Early Diagnosis and Treatment of Cancer Series: Colorectal Cancer

269 Pages·2010·11.954 MB·English

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EARLY DIAGNOSIS AND TREATMENT OF CANCER: ISBN-13: 978-1-4160-4686–8
COLORECTAL CANCER
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Library of Congress Cataloging-in-Publication Data
Early diagnosis and treatment of cancer: colorectal cancer / edited by Susan L. Gearhart, Nita Ahuja.
p. ; cm.—(Early diagnosis and treatment of cancer series)
Includes bibliographical references and index.
ISBN 978-1-4160-4686-8
1. Colon (Anatomy)—Cancer. 2. Rectum—Cancer. I. Gearhart, Susan L. II. Ahuja, Nita.
III. Series: Early diagnosis and treatment of cancer series.
[DNLM: 1. Colorectal Neoplasms—diagnosis. 2. Colorectal Neoplasms—therapy. 3. Early
Diagnosis. WI 529 C719035 2010]
RC280.C6C6627 2011
616.99′4347—dc22
2010012920
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Last digit is the print number: 9 8 7 6 5 4 3 2 1
This book is dedicated to all the patients with colorectal cancer that we
have had the privilege to treat. Your courage in facing this disease
inspires us to continue to seek a cure for colorectal cancer both as
surgeons and as scientists.
Series Preface
Seen on a graph, the survival rate for many ■ What lifestyle factors might affect the
cancers resembles a precipice. Discovered at an outcome of treatment?
early stage, most cancers are quickly treatable,
and the prognosis is excellent. In late stages, Each volume in the series is edited by an
however, the typical treatment protocol becomes authority within the subfi eld, and the contribu-
longer, more intense, and more harrowing for tors have been chosen for their practical skills as
the patient, and the survival rate declines steeply. well as their research credentials. Key Points at
No wonder, then, that one of the most impor- the beginning of each chapter help the reader
tant means in fi ghting cancer is to prevent or grasp the main ideas at once. Frequent illustra-
screen for earlier stage tumors. tions make the techniques vivid and easy to
Within each oncologic specialty, there is a visualize. Boxes and tables summarize recom-
strong push to identify new, more useful tools mended strategies, protocols, indications and
for early diagnosis and treatment, with an contraindications, important statistics, and other
emphasis on methods amenable to an offi ce- essential information. Overall, the attempt is to
based or clinical setting. These efforts have make expert advice as accessible as possible to
brought impressive results. Advances in imaging a wide variety of health care professionals.
technology, as well as the development of For the fi rst time since the inception of the
sophisticated molecular and biochemical tools, National Cancer Institute’s annual status reports,
have led to effective, minimally invasive appro- the 2008 “Annual Report to the Nation on the
aches to cancer in its early stages. Status of Cancer,” published in the December
This series, Early Diagnosis and Treatment of 3 issue of the Journal of the National Cancer
Cancer, gathers state-of-the-art research and Institute, noted a statistically signifi cant decline
recommendations into compact, easy-to-use in “both incidence and death rates from all
volumes. For each particular type of cancer, the cancers combined.” This mark of progress
books cover the full range of diagnostic and treat- encourages all of us to press forward with our
ment procedures, including pathologic, radio- efforts. I hope that the volumes in Early Diag-
logic, chemotherapeutic, and surgical methods, nosis and Treatment of Cancer will make health
focusing on questions like these: care professionals and patients more familiar
with the latest developments in the fi eld, as well
■ What do practitioners need to know about as more confi dent in applying them, so that early
the epidemiology of the disease and its risk detection and swift, effective treatment become
factors? a reality for all of our patients.
■ How do patients and their families wade
through and interpret the myriad of testing? Stephen C. Yang, MD
■ What is the safest, quickest, least invasive way The Arthur B. and Patricia B. Modell
to reach an accurate diagnosis? Professor of Thoracic Surgery
■ How can the stage of the disease be Chief of Thoracic Surgery
determined? The Johns Hopkins Medical Institutions
■ What are the best initial treatments for early-
stage disease, and how should the practitioner
and the patient choose among them?
