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Colorectal Cancer Survivorship: Second Primary Cancers
VideoTranscript
Professional Oncology Education
Colorectal Cancer Survivorship: Second Primary Cancers
Time: 7:40
Therese B. Bevers, M.D.
Professor, Clinical Cancer Prevention
Medical Director, Cancer Prevention Center
The University of Texas, MD Anderson Cancer Center
Colorectal Cancer
Survivorship:
Second Primary Cancers
I am Dr. Therese Bevers, Professor of Clinical Cancer
Prevention and Medical Director of the Cancer
Prevention Center at the University of Texas MD
Anderson Cancer Center. I’m going to talk today
about second primary cancers in colorectal cancer
survivors.
Spanish Translation
Supervivencia al cáncer colorrectal: Segundos cánceres
primarios
Transcripción del video
Educación Oncológica Profesional
Supervivencia al cáncer colorrectal: Segundos cánceres
primarios
Duración: 7:40
Dra. Therese B. Bevers
Profesora de Prevención Clínica del Cáncer
Directora Médica del Centro de Prevención del
Cáncer
MD Anderson Cancer Center de la Universidad de Texas
Soy la Dra. Therese Bevers, profesora de Prevención
Clínica del Cáncer y directora médica del Centro de
Prevención del Cáncer en el MD Anderson Cancer
Center de la Universidad de Texas. Hoy hablaré sobre
los segundos cánceres primarios en los
sobrevivientes de cáncer colorrectal.
Therese B. Bevers, M.D.
Professor, Clinical Cancer Prevention
Medical Director, Cancer Prevention Center
1
Objectives
Upon completion of this lesson, participants will be able to:
• Identify risk of second primary cancers after
colorectal cancer
The objectives of this lesson are to identify the risk of
second primary cancers after having had colorectal
cancer; outline the mechanisms related to the
development of these second primary cancers; and
discuss risk reduction and screening strategies for
second primary cancers.
Los objetivos de esta lección son: identificar el riesgo
de segundos cánceres primarios después del cáncer
colorrectal, delinear los mecanismos relacionados con
el desarrollo de estos segundos cánceres primarios, y
analizar estrategias para reducir los riesgos y detectar
segundos cánceres primarios.
Let’s start off with the definition for second primary
cancers. This is a new primary cancer developing in a
person with a history of cancer. However, upon
thinking about that it is somewhat simplistic because
the questions begin to arise, “What about a cancer
occurring in the same organ as the patient already
had a cancer?” So, to be more specific, a second
primary cancer is a neoplasm that arises in a tissue
that is distinct from the first primary and it develops
subsequent to the initial cancer by some time --defined time period. Typically, this is greater than two
months.
Comencemos definiendo qué es un segundo cáncer
primario. Es un nuevo cáncer primario que se
desarrolla en una persona con historial de cáncer.
Esta es una explicación un tanto simplificada, pues
surgen preguntas como: “¿Qué hay de un cáncer que
aparece en el mismo órgano donde el paciente ya
tenía cáncer?”. Más específicamente, un segundo
cáncer primario es un neoplasma que se origina en
un tejido diferente al del primer cáncer y que se
desarrolla con posterioridad al cáncer inicial,
generalmente más de dos meses después.
• Outline mechanisms related to the development of
these second primary cancers
• Discuss risk reduction and screening strategies for
second primary cancers
Second Primary Cancer (SPC)
• New primary cancer developing in a person with a
history of cancer
• A neoplasm that:
– Arises in a tissue distinct from the first primary
– Develops subsequent to the initial cancer by some
defined time period
Krueger H et al., Prog Exp Tumor Res 2008 40:7-16
2
Metachronous Colorectal Cancer
• By our definition, metachronous colorectal cancer is
not a SPC
• Common, even after controlling for familial patterns
By our definition, metachronous colorectal cancer is
not a second primary cancer even after controlling for
familial patterns. However, we do see that it occurs at
a higher rate than first primaries of the colorectum.
This is probably related to genetic factors other than
those due to familial adenomatous polyposis or Lynch
Syndrome.
Según esta definición, el cáncer colorrectal
metacrónico no sería un segundo cáncer primario,
pero aun después de hacer un control de patrones
familiares, vemos que ocurre a una tasa superior que
los primeros cánceres primarios de colon y recto. Esto
probablemente esté relacionado con factores
genéticos distintos de los de la poliposis
adenomatosa familiar o el síndrome de Lynch.
You may be surprised to find out that collectively
second primary cancers are the fifth most common
type of cancer after excluding for non-melanoma skin
cancers.
Puede resultar sorprendente descubrir que,
colectivamente, los segundos cánceres primarios son
el quinto tipo de cáncer más común, si excluimos los
cánceres de piel distintos del melanoma.
