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Cancer develops when cells in a part of the body begin to grow out of control. Although there are many kinds of cancer, they all start because of out-of-control growth of abnormal cells.
Normal body cells grow, divide, and die in an orderly fashion. During the early years of a person’s life, normal cells divide more rapidly until the person becomes an adult. After that, cells in most parts of the body divide only to replace worn-out or dying cells and to repair injuries.
Because cancer cells continue to grow and divide, they are different from normal cells. Instead of dying, they outlive normal cells and continue to form new abnormal cells.
Cancer cells can sometimes travel to other parts of the body where they begin to grow and replace normal tissue. This process, called metastasis, occurs as the cancer cells get into the bloodstream or lymph vessels of our body. When cells from a cancer like colorectal cancer spread to another organ like the liver, the cancer is still called colorectal cancer, not liver cancer.
Cancer cells develop because of damage to DNA. This substance is in every cell and directs all activities. Most of the time when DNA becomes damaged the body is able to repair it. In cancer cells, the damaged DNA is not repaired. People can inherit damaged DNA, which accounts for inherited cancers. More often, though, a person’s DNA becomes damaged by exposure to something in the environment, like smoking.
Cancer usually forms as a tumor. Some cancers, like leukemia, do not form tumors. Instead, these cancer cells involve the blood and blood-forming organs and circulate through other tissues where they grow.
Remember that not all tumors are cancerous. Benign (non-cancerous) tumors do not spread to other parts of the body
(metastasize) and, with rare exceptions, are not life threatening.
Different types of cancer can behave very differently. For example, lung cancer and breast cancer are very different diseases. They grow at different rates and respond to different treatments. That is why people with cancer need treatment that is aimed at their particular kind of cancer.
Cancer is the second leading cause of death in the United States. Nearly half of all men and a little over one third of all women in the United States will develop cancer during their lifetimes. Today, millions of people are living with cancer or have had cancer. The risk of developing most types of cancer can be reduced by changes in a person’s lifestyle — for example, by quitting smoking, eating a better diet, and increasing physical activity. The sooner a cancer is found and treatment begins, the better are the chances for living for many years.

Can Colorectal Polyps and Cancer Be Found Early?

Colorectal Cancer Screening

Screening tests are used to spot a disease early, before you have symptoms or a history of that disease. Screening for colorectal cancer means it can be found at an early curable stage, and it can also be prevented by finding and removing polyps that might eventually become cancerous. There are several tests used to screen for colorectal cancer:
Fecal occult blood test: The fecal occult blood test (FOBT) is used to find occult (hidden) blood in feces. Blood vessels at the surface of colorectal polyps or adenomas or cancers are often fragile and easily damaged by the passage of feces. The damaged vessels usually release a small amount of blood into the feces. Only rarely is there enough bleeding to color the stool red. The FOBT detects blood through a chemical reaction. The traditional version of this test cannot tell whether blood is from the colon or from other portions of the digestive tract (i.e., the stomach). Therefore, if this test is positive, additional testing is needed to see if there is a cancer, polyp, or other cause of bleeding such as ulcers, hemorrhoids, diverticulosis (tiny pouches that form at weak spots in the colon wall), or inflammatory bowel disease (colitis). Even foods or drugs can affect the test, so some doctors suggest that you should try to avoid the following with this test:

Nonsteroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen (Advil), naproxen (Aleve), or aspirin (more than 1 adult aspirin per day), for 7 days before testing (they can cause bleeding)
Vitamin C in excess of 250 mg daily from either supplements or citrus fruits, and juices for 3 days before testing (they can affect the chemicals in the test)
Red meats for 3 days before testing (components of blood in the meat may cause the test to show positive)

However, research has shown that some people never do the FOBT test or don’t give it to their doctor because they worry that something they ate may interfere with the test. For this reason, many doctors tell their patients it isn’t essential to follow these restrictions in their diet. The most important thing is to get the test done. People should try to avoid taking aspirin or related drugs for minor aches. But if you take these medications daily for heart problems or other conditions, don’t stop them for this test without approval from your doctor.
People having this test will receive a kit with instructions that explain how to take a stool or feces sample at home (usually 3 specimens smeared onto a small square of paper). The kit is then returned to the doctor’s office or a medical laboratory for testing. It is not necessary that the kit be returned immediately because the test is still accurate if the smeared feces have dried. A test of a stool sample that your doctor took from a digital rectal exam is not an adequate substitute.
Fecal immunochemical test: A newer kind of stool blood test kit, known as a fecal immunochemical test (FIT), detects a specific portion of a human blood protein. This test is done essentially the same way as conventional FOBT, but is more specific and reduces the number of false positive results. Vitamins or foods do not affect the fecal immunochemical test, and some forms require only 2 stool specimens (as opposed to 3 for conventional FOBT), so people may find it easier to use. The fecal immunochemical test has some of the same drawbacks as conventional FOBT, such as an inability to detect a tumor that is not bleeding.
Flexible sigmoidoscopy: A sigmoidoscope is a slender, flexible, hollow, lighted tube about the thickness of a finger. It is inserted through the rectum into the lower part of the colon. Not only can your doctor look through this to find any abnormality, the sigmoidoscope can be connected to a video camera and display monitor for a better view. This test may be somewhat uncomfortable, but it should not be painful. Because the sigmoidoscope is only 60 centimeters (around 2 feet) long, the doctor is able to see less than half of the colon with this procedure. Before the sigmoidoscopy, you will need to have a bowel preparation to clean out your lower colon. If an adenomatous polyp or colorectal cancer is found on this examination, you will need to have additional testing such as a colonoscopy to look for polyps of cancer in the rest of the colon.
Colonoscopy: A colonoscope is a longer version of a sigmoidoscope. It is inserted through the rectum and allows your doctor to see the lining of your entire colon. The colonoscope is also connected to a video camera and display monitor so the doctor can closely examine the inside of the colon.
If a small polyp is found, your doctor may remove it. Polyps, even those that are not cancerous, can eventually become cancerous. For this reason, they are usually removed. This is done by passing a wire loop through the colonoscope to cut the polyp from the wall of the colon with an electrical current. The polyp can then be sent to a lab to be checked under a microscope to see if it has any areas that have changed into cancer.
If your doctor sees a large polyp or tumor or anything else abnormal, a biopsy will be done. In this procedure, a small piece of tissue is taken out through the colonoscope. Examination of the tissue can help determine if it is a cancer, a benign (noncancerous) growth, or a result of inflammation.
If you have a colonoscopy, you will need to follow a clear-liquid diet and take laxatives the day before the test and an enema that morning to clean your colon so no stool will block the view. Colonoscopy can be uncomfortable. To avoid this, you will be given a sedating medication through a vein to make you feel relaxed and sleepy during the procedure. Colonoscopy may be done in a hospital outpatient department or ambulatory care center and usually takes 15 to 30 minutes, although it may take longer if polyp removal is involved.
Medicare will pay for colonoscopy at specified intervals for all people covered by Medicare who are older than 50.
Barium enema with air contrast: This procedure is also called a double-contrast barium enema. Barium sulfate, a chalky substance, is used to partially fill and open up the colon. The barium sulfate is given through a small tube placed in your anus. When the colon is about half-full of barium, you will be turned on the x-ray table so the barium spreads throughout the colon. Then air will be pumped into your colon through the same tube to make it expand. This produces the best pictures of the lining of your colon. You will need to cleanse your bowel the night before with laxatives and have an enema the morning of the exam.
Virtual colonoscopy: This can be thought of as a super x-ray of the colon and rectum. The preparation is the same as for a barium enema x-ray or colonoscopy. No contrast agent is used. Only air is pumped into the colon to distend it. Then a special CT scan called helical CT or spiral CT is done. This is probably more accurate than the barium enema but not quite as good as colonoscopy for finding very small polyps. The potential advantages are believed to be that the test can be done quickly, with no sedation, and at a lower cost than colonoscopy. A disadvantage is that if a polyp or growth is found, a biopsy or polyp removal needs to be done later with a colonoscopy. Virtual colonoscopy is currently not included among the tests recommended by American Cancer Society for early detection of colorectal cancer.

