COLON CANCER

Service Date: 8/27/2013

HPI: Mrs. PX is here today with her husband and daughter. Dr. K has asked me to evaluate her to discuss adjuvant chemotherapy for her newly diagnosed colon
cancer. Denies any significant comorbidities whatsoever. She underwent a CT scan on May 2, which showed elongated segment of mid sigmoid colon with some
findings suggestive of acute diverticulitis. She felt somewhat better with antibiotics but had recurrent symptoms. She had a repeat CT scan done in June, which
showed a persistent area of sigmoid thickening with perhaps slightly decreased inflammatory change. It was felt the appearance was concerning for colon cancer.
She was referred to Dr. JM and underwent a colonoscopy on July 10. This showed a large mass present within the sigmoid colon at 30 cm. The mass filled the entire
lumen and the colonic scope could not pass beyond a lesion. Biopsies of this, however, are consistent with an invasive moderately differentiated adenocarcinoma.
At that point, she was referred to Dr. K. Her CEA was 2.5.
On July 16, 2013, Dr. K performed an open sigmoidectomy. There was no evidence of diffuse extracolonic disease. The sigmoid colon was growing into the anterior
peritoneal reflection of the bladder, which was resected and blocked from the sigmoid. The pathology on this showed a well differentiated to moderately
differentiated adenocarcinoma. It was a T4b lesion with what appeared to be a contained perforation. The surgical margins were negative including the bladder
margin. There was clear transmural extension into adipose tissue, and again, with features consistent of perforation that would appear to be contained. There was
19 lymph nodes taken, which were examined. Histologic features were felt to be concerning for microsatellite instability. However, mismatch repair evaluation by
immunohistochemical stain was normal, most suggestive of a sporadic cancer.
She actually ended up having to stay in the hospital for a couple of weeks with some postoperative challenges but recovered well from those and was discharged
home on August 1.
She saw Dr. K back a week ago and was referred to me to consider adjuvant chemotherapy. In terms of other staging, she had a chest x-ray in the hospital where
there was nothing to suggest cancer. Liver function tests on July 24, were normal.

Impression:
Mrs. PX appears to have a T4, N0, stage II cancer. We discussed that although this is stage II, it certainly would be considered a high-risk stage II with risk of eventual
systemic metastasis and death, likely at least 20%. Discussed my recommendation for adjuvant chemotherapy. I think this is especially appropriate given her young
age and otherwise excellent performance status. I did discuss that absolute survival benefit from adjuvant chemotherapy is probably 4-5%, which again, to me, is
appropriate use of chemotherapy at this point. Discussed various treatment regimens. Given high-risk features of her disease, I would recommend treating with
FOLFOX. We discussed potential risks. Discussed risks of severe infection, GI toxicity, permanent neuropathy, organ damage, cytopenias, anemia, allergic reactions,
etc. Discussed small risk of complete alopecia and more likely significant hair thinning. Discussed the need for port placement with attendant risks associated with
that.
After extended discussion, she is agreeable to this, as is her family. We will make arrangements for port placement and initiation of chemotherapy.

Plan:
1. Port placement.
2. Labs today, CBC, ferritin, CMP.
3. Follow-up next week to initiate FOLFOX, anticipate 12 total treatments, as tolerated.
4. Typical medications have been sent to her pharmacy.
Service Date: 11/21/2018

History of Present Illness: Mrs. PX is here for follow up for surveillance of colon cancer. She is doing well today. She denies any new pains, bleeding, and all other
complaints. Colonoscopy: Normal. 3 yr follow up recommended.

She has a T4, N0, stage II colon cancer, as outlined in initial note, August 27, 2013.
She had no metastatic disease. MSI evaluation was normal, most suggestive of a sporadic cancer.
No family history of colon cancer.
Initiated adjuvant FOLFOX chemotherapy, September 3, 2013.
Progressive neuropathy - stopped oxaliplatin with 9th dose. Finished adjuvant FOLFOX chemotherapy with final dose March 25,2014. Due to neuropathy, oxaliplatin
was omitted, beginning with 9th dose and not re instituting. Colonoscopy June 2014 showed a couple of adenomatous polyps. CT scan July 2014, without evidence
of recurrence. CT scan October 2015, stable lung nodules not increased from prior CT scan. Nothing to suggest re-current disease based on history.
Discussed appropriate surveillance as directed by Dr. K. Next CT scan in March/April 2016. Colonoscopy scheduled for June 2016. Continuing dermatology changes
on bilateral upper extremities. Possibly due to chemotherapy. Advised to see a dermatologist for a follow up. Continues to do well with no evidence of recurrent
disease. I again reviewed guidelines in regard to f/u.
5/16/18: CBC normal. She is approx. 4 years from chemo completion, and she continues to do well. We discussed her low risk of recurrence at this point in her
follow up. This summer, she has a routine colonoscopy and CT scan scheduled via Dr. K. According to NCCN guidelines, we will continue to follow her every 6 months
until her 5 years post chemo.
11/21/18: Doing well today with no concerns. She has yet to have a CT scan this year and will schedule today. Colonoscopy normal.

Plan:
- Continue surveillance as directed by Dr. K with scans and scopes when appropriate.
- CMP, CMP, CEA and Vit D today to monitor disease.
- CT scan ordered. This is the final needed scan.
- Repeat colonoscopy in 3 years.
- Continue oral vitamin D.
- Encouraged to call with progressive sx or concerns.
- RTC in 6 months or sooner prn. She will not need medical oncology f/u after that time.