Preface
In the United States, colorectal cancer ranks as an introduction to the current understanding of
the third most common cancer in both inci- the epidemiology, risk factors, and treatment
dence and death for both men and women. In options for colorectal cancer. Like the rest of
2009, an estimated 146,970 new patients were this series, this book is designed to provide up-
diagnosed with colorectal cancer, and 49,920 to-date information regarding safe and effective
colorectal cancer-related deaths occurred. methods to reach a diagnosis, obtain accurate
Worldwide, colorectal cancer has an estimated clinical staging of the disease, and choose the
incidence of 1.02 million cases, making it the best method of treatment.
third most common cancer. The highest inci- Included in this volume are discussions of
dences of colorectal cancer have been reported hereditary colon cancer syndromes, indications
in North America, Australia/New Zealand, and for genetic screening, and potential chemopre-
Western Europe, with the lowest incidence in vention methods. Since the stage of diagnosis
parts of Africa and Asia. is the most signifi cant predictor of outcome,
Recent advances have made the future of the book includes several chapters on screen-
colorectal cancer patients more promising. ing techniques for early diagnosis of colorectal
Colorectal cancer is considered to be a disease cancer. The book is also designed to guide the
that goes in a stepwise progression from normal reader in formulating a logical, step-by-step
colon to adenoma and then to invasive cancer. treatment or patient care plan. Each chapter
Knowledge of this stepwise progression presents regarding treatment is comprehensive and
an opportunity to intervene and identify prein- timely, and key points emphasize the impor-
vasive lesions using endoscopic techniques and tant aspects of each individual step in the
population-wide screening. The introduction of process.
widespread screening in the United States We thank the contributors—all leaders in
occurred in the 1970s and 1980s, when research- their respective fi elds—for their dedication and
ers demonstrated the feasibility of testing for tireless efforts in putting together this volume.
occult blood in stool and initiated randomized We hope that the book will serve as an impor-
clinical trials. In 1985, the diagnosis of colon tant resource guide for health care providers
cancer in President Ronald Reagan led to who strive to improve the lives of patients with
increased public awareness of this disease. both early and advanced stages of colorectal
Finally, the introduction of Medicare reimburse- cancer. Finally, this volume is dedicated to all
ment for all individuals in 2001 led not only to our patients with colorectal cancer who con-
improvements in adherence to screening guide- tinue to inspire us to seek a cure.
lines but also to increased likelihood of diagnos-
ing the cancer at an early stage. Susan L. Gearhart, MD
This volume on Early Diagnosis and Treat- Nita Ahuja, MD
ment of Cancer: Colorectal Cancer is meant as
Contributors
Nita Ahuja, MD Matthew T. Hueman, MD, FACS
Assistant Professor of Surgery and Oncology, Department Assistant Professor of Surgery, Uniformed Services
of Surgery, The Johns Hopkins University, Baltimore, University; Surgical Oncologist and Associate Program
Maryland Director, General Surgery, Department of Surgery,
Walter Reed Army Medical Center, Washington, DC
Vanita Ahuja, MD, MPH
Associate Program Director, York Hospital–Wellspan Ajay Jain, MD
Health, York, Pennsylvania Assistant Professor of Surgery, University of Maryland
Medical Center, Baltimore, Maryland
Debashish Bose, MD, PhD
Fellow, Department of Surgical Oncology, The University Michel I. Kafrouni, MD
of Texas MD Anderson Cancer Center, Houston, Texas Gastroenterology, Johns Hopkins Hospital, Baltimore,
Maryland; Private Practice, Gastroenterology Consultants,
David Chang, MPH, PhD
P.A., Houston, Texas
Johns Hopkins University School of Medicine, Baltimore,
Maryland John H. Kwon, MD
Assistant Professor, University of Chicago, Chicago,
Kathryn M. Chu, MD, MPH
Illinois
Clinical Assistant Professor, Johns Hopkins University
School of Medicine, Baltimore, Maryland Wells Messersmith, MD
Assistant Professor, Director, GI Cancers Program,
Stephanie R. Downing, MD
University of Colorado Denver, Denver, Colorado
General Surgery, Department of Surgery, Howard
University Hospital, Howard University College of Melissa A. Munsell, MD
Medicine, Washington, DC; Research Associate, Associate Physician, Southern California Permanente