American Cancer Society Colorectal Cancer Screening Guidelines

Beginning at age 50, men and women who are at average risk for developing colorectal cancer should have 1 of the 5 screening options below:
1.     a fecal occult blood test (FOBT)* or fecal immunochemical test (FIT) every year, or
2.     flexible sigmoidoscopy every 5 years, or
3.     an FOBT or FIT every year plus flexible sigmoidoscopy every 5 years, or
o        (Of these first 3 options, the combination of FOBT or FIT every year plus flexible sigmoidoscopy every 5 years is preferable.)
4.     double-contrast barium enema every 5 years, or
5.     colonoscopy every 10 years
In a digital rectal examination (DRE), a doctor examines your rectum with the gloved end of his/her finger. Although a DRE is often included as part of a routine physical exam, it is not recommended as a stand-alone test for colorectal cancer. However, your doctor should do a DRE before inserting the sigmoidoscope or colonoscope. This simple test, which is not painful, can detect masses in the anal canal or lower rectum. By itself, however, it is not a very sensitive test for detecting colorectal cancer due to its limited reach.
Colonoscopy should be done if the FOBT or FIT shows blood in the stool, if sigmoidoscopy results show a polyp, or if double-contrast barium enema.studies find anything abnormal. If possible, polyps should be removed during the colonoscopy.
You should begin colorectal cancer screening earlier and/or undergo screening more often if you have any of the following colorectal cancer risk factors:

a strong family history of colorectal cancer or polyps (cancer or polyps in a first-degree relative [parent, sibling, or child] younger than 60, or in 2 first-degree relatives of any age)
a known family history of hereditary colorectal cancer syndromes (familial adenomatous polyposis and hereditary nonpolyposis colon cancer)
a personal history of colorectal cancer or adenomatous polyps
a personal history of chronic inflammatory bowel disease

Medicare Coverage for Colorectal Screening

Recently, Medicare started paying for screening colonoscopy in all people covered by Medicare who are 50 and older. Previously, Medicare covered the exam only for people in a narrow definition of “high risk” for colorectal cancer. While family history of the disease does put some people at high risk, the greatest risk factor by far is simply getting older.
The American Cancer Society helped lead efforts to expand Medicare’s coverage of colonoscopy. With this
accomplishment, people on Medicare can now get the full range of screening tests for colorectal cancer.

What Colorectal Cancer Screening Does Medicare Cover?

fecal occult blood test (FOBT) or fecal immunochemical test (FIT) yearly for all Medicare beneficiaries 50 years and over
flexible sigmoidoscopy (flex-sig) every 4 years for beneficiaries 50 years and over who are at average risk
colonoscopy every 2 years for all beneficiaries at high risk
colonoscopy once every 10 years for beneficiaries age 50 and over who are at average risk
double contrast barium enema (DCBE) as an alternative if a physician determines that its screening value is equal to or better than flexible sigmoidoscopy or colonoscopy

What Would a Medicare Beneficiary Expect to Pay for a Colorectal Cancer Screening Test?

FOBT/FIT: People over 50 years old with Medicare pay no coinsurance and no Part B deductible.
Flexible sigmoidoscopy: Patient pays 20% of Medicare-approved amount after the yearly Part B deductible.
Colonoscopy: Patient pays 20% of Medicare-approved amount after the yearly Part B deductible.
DCBE: When substituted for flexible sigmoidoscopy or colonoscopy, patient pays 20% of Medicare-approved amount after the yearly Part B deductible.

How Is Colorectal Cancer Diagnosed?

You will need to undergo a diagnostic workup if your doctor finds something suspicious during a screening examination or if you have symptoms of colorectal cancer.
If you have any such symptoms, please see your doctor immediately. He or she will need to take a complete medical history and perform a physical exam to determine the cause of your symptoms. Additional tests may be done to find out if you have colorectal cancer, or a different condition that may have some of the same symptoms.

Signs and Symptoms of Colorectal Cancer

If you have any of the following you should check with your doctor:

a change in bowel habits such as diarrhea, constipation, or narrowing of the stool that lasts for more than a few days
a feeling that you need to have a bowel movement that is not relieved by doing so
rectal bleeding or blood in the stool (often, though, the stool will look normal)
cramping or steady abdominal (stomach area) pain
weakness and fatigue

Other conditions, such as infections, hemorrhoids, and inflammatory bowel disease, can also cause these symptoms. But only a doctor can determine their cause. It is important to talk to your doctor since finding colorectal cancer early makes successful treatment more likely. It is also possible to have colon cancer and not have any symptoms. If the doctor suspects colon cancer, you may need to have more tests done. Remember that most people with colorectal cancer have normal-looking stool.
Whether you are undergoing diagnosis because of the results of a screening exam or because you have symptoms, your doctor may perform the following:
Medical history and physical exam: When your doctor “takes a history,” he or she will ask you a series of questions about your symptoms and risk factors, including your family history. Your doctor will carefully examine your abdomen to feel for masses or enlarged organs, and also examine the rest of your body. Your doctor may also perform a digital rectal examination (DRE).
FOBT, sigmoidoscopy, barium enema, double-contrast barium enema, colonoscopy: Your doctor may recommend one or more of these tests to further investigate a suspicious finding or determine the cause of your symptoms.
Blood tests: Your doctor may also order a blood count. This will determine whether you are anemic. Many people with colorectal cancer become anemic because of prolonged bleeding from the tumor. You may also have a blood test of your liver function, because colorectal cancer can spread to the liver and cause abnormalities.
In addition, colorectal cancer produces substances such as carcinoembryonic antigen (CEA) and CA 19-9 that are released into the bloodstream. Blood tests for these “tumor markers” are used most often with other tests for follow-up of patients who already have been treated for colorectal cancer. They may provide an early warning of a cancer that has returned.
These tumor markers are not used to find cancer in people who have never had a cancer and appear to be healthy. Tumor marker levels can be normal in a person who has cancer and can be abnormal for reasons other than cancer. For example, higher levels may also be present in the blood of some people with ulcerative colitis, non-cancerous tumors of the intestines, or some types of liver disease or chronic lung disease. Smoking can also raise CEA levels.
Biopsy: Usually if a suspected colorectal cancer is found by any test, it is biopsied during colonoscopy. In a biopsy, the doctor removes a small piece of tissue. This is sent to the pathology laboratory where a pathologist, a doctor especially trained to diagnose cancer and other diseases in tissue samples, examines the tissue under a microscope.

Imaging Tests

Ultrasound: Ultrasound involves the use of sound waves and their echoes to produce a picture of internal organs or masses. A small microphone-like instrument called a transducer emits sound waves. These high-frequency sound waves are transmitted into the area of the body being studied and echoed back. The sound wave echoes are picked up by the transducer and converted by a computer into an image that is displayed on a computer screen. Abdominal ultrasound can look for tumors in your liver, gallbladder, pancreas, or even inside your abdomen. It can’t look for tumors of the colon.
This is a very easy procedure. It uses no radiation, which is why it is frequently used to look at developing fetuses. When you undergo an ultrasound examination, you simply lie on a table and a technician moves the transducer over the skin overlying the part of your body being examined. Usually, the skin is first lubricated with oil.
Two special types of ultrasound examinations can be used to evaluate people with colon and rectal cancer. Endorectal ultrasound uses a special transducer that can be inserted directly into the rectum. This test is used to see how far through the wall a rectal cancer may have penetrated and whether it has spread to nearby organs or tissues such as lymph nodes. Intraoperative ultrasound is done after the surgeon has opened the abdominal cavity. The transducer can be placed against the surface of the liver, making this test very useful in detecting metastases of colorectal cancer to the liver.
Computed tomography (CT): The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, as does a conventional x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image of a slice of your body. The machine will take pictures of multiple slices of the part of your body that is being studied. This test can help tell if your colon cancer has spread into your liver or other organs. Often after the first set of pictures is taken you will receive an intravenous injection of a dye (a contrast agent) that helps outline structures in your body. A second set of pictures is then taken. You may be asked to drink 1 to 2 pints of a solution of contrast material. This helps outline the intestine so that it is not mistaken for tumors.
A special kind of CT, the spiral CT, uses a special scanner that can provide greater detail and is sometimes useful in finding metastases from colorectal cancer. For spiral CT with portography (looking at the portal vein — the large vein leading into the liver from the intestine), contrast material is injected into veins that lead to the liver, to help find metastases from colorectal cancer to that organ. CT scans can also be used to precisely guide a biopsy needle into a suspected metastasis. For this procedure, called a CT-guided needle biopsy, the patient remains on the CT scanning table, while a radiologist advances a biopsy needle toward the location of the mass. CT scans are repeated until the doctors are confident that the needle is within the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ½ inch long and less than 1/8 inch in diameter) is removed and examined under a microscope.
CT scans are more tedious than regular x-rays because they take longer and you need to lie still on a table while they are being done. But they are getting faster and your stay might be pleasantly short. Also, you might feel a bit confined by the ring you lie within when the pictures are being taken.
You will need to put up with the intravenous (IV) line through which the contrast dye is injected. The injection can also cause some flushing. Some people are allergic and get hives or, rarely, more serious reactions like trouble breathing and low blood pressure. Please be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays.
A new experimental application of the CT is to perform a “virtual colonoscopy.” After cleansing the stool from the colon and filling the colon with air, a computer-assisted reconstruction of the colon from CT images is possible. It requires the same preparation as for a colonoscopy. Also, the colon is inflated with air so that it can be viewed more clearly; this stretches the colon and can cause some discomfort. If abnormalities are detected, a follow-up colonoscopy will be required to take tissue samples of the abnormal areas.
Magnetic resonance imaging (MRI): MRI scans involve the use of radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a detailed image of parts of the body. Not only does this produce cross-sectional slices of the body like a CT scanner, it can also produce slices that are parallel with the length of your body. A contrast material might be injected just as with CT scans, but is used less often.
MRI scans are particularly helpful in examining the brain and spinal cord. MRI scans are a little more uncomfortable than CT scans. First, they take longer — often up to an hour. Also, you often have to be placed inside a tube, which is confining and can upset people with a fear of enclosed spaces. The machine also makes a thumping noise, but some places will provide headphones with music to block this out.
Chest x-ray: This test may be done to determine whether colorectal cancer has spread to the lungs.
Positron emission tomography (PET): PET scans involve the use of glucose (a form of sugar) that contains a radioactive atom. A small amount of the radioactive material is injected into your arm. Then you are put into the PET machine where a special camera can detect the radioactivity. Because of their high rate of metabolism, cancer cells absorb large amounts of the radioactive sugar. PET is useful when your doctor thinks the cancer has spread, but doesn’t know to where. PET scans can be used instead of several different x-rays because it scans your whole body and may find spread of the cancer where CT scans haven’t.
Angiography: For this test, doctors insert a very thin tube into a blood vessel that goes to the area to be studied. Contrast dye is injected rapidly and a series of x-ray images is then taken. This can show surgeons the location of blood vessels next to a liver metastasis from colorectal cancer, so that they can remove the metastasis without causing a lot of bleeding.