• Occur at higher rate than first primaries of the colorectum
– Genetic factors other than Familial adenomatous polyposis
(FAP)/ Lynch Syndrome have been implicated
Krueger H et al., Prog Exp Tumor Res. 2008 40:85-91
Fifth Most Common Type of Cancer*
• Colorectal
• Lung
• Breast
• Prostate
• Second primary cancer
*Excluding non-melanoma skin cancers
Rheingold SR et al., Holland-Frei Cancer Medicine. 6th edition. Bast, RC et al. (eds)
Hamilton: BC Decker 2000, pps 2399-2406
3
Incidence of Second Primary Cancer:
Colorectal Cancer
• Higher for individuals with early onset colorectal cancer
– Related to genetic syndromes
• Higher for females –
– Female survivors live longer than male survivors
– Related to second primary cancer of breast and
gynecologic organs
In looking at the incidence of second primary cancers
after having had colorectal cancer, we see it is higher
for individuals with early onset colorectal cancer. And,
this is likely related to genetic syndromes. It’s also
higher for females who live longer than their male
counterparts. And, also, related to the fact that there
are more s --- cancers that can occur in females such
as breast, cervical, uterine, and ovarian than can
occur in males, such as testicular or prostate.
Al analizar la incidencia de los segundos cánceres
primarios después del cáncer colorrectal, vemos que
es mayor en las personas con cáncer colorrectal
temprano. Esto tal vez esté relacionado con
síndromes genéticos. También es mayor en las
mujeres que viven más que sus contrapartes
masculinas. Asimismo, se relaciona con el hecho de
que existen más tipos de cáncer en las mujeres
(cáncer de mama, cervical, de útero y de ovarios) que
en los hombres (cáncer testicular o de próstata).
If we look at the cumulative incidence of developing a
second cancer among patients with a history of colon
cancer that cumulative incidence is about 15%. We
see that the vast majority of the cancers are in the
digestive tract. And, there is a substantial percentage
of metachronous colorectal cancers. It, however, is
this constellation of cancers those that are not in the
colon or rectum that we need to pay attention to,
because if we did not identify these risks, we would
not pick them up through routine surveillance of the
patient for their colon cancer.
La incidencia acumulativa de desarrollar un segundo
cáncer en los pacientes con historial de cáncer de
colon es del 15%, aproximadamente. La gran mayoría
de los cánceres se encuentran en el tracto digestivo y
hay un porcentaje considerable de cánceres
colorrectales metacrónicos. Debemos prestar
atención a los numerosos tipos de cáncer que no
ocurren en el colon o el recto. Si no identificamos
estos riesgos, no los detectaremos en los controles de
rutina de los pacientes con cáncer de colon.
• Possibly genetic in origin
Krueger H et al., Prog Exp Tumor Res. 2008 40:85-91
Second Primary Cancer in Colon Cancer
Cumulative incidence of developing a second cancer among
patients with cancer of the colon, both sexes, SEER 1973-2000
Mysliwiec PA et al., NIH Publ. No. 05-5302. Bethesda, MD 2006
4
Second Primary Cancer in Colon Cancer
• Increased risk of:
–
–
–
–
–
–
–
–
Individuals with a history of colon cancer have an
increased risk of the cancers listed on this screen.
You will see that many of them in fact do arise in the
GI tract.
Las personas con historial de cáncer de colon tienen
mayor riesgo de sufrir estos cánceres y muchos de
ellos se producen en el tracto gastrointestinal.
Individuals with a pri --- history of rectal cancer overall
are not at increased risk for a second primary cancer.
However, if their rectal cancer occurred at a younger
age, they actually do have a 51% increased risk of an
SPC. This includes cancers of the small intestine, bile
ducts, and uterus. And, again, these tumors often are
associated with a genetic predisposition.
Not
surprisingly then, the risk would be lower in patients
diagnosed with rectal cancer at an older age. Now,
rectal cancer patients who were treated with radiation
actually have an increased risk of second primary
cancers occurring in the radiation field, such as the
uterus or the bladder.
En general, un historial de cáncer de recto no
conlleva un mayor riesgo de segundo cáncer primario,
pero si el cáncer de recto ocurrió a una edad
temprana, el riesgo aumenta un 51%. Esto incluye los
cánceres de intestino delgado, conductos biliares y
útero. Estos tumores a menudo están asociados con
una predisposición genética. El riesgo es menor en
los pacientes diagnosticados con cáncer de recto a
una edad mayor. Los pacientes con cáncer de recto
tratados con radiación tienen mayor riesgo de
segundo cáncer primario en el campo irradiado, como
el útero o la vejiga.
