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KEY CONCEPTS

KEY CONCEPTS

  • imageAdvancing age, high-risk adenomatous polyps, inherited and acquired genetic susceptibilities, inflammatory bowel disease, diabetes mellitus, and lifestyle factors are associated with colorectal cancer risk.

  • imageRegular use of aspirin and other nonsteroidal anti-inflammatory drugs reduces risk of colorectal cancer, but is not currently recommended for routine cancer prevention.

  • imageEffective colorectal cancer detection programs incorporate routine screening starting at age 50 years for average-risk individuals. Colorectal adenomas can progress to cancer and should be removed.

  • imageThe treatment goal for stages I, II, and III colon cancer is cure; surgery should be offered to all eligible patients for this purpose. Six months of fluoropyrimidine-based adjuvant systemic therapy reduces the risk of cancer recurrence and overall mortality in patients with stage III and select patients with stage II colon cancer. An oxaliplatin-containing regimen further reduces risk as compared with fluoropyrimidine alone in stage III patients.

  • imageCombined modality neoadjuvant therapy consists of fluoropyrimidine-based chemosensitized radiation therapy and surgery for patients with stage II or III cancer of the rectum and is considered standard of care to decrease risk of local and distant disease recurrence.

  • imagePreoperative chemotherapy may reduce tumor size and convert unresectable disease to resectable disease in selected patients with metastatic colorectal cancer. This strategy offers the potential for prolonging overall survival and cure for metastatic disease.

  • imageChemotherapy is palliative for metastatic disease. A fluoropyrimidine with oxaliplatin or irinotecan improves survival compared to fluoropyrimidine monotherapy and should be offered to patients who are candidates for aggressive treatment. The ability for patients to receive all active cytotoxic agents (eg, fluoropyrimidine, oxaliplatin, and irinotecan) during the course of their disease improves their overall survival.

  • imageBevacizumab plus fluoropyrimidine-based chemotherapy as initial therapy for metastatic disease is considered standard of care and provides a survival benefit as compared with combination chemotherapy alone.

  • imageThe addition of an epidermal growth factor receptor (EGFR) inhibitor (cetuximab or panitumumab) to initial treatment for RAS and BRAF wild-type, left-sided advanced or metastatic disease may improve tumor response rates (RRs) and survival. Individuals who have disease progression after initial therapy not containing an EGFR inhibitor may benefit from cetuximab or panitumumab, combined with other drugs. However, patients with RAS gene mutations or those with right-sided tumors should not receive cetuximab or panitumumab as these tumor features predict lack of treatment response.

  • imageImmune checkpoint inhibitors are effective in metastatic colorectal cancer patients with deficient DNA mismatch-repair (MMR) genes or high microsatellite instability (MSI-H) and who have progressed after two or more regimens.

PATIENT CARE PROCESS

Patient Care Process for Colorectal Cancer

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Collect

  • Patient characteristics (eg, age, race, sex)

  • Patient history (lifestyle factors—alcohol use, tobacco use, physical activity)

  • Patient characteristics (eg, social history/situation, insurance coverage) and treatment preferences

  • Patient medical and family history (eg, performance status, concurrent disease states [inflammatory bowel disease, colorectal cancer, polyps])

  • Clinical presentation signs and symptoms (see Clinical Presentation Box)

  • Current signs and symptoms and evaluation of tumor growth (for follow-up visits)

  • Current medications ...

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