How Is Colorectal Cancer Staged?

Staging is a process that tells the doctor how widespread your cancer may be at the time of diagnosis. It will show whether the cancer has spread and how far. The treatment and outlook for colorectal cancer depends, to a large extent, on its stage. For early cancer, surgery may be all that is needed. For more advanced cancer, other treatments, such as chemotherapy or radiation therapy, may be required. Please be sure to ask your doctor to explain the stage of your cancer so that you can make the best choice about your treatment.
More than one system is used for staging colorectal cancer. These include the Dukes, Astler-Coller, and AJCC/TNM systems. This section concentrates on American Joint Committee on Cancer (AJCC) system (also called the TNM system), which describes stages using Roman numerals I through IV. Both the Dukes system and the Astler-Coller system use A through C; the Astler-Coller system adds stage D and has more subdivisions.
All 3 systems describe the spread of the cancer in relation to the layers of the wall of the colon or rectum, organs next to the colon and rectum, and other organs farther away. Because for most patients, this stage is unknown until after surgery, most doctors wait till then to decide on the cancer’s stage. The stages described below are called pathologic stages. The pathologic stage is determined by the findings of the pathologist from looking at the cancer and other actual tissue that has been removed.
The AJCC/TNM System describes the extent of the primary Tumor (T), the absence or presence of metastasis to nearby lymph Nodes (N), and the absence or presence of distant Metastasis (M).

T Categories for Colorectal Cancer

T categories of colorectal cancer describe the extent of spread through the layers that form the wall of the colon and rectum. These layers, from the inner to the outer, include the lining (mucosa), the fibrous tissue beneath this muscle layer (submucosa), a thick layer of muscle that contracts to force the contents of the intestines along (muscularis propria), and the thin outermost layers of connective tissue (subserosa and serosa) that cover most of the colon but not the rectum.

Tx: No description of the tumor’s extent is possible because of incomplete information.
Tis: The cancer is in the earliest stage. It has not grown beyond the mucosa (inner layer) of the colon or rectum. This stage is also known as carcinoma in situ or intramucosal carcinoma.
T1: The cancer has grown through the mucosa and extends into the submucosa.
T2: The cancer has grown through the submucosa and extends into the muscularis propria.
T3: The cancer has grown completely through the muscularis propria into the subserosa but not to any neighboring organs or tissues.
T4: The cancer has spread completely through the wall of the colon or rectum into nearby tissues or organs.

N Categories for Colorectal Cancer
N categories indicate whether or not the cancer has spread to nearby lymph nodes and, if so, how many lymph nodes are involved.

Nx: No description of lymph node involvement is possible because of incomplete information.
N0: No lymph node involvement is found.
N1: Cancer cells found in 1 to 3 nearby lymph nodes.
N2: Cancer cells found in 4 or more nearby lymph nodes.

M Categories for Colorectal Cancer

M categories indicate whether or not the cancer has spread to distant organs, such as the liver, lungs, or distant lymph nodes.

Mx: No description of distant spread is possible because of incomplete information.
M0: No distant spread is seen.
M1: Distant spread is present.

Stage Grouping

Once a patient’s T, N, and M categories have been determined, usually after surgery, this information is combined in a process called stage grouping to determine the stage, expressed in Roman numerals from stage I (the least advanced stage) to stage IV (the most advanced stage). The following guide illustrates how TNM categories are grouped together into stages:
Stage 0: Tis, N0, M0: The cancer is in the earliest stage. It has not grown beyond the inner layer (mucosa) of the colon or rectum. This stage is also known as carcinoma in situ or intramucosal carcinoma.
Stage I: T1, N0, M0, or T2, N0, M0: The cancer has grown through the mucosa into the submucosa or it may also have grown into the muscularis propria, but it has not spread into nearby lymph nodes or distant sites.
Stage IIA: T3, N0, M0: The cancer has grown through the wall of the colon or rectum into the outermost layers. It has not yet spread to the nearby lymph nodes or distant sites.
Stage IIB: T4, N0, M0: The cancer has grown through the wall of the colon or rectum into other nearby tissues or organs. It has not yet spread to the nearby lymph nodes or distant sites.
Stage IIIA: T1-2, N1, M0: The cancer has grown through the mucosa into the submucosa or it may also have grown into the muscularis propria, and it has spread to 1-3 nearby lymph nodes but not distant sites.
Stage IIIB: T3-4, N1, M0: The cancer has grown through the wall of the colon or rectum or into other nearby tissues or
organs and has spread to 1-3 nearby lymph nodes but not distant sites.
Stage IIIC: Any T, N2, M0: The cancer can be any T but has spread to 4 or more nearby lymph nodes but not distant sites.
Stage IV: Any T, Any N, M1: The cancer can be any T, any N, but has spread to distant sites such as the liver, lung,
peritoneum (the membrane lining the abdominal cavity), or ovary.

Comparison of AJCC, Dukes, and Astler-Coller Stages

If your stage is reported in letters rather than numbers, this table can be used to find the matching AJCC/TNM stage. As you can see, the Dukes and Astler-Coller staging systems often combine different AJCC stage groupings and are not as precise.

AJCC/TNM Dukes Astler-Coller

O
I A A, B1
IIA B B2
IIB B B3
IIIA C C1,
IIIB C C2, C3
IIIC C C1, C2, C3
IV D
If you have any questions about your stage, please ask your doctor to explain the extent of your disease.
Five-year relative survival by AJCC stage*: These numbers reflect the percent of people who are alive 5 years or more after being diagnosed with colon cancer, depending on what stage they were in when they were diagnosed. See below for definition of 5-year relative survival. The survival for rectal cancer, stage for stage, is about the same**.
Stage I 93%
Stage IIA 85%
Stage IIB 72%
Stage IIIA 83%
Stage IIIB 64%
Stage IIIC 44%
Stage IV 8%
The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed. Many of these patients live much longer than 5 years after diagnosis. The 5-year rate is used to produce a standard way of discussing prognosis. Five-year relative survival rates don’t include patients dying of other diseases. Five-year relative survival rates are considered to be a more accurate way to describe the prognosis for patients with a particular type and stage of cancer. Of course, 5-year rates are based on patients diagnosed and initially treated more than 5 years ago. They may no longer be accurate because improvements in treatment may result in a better outlook for recently diagnosed patients.

How Is Colorectal Cancer Treated?

The following information is a summary of the types of treatments available to people with colorectal cancer. The usual treatments for colorectal cancers at each stage are then discussed.
The 3 main types of treatment for colon cancer and rectal cancer are surgery, radiation therapy, and chemotherapy. Newer, targeted therapies called monoclonal antibodies are now beginning to be used as well. Depending on the stage of the cancer, 2 or more of these types of treatment may be combined at the same time or used after one another.
After the cancer has been found and staged, your doctor will recommend one or more treatment options. It is important to take time and think about all of the choices. You may want to ask for a second opinion. This can provide more information and help you feel more confident about the treatment plan you choose. It is also important to know that your chances for having the best possible outcome are highest in the hands of a medical team that is experienced in treating colorectal cancer.