Tongue
Oropharyngeal
Stomach
Small intestine
Bile ducts
Uterus
Kidney
Ureter
Mysliwiec PA et al., NIH Publ. No. 05-5302. Bethesda, MD 2006
Second Primary Cancer in Rectal Cancer
Overall, risk for SPC not increased in rectal cancer patients
• Rectal cancer at younger age associated with 51%
increased risk of SPC
- Small intestine, bile ducts, uterus
- Tumors associated with genetic predisposition
• Risk lower in patients diagnosed at older ages
Risk of SPC increased in rectal patients treated with radiation
• Uterus, bladder
Mysliwiec PA et al., NIH Publ. No. 05-5302. Bethesda, MD 2006
5
Three Second Primary Cancer
Carcinogenic Pathways
• Common lifestyle/environmental factors
I would like to review the three carcinogenic pathways
for the development of second primary cancer. These
are common lifestyle or environmental factors,
common genetic pathway, and iatrogenic effect of
treatment.
Veamos las tres vías cancerígenas para el desarrollo
de un segundo cáncer primario: los factores comunes
de estilo de vida o ambientales, la vía genética
común, y el efecto iatrogénico del tratamiento.
We see that obesity is a known risk factor for
colorectal cancer, but it has been well identified that
obesity increases the risk for other cancers. So this is
a common lifestyle factor that puts an obese colorectal
cancer patient at increased risk for second primaries.
La obesidad es un factor de riesgo conocido del
cáncer colorrectal y también aumenta el riesgo de
otros cánceres. Es un factor común de estilo de vida
que en los pacientes obesos con cáncer colorrectal
aumenta el riesgo de un segundo cáncer primario.
• Common genetic pathway
• Iatrogenic effect of treatment
Krueger H et al., Prog Exp Tumor Res. 2008 40:1-6
Common Lifestyle/Environmental Factors
Obesity
• Known risk factor for colorectal cancer
• Increases risk for other cancers
WCRF/AICR, Nutrition, Physical Activity, and the Prevention of Cancer:
a Global Perspective. Washington, DC: AICR 2007
6
Obesity and Cancer
Convincing increased risk:
Probable increased risk:
• Breast
We see that there’s convincing risk for obesity being
linked to the development of colon cancer. It also has
convincing evidence regarding the link to endometrial
cancer and kidney cancer, both of which are
increased in colon cancer survivors.
Hay un riesgo convincente de que la obesidad está
relacionada con el cáncer de colon. También hay
pruebas convincentes en su relación con el cáncer de
endometrio y riñón, con mayor riesgo para los
sobrevivientes de cáncer de colon.
Now, there are common genetic pathways both Lynch
Syndrome and Familial Adenomatous Polyposis.
These are the cancers that can be seen with either of
these syndromes and the ones highlighted in red are
the ones that are more commonly seen in patients
with a history of colorectal cancer.
Existen vías genéticas comunes para el síndrome de
Lynch y la poliposis adenomatosa familiar. Estos
cánceres pueden ocurrir con cualquiera de estos
síndromes y los resaltados en rojo son más comunes
en los pacientes con historial de cáncer colorrectal.
• Gallbladder
(among postmenopausal women)
• Colon
Limited-suggestive
increased risk:
• Endometrium
• Esophagus
• Liver
• Kidney
• Pancreas
WCRF/AICR, Nutrition, Physical Activity, and the Prevention of Cancer:
a Global Perspective. Washington, DC: AICR 2007
Common Genetic Pathway
Lynch Syndrome
FAP
• Uterus
•
•
•
•
- May be “sentinel cancer”
in women with Lynch Syndrome
•
•
•
•
•
•
•
Small intestine
Stomach
Bile ducts
Ovary
Kidney
Ureter
Brain
Stomach
Small intestine
Thyroid
Brain
Watson P and Lynch HT. Cancer 1993 71(3):677
Burt RW. Gastroenterology 2000 119(3):837
Lu KH, et al., Obstet Gynecol 2005 105(3):569
7
Iatrogenic Effects of Treatment
• Excess risk for SPC related to treatment seen only in
rectal cancer patients treated with radiation therapy
– Uterus, bladder
• Decreased risk of prostate cancer
– “Nascent but quiescent” prostate cancers “cured”
by spillover radiation
Iatrogenic effects of treatment are those that are
related to the treatment we actually use to bring about
the full treatment of the cancer and, thus, making the
colorectal cancer patient a survivor. There is an
excess risk of second primary cancers for those rectal
cancer patients who received radiation and that risk is
confined to the radiation field so thus it would be the
uterus or the bladder. Interestingly enough in men,
there is a decreased risk of prostate cancer. It’s been
suggested that possibly nascent but quiescent,
prostate cancers are cured by the spillover radiation
for the rectal cancer treatment.