Department of Surgery, Johns Hopkins University School Medical Group, Anaheim, California
of Medicine, Baltimore, Maryland
Jamila Mwidau, MD
Khaled El-Shami, MD, PhD Johns Hopkins University School of Medicine, Baltimore,
Assistant Professor of Oncology and Medicine, Lombardi Maryland
Comprehensive Cancer Center at Georgetown University;
Sujatha Nallapareddy, MD
Attending Oncologist, Georgetown University Hospital,
Developmental Therapeutics and GI Malignancies,
Washington, DC
University of Colorado Denver, Denver, Colorado
Susan L. Gearhart, MD
Emmanouil P. Pappou, MD
Assistant Professor of Colorectal Surgery and Oncology,
Department of Surgery, The Johns Hopkins University
Department of Surgery, The Johns Hopkins University,
School of Medicine, Baltimore, Maryland
Baltimore, Maryland
Timothy M. Pawlik, MD, MPH
Francis M. Giardiello, MD
Associate Professor of Surgery and Oncology, Johns
John G. Rangos Sr. Professor of Medicine, Johns Hopkins
Hopkins University, Johns Hopkins Hospital, Baltimore,
University School of Medicine, Baltimore, Maryland
Maryland
Samuel A. Giday, MD
Cheryl J. Pendergrass, MS, CGC
Robert E. Meyerhoff Professor, Director, Endoscopic
Genetic Counselor, The Johns Hopkins University
Ultrasound Unit, Division of Gastroenterology and
School of Medicine, Baltimore Maryland
Hepatology, Johns Hopkins University School of
Medicine, Johns Hopkins Hospital, Baltimore, Maryland Nicole A. Phillips, BS
University of Chicago, Chicago, Illinois
Joseph M. Herman, MD, MSc
Assistant Professor of Radiation Oncology, Richard Schulick, MD
The Johns Hopkins University School of Medicine, Professor of Surgery and Oncology, Chief, Cameron
Baltimore, Maryland Division of Surgical Oncology, Johns Hopkins University,
Baltimore, Maryland
Karen M. Horton, MD
Professor of Radiology, The Russell H. Morgan Eun Ji Shin, MD
Department of Radiology and Radiological Science, Assistant Professor of Medicine, Johns Hopkins University
Johns Hopkins Medical Institutions, Baltimore, Maryland School of Medicine, Baltimore, Maryland
xiv Contributors
Jason K. Sicklick, MD Susan Tsai, MD
Chief Administrative Fellow, Department of Surgery, Surgical Oncology Fellow, Johns Hopkins Medical
Memorial Sloan-Kettering Cancer Center, New York, Institutions, Baltimore, Maryland
New York
Elizabeth C. Wick, MD
Jerry Stonemetz, MD Assistant Professor of Colorectal Surgery, Johns Hopkins
Clinical Associate, Johns Hopkins Medical Institutions, University; Attending Surgeon, Johns Hopkins Hospital,
Baltimore, Maryland Baltimore, Maryland
Eden R. Stotsky, BSN, RN Michelle N. Zikusoka, MD
Nurse Clinician, Johns Hopkins Hospital, Baltimore, Department of Medicine, Johns Hopkins University,
Maryland Baltimore, Maryland
Epidemiology and Risk Factors
of Colorectal Cancer
1
Kathryn M. Chu
rectum (Fig. 1-1A). Carcinoid tumors develop
K E Y P O I N T S
from gastrointestinal neuroendocrine cells. Gas-
● Colorectal cancer (CRC) is the third most common
trointestinal stromal tumors develop from inter-
cancer and the third most common cause of cancer
death in the United States. stitial cells of Cajal and can be found anywhere
● Over the past 20 years, the incidence of CRC has in the gastrointestinal tract (Fig. 1-1B). Lym-
declined. phoma may originate in the colon and rectum
● Developed countries have a higher incidence of CRC but is more commonly found in the lymphatic
than do developing countries.
system. Squamous cell cancer of the anus is
● Adenocarcinoma is the most common type of
CRC. associated with human papilloma virus infection
● Persons over 50 years of age have the greatest risk (Fig. 1-1C).
for CRC.
● A higher incidence of CRC is found among blacks
than among other races.
● Men have a slightly higher risk of developing CRC Incidence of Adenocarcinoma
than do women.
of the Colon and Rectum
● Known risk factors for CRC include family history,
obesity, poor diet, alcohol and cigarette use, and lack Colorectal cancer (CRC) is found throughout
of exercise.
the world, but the incidence of this disease
varies widely (Fig. 1-2). Developed countries
have a higher incidence of CRC than do devel-
oping countries, with the highest incidences
occurring in Australia, North America, and
Northern and Western Europe. The United
Epidemiology States has one of the highest rates of CRC in
the world. The incidence is almost 10-fold lower
Types of Colon and Rectal Cancer
in parts of Africa and Asia.2,3
Several types of primary cancer are located in CRC is the third most common cancer in
the colon and rectum.1 These include adenocar- the United States for men and women4,5 (Fig.