Surgery

Colon surgery: Surgery is the main treatment for colon cancer. The most commonly performed operation is called a segmental resection. To prepare for this surgery you will be given a bowel prep which may consist of laxatives and enemas. Just before the surgery you will be given general anesthesia, which puts you into a deep sleep. During the surgery, your surgeon will make an incision in your abdomen. Then he or she will remove the cancer and a length of normal colon on either side of your cancer, as well as the nearby lymph nodes. Usually, about one fourth to one third of your colon is removed, but more or less tissue may be removed depending on the exact size and location of your cancer. The remaining sections of your colon are then reattached. When you wake up you will have some pain and will need to be given painkillers, usually morphine, for 2 or 3 days.
For the first couple of days, you will be given intravenous fluids and not be able to eat. But a colon resection rarely causes any major problems with digestive functions and you should be able to eat in a few days. If the tumor is large and has blocked your colon, or it has punched a hole in your colon so wastes have leaked out, a temporary colostomy may be needed. A colostomy is made when the end of the colon is brought through an opening in the abdomen to the outside for the purpose of getting rid of body wastes. A pouch is then used to hold that waste. Rarely, if a tumor can’t be removed, a permanent colostomy is needed.
It is possible to remove some very early colon cancers (stage 0 and some stage I tumors), or cancerous polyps, by surgery through a colonoscope. When this is done, the surgeon does not have to cut into the abdomen. This is called a polypectomy. The cancer is cut out across the base of the polyp’s stalk, the area that resembles the stem of a mushroom. Local excision removes superficial cancers and a small amount of nearby tissue.
It is sometimes possible to remove segments of the colon and nearby lymph nodes through a laparoscope. This is sometimes called “laparoscopic” or “keyhole” surgery. Using a canula (a narrow tube-like instrument), the surgeon enters the abdomen. A laparoscope (a tiny telescope connected to a video camera) is inserted through the canula, giving the surgeon a magnified view of the internal organs, which is displayed on a television monitor. Several other canulas are inserted to allow the surgeon to work inside and remove part of the colon. These incisions are usually small and heal quickly. Although using laparoscopic surgery to remove colon cancers was once considered experimental, this is no longer true. A recent study has shown that laparoscopic surgery is as likely to be curative as the standard approach and patients recover faster and feel better than they do after conventional colon surgery.
Rectal surgery: Surgery is usually the main treatment for rectal cancer, although radiation and chemotherapy may also be used in addition to surgery. Several surgical methods are used for removing or destroying rectal cancers.
Polypectomy and local excision can be used to remove superficial cancers or polyps. Local transanal resection involves cutting through all layers of the rectum to remove invasive cancers as well as some surrounding normal rectal tissue. Polypectomy, local excision, and local transanal resection are done with instruments inserted through the anus, without making a surgical opening in the skin of the abdomen. This procedure can be used to remove some stage I rectal cancers that are relatively small and not too far from the anus.
Some stage I rectal cancers and most stage II or III rectal cancers are removed by either low anterior resection or abdominoperineal (AP) resection. Low anterior resection is used for cancers in the upper two thirds of your rectum, close to where it connects with the colon. In this procedure the tumor can be removed without affecting the anus. After low anterior resection, your colon will be attached to the anus and your waste will be eliminated in the usual way.
A low anterior resection is like most abdominal operations. You will take laxatives and enemas before surgery. Just before surgery you will be given general anesthesia, which puts you into a deep sleep. The surgeon makes the incision only in the
abdomen. Then the surgeon removes the cancer along with a margin of normal tissue on either side of the cancer. In addition, the surgeon will also remove lymph nodes and a large amount of fatty and fibrous tissue around the rectum. Then the colon can be reattached to the rectum that is remaining so that a permanent colostomy is not necessary. Sometimes, when special techniques are necessary to prevent a permanent colostomy, you may need to have a temporary colostomy opening for about 8 weeks while the surgical site heals. A second operation is then performed to close the temporary colostomy opening.
If the cancer is in the distal third of the rectum (the part nearest to the anus) and especially if it is growing into the sphincter muscle (the muscle that keeps the anus closed and prevents stool leakage), the anus and sphincter muscle may also need to be removed. Then an operation called an abdominoperineal resection is necessary. Here, not only does the surgeon make an incision in the abdomen, he or she must also make an incision in the perineal area around the anus. This incision allows the surgeon to remove the anus and the tissues surrounding it including the sphincter muscle. Having this procedure also means you will need a permanent colostomy to eliminate your stool.
The usual hospital stay for either of these procedures is 4 to 7 days depending on your overall health. Recovery time at home may be 3 to 6 weeks. If you have had a colostomy, you will need help in learning how to manage it. Specially trained ostomy nurses or enterostomal therapists can do this. They will usually see you in the hospital before your operation to mark a site for the colostomy opening, and later can come to your house or an outpatient setting to provide you with more training.
If the rectal cancer is growing into nearby organs, a pelvic exenteration may be recommended. This is a very extensive operation. Not only will the surgeon remove your rectum, but also nearby organs such as the bladder, prostate, or uterus when the cancer has spread to these organs. You will need a colostomy after pelvic exenteration. If your bladder is removed, you will also need a urostomy (opening where urine exits the front of the abdomen and is held in a portable pouch).
Side effects of surgery: Side effects include bleeding from the surgery, blood clots in the legs, and damage to nearby organs during the operation. Rarely, the connections between the ends of the intestine may not hold together completely and leak. If an infection occurs, it is possible that the incision might open up, causing a gaping wound. Later, after the surgery, you might develop what are called adhesions that could cause the bowel to become blocked.
Sexual impact of colorectal surgery: If you are a man, an abdominal perineal resection can cause you to have “dry” orgasms by damaging the nerves that control ejaculation. Sometimes the surgery only causes retrograde ejaculation, which means the semen goes backward into your bladder. The difference between no emission at all and retrograde ejaculation becomes important if you want to father a child. Retrograde ejaculation is less serious, because infertility specialists can recover sperm cells from your urine and these cells can be used to make a woman pregnant. If sperm cells cannot be recovered from your semen or urine, infertility specialists may be able to retrieve them directly from your testicle by minor surgery, and then use them for in vitro fertilization to produce a pregnancy. In some situations, AP resection may stop your erections or ability to reach orgasm. In other cases your pleasure at orgasm may become less intense. Normal aging may cause some of these changes, but they may be enhanced by the surgery.
If you are a woman having a colostomy, you should not normally expect any loss of sexual function. No matter what your gender, more information on dealing with the sexual impact of cancer and its treatment is available in the American Cancer Society documents, “Sexuality and Cancer: For the Man Who Has Cancer and His Partner” and “Sexuality and Cancer: For the Woman Who Has Cancer and Her Partner.”
Surgical treatment of colorectal cancer metastases: Sometimes, treatment of cancer that has spread to other organs, or metastasized, can help you to live longer — or even to be cured. If only a small number of metastases are present in the liver, lungs, or ovaries, they may be removed by surgery. If only a few liver metastases are present, completely removing them along with the colorectal tumor may even cure you. Liver metastases may also be destroyed by freezing them (cryosurgery), by heating them with microwaves, by injecting material into large blood vessels feeding the tumor to block blood flow (embolization), or by injecting concentrated alcohol into the tumor. These methods do not require a surgical operation. The freezing probe, microwave probe, or needle is inserted through the skin and guided to the tumor by CT scans or ultrasound images. However, these methods are not curative.
Radiation Therapy
Radiation therapy uses high-energy rays that destroy cancer cells. After surgery for rectal cancer, radiation can kill small deposits of cancer that may not be seen during surgery. If a rectal cancer’s size and/or position make surgery difficult, radiation may be used before surgery to shrink the tumor. Radiation also may be used to ease (palliate) symptoms if you have advanced cancer causing intestinal blockage, bleeding, or pain. Chemotherapy can make radiation therapy more effective against some colon and rectal cancers, and these 2 treatments are often used together.
The main use for radiation therapy in people with colon cancer is when the cancer has attached to an internal organ or the lining of the abdomen. When this occurs, the surgeon cannot be certain that all the cancer has been removed, and radiation therapy is used to kill the cancer cells remaining after surgery. For rectal cancer, radiation therapy is usually given to prevent the cancer from coming back in the pelvis where the tumor started. It may be given either before or after surgery, but recently doctors have begun to favor preoperative treatment, along with chemotherapy. Radiation therapy is given to treat local recurrences in rectal cancers that are causing symptoms such as pain. Radiation therapy is seldom used to treat metastatic colon cancer because of side effects and relative resistance when given at the lower tolerated doses.
External-beam radiation therapy focuses radiation on the cancer from a machine outside the body called a linear accelerator. This is the type of radiation therapy most often recommended for people with colon cancer. Treatments are given 5 days a week for several weeks. Each treatment lasts only a few minutes and is similar to having a diagnostic x-ray test. As with a diagnostic x-ray, the radiation passes through the skin and other tissues before it reaches the tumor. The actual radiation exposure is very quick, and most of the time is spent precisely positioning the patient so that the radiation is aimed accurately at the cancer.
Endocavitary radiation therapy, like external-beam radiation therapy, is delivered from a radiation source outside the body. It is a hand-held device that is placed into the anus. The device delivers high-intensity radiation over a few minutes. This is repeated about 3 more times at about 2-week intervals for the full dose. The advantage is that the radiation is aimed through the anus and reaches the rectum without passing through the skin and other tissues of the abdomen. This can allow some patients, particularly elderly persons, to avoid radical surgery and colostomy. It is used only for small tumors.
Sometimes external beam therapy is also given.
Brachytherapy (internal radiation therapy) uses small pellets of radioactive material placed next to or directly into the cancer. Internal radiation is sometimes used in treating people with rectal cancer, particularly sick or elderly people who would not be able to tolerate curative surgery. This is generally a one-time only procedure and doesn’t require daily visits for several weeks.
Side effects of radiation therapy: Side effects of radiation therapy for colon and rectal cancer include mild skin irritation, nausea, diarrhea, rectal irritation, bladder irritation, fatigue, or sexual problems (impotence in men and vaginal irritation in women). Most of these will lessen after treatments are completed. The sexual problems and rectal and bladder irritation can persist. Some degree of rectal and/or bladder irritation may be a permanent side effect. This can lead to diarrhea, bleeding, and frequent urination. If you have these or other side effects, talk to your doctor. There may be ways to lessen many of them.

