and possibly to the muscle layer
Stage II – Cancer has spread through the muscle layer and possibly through the serosa, and possibly nearby organs. No lymph nodes involved.
Stage III – Cancer has spread to the mucosa and possibly through the submucosa, serosa and muscle wall. Cancer has spread to nearby lymph nodes.
Stage IV – Cancer has spread through the muscle wall and may have spread to nearby organs and lymph nodes. Cancer has spread to one or more organs not near the rectum, such as liver or lung.
Neoadjuvant therapy – makes it easier to remove the tumor with clean margins, lessens problems with bowel control after surgery
Cryosurgery – Instrument is used to freeze and destroy abnormal tissue. Carcinoma in situ or stage 0
Local excision – Cancer has not spread to the wall of the rectum Trans Anal Minimally Invasive Surgery
Resection – Cancer has spread to the wall. Portion or all of the rectum is removed. Lymph nodes removed. Will cover more later.
RFA – High – energy radio waves. Probe through the skin, uses and electric current. Used on liver/lung
Pelvic Exenteration – Cancer has spread to nearby organs. Lower colon, bladder, and lymph nodes are removed. In women, the cervix , vagina and ovaries are removed. In men, the prostate is removed.
Needs to be done in a high volume center with a dedicated colorectal surgeon – better outcomes
LAR – part of the rectum is removed and the reattached to the remaining part of the rectum wither right away or later
Chemo – Capecitabine, FOLFOX
Arterial embolization – catheter is inserted in the femoral artery to the hepatic artery and small particles are injected to block up the artery
Radioembolization – small beads (microspheres) coated with radioactive ytrium-90 in the hepatic artery
4 in 10 patients are KRAS mutations
Stage I – 5 year survival rate 87%
Stage IIA 80%, IIB 49%
Stage IIIA 84%, IIIB 71%, IIIC 58%
Stage IV 12%
Take care of emotions, express thoughts and feelings, time to heal, communicate, find ways to relax, use min-body approaches, focus on solutions