cinoma, carcinoid tumor, gastrointestinal stromal 1-3). Approximately 147,000 people (76,000
tumor, lymphoma, and squamous cell cancer men and 71,000 women) will be diagnosed in
of the anus. The majority (95%) of cancers of 2010 (Fig. 1-4). The incidence of CRC has been
the colon and rectum are adenocarcinomas or decreasing over the last 20 years. In 2004,
tumors arising from intestinal glands. The epi- the reported incidence of CRC was 48.2 per
demiology of this type of tumor is discussed in 100,000, whereas in 1985 the reported inci-
this chapter. Metastases to the colon and rectum dence was 66.3 per 100,000. This decline is
are rare but can occur with melanoma and breast believed to be related to an increase in screening
cancer. Carcinoid tumors arise more commonly for CRC (detection and removal of colorectal
in the small bowel and appendix, although on polyps),4,5 although changes in lifestyle may also
occasion these tumors can be identifi ed in the play a role.
B
A
C D
Figure 1-1. A, Carcinoid tumor of the rectum. B, Gastrointestinal stromal tumor of the colon. C, Squamous cell cancer
of the anus. D, Adenocarcinoma of the colon.
Males Females
Japan 49.3 26.5
Australia/New Zealand 48.2 36.9
North America 44.4 32.8
Western Europe 42.9 29.8
Northern Europe 37.5 26.4
Southern Europe 35.9 23.5
Eastern Europe 30.1 20.1
South America 16.4 14.8
Micro/Polynesia 15.1 11.1
Caribbean 14.9 15.1
China 13.6 9.2
Southeastern Asia 12.5 9.9
Southern Africa 11.3 8.9
Western Asia 11.1 9.9
Central America 7.9 7.4
Melanesia 7.9 4.1
Eastern Africa 6.1 4.1
Northern Africa 5.1 4.0
Western Africa 5.1 3.5
South Central Asia 4.7 3.5
Middle Africa 2.3 3.3
60 50 40 30 20 10 0 10 20 30 40 50 60
Age
Figure 1-2. Age-standardized incidence rates per 100,000 for colorectal cancer by gender. (From Parkin DM, Bray F,
Ferlay J, Pisani P: Global cancer statistics, 2002. CA Cancer J Clin 55:74–108, 2005.)
Chapter 1 Epidemiology and Risk Factors of Colorectal Cancer 3
250
Prostate
200
0
0
0 150
0,
0
1
per Lung and bronchus
e 100
Rat Colon and rectum
50 Urinary bladder
Non-Hodgkin lymphoma
Melanoma of the skin
0
A 1975 1978 1981 1984 1987 1990 1993 1993 1999 2002 2005
250
200
0
0
0 150
0, Breast
0
1
er
p
e 100
at
R
Colon and rectum Lung and bronchus
50
Uterine corpus
Ovary
Non-Hodgkin lymphoma
0
B 1975 1978 1981 1984 1987 1990 1993 1993 1999 2002 2005
Figure 1-3. A, Age-adjusted cancer incidence rates for various cancers in men in the United States, 1975–2004. B, Age-
adjusted cancer incidence rates for various cancers in women in the United States, 1975–2004. Data are age adjusted to
the 2000 United States standard population and adjusted for delays in reporting. (From Cancer Statistics, 2008. American
Cancer Society Statistics on Cancer 2008.)
Stage at Time of Diagnosis
III) or directly beyond the primary site (stage
There are several historical colorectal staging IIb), 19% are diagnosed after the cancer metas-
systems, including the Dukes and Astler-Coller tasized (distant stage or stage IV), and for 5%
systems. The most widely used staging system the staging information is unknown.5 The most
is the TNM system of the American Joint Com- common site of metastasis for stage IV CRC is
mittee on Cancer (AJCC).6 In this system, the the liver.