Chemotherapy

Use of chemotherapy after surgery can increase the survival rate for patients with some stages of colon cancer and rectal cancer. This is called adjuvant (additional) chemotherapy. It is given when there is no evidence of cancer but there is a chance that it might come back. Chemotherapy can also help shrink tumors and relieve symptoms of advanced cancer. This is called palliative chemotherapy.
Systemic chemotherapy uses anticancer drugs that are injected into a vein or given by mouth. These drugs enter the bloodstream and reach all areas of the body. This treatment is useful for cancers that have metastasized (spread) beyond the organ they started in. In regional chemotherapy, drugs are injected directly into an artery leading to a part of the body containing a tumor. This approach concentrates the dose of chemotherapy reaching the cancer cells. It reduces side effects by limiting the amount reaching the rest of the body. Hepatic artery infusion is an example of regional chemotherapy sometimes used for colon cancer that has spread to the liver.
Fluorouracil (5-FU) is the drug most often used to treat colon cancer. In adjuvant therapy, it is often given together with another drug, leucovorin, which increases its effectiveness. In the past, 5-FU was usually injected slowly into a vein over about 5 minutes and then followed by the leucovorin. These injections were given daily for 5 days, followed by 3 weeks off chemotherapy or weekly for 6 weeks, followed by 2 weeks off treatment.
Recently it has been found that a different way of giving these drugs may be better. In this regimen, called the de Gramont regimen, the 5-FU is given continuously over 2 days as well as by rapid injection on the first day. The leucovorin is given on the first and second day over 2 hours. The de Gramont regimen is given every other week.
In all of these schedules, alternating periods of treatment and recovery are repeated over a period of 6 months to 1 year. In some regimens the 5-FU is given continuously and patients wear a small battery-operated pump that continuously infuses 5FU into an intravenous catheter. Leucovorin and 5-FU are also used for palliative treatment (to control the growth of the cancer or relieve symptoms). Generally, 5-FU/leucovorin is given for 6 months.
Capecitabine (Xeloda) is an oral chemotherapy drug that is changed to 5-FU once it gets to the tumor site. This drug can be used instead of intravenous 5-FU and acts as if the 5-FU were being given continuously. The side effects of treatment with this drug are nausea, diarrhea, and a syndrome of hand and foot redness that is sometimes accompanied by skin peeling.
Irinotecan (Camptosar) is often used to help control colorectal cancer. It formerly was used in patients no longer responding to palliative 5-FU therapy. But it has been found that irinotecan combined with 5-FU and leucovorin is more effective than 5-FU and leucovorin alone as the first treatment in people with metastatic colorectal cancer, so it is now often used as the first treatment in this situation. This combination may also be more effective as an adjuvant therapy after surgery. Clinical trials have begun to study whether irinotecan would be effective in preventing recurrence.
Although adding irinotecan to the standard chemotherapy combination of 5-FU and leucovorin makes the treatment more effective, it may also make your side effects (such as diarrhea, nausea, and low white blood cell counts) more severe. Irinotecan can cause severe diarrhea, so you must tell your doctor right away if you develop diarrhea. Your doctors may not recommend irinotecan if you are elderly or have other serious health problems. If these severe side effects are uncontrolled, they may lead to death.
These side effects are not as much a problem in patients who do well with the first treatment. If you are already on this
combination and have not had any major problems, you are probably safe.
Oxaliplatin (Eloxatin) is another drug recently approved by the FDA for use in colorectal cancer. Oxaliplatin is very effective when combined with 5-FU and leucovorin (LV). The major side effect of oxaliplatin is that it causes numbness and tingling — and extreme sensitivity to temperature — in various parts of the body, mostly arms and legs. This can last for months but almost always goes away.
Patients with more advanced cancers, which includes some with stage II and all with stage III have a higher chance that the cancer will return, often at a distant site. Many clinical trials have tested different combinations of drugs to prevent this recurrence. The most effective adjuvant treatment seems to be a chemotherapy combination called FOLFOX (Folinic acid, 5FU, Oxaliplatin). This is a combination of 5-FU and leucovorin (also called folinic acid) given by the de Gramont method along with oxaliplatin. Another regimen gives the 5-FU and leucovorin weekly by rapid intravenous infusion along with the oxaliplatin. Although this may be as effective as FOLFOX 4, it appears to have more side effects, mainly causing severe diarrhea. Other regimens that may be used are combinations of 5-FU and leucovorin.
Side effects of chemotherapy: Chemotherapy drugs kill cancer cells but also damage some normal cells. Your doctor and other health providers can help to avoid or minimize side effects, which will depend on the type of drugs, the amount taken, and the length of your treatment. You might temporarily experience nausea and vomiting, loss of appetite, loss of hair, hand and foot swelling and rashes, and mouth sores. Diarrhea can be troubling, especially if you are receiving irinotecan (Camptosar), but it can also occur with 5-FU/leucovorin treatment. Nerve damage from oxaliplatin can also be troubling but eventually disappears.
Because chemotherapy can damage the blood-producing cells of the bone marrow, you may develop low blood cell counts. This can result in an increased chance of infection (due to a shortage of white blood cells), bleeding or bruising after minor cuts or injuries (due to a shortage of blood platelets), and fatigue (due to low red blood cell counts). Please talk with your doctor if you have any unrelieved side effects.
Most side effects disappear once treatment is stopped. Your hair will grow back after treatment ends, though it may look different. There are remedies for many of the temporary side effects of chemotherapy — for example, antiemetic drugs that can prevent or reduce nausea and vomiting.
Elderly people seem to be able to tolerate chemotherapy for colorectal cancer. There is no reason to withhold treatment in otherwise healthy people because of age.

Targeted Therapies

Targeted therapies are those that specifically attack some part of cancer cells that make them different from normal cells. Because of this, they should cause fewer side effects than chemotherapy drugs.
Cetuximab (Erbitux) was the first targeted therapy approved for treating colorectal cancer. It is a manmade protein called a monoclonal antibody that specifically attacks the epidermal growth factor receptor (EGFR), a molecule that often appears in high amounts on the surface of cancer cells.
The FDA has approved cetuximab for use with irinotecan or without irinotecan in those who can’t take irinotecan or whose cancer is no longer responding to it. In about 10% of patients whose cancers continue to grow despite other treatments, cetuximab will cause tumor shrinkage. This figure is doubled when cetuximab is combined with irinotecan, even if the patients have already been treated with irinotecan and are no longer responding.
Cetuximab is given by intravenous injection. The most serious side effect of cetuximab is an allergic reaction during the first infusion, which could cause problems with breathing and low blood pressure. Other less serious side effects may include an acne-like rash, dry skin, tiredness, fever, and constipation.
Bevacizumab (Avastin), another monoclonal antibody, is approved for first-line use against metastatic colorectal cancer. It is used along with chemotherapy drugs. This antibody is directed against vascular endothelial growth factor (VEGF), a protein that helps tumors form new blood vessels to get nutrients (a process known as angiogenesis). In one study, when bevacizumab was given along with an irinotecan-containing chemotherapy regimen, it increased the shrinkage rate in tumors by 30% compared to patients who were given the same chemotherapy without bevacizumab. It also nearly doubled the time it took for the tumors to grow back. Bevacizumab is the first anti-angiogenesis drug approved to treat colorectal cancer. It is given by intravenous infusion.
Rare but possibly serious side effects include bleeding, holes forming in the colon (requiring surgery to correct), and slow wound healing. More common side effects include high blood pressure, tiredness, blood clots, low white blood cell counts, headaches, mouth sores, loss of appetite, and diarrhea.
Clinical trials are in progress that are testing whether adding either bevacizumab or cetuximab to chemotherapy will further lower the chance of recurrence.

