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Hyunjee Song, 2018 PharmD Candidate, and Michael R. Page, PharmD, RPh
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Recognizing Available Therapies and Treatment Differences Within Classes in Colorectal Cancer
David Bai, 2018 PharmD Candidate, and Michael R. Page, PharmD, RPh
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Recognizing Available Therapies and Treatment Differences Within Classes in Colorectal Cancer

David Bai, 2018 PharmD Candidate, and Michael R. Page, PharmD, RPh
Colorectal cancers include cancers of both the colon and rectum. Cancer cells may stay localized to the colon or rectum, or may grow into surrounding tissues and travel to other organs. Left untreated, cancer may lead to complications that affect normal body functions, eventually resulting in death. Colorectal cancer is the third leading cause of cancer-related deaths in women and the second in men in the United States, and is estimated to cause 50,260 deaths in this country in 2017 alone.1 Optimizing treatments and creating treatment innovations for colorectal cancer remain important priorities for clinicians, researchers, and managed care professionals.
Risk Factors for Colorectal Cancer
Factors associated with an increased risk of developing colorectal cancer relate to age, ethnic background, and comorbidities. As in many other types of cancer, the probability of developing colorectal cancer increases with advancing age; individuals 50 years or older are at greater risk than those younger. Patients of certain ethnic backgrounds, including African American or Ashkenazi Jewish descent, may also be at increased risk.2

Certain comorbidities and genetic conditions may increase the risk of developing colorectal cancer. These predisposing comorbidities include type 2 diabetes and inflammatory bowel diseases, including ulcerative colitis and Crohn’s disease.3 The genetic diseases associated with an increased risk of developing colorectal cancer include Lynch syndrome, familial adenomatous polyposis (FAP), Turcot syndrome, Peutz-Jehgers syndrome, and MUTYH-associated polyposis.2,3

Modifiable lifestyle-related risk factors include obesity, lack of exercise, poor diet, tobacco use, and alcohol use.4
 
Screening and Testing for Colorectal Cancer
Screening and testing for colorectal cancer is key to early detection. In some cases, signs may be detected in an ordinary physical exam through palpation for abdominal masses or through a digital rectal exam. Other tests may include examination of stool for presence of blood, and evaluation of patients for laboratory abnormalities such as anemia, liver enzyme elevations, and certain tumor markers, which are detectable through a blood test.5

Although results of the above tests may raise clinical suspicion of colorectal cancer, these tests alone are not sufficient to establish a diagnosis. For a definitive diagnosis, colonoscopy is required, which involves inserting a colonoscope into the rectum to examine intestinal tissue. During a colonoscopy, biopsies may be performed and tissues may be examined by a pathologist; polyps may also be resected to reduce the risk of progression to colon cancer.5

Imaging tools may also be used to evaluate patients, including computed topography scanning, ultrasound, magnetic resonance imaging, chest X-ray, positron emission topography, and angiography. Angiography and use of a radioactive form of sugar may be used to determine the metabolic activity of cancer cells to further characterize tumors. Imaging tests may help identify whether or not tumors have spread to other locations in the body, including the lungs and brain.5

Screening for colorectal cancer varies depending on a patient’s risk of developing cancer. For the most patients, screening through colonoscopy should be performed starting at age 50, with repeat testing every 10 years. Alternative methods may include flexible sigmoidoscopy every 5 years or fecal immunochemical testing annually.6

More frequent testing is required in patients with a greater risk of cancer due to presence of certain risk factors. For instance, patients with inflammatory bowel disease (IBD) require a colonoscopy within 8 years of receiving their IBD diagnosis. After testing, they will be categorized as low-risk or high-risk, requiring repeat testing every 2 to 3 years or every year, respectively.7

Patients with certain genetic conditions, such as FAP and Lynch syndrome, require earlier and more frequent testing for colorectal cancer. For patients who have been definitively diagnosed with FAP via a genetic test, an annual colonoscopy is required beginning as early as age 10 years, and no later than age 15 years. Similarly, patients whose genetic test indicates Lynch syndrome may require an initial colonoscopy between the ages of 20 and 25  » years, or 2 to 5 years prior to reaching the age at diagnosis of the person in the family who was youngest when diagnosed with colorectal cancer (whichever is earlier). Afterwards, patients may require further screenings every 1 to 2 years.8

Because family history is also a risk factor for colorectal cancer, patients with relatives who have developed colorectal cancer may require earlier screening than members of the general population. For patients with 1 or more first-degree relatives who developed colorectal cancer, regardless of age at diagnosis, a colonoscopy is recommended beginning at age 40, or 10 years prior to reaching the age at diagnosis of the person in the family who was youngest when diagnosed with colorectal cancer (whichever is earlier). Afterwards, colonoscopies should be repeated every 5 to 10 years. For patients with 1 or more second-degree relative aged less than 50 years at diagnosis, colonoscopies should begin at age 50 years and be repeated every 5 to 10 years.7
 


 
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