Colorectal Cancer

Question 1

risk factors

Answer 1

-PMH of polyps
-IBD
-family history of CRC
-smoking*
-heavy alcohol use*
-physical inactivity*
-genetic predisposition (FAP and HNPCC/Lynch syndrome)

Question 2

prevention strategies

Answer 2

-fiber supplementation
-dietary fat reduction
-COX2 inhibition

Question 3

treatment based on stage

Answer 3

stage 1: no adjuvant chemo
stage 2: no treatment OR adjuvant chemo
stage 3: adjuvant chemo
stage 4: chemo, targeted therapy, immunotherapy

Question 4

treatment considerations

Answer 4

-stage of disease
-performance status of patient
-co-morbidities
-pharmacogenomics

Question 5

favorable prognostic factors

Answer 5

-early disease (stage 1-2)
-grade 1-2 lesions
-no angiolymphatic invasion
-negative margins

Question 6

unfavorable prognostic factors

Answer 6

-advanced disease (stage 3-4)
-grade 3-4 lesions
-lymphovascular invasion
-bowel obstruction/perforation
-T4 disease
-performance status
-lymph node involvement and number >4

Question 7

chemo agents

Answer 7

5-FU, capecitabine, oxaliplatin, irinotecan

Question 8

capecitabine pearl

Answer 8

CI in dihydropyrimidine dehydrogenase (DPD) deficiency

Question 9

oxaliplatin neuropathy vs cold sensitivity treatment

Answer 9

-eating/drinking at room temp
-GABA analogues
-SNRI (duloxetine)

Question 10

irinotecan diarrhea treatment

Answer 10

-“I ran to the can”
-acute: atropine or diphenolxylate (<24h)
-delayed: loperamide (>24h)

Question 11

bevacizumab (anti-angiogenesis therapy)

Answer 11

-metastatic colorectal cancer with infusion 5-FU based regimens
-HTN must be controlled prior to initiation
-must be d/c 4 wks before surgery and restarted 4 wks after (delayed wound healing)

Question 12

ramucirumab (VEGFR2i)

Answer 12

-in combo with FOLFIRI for patients who have progressed on bevacizumab, oxaliplatin, and 5-FU containing regimens
-admin over 60 min prior to FOLFIRI
-continue until disease progression or toxicity

Question 13

EGFRi

Answer 13

-must be KRAS-wild type
-used in metastatic CRC
-rash common: prevention is key

Question 14

EGFRi agents

Answer 14

cetuximab and panitumumab

Question 15

EGFRi grade 1 (mild) rash treatment

Answer 15

-macular/papular eruption or asymptomatic
-emphasize limited sun exposure and moisturize
-hydrocortisone 2.5% cream +/- clindamycin 1% gel

Question 16

EGFRi grade 2 (moderate) rash treatment

Answer 16

-pruritis, papules, pustules
-hydrocortisone 2.5% cream +/- clindamycin 1% gel
and
-minocycline po/doxycycline po

Question 17

EGFRi grade 3 (severe) rash treatment

Answer 17

-generalized erythroderma
-hold treatment until grade 2 and dose reduce
-add higher potency topical steroid (triamcinolone/fluocinolone)

Question 18

EGFRi grade 4 (severe) rash treatment

Answer 18

-ulcerative or blistering
-d/c drug
-systemic steroids, IV antibiotics, IV hydration

Question 19

regorafenib (multikinase inhibitor)

Answer 19

later line treatment in mCRC as single agent

Question 20

trifluridine + tipiracil

Answer 20

-mCRC if previously received fluoropyrimidine, oxaliplatin, irinotecan, anti-VEGF, anti-EGFR
-commonly combined with bevacizumab
-severe myelosuppression: monitor prior to and on day 15 of each cycle

Question 21

immunotherapy agents

Answer 21

-pembrolizumab and nivolumab

Question 22

immunotherapy

Answer 22

-for MSI-H tumors only
-typically in stage 4 disease

Question 23

BRAF mutation

Answer 23

-cetuximab + encorafenib
-doublet therapy: 2nd or 3rd line

Question 24

general principle of treatment

Answer 24

5-FU based regimens are the standard of care

Question 25

stage 1 treatment

Answer 25

-surgical excision of primary tumor and removal of LNs -surveillance (no adjuvant chemo)

Question 26

stage 2 treatment

Answer 26

-surgical excision of primary tumor and removal of LNs -2a no high risk: consider adjuvant chemo, clinical trial or obs -2a with high risk: adjuvant chemo or obs -2b+2c: adjuvant or obs

Question 27

adjuvant chemo options

Answer 27

-single agent capecitabine (low risk) -5-FU/leucovorin (low risk) -FOLFOX (high risk) -capeOX (high risk)

Question 28

stage 2 treatment pearls

Answer 28

-if MSI is high, adjuvant therapy is not recommended -oxaliplatin not shown to have survival benefit in >70yo

Question 29

stage 3 treatment

Answer 29

-surgical excision of primary tumor and removal of LNs -targeted therapy and irinotecan should not be used in adjuvant setting -FOLFOX or CapeOX preferred

Question 30

stage 3 treatment pearls

Answer 30

-RT + capecitabine/5-FU used neoadjuvant for rectal cancer only -FOLFOX/CapeOX is superior to 5-FU/leucovorin in stage 3 -if oxiplatin toxicity is intolerable, dose reduce or d/c after 3-4mo or sooner if >grade2

Question 31

stage 4 treatment

Answer 31

-resectable liver or lung only metastases: surgical excision with resection + neoadjuvant chemo -unresectable liver or lung only lesions: chemo + eval every 2mo

Question 32

summary

Answer 32

stage 2: adjuvant FOLFOX or CapeOX (in hr 2a, 2b, 2c) stage 3: FOLFOX or CapeOX stage 4: -FOLFOX or FOLFIRI or CapeOX -add bevacizumab add cetuximab or penitumumab is KRAS wild type -trastuzumab for HER2 amplification -immunotherapy is MSI-H -cetuximab and encorafenib for BRAF V600E mutation -oral agents (regorafenib and trifluridine/tipiracil)