Cost of Drugs

Some of the cancer drugs described are very expensive. 5-FU and leucovorin are inexpensive, but 8 weeks of treatment with a combination that includes oxaliplatin or irinotecan and either bevacizumab or cetuximab will cost at least $20,000 to $30,000. Patients on Medicare without any other insurance will need to pay for 20% of this cost.

Clinical Trials

The purpose of clinical trials: Studies of promising new or experimental treatments in patients are known as clinical trials. A clinical trial is only done when there is some reason to believe that the treatment being studied may be valuable to the patient. Treatments used in clinical trials are often found to have real benefits. Researchers conduct studies of new treatments to answer the following questions:

Is the treatment helpful?
How does this new type of treatment work?
Does it work better than other treatments already available?
What side effects does the treatment cause?
Are the side effects greater or less than the standard treatment?
Do the benefits outweigh the side effects?
In which patients is the treatment most likely to be helpful?

Types of clinical trials: There are 3 phases of clinical trials in which a treatment is studied before it is eligible for approval by the FDA (Food and Drug Administration).
Phase I clinical trials: The purpose of a phase I study is to find the best way to give a new treatment and how much of it can be given safely. The cancer care team watches patients carefully for any harmful side effects. The treatment has been well tested in lab and animal studies, but the side effects in patients are not completely known. Doctors conducting the clinical trial start by giving very low doses of the drug to the first patients and increasing the dose for later groups of patients until side effects appear. Although doctors are hoping to help patients, the main purpose of a phase I study is to test the safety of the drug.
Phase II clinical trials: These studies are designed to see if the drug works. Patients are given the highest dose that doesn’t cause severe side effects (determined from the phase I study) and closely observed for an effect on the cancer. The cancer care team also looks for side effects.
Phase III clinical trials: Phase III studies involve large numbers of patients — often several hundred. One group (the control group) receives the standard (most accepted) treatment. The other group receives the new treatment. All patients in phase III studies are closely watched. The study will be stopped if the side effects of the new treatment are too severe or if one group has had much better results than the others.
If you are in a clinical trial, you will have a team of experts taking care of you and monitoring your progress very carefully. The study is especially designed to pay close attention to you.
However, there are some risks. No one involved in the study knows in advance whether the treatment will work or exactly what side effects will occur. That is what the study is designed to find out. While most side effects disappear in time, some can be permanent or even life threatening. Keep in mind, though, that even standard treatments have side effects. Depending on many factors, you may decide to enroll in a clinical trial.
Deciding to enter a clinical trial: Enrollment in any clinical trial is completely up to you. Your doctors and nurses will explain the study to you in detail and will give you a form to read and sign indicating your desire to take part. This process is known as giving your informed consent. Even after signing the form and after the clinical trial begins, you are free to leave the study at any time, for any reason. Taking part in the study does not prevent you from getting other medical care you may need.
To find out more about clinical trials, ask your cancer care team. Among the questions you should ask are:

Is there a clinical trial for which I would be eligible?
What is the purpose of the study?
What kinds of tests and treatments does the study involve?
What does this treatment do? Has it been used before?
Will I know which treatment I receive?
What is likely to happen in my case with, or without, this new treatment?
What are my other choices and their advantages and disadvantages?
How could the study affect my daily life?
What side effects can I expect from the study? Can the side effects be controlled?
Will I have to be hospitalized? If so, how often and for how long?
Will the study cost me anything? Will any of the treatment be free?
If I am harmed as a result of the research, what treatment would I be entitled to?
What type of long-term follow-up care is part of the study?
Has the treatment been used to treat other types of cancers?

The American Cancer Society offers a clinical trials matching service for patients, their family, and friends. You can reach this service at 1-800-303-5691 or on our Web site at http://clinicaltrials.cancer.org/ . Based on the information you provide about your cancer type, stage, and previous treatments, this service can compile a list of clinical trials that match your medical needs. In finding a center most convenient for you, the service can also take into account where you live and whether you are willing to travel.
You can also get a list of current clinical trials by calling the National Cancer Institute’s (NCI) Cancer Information Service toll free at 1-800-4-CANCER or by visiting the NCI clinical trials Web site at www.cancer.gov/clinical_trials/.

Complementary and Alternative Methods

Complementary and alternative therapies are a diverse group of health care practices, systems, and products that are not part of usual medical treatment. They may include products such as vitamins, herbs, or dietary supplements, or procedures such as acupuncture, massage, and a host of other types of treatment. There is a great deal of interest today in complementary and alternative treatments for cancer. Many are now being studied to find out if they are truly helpful to people with cancer.
You may hear about different treatments from family, friends, and others, which may be offered as a way to treat your cancer or to help you feel better. Some of these treatments are harmless in certain situations, while others have been shown to cause harm. Most of them are of unproven benefit.
The American Cancer Society defines complementary medicine or methods as those that are used along with your regular medical care. If these treatments are carefully managed, they may add to your comfort and well-being. Alternative medicines are defined as those that are used instead of your regular medical care. Some of them have been proven not to be useful or even to be harmful, but are still promoted as “cures.” If you choose to use these alternatives, they may reduce your chance of fighting your cancer by delaying, replacing, or interfering with regular cancer treatment.
Before changing your treatment or adding any of these methods, discuss this openly with your doctor or nurse. Some methods can be safely used along with standard medical treatment. Others, however, can interfere with standard treatment or cause serious side effects. That is why it’s important to talk with your doctor. More information about specific complementary and alternative therapies used for cancer is available through our toll-free number (1-800-ACS-2345) or on our Web site.

Treatment by Stage of Colon Cancer

For all but stage IV disease, surgery to remove the colon tumor is the primary or first treatment. Adjuvant therapy
(additional treatments) may also be used.
Stage 0: Since your cancer has not grown beyond the inner lining of the colon, surgery to take out the cancer is all that is needed. This may be accomplished in many cases by polypectomy or local excision through the colonoscope. Colon resection may be necessary if your tumor is too big to be removed by local excision.
Stage I: Your cancer has grown through several layers of the colon. But it has not spread outside the colon wall itself. Surgical resection to remove the cancer is the standard treatment. You do not need any additional therapy.
Stage II: Your cancer has grown through the wall of the colon and may extend into nearby tissue. It has not yet spread to the lymph nodes. Surgical resection is usually the only treatment you need. If your doctor thinks your cancer is likely to come back because of its appearance under the microscope or because it was growing into other tissues, radiation therapy or chemotherapy may be recommended. Radiation therapy can be given to the area of your abdomen where the cancer was growing. Chemotherapy is not standard treatment for this stage of colon cancer, but many doctors recommend it if the risk of recurrence seems high. There are clinical trials studying this issue, and you might consider enrolling in one. If your doctor recommends chemotherapy, it will likely be the FOLFOX regimen, although some doctors may prefer other regimens such as 5-FU and leucovorin or capecitabine because they are better suited to your health needs.
Stage III: This is a more advanced stage. Your cancer has spread to nearby lymph nodes. But it has not yet spread to other parts of the body. Surgical resection is the first treatment. You should then receive chemotherapy. It will likely be the FOLFOX regimen, although some doctors may prefer other regimens such as 5-FU and leucovorin or capecitabine because they are better suited to your health needs. You may need radiation therapy if your cancer was large enough to grow into adjacent tissues.
Stage IV: In this stage the cancer has spread to distant organs and tissues such as the liver, lungs, peritoneum, or ovaries. The goal of surgery (segmental resection or diverting colostomy) in this stage is usually to relieve or prevent blockage of the colon and to prevent other local complications. In some patients with extensive metastases (spread of cancer), blockage can be prevented or managed by inserting a tube through the tumor (stent) during colonoscopy so that surgery can be avoided. If your cancer is small and your health poor, you might not have surgery.
Surgery in stage IV is usually not done with the expectation of curing the colon cancer. However, if only a few small metastases (usually 5 or fewer) are present in the liver and can be completely removed along with the colon cancer, surgery can help you live longer and may even cure you. You may also be treated with chemotherapy after this. It could be given directly into the arteries that lead into the liver. Another alternative would be intravenous chemotherapy with 5-FU and leucovorin with or without oxaliplatin, the FOLFOX regimen. Recently, doctors have found that adding bevacizumab (Avastin) to this regimen is more effective. Capecitabine pills or irinotecan combined with cetuximab are other alternatives.
If metastases cannot be surgically removed because they are too large or there are too many of them, it may be possible to destroy the tumors by freezing, heating with microwaves, or other nonsurgical methods. Chemotherapy or radiation therapy (or both) may be given to relieve, delay, or prevent symptoms.
Recurrent colon cancer: Recurrent cancer means that your cancer has returned after treatment. The recurrence may be local (near the area of the initial tumor) or it may affect distant organs. Surgery to remove local recurrences can sometimes help you live longer. As with stage IV colon cancer, surgery to remove metastases can also sometimes help you and, along with chemotherapy, can still be curative.
If the metastases can’t be removed, chemotherapy with FOLFOX or irinotecan with 5-FU and leucovorin are the main treatments. The FOLFOX may be combined with bevacizumab and the irinotecan with cetuximab. Capecitabine or 5 FU and leucovorin are other options. Drugs are selected based on which, if any, chemotherapy drugs you received before the cancer came back and how long ago you received them. You also might want to discuss appropriate clinical trials with your doctor.