four stages are based on the depth of invasion of In recent years, a greater proportion of CRC
the primary tumor (T), lymph node status (N), has been diagnosed at earlier stages.7 This shift
and distant metastasis (M) (Table 1-1 and Box refl ects the trend toward increased and improved
1-1). Approximately 39% of colon and rectum screening. Gross and associates demonstrated
cancer cases are diagnosed while the cancer is that when Medicare began to reimburse for
still confi ned to the primary site (localized stage screening colonoscopy in 1998, a signifi cantly
or stage I/IIa), 36% are diagnosed after the higher percentage of cancers were diagnosed at
cancer has spread to regional lymph nodes (stage an early stage (stage I).8
4 Chapter 1 Epidemiology and Risk Factors of Colorectal Cancer
Estimated New Cases* Estimated Deaths
Male Female Male Female
Prostate Breast Lung and bronchus Lung and bronchus
192,280 (25%) 192,370 (27%) 88,900 (30%) 70,490 (26%)
Lung and bronchus Lung and bronchus Prostate Breast
116,090 (15%) 103,350 (14%) 27,360 (9%) 40,170 (15%)
Colon and rectum Colon and rectum Colon and rectum Colon and rectum
75,590 (10%) 71,380 (10%) 25,240 (9%) 24,680 (9%)
Urinary bladder Uterine corpus Pancreas Pancreas
52,810 (7%) 42,160 (6%) 18,030 (6%) 17,210 (6%)
Melanoma of the skin Non-Hodgkin lymphoma Leukemia Ovary
39,080 (5%) 29,990 (4%) 12,590 (4%) 14,600 (5%)
Non-Hodgkin lymphoma Melanoma of the skin Liver and intrahepatic Non-Hodgkin lymphoma
35,990 (5%) 29,640 (4%) bile duct 12,090 (4%) 9,670 (4%)
Kidney and renal pelvis Thyroid Esophagus Leukemia
35,430 (5%) 27,200 (4%) 11,490 (4%) 9,280 (3%)
Leukemia Kidney and renal pelvis Urinary bladder Uterine corpus
25,630 (3%) 22,330 (3%) 10,180 (3%) 7,780 (3%)
Oral cavity and pharynx Ovary Non-Hodgkin lymphoma Liver and intrahepatic bile duct
25,240 (3%) 21,550 (3%) 9,830 (3%) 6,070 (2%)
Pancreas Pancreas Kidney and renal pelvis Brain and other nervous system
21,050 (3%) 21,420 (3%) 8,160 (3%) 5,590 (2%)
All sites All sites All sites All sites
766,130 (100%) 713,220 (100%) 292,540 (100%) 269,800 (100%)
*Excludes basal and squamous cell skin cancers and in situ carcinoma except urinary bladder.
Figure 1-4. Leading sites of new cancer cases and deaths in the United States by gender, 2009 estimates. (From
Cancer Facts and Figures 2009. © 2009, American Cancer Society, Inc. Surveillance Research.)
Table 1-1. American Joint Committee on Cancer Box 1-1. American Joint Committee on Cancer
Staging of Colorectal Cancer TNM Classifi cation of Colorectal Cancer
Stage T N M Primary Tumor (T)
T0 No evidence of primary tumor
Stage I T1–2 N0 M0 T1 Tumor invades submucosa
Stage IIA T3 N0 M0 T2 Tumor invades muscularis propria
Stage IIB T4a N0 M0 T3 Tumor invades through muscularis propria into
Stage IIC T4b N0 M0 pericolorectal tissue
Stage IIIA T1–2 N1 M0 T4a Tumor penetrates the surface of the visceral
T1 N2a M0 peritoneum
Stage IIIB T3–4 N1 M0 T4b Tumor directly invades or is adherent to other
T2–3 N2a M0 organs or structures
T1–2 N2b M0
Stage IIIC T4a N2a M0 Regional Lymph Nodes (N)
T3–4a N2b M0 N0 No invasion of regional lymph nodes
T4b N1–2 M0 N1a Invasion into one regional lymph node
Stage IVA Any T Any N M1a N1b Invasion into two to three regional lymph nodes
Stage IVB Any T Any N M1b N1c Tumor deposits without invasion into regional
lymph nodes
Adapted from Greene FL: AJCC Cancer Staging Manual, 7th ed. N2a Invasion into four to six regional lymph nodes
New York: Springer, 2010, p 199. N2b Invasion into seven or more regional lymph nodes
Distant Metastasis (M)
Location of Primary Tumor
M0 No distant metastasis present
Approximately 30% of CRC is located in the M1a Single distant metastasis
right colon, 10% in the transverse colon, 15% in M1b Multiple distant metastasis
the left (descending) colon, 25% in the sigmoid
Adapted from Greene FL: AJCC Cancer Staging Manual, 7th ed.
colon, and 20% in the rectum (Fig. 1-5). In the New York: Springer, 2010, pp 197–198.