Cancer of the colon is the disease characterized by the development of malignant cells in the lining or epithelium of the first and longest portion of the large intestine. Malignant cells have lost normal control mechanisms governing growth. These cells may invade surrounding local tissue, or they may spread throughout the body and invade other organ systems.
Synonyms for the colon include the large bowel or the large intestine. The rectum is the continuation of the large intestine into the pelvis that terminates in the anus.
The colon is a tubular organ beginning in the right lower abdomen. It ascends on the right side of the abdomen, traverses from right to left in the upper abdomen, descends vertically down the left side, takes an S-shaped curve in the lower left abdomen, and then flows into the rectum as it leaves the abdomen for the pelvis. These portions of the colon are named separately though they are part of the same organ:
- cecum, the beginning of the colon
- ascending colon, the right vertical ascent of the colon
- transverse colon, the portion traversing from right to left
- descending colon, the left vertical descent of the colon
- sigmoid colon, the S-shaped segment of colon above the pelvis
These portions of the colon are recognized an-atomically based on the arterial blood supply and venous and lymphatic drainage of these segments of the colon. Lymph, a protein-rich fluid that bathes the cells of the body, is transported in small channels known as lymphatics that run alongside the veins of the colon. Lymph nodes are small filters through which the lymph travels on its way back to the bloodstream. Cancer can spread elsewhere in the body by invading the lymph and vascular systems. Therefore, these anatomic considerations become very important in the treatment of colon cancer.
The small intestine is the continuation of the upper gastrointestinal tract responsible for carrying ingested nutrients into the body. The waste left after the small intestine has completed absorption of nutrients amounts to a few liters (about the same as quart) of material per day and is directly delivered to the colon (at the cecum) for processing. The colon is responsible for the preservation of fluid and electrolytes as it propels the increasingly solid waste toward the rectum and anus for excretion.
When cells lining the colon become malignant, they first grow locally and may invade partially or totally through the wall of the bowel and even into adjacent structures and organs. In the process, the tumor can penetrate and invade the lymphatics or the capillaries locally and gain access to the circulation. As the malignant cells work their way to other areas of the body, they again become locally invasive in the new area to which they have spread. These tumor deposits, originating from the colon primary tumor, are then known as metastases. If metastases are found in the regional lymph nodes from the primary, they are known as regional metastases, or regional nodal metastases. If they are distant from the primary tumor, they are known as distant metastases. The patient with distant metastases has systemic disease. Thus, the cancer originating in the colon begins locally and, given time, can become systemic.
By the time the primary tumor is originally detected, it is usually larger than 1 cm (about 3/8 in) in size and has over one million cells. This amount of growth itself is estimated to take about three to seven years. Each time the cells double in number, the size of the tumor quadruples. Like most cancers, the part that is identified clinically is later in the progression than would be desired and screening becomes a very important endeavor to aid in earlier detection of this disease.
In 2008, the American Cancer Society estimated there would be approximately 108,070 cases of colon cancer diagnosed in the United States. Together, colon and rectal cancers account for 10% of cancers in men and 11% of cancers in women. It is the second most common site-specific cancer affecting both men and women. About 49,960 people were anticipated to die from colon and rectal cancer in the United States in 2008. Shortly before 2008 the incidence of this disease decreased slightly, as did the mortality rate. It is difficult to tell if the decrease in mortality reflects earlier diagnosis, less death related to the actual treatment of the disease, or a combination of both factors.
Cancer of the colon is thought to arise sporadically in about 70% of those who develop the disease. About one-third of people with colon cancer are thought to have genetic predisposition, meaning their genes carry a trigger for the disease. Development of colon cancer at an early age, or at multiple sites, or recurrent colon cancer, suggests a genetically transmitted form of the disease as opposed to the sporadic form.
Causes and symptoms
Causes of colon cancer often are environmental in sporadic cases (approximately 70% of cases) and genetic or familial, in nearly one-third of cases in the United States. Since malignant cells have a changed genetic makeup, this means that in about 70% of cases, the environment spontaneously induces change, whereas those born with a genetic predisposition are either destined to get the cancer or less environmental exposure can induce the cancer. Exposure to agents in the environment that may induce mutation is the process of carcinogenesis and is caused by agents known as carcinogens (cancer-causing agents). Specific carcinogens have been difficult to identify; however, dietary factors seem to be involved.
Colon cancer is more common in industrialized nations. Diets high in fat, red meat, total calories, and alcohol seem to predispose people to the disease. Diets high in fiber appear to decrease risk. High-fiber diets may help lessen exposure of the colon lining to carcinogens from the environment, as the transit time through the bowel is faster with a high-fiber diet than it is with a low fiber diet .
Age plays a definite role in the predisposition to colon cancer. Two-thirds of all cases occur after age 50 and the average age for those who develop the disease is 62.
There is also a slight increase risk for colon cancer in individuals who smoke.
Patients who suffer from inflammatory diseases of the colon known as ulcerative colitis and Crohn's colitis are also at increased risk.
Researchers know there is a genetic link to many cases of colon cancer, those called familial cases. These are the types of colon cancer that tend to run in families. These types are hereditary nonpolyposis colon cancer (HNPCC) and familial adenomatous polyposis (FAP).
The development of polyps of the colon almost always precedes the development of colon cancer by five or more years. Polyps are benign growths of the colon lining. They can be unrelated to cancer, precancerous, or malignant. Polyps, when identified, are removed for diagnosis. If the polyps are benign, the patient should undergo careful surveillance for the development of more polyps or the development of colon cancer.
