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COLON CANCER AND RECTAL CANCER - Screening, Symptoms, Diagnosis & Treatment

Introduction
What is colorectal cancer?
Who is at risk?
What are screening tests, and why are they so important?
What tests are used to screen people for colorectal cancer?
Do insurance companies pay for colorectal cancer screening?
Does colorectal cancer cause symptoms?
How is colorectal cancer diagnosed?
How is colorectal cancer treated?
Do patients with colorectal cancer participate in clinical trials (research studies)?
Colorectal Cancer Screening Guidelines
Video References

Introduction: Do Hemorrhoids Cause Colon & Rectal Cancer?
People assume they have "piles" or hemorrhoids whenever there is any symptom in the rectal area. This is a misconception. Hemorrhoids do not a cause colorectal cancer. A study done at the Hemorrhoid Care Medical Clinic in 1988, showed that approximately 90% of colon and rectal cancer patients initially thought that they had hemorrhoids, and presented with symptoms of rectal itching and rectal bleeding. So a belief that one has hemorrhoids, could be considered a colorectal cancer warning sign.

Other warning signs of colon and rectal cancer are:

  • Excess Gas
  • Constipation
  • Blood in Stools
  • Change in Bowel Habits
  • Persistent Abdominal Discomfort
  • Change in Shape of Color of Stools
  • Sensation of Incomplete Evacuation
  • Feelings of Tiredness or Exhaustion

Cancer of the colon and rectum is the second most common cause of cancer death in the U.S.A. today. 1 out of every 17 Americans will get colorectal cancer at some point in their life. Early diagnosis is the key to achieving survival. With better diagnostic modalities and more aggressive approaches, we can improve the present rate of survival from 62% to 81%, which means an additional 56,000 patients will live each year.

According to the American Cancer Society (ACS), 90% of all colorectal cancer cases and deaths are thought to be preventable, based on existing approaches to prevention and early detection. Screening tests that detect occult blood in the stool or identify adenomatous polyps can prevent the occurrence of colorectal cancers by allowing the detection and removal of pre-cancerous lesions before they undergo malignant transformation.

Approximately the five-year survival rate for colon cancer is 90% when it is diagnosed at an early, localized stage. However, only 37% of diagnoses are made in the early stage. As a result, colon cancer is the second deadliest cancer in the US.

Get the test. Get the polyp. Get the cure.

Colon cancer almost always starts with a colon polyp, developing with no symptoms. Finding and removing polyps through early detection testing before they become cancerous can stop colon cancer before it even starts. In fact, if all Americans 50 years of age or older had regular tests, annual deaths from colon cancer could be cut in half.

The death rate from colorectal cancer has been going down for the past 20 years. This may be because there are fewer cases, because more of the cases are found early, and also because treatments have improved.

That is why for most proctologists and gastrointestinal specialists, the diagnosis and treatment of colorectal cancer is a priority concern.

Questions and Answers About Screening,
Early Detection, and Treatment for Colorectal Cancer

What is colorectal cancer?
Cancer that begins in the colon is called colon cancer, and cancer that begins in the rectum is called rectal cancer. Cancers affecting either of these organs may also be called colorectal cancer.

The colon and rectum are parts of the body's digestive system, which removes nutrients from food and stores waste until it passes out of the body. Together, the colon and rectum form a long, muscular tube called the large intestine (also called the large bowel). The colon is the first 6 feet of the large intestine, and the rectum is the last 8 to 10 inches.


Colon, rectum, and other parts of digestive system

Colorectal cancer is a disease in which cells in the colon or rectum become abnormal and divide without control or order, forming a mass called a tumor. Tumors can be either benign or malignant.

Benign tumors are not cancer. They often can be removed and, in most cases, they do not come back. Cells in benign tumors do not spread to other parts of the body. Most important, benign tumors are rarely a threat to life.

Malignant tumors are cancer. Cells in malignant tumors are abnormal and divide without control or order. These cancer cells can invade and destroy the tissue around them. Cancer cells can also break away from a malignant tumor. They may enter the bloodstream or lymphatic system (the tissues and organs that produce and store cells that fight infection and disease). This process, called metastasis, is how cancer spreads from the original (primary) tumor to form new (secondary) tumors in other parts of the body.

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Who is at risk?
The exact causes of colorectal cancer are not known. However, studies show that certain factors increase a person's chance of developing colorectal cancer:

Age. Colorectal cancer is more likely to occur as people get older. Most people who develop colorectal cancer are over the age of 50. However, the disease can occur at any age.

Diet. The development of colorectal cancer seems to be associated with a diet that is high in fat and calories and low in foods with fiber, such as whole grains, fruits, and vegetables. Eating a high fiber diet helps to prevent colorectal cancer. Patients that follow Researchers are exploring how these and other dietary components play a role in the development of colorectal cancer.

Polyps. Polyps are benign growths (not cancer) on the inner wall of the colon or rectum. They are relatively common in people over age 50. Because most colorectal cancers develop in polyps, detecting and removing these growths may be a way to prevent colorectal cancer. Familial polyposis is a rare, inherited condition in which hundreds of polyps develop in the colon and rectum. Unless this condition is treated, a person who has it is extremely likely to develop colorectal cancer.