Treatment by Stage of Rectal Cancer

Except for some patients with stage IV cancer, surgery to remove the rectal cancer is the first treatment. Adjuvant therapy (additional treatments) may also be used.
Stage 0: At this stage the cancer has not grown beyond the inner lining of the rectum. Removing or destroying the cancer is all that is needed. You can be treated with a polypectomy, local excision, or full thickness rectal resection. You will need no further treatment.
Stage I: In this stage your cancer has grown through the first layer of the rectum into deeper layers but has not spread outside the rectal wall itself. Primary surgery is usually either low anterior resection or abdominoperineal resection, depending on exactly where the cancer is found within your rectum. Some small stage I rectal cancers may be treated by removing them through the anus without an abdominal incision. You should need no further treatment.
If you are too sick or old to withstand surgery, you may be treated only with radiation therapy. Sometimes this is endocavitary radiation therapy (aiming radiation through the anus) or brachytherapy (placing radioactive pellets directly into the cancer). However, this has not been proven to be as effective as surgery.
Stage II: The cancer has grown through the wall of your rectum into nearby tissue. It has not yet spread to the lymph nodes. Stage II rectal cancers are usually treated by low anterior resection or abdominoperineal resection, along with both chemotherapy and radiation therapy. Radiation can be given either before or after your surgery. Most doctors now favor giving the radiation therapy along with chemotherapy before surgery. Also, many doctors now favor giving adjuvant chemotherapy after surgery. It will likely be the FOLFOX regimen, although some doctors may prefer other regimens such as 5-FU and leucovorin or capecitabine because they are better suited to your health needs.
In some cases of stage II rectal cancer, transanal full thickness rectal resection can be done after chemotherapy and radiation therapy. This approach can prevent the need for abdominoperineal resection and colostomy in some cases. The problem with this is there is no way of knowing whether the cancer has spread to your lymph nodes or being sure the cancer hasn’t spread further in your pelvis. Because of this, this procedure isn’t generally recommended.
Stage III: Your cancer has spread to nearby lymph nodes but not to other parts of your body. The rectal tumor is usually removed by low anterior resection or abdominoperineal resection. Radiation therapy will be given before or after surgery. As in stage II, many doctors now prefer to give the radiation therapy along with chemotherapy before surgery because it lowers the chance that the cancer will come back in the pelvis. It will also be used for large tumors to make the surgery more effective.
You should then receive chemotherapy. The FOLFOX regimen is the one that many experts recommend. Alternatives are 5FU and leucovorin or capecitabine, which may better suit their health needs.
Stage IV: Your cancer has spread to distant organs and tissues such as your liver or lungs. The goal of surgery in this stage is to relieve or prevent blockage of your rectum by the cancer and to prevent local complications such as bleeding. Sometimes inserting a tube through the cancer (stent) during colonoscopy can open the blockage. The cancer usually cannot be cured by rectal surgery because it has spread. However, in some cases, it may be possible to remove the rectal tumor, as well as the metastases if only a few are present.
This surgery can help you live longer and/or relieve some of your symptoms. If only a few liver metastases are present, completely removing them along with the rectal tumor may even cure you. If metastases cannot be removed by surgery because they are too large or there are too many of them, it may be possible to destroy the tumors by freezing (cryosurgery), heating with microwaves, photocoagulation (vaporizing the tumor with a laser), or other nonsurgical methods. You may also receive chemotherapy or radiation therapy (or both) to relieve, delay, or prevent symptoms.
It is usually important to treat the rectal tumor with either surgery or radiation therapy, perhaps combined with chemotherapy to prevent blocking of the rectum and/or spread into surrounding tissues. If it appears that the cancer can’t be removed or shrunk, then a colostomy will be done to get around any rectal blockage.
If you have only liver metastases, you may be treated with chemotherapy given directly into the artery leading to the liver. This shrinks the cancers in the liver more effectively than if the chemotherapy is given intravenously. If there are only a few liver metastases, removing them with surgery may prolong life and even be curative.
Recurrent rectal cancer: Recurrent cancer means that the cancer has returned after treatment. It may come back locally (near the area of the initial rectal tumor) or in distant organs. Surgery to remove local recurrences can help you live longer. If the tumor cannot be completely removed, combined chemotherapy and radiation therapy may be used. Sometimes, this combination shrinks the cancer enough that complete surgical removal is then possible. If the metastases can’t be removed, chemotherapy with FOLFOX or irinotecan along with 5-FU and leucovorin are the main treatments. The FOLFOX may be combined with bevacizumab and the irinotecan/FU/leucovorin with cetuximab. Capecitabine and 5-FU with leucovorin are other options.
Drugs are selected based on which, if any, chemotherapy drugs you received before the cancer came back and how long ago you received them along with your particular health needs. You also might want to discuss with your doctor whether you might enroll in a clinical trial.

What Happens After Treatment for Colorectal Cancer?

During and after treatment for colorectal cancer, you may be able to speed up your recovery and improve your quality of life by taking an active role. You have the right to learn about the benefits and disadvantages of each of your treatment options, and ask questions of your cancer care team if there is anything you do not understand. If you have side effects with your treatment, be sure to report these promptly to your cancer care team so that they can take steps to minimize them and shorten their duration.
Remember that your body is as unique as your personality and your fingerprints. Although understanding your cancer’s stage and learning about the effectiveness of your treatment options can help predict what health problems you may face, no one can say precisely how you will respond to cancer or its treatment.
You may have special strengths, such as a history of excellent nutrition and physical activity, a strong family support system, or a deep faith, and these strengths may make a difference in how you respond to cancer. In fact, behavioral scientists have recently found that some people who took advantage of a social support system, such as a cancer support group, survived with a better quality of life. There are also experienced professionals in mental health services, social work services, and pastoral services who may assist you in coping with your illness.
You can also help in your own recovery from cancer by making healthy lifestyle choices. If you use tobacco, quitting will improve your overall health, and the full return of your sense of smell may help you enjoy a healthy diet during recovery. If you use alcohol, try to limit your intake to 1 or 2 drinks per day. Good nutrition can help you get better after treatment. Eat a nutritious and balanced diet, with plenty of fruits, vegetables, and whole grain foods. Ask your cancer care team if you could benefit from a special diet — they may have specific recommendations for people who have had radiation therapy, a colostomy, or other colorectal surgery.
If you are in treatment for cancer, be aware of the battle that is going on in your body. Radiation therapy and chemotherapy add to the fatigue caused by the disease itself. Give your body all the rest it needs so that you will feel better as time goes on. Ask your cancer care team whether your cancer or its treatments might limit your exercise program or other activities. You may also consider asking what type of exercise regimen is appropriate for you during and after treatment.
Surgery and radiation therapy may sometimes affect a person’s feelings about their body and may lead to specific physical problems that affect sexuality. Your cancer care team can help with these issues, so don’t hesitate to share your concerns.
A cancer diagnosis and its treatment are major life challenges, with an impact on you and everyone who cares for you. Before you get to the point where you feel overwhelmed, consider attending a meeting of a local support group. If you need individual assistance in other ways, contact your hospital’s social service department or the American Cancer Society for help in contacting counselors or other services.
Follow-up care: For years after treatment ends, regular follow-up exams will be important. These can detect recurrence, that is, a return of the cancer. Most recurrences are found in the first 2 to 3 years after surgery.
Be sure to report any new or persistent symptoms to your doctor right away. Follow-up usually includes a careful general physical exam and rectal exam, as well as blood tests for tumor markers such as carcinoembryonic antigen (CEA). Colonoscopy is done within 1 year of surgical resection of the colorectal cancer. If that result is normal, it is repeated in 3 years. If that result is normal, then the colonoscopy is repeated again in 5 years. Other imaging studies such as chest x-rays, CT scans, and MRI scans may also be done if symptoms or other test results suggest your cancer has come back.
Imaging: Because removing a few liver metastases may be curative, your doctor may want to pay special attention to
examining your liver with frequent CT scans or PET scans, especially in the first 2 years after surgery.
Tumor markers: Carcinoembryonic antigen (CEA) and CA 19-9 are substances in the blood of some people with colorectal cancer. Tests for these substances are sometime useful if you have any symptoms that suggest the cancer has come back. Some doctors perform these tests routinely in order to detect recurrences before you have symptoms. Usually these are most important in the first 2 years after treatment, when most recurrences occur.
For patients with a colostomy: If you have a colostomy, you may feel worried or isolated from normal activities. Whether your ostomy is temporary or permanent, an enterostomal therapist (a health care professional trained to help people with their colostomies) can teach you about the care of your colostomy. You can ask the American Cancer Society about programs offering information and support in your area.