Colon cancer causes symptoms related to its local presence in the large bowel or by its effect on other organs if it has spread. These symptoms may occur alone or in combination:
- a change in bowel habit
- blood in the stool
- bloating, persistent abdominal distention
- a feeling of fullness even after having a bowel movement
- narrowing of the stool—so-called ribbon stools
- persistent, chronic fatigue
- abdominal discomfort
- unexplained weight loss
- and, very rarely, nausea and vomiting
Most of these symptoms are caused by the physical presence of the tumor mass in the colon. Similar symptoms can be caused by other processes;these are not absolutely specific to colon cancer. The key is recognizing that the persistence of these types of symptoms without ready explanation should prompt the individual to seek medical evaluation.
If a tumor develops in the colon, it will begin to cause symptoms as it reaches a certain size. The symptoms are caused by the tumor blocking the opening in the colon. In addition, the tumor commonly oozes blood that is lost in the stool. (Often, this blood is not visible.) This results in anemia and chronic fatigue. Weight loss is a late symptom, often implying substantial obstruction or the presence of systemic disease.
In all other cancers (breast and prostate, for example), screening tests look for small, malignant lesions. Screening for colorectal cancers, however, is the search for pre-malignant, benign polyps. This screening can be close to 100% effective in preventing cancer development, not just in detecting small cancers.
Screening involves physical exam, simple laboratory tests, and the visualization of the lining of the colon. To visualize the colon epithelium, clinicians use x rays (indirect visualization) and endoscopy (direct visualization).
The physical examination involves the performance of a digital rectal exam (DRE). The DRE includes manual examination of the rectum, anus, and the prostate. During this examination, the physician examines the anus and the surrounding skin for hemorrhoids , abscesses, and other irregularities. After lubricating the gloved finger and anus, the examiner gently slides the finger into the anus and follows the contours of the rectum. The examiner notes the tone of the anus and feels the walls and the edges for texture, tenderness, and masses as far as the examining finger can reach. At the time of this exam, the physician checks the stool on the examining glove with a chemical to see if any occult (invisible) blood is present. At home, after having a bowel movement, the patient is asked to swipe a sample of stool obtained with a small stick on a card. After three such specimens are collected, the cards are then easily chemically tested for occult blood also. (The stool analysis mentioned here is known as a fecal occult blood test, or FOBT, and, while it can be helpful, it is not 100% accurate; only about 50% of cancers are FOBT-positive.) These exams are accomplished as an easy part of a routine yearly physical exam.
Proteins are sometimes produced by cancers, and these may be elevated in the patient's blood. When this occurs, the protein produced is known as a tumor marker. There is a tumor marker for some cancers of the colon; it is known as carcinoembryonic antigen, or CEA. Unfortunately, this protein may be made by other adenocarcinomas as well, or it may not be produced by a particular colon cancer. Therefore, screening by chemical analysis for CEA has not been helpful. CEA has been helpful when used in a follow-up role for patients treated for colon cancer if their tumor makes the protein.
Indirect visualization of the colon may be accomplished by placing barium through the rectum and filling the colon with this compound. Barium produces a white contrast image of the lining of the colon on x ray and thus the contour of the lining of the colon may be seen. Detail can be increased if the barium used is thinned and air also introduced. These studies are known as the barium enema (BE), and the double contrast barium enema (DCBE).
Direct visualization of the colon lining is accomplished using a scope or endoscope. The physician introduces the instrument through the rectum. Older, shorter scopes were rigid. As of 2008, using fiberoptic technology, the scopes are flexible and can reach much farther. If the left colon only is visualized, it is called flexible sigmoidoscopy. When the entire colon is visualized, the procedure is known as colonoscopy .
Unlike the indirect visualizations of the colon (the BE and the DCBE), the endoscopic screenings allow the physician to remove polyps and biopsy suspicious tissue. (A biopsy is a removal of tissue for examination by a pathologist.) For this reason, many physicians prefer endoscopic screening. All of the visualizations, the BE, DCBE, and each type of endoscopy, require pre-procedure preparation (evacuation) of the colon.
In 2008, the American Cancer Society revised guidelines for the early detection of colon cancer for those individuals who are at normal risk and who are over 50 years of age. The tests that will diagnose both polyps and cancer are:
- flexible sigmoidoscopy every 5 years
- colonoscopy every 10 years
- double contrast barium enema every 5 years
- CT colonography (virtual colonoscopy) every 5 years
The tests that focus specifically on finding cancer only are:
- fecal occult blood test (FOBT) every year
- fecal immunochemical test (FIT) every year
- stool DNA test (sDNA), interval uncertain
The tests that are recommended to find both cancer and polyps are more invasive. These tests are preferred over the tests that mainly find cancer. If results are positive from sigmoidoscopy, double contrast barium enema, CT colonography, FOBT, FIT, and/or sDNA, a colonoscopy should be performed.
Evaluation of patients with symptoms
If patients have symptoms that could possibly be related to colon cancer, the entire colon is examined. The combination of a flexible sigmoidoscopy and DCBE may be performed, but the preferred evaluation of the entire colon and rectum is a complete co-lonoscopy. Colonoscopy allows direct visualization, photography, and the opportunity to obtain a biopsy of any abnormality visualized. If, for technical reasons, the entire colon is not visualized endoscopically, a DCBE should complement the colonoscopy.
The diagnosis of colon cancer is actually made by the performance of a biopsy of any abnormal lesion in the colon. The 2008 recommendations included evaluation of at least 12 lymph nodes to accurately identify Stage II colon cancers. When a tumor growth is identified, it could be either a benign polyp (or lesion) or a cancer; the biopsy resolves the issue. The endoscopist may take many samples to exclude any sampling errors.
If the patient has advanced disease at the time of diagnosis, areas where the tumor has spread (such as the liver) may be amenable to biopsy. Such biopsies are usually