Personal history. A person who has already had colorectal cancer may develop colorectal cancer a second time. Also, research studies show that women with a history of ovarian, uterine, or breast cancer have a somewhat increased chance of developing colorectal cancer.

Family history. Close relatives (parents, siblings, or children) of a person who has had colorectal cancer are somewhat more likely to develop this type of cancer themselves, especially if the relative developed the cancer at a young age. If many family members have had colorectal cancer, the chances increase even more.

Ulcerative colitis. Ulcerative colitis is a condition in which the lining of the colon becomes inflamed. People who have ulcerative colitis are more likely to develop colorectal cancer.

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What are screening tests, and why are they so important?
Screening tests are examinations that check for health problems before they cause symptoms. Screening tests are important because finding health problems at an early stage often means that treatment will be more successful.

Colorectal cancer screening tests are used to detect cancer, polyps that may eventually become cancerous, or other abnormal conditions.

Most people who undergo colorectal screening do not have any colorectal abnormality. For those who do, diagnosis and treatment can occur promptly.

What tests are used to screen people for colorectal cancer?
People who have any risk factors for colorectal cancer should ask their doctor when to begin screening for colorectal cancer, what tests to have, and how often to schedule appointments. Doctors may suggest one or more of the tests listed below as a part of regular checkups.

A fecal occult blood test (FOBT) is a test for hidden blood in the stool. This test has been proven to reduce the death rate of colorectal cancer.

A sigmoidoscopy is an examination of the rectum and lower colon with a lighted instrument.

A colonoscopy is an examination of the rectum and entire colon with a lighted instrument.

A double contrast barium enema is a series of x-rays of the colon and rectum. The x-rays are taken after the patient is given an enema with a white, chalky solution that contains barium to outline the colon and rectum on the x-rays.

A digital rectal exam (DRE) is a test in which the doctor inserts a lubricated, gloved finger into the rectum to feel for abnormal areas.

Virtual Colonoscopy is an imaging study of the colon and rectum performed with computed tomography (CT), sometimes called a CAT scan, or with magnetic resonance imaging (MRI).

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Do insurance companies pay for colorectal cancer screening?
People should check with their health insurance provider to determine their colorectal cancer screening benefits. People who are age 50 or older and are covered by Medicare are eligible for colorectal cancer screening benefits. Additional information is available on the Medicare Web site at http://www.medicare.gov/health/overview.asp on the Internet.

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Does colorectal cancer cause symptoms?
Common symptoms of colorectal cancer include the following:

  • Change in bowel habits
  • Diarrhea, constipation, or feeling that the bowel does not empty completely
  • Blood in the stool (either bright red or very dark in color)
  • Stools that are narrower than usual
  • General abdominal discomfort (frequent gas pains, bloating, fullness, and/or cramps)
  • Weight loss with no known reason
  • Constant tiredness
  • Vomiting

These symptoms can be caused by cancer or by a number of other conditions. It is important to check with a doctor.

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How is colorectal cancer diagnosed?
To find the cause of symptoms, the doctor evaluates one's personal and family medical history. The doctor also performs a physical exam and may order one or more diagnostic tests. These may include a blood test called a CEA assay to measure a protein called carcinoembryonic antigen that is sometimes higher in patients with colorectal cancer.
The doctor may also order x-rays of the gastrointestinal tract , sigmoidoscopy , or colonoscopy. If abnormal tissue is found during these tests, a biopsy (the removal of tissue for examination under a microscope by a pathologist) is performed to determine if a person has cancer.

If the diagnosis is cancer, the doctor will want to learn the stage (or extent) of disease. Staging is a careful attempt to find out whether the cancer has spread and, if so, to what parts of the body. Knowing the stage of the disease helps the doctor plan treatment. Additional tests may be performed to help determine the stage.

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How is colorectal cancer treated?
Treatment for colorectal cancer depends on a number of factors, including the general health of the patient and the size, location, and extent of the tumor. Many different treatments and combinations of treatments are used to treat colorectal cancer.

Surgery to remove the cancer is the most common treatment for colorectal cancer. The type of surgery that a doctor performs depends mainly on where the cancer is found.

Chemotherapy is the use of anticancer drugs to kill cancer cells. The anticancer drugs circulate in the bloodstream and affect cancer cells throughout the body.

Radiation therapy, also called radiotherapy, involves the use of high-energy x-rays to kill cancer cells. Radiation therapy affects the cancer cells only in the treated area.

Biological therapy, also called immunotherapy, uses the body's immune system, either directly or indirectly, to fight cancer. The immune system recognizes cancer cells in the body and works to eliminate them. Biological therapies are designed to repair, stimulate, or enhance the immune system's natural anticancer function.

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Do patients with colorectal cancer participate in clinical trials (research studies)?
Yes, patients with all stages of colorectal cancer can take part in clinical trials (research studies). Clinical trials to evaluate new ways to treat cancer are an appropriate treatment option for many patients with this disease. Through research, doctors learn new ways to treat cancer that may be more effective than the standard therapy. Research has led to significant advances in the treatment of colorectal cancer. Information about ongoing clinical trials is available from the Cancer Information Service (see below), or from the National Cancer Institute's cancerTrials™ Web site at http://cancertrials.nci.nih.gov on the Internet.