Los efectos iatrogénicos son aquellos relacionados
con el tratamiento completo utilizado para combatir el
cáncer, que hacen del paciente con cáncer colorrectal
un sobreviviente. Existe un gran riesgo de un
segundo cáncer primario en los pacientes con cáncer
de recto que recibieron radioterapia, pero se limita al
campo irradiado, es decir, el útero o la vejiga.
Curiosamente, en los hombres reduce el riesgo de
cáncer de próstata. Se ha sugerido que los cánceres
de próstata incipientes, pero quiescentes, se curan
con la radiación indirecta del tratamiento del cáncer
de recto.
In managing the risk of second primary cancers, it’s
important to understand those carcinogenic pathways
and then target those risks that are identified. If we
identify that someone is obese or overweight, we want
to work at controlling the obesity through energy
balance. That means calories in, what you consume,
is --- equals calories out or exercise. We would like to
maintain the BMI or body mass index between 18 and
25. It is important to identify patients with a BMI
greater than 25 and offer them resources and support
for weight reduction and offer an appropriate exercise
prescription.
Para controlar el riesgo de un segundo cáncer
primario es importante comprender estas vías
cancerígenas y luego concentrarse en los riesgos
identificados. Si identificamos que una persona es
obesa o tiene sobrepeso, debemos controlar la
obesidad a través del equilibrio de energía. Las
calorías consumidas deben quemarse con el ejercicio.
Queremos mantener el índice de masa corporal entre
18 y 25. Es importante identificar a los pacientes con
un IMC mayor que 25 y ofrecerles recursos y apoyo
para bajar de peso, así como una receta de ejercicio
adecuada.
Mysliwiec PA et al., NIH Publ. No. 05-5302. Bethesda, MD 2006
Managing Risk of Second Primary Cancers
• Controlling obesity through energy balance
– Calories in (diet) = calories out (exercise)
– Maintain BMI between 18-25
• Identify patients with BMI > 25
– Offer resources and support for weight reduction
– Offer exercise prescription
8
Early Detection of Second Primary Cancers
• Follow current screening recommendations
– Women: breast, cervical
– Men: prostate
– Screening guidelines available at:
http://utm-ext01a.mdacc.tmc.edu/mda/cm/cwtguide.nsf/luhtml/sidebar1
• For individuals with Lynch Syndrome or FAP
– Management guidelines can be found within this lecture series in
Dr. Lynch’s presentation on Cancer Screening for Patients with
Inherited Colorectal Cancer
– Consider referral to specialist in Lynch Syndrome or FAP
Summary
• Colorectal cancer survivors are at increased risk of SPC
• Managing risk of second primary cancers involves:
– Identify risks for SPC
– Modify risks for SPC
It’s also important that colorectal cancer [survivors]
follow current cancer screening recommendations.
They are not immune to developing a cancer that
would otherwise have developed had they not had
colorectal cancer. For women, they should screen for
breast and cervical cancer and men, if they so elect
after counseling, screen for prostate cancer. MD
Answer has --- MD Anderson has cancer screening
guidelines available at the URL on this slide. For
individuals with Lynch Syndrome or FAP,
management guidelines will be discussed by Dr.
Patrick Lynch in his presentation on Cancer Screening
for Patients with Inherited Colorectal Cancer. These
individuals are appropriate for referral to a specialist in
Lynch Syndrome or FAP.
In summary, colorectal cancer survivors are at
increased risk of a second primary cancer. The risk
can be managed by identifying that risk, modifying it
by offering risk reduction strategies, such as weight
management, and implementing appropriate
screening to detect second primary cancers early. I
hope you have enjoyed this lecture. We welcome
your feedback.
También es importante que los sobrevivientes sigan
las recomendaciones de detección actuales, pues no
son inmunes a desarrollar un cáncer que se hubiera
desarrollado aun sin cáncer colorrectal. Las mujeres
deben hacerse exámenes de detección de cáncer de
mama y cervical, y los hombres de cáncer de
próstata, tras recibir asesoramiento. El MD Anderson
dispone de recomendaciones para la detección de
cáncer en el URL indicado aquí. Para los pacientes
con síndrome de Lynch o poliposis, las pautas serán
analizadas por el Dr. Patrick Lynch en su
presentación sobre la detección para los pacientes
con cáncer colorrectal heredado, pero deben ser
referidos a un especialista en síndrome de Lynch o
poliposis.
En resumen, los sobrevivientes de cáncer colorrectal
tienen un mayor riesgo de un segundo cáncer
primario, que puede controlarse identificándolo y
modificándolo con estrategias de reducción, como el
control de peso, y con un examen adecuado para
detectar un segundo cáncer primario de manera
temprana. Espero que hayan disfrutado de esta
disertación. Agradeceremos sus comentarios.
– Implement appropriate screening to detect SPC early
9