Connections: Colorectal cancer shifts to new guidelines and genomic profiling | Spring 2021

Connections is a quarterly newsletter for primary care providers covering the latest developments and advances in medicine at OHSU. Learn about the many clinical, education and outreach resources available to you and your patients.

Explore more in the Connections magazine

From OHSU Knight Cancer Institute

Flavio G. Rocha, M.D., FACS, FSSO

Flavio G. Rocha, M.D., FACS, FSSO

As physician-in-chief of Knight Cancer Institute, Dr. Rocha is a surgical oncologist who specializes in tumors of the liver, pancreas and bile ducts. His research interests are in pancreatic cancer and cholangiocarcinoma.

New data about colorectal cancer (CRC) in recent years is affecting patient demographics, screening guidelines and the therapeutic options available as we discover more about the biology of these cancers. Historically, CRC is the third most lethal cancer in both men and women in the U.S.

Rising incidence in younger population

Most CRCs occur in people over 50 years old, but the National Cancer Institute reports that the incidence of colorectal cancers in younger adults has increased by 51% since 1994.

Data suggest that younger people account for 11% of colon cancers and 18% of rectal cancers.

The death rate from CRC in this age group is also rising. Following this trend, the number of cases in this younger demographic is anticipated to climb 50% by 2030.

The cause for higher risk in young adults is unclear. Because these patients are under the standard screening age, most receive a diagnosis once they are symptomatic with more advanced disease.

Baseline CRC screening moves to age 45

Colorectal cancer remains a common cause of cancer death in the U.S. Fortunately, when colorectal cancer is found early it is more treatable and less deadly.

For the past two decades, rates of colon cancer in people under age 50 have continued to rise. Although the reasons for this increase are uncertain, screening at a younger age could save lives.

New guidelines from the U.S. Preventive Services Task Force, the American Cancer Society and the American College of Gastroenterology recommend that screening for colorectal cancer for individuals with average risk of CRC begin at age 45. Individuals with a family history of colon cancer or other risks for colon cancer may need to start screening earlier.

Several recent celebrity deaths at an early age have brought CRC screening into the public eye. The late actor Chadwick Boseman, star of Black Panther and other films, was diagnosed with stage 3 colon cancer at age 39.

Patients should discuss the best screening method (FIT test or colonoscopy) as well as when to start screening with their primary care provider based on their personal and family health history.

Genomic differences influence tumor treatment

Research shows distinct clinical and biologic differences between left- and right-sided tumors in the colon.

Right-sided tumors appear to be more aggressive because of molecular differences, including microsatellite instability, BRAF mutations and other factors. This insight can be prognostic to outcomes and influence which therapies may be effective. For example, anti-EGFR therapy isn’t successful with tumors that express KRAS mutations.

However, in right-sided tumors with gene mutations, immunotherapy may be more effective than chemotherapy. Immunotherapy has fewer side effects and is now being used as a first-line therapy in trials for colorectal metastatic disease. With this new information, genomic profiling is now a critical component of evaluation for CRC.

CRC evaluations and collaboration

We used to think stage 4 colorectal cancer was incurable, but we now have options.

For the best evaluation of treatment strategies and trial eligibility, our team would like to see patients at initial diagnosis.

Most patients will receive the majority of their preop and postop care with their local providers. Working with those providers, we can collaborate on a treatment plan and how to deliver that care close to the patient’s home.

When to consult or refer

Patients with:

  • Colorectal metastatic disease
  • Complicated surgical cases
  • Complicated comorbidities
  • Eligibility for clinical trials
  • Rectal cancer

Rectal cancer calls for specialized team

OHSU anticipates becoming a Commission on Cancer nationally accredited program for rectal cancer in 2021.

Unlike most colon cancers that are straightforward to treat, rectal cancer is complex. Rectal cancer patients require specialized expertise, best served by a multidisciplinary team and a personalized approach.

Rectal cancer patients benefit from treatment in a center with high volume and a comprehensive team trained in the specialized radiology, pathology, radiation oncology and more unique to rectal cancer. At OHSU, we also have expertise in organ preservation for rectal cancer that can avoid chemotherapy and preserve continent function.

Contact us

From the latest technology to the newest drugs that are increasing survival, OHSU Knight Cancer Institute — Oregon’s only NCI-designated Comprehensive Cancer Center — offers a full range of options for oncology patients. We are always available to answer questions.

Please call the OHSU Physician Advice and Referral Service at 503-494-4567. To refer a patient, please fax to 503-346-6854.