Cancer Information Service
Toll-free: 1-800-4-CANCER (1-800-422-6237)
TTY (for deaf and hard of hearing callers): 1-800-332-8615

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Colorectal Cancer Screening Guidelines

American Society of Colon and Rectal Surgeons – 2006
“There is no relationship between hemorrhoids and cancer. However, the symptoms of hemorrhoids, particularly bleeding, are similar to those of colorectal cancer and other diseases of the digestive system. Therefore, it is important that all symptoms are investigated by a physician specially trained in treating diseases of the colon and rectum and that everyone 50-years or older undergo screening tests for colorectal cancer.” Rectal bleeding should not then be assumed due to hemorrhoids until colorectal cancer and other digestive diseases have been ruled out as a possible cause.

Medicare Guide to Preventative Services – April 2007
Colorectal Cancer Screening Tests
• Fecal Occult Blood (FOBT)
• Flexible Sigmoidoscopy
• Colonoscopy
• Barium Enema

Unless the words “High Risk” are specified, all of the following guidelines are for patients who are at a normal risk for developing colorectal cancer:

High Risk Factors
• A sibling, parent, or child had an adenomatous polyp or colon cancer
• Family history of adenomatous polyposis or hereditary colorectal cancer
• A personal history of adenomatous polyps, colorectal cancer, or Inflammatory Bowel Disease (IBD)

A patient is at “high risk” if he has any of these above risk factors.

After age 50, all annual time periods listed below are given a 30 day grace period; whereby the physician may commence Colorectal Cancer Screening up to 30 days earlier than specified:

Medicare Covered Fecal Occult Blood (FOBT)
• Annually if age 50

Medicare Covered Flexible Sigmoidoscopy
• Beginning age 50, then once every 4 years

Medicare Covered Colonoscopy
• Once every 2 years for a patient with high risk factors (without regard to age)
• Beginning age 50, then once every 10 years
• Must be at least 4 years after a Flexible Sigmoidoscopy.

Medicare Covered Barium Enema
• As an alternative to Colonoscopy of Flexible Sigmoidoscopy
• Once every 2 years for a patient with high risk factors (without regard to age)
• Beginning age 50, then once every 4 years
• Preferably a double contrast Barium Enema

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American College of Gastroenterology (ACG) Guidelines - March 2009:

1) The starting age is lowered to 45 years for African Americans. Perhaps also at age 45 years, for patients who are obese or who have an "extreme smoking history."

2) It is reasonable to consider screening at an age earlier than 50 years (i.e. 45 years) in patients with characteristics known to promote colorectal cancer, including a history of smoking and obesity (defined as a BMI >30). However, there is no formal recommendation for earlier screening in these subgroups of patients at this time.

3) If the colorectal cancer or advanced adenoma in the first-degree family member is diagnosed at younger than 60 years, or if there are 2 first-degree relatives with colorectal cancer or advanced adenoma, screening colonoscopy should begin at age 40 years, or 10 years younger than the age at diagnosis of the youngest affected relative. Colonoscopy should be repeated at 5-year intervals for these patients.

4) Patients with familial adenomatous polyposis should undergo annual flexible sigmoidoscopy or colonoscopy until colectomy is performed.

5) Another preferred screening test is annual Fecal Immunochemical Test (FIT). A previous study found that FIT was superior to older guaiac-based fecal occult blood tests to detect both advanced adenomas and colorectal cancer in adults being screened for colorectal cancer; and because fecal DNA testing is too expensive.

6) Alternative and less-preferred screening tests for colorectal cancer include flexible sigmoidoscopy every 5 years, or computed tomographic colonography every 5 years. Double-contrast barium enema testing is no longer part of the screening recommendations for colorectal cancer. Its use has declined dramatically, and computed tomographic colonography is more effective in diagnosing polyps.

7) In the current recommendations from the ACG, colonoscopy is the test of choice to screen for colorectal cancer. Annual screening with FIT is the first alternative to colonoscopy screening, followed by flexible sigmoidoscopy and computed tomographic colonography. Double-contrast barium enema to screen for colorectal cancer is no longer recommended.

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Video References
1. Video: Colon Cancer Tutorial - The National Library of Medicine
= http://www.nlm.nih.gov/medlineplus/tutorials/coloncancer/htm/index.htm

2. Video: Colon Cancer Surgery Tutorial - The National Library of Medicine
http://www.nlm.nih.gov/medlineplus/tutorials/coloncancersurgery/htm/index.htm

3) Video: Radiation Therapy Tutorial - The National Library of Medicine
http://www.nlm.nih.gov/medlineplus/tutorials/radiationtherapyintroduction/htm/index.htm

4) Video: Chemotherapy Tutorial - The National Library of Medicine
http://www.nlm.nih.gov/medlineplus/tutorials/chemotherapyintroduction/htm/index.htm

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