What’s New in Colorectal Cancer Research and Treatment?

Research is always under way in the area of colorectal cancer. Scientists are looking for causes and ways to prevent
colorectal cancer as well as ways to improve treatments.
Tumor growth factors: Researchers have discovered naturally occurring substances in the body that promote cell growth. These hormone-like substances are called growth factors. Growth factors activate cells by attaching to growth factor receptors, which are present on the outer surface of the cells. Some cancer cells grow especially fast because they contain more growth factor receptors than normal cells do. One of the growth factors that has been linked to colorectal cancers is called epidermal growth factor (EGF).
New drugs that specifically kill cancer cells by attacking EGF receptors have proven effective and are now being used. More are being developed.
Another growth factor, known as vascular endothelial growth factor (VEGF), helps tumors develop new blood vessels to get nutrients. Several drugs are now in development to try to block VEGF in order to cut off the tumor’s blood supply. These drugs are known as antiangiogenesis drugs.
One such drug, bevacizumab (Avastin), is a monoclonal antibody that attacks VEGF. This has proven effective also and is now being used to treat colorectal cancer. Other drugs that act against blood vessels are being developed and tested.
Chemoprevention: Chemoprevention is the use of natural or man-made chemicals to lower a person’s risk of developing cancer. Researchers are testing whether fiber supplements, minerals (such as calcium), and vitamins can lower colorectal cancer risk. Some studies have found that people who take multivitamins containing folic acid (also known as folate) have a
lower colorectal cancer risk than people who do not. Studies of vitamin A, C, D, and E supplements have yielded conflicting results. But recent studies have found that people who took vitamin D supplements had a reduced rate of colorectal cancer. Increasing calcium intake by using calcium supplements or eating extra amounts of low-fat dairy products may reduce formation of colorectal adenomatous polyps.
Although taking aspirin or some other non-steroidal anti-inflammatory drugs (NSAIDS) is associated with a lower risk of colorectal cancer, these drugs can cause stomach ulcers and other side effects. For this reason, taking NSAIDS specifically for this purpose is not recommended for people at average colorectal cancer risk.
NSAIDs, such as sulindac and celecoxib (Celebrex), have been shown to reduce formation of adenomatous polyps in people with familial adenomatous polyposis (FAP). The FDA has recently approved celecoxib for reducing polyp formation in people with FAP. However, recent celecoxib data are now being evaluated for a potential increased heart risk.
Studies indicate that a diet high in fruits and vegetables may lower colorectal cancer risk, as well as the risk of several other diseases. This hasn’t been completely proven by all studies. Nearly all experts, however, agree fiber supplements alone are not as beneficial as getting dietary fiber by eating foods from plant sources. But it is important that you eat enough servings - at least 5 a day!
Most experts recommend that people not take large doses of vitamins, minerals, or other agents unless they are part of a study or are under the advice and care of a doctor.
Genetics: Scientists are learning more about some of the inherited and acquired changes in DNA that cause cells of the colon and rectum to become cancerous. Recent discoveries of inherited genes that increase a person’s risk of developing colorectal cancer are already being used in genetic tests to inform people most at risk.
Advances in understanding how these genes work are expected to eventually lead to new drugs and gene therapies to correct these gene problems. Early phases of gene therapy trials are already in progress. Researchers have developed ways to package DNA of normal p53 genes into a virus designed in the laboratory. Most colorectal cancer cells have defects of this tumor suppressor gene that contribute to their abnormal growth and spread. Studies are under way to see whether these designer viruses containing normal p53 genes can infect colorectal cancer cells and either stop their growth or cause them to “self-destruct.”
Earlier detection: Studies continue to evaluate the effectiveness of current colorectal cancer screening methods and evaluate new approaches to informing the public about the importance of taking advantage of these methods. Less than half of Americans older than age 50 have any colorectal cancer screening at all. If everyone were tested, tens of thousands of lives could be saved each year. The American Cancer Society and other public health organizations are working to increase awareness of colorectal cancer screening among the general public and health care professionals. Meanwhile, new imaging and laboratory tests are also being developed and tested.
Researchers know of DNA mutations that often affect certain genes (such as the APC gene, K-ras oncogene, and p53 tumor suppressor gene) in colorectal cancer cells. Studies are testing new ways to recognize these DNA mutations in cells found in stool samples, to see if this screening approach is useful in finding large polyps and colorectal cancers at an earlier stage.
Cells from the lining layer of the colon and rectum are constantly shed into the stool and replaced by new cells. The cells that slough off the lining typically undergo apoptosis, a specific type of cell death that causes recognizable changes in the cells’ DNA. Cells that slough off from the surface of colon cancers do not usually undergo these changes. Finding intact-appearing DNA (that lacks the changes of apoptosis) in stool samples appears to be useful in finding colorectal cancers. Recent studies that have combined DNA tests to look for gene mutations and for intact-appearing DNA have shown promising results. Nonetheless, more research is needed to confirm the accuracy of these tests before widespread use can be recommended.
Virtual colonoscopy is a special type of CT scan that can find colorectal polyps and cancers at least as accurately as a barium enema. This test is described in more detail in the section on “Can Colorectal Polyps and Cancer Be Found Early?” Although virtual colonoscopy is currently not included among the tests recommended by American Cancer Society for early detection of colorectal cancer, the Society is carefully following progress in this area as technology improves and more results become available about its accuracy.
Immunotherapy: Experimental treatments that boost the patient’s immune reaction to fight colorectal cancer more effectively are being tested in clinical trials. Some treatments use drugs like interferons and interleukins that boost the immune system in general.
In active immunotherapy, the patient is given a vaccine that might cause the immune system to recognize some of the abnormal chemicals in colorectal cancer cells and kill these cells. For example, the K-ras oncogene product is altered in many colorectal cancers and researchers are testing ways to help the patient’s immune system attack cells with an altered ras protein. Researchers are also testing vaccines to direct a patient’s immune system to attack colorectal cancer cells that produce carcinoembryonic antigen (CEA). There are also studies where patients’ tumor cells are used to produce a vaccine. The vaccine is used for adjuvant therapy in the hope of preventing recurrence.
Passive immunotherapy uses antibodies made in the laboratory and then injected into patients to seek out colorectal cancer cells that contain abnormal ras protein or other abnormal or overproduced proteins like carcinoembryonic antigen (CEA) or the HER-2 oncogene product. Toxins or radioactive atoms can be attached to these antibodies, so that the cell-killing chemicals or radiation is targeted specifically to the cancer cells and do not attack the healthy cells of the body. Two antibodies, cetuximab (Erbitux) and bevacizumab (Avastin), are discussed previously in the tumor growth factor section.
Chemotherapy: Many clinical trials are testing new chemotherapy drugs or drugs that are now used against other cancers (such as cisplatin or gemcitabine). Other studies are looking at ways to combine drugs already known to be active against colorectal cancer, such as irinotecan or oxaliplatin, to improve their effectiveness. Still other studies are testing the best ways to combine chemotherapy with radiation therapy or immunotherapy.

What Is Cancer?

What Is Colorectal Cancer?

The colon has 4 sections:

What Are the Key Statistics About Colorectal Cancer?

What Are the Risk Factors for Colorectal Cancer?

Do We Know What Causes Colorectal Cancer?

Can Colorectal Cancer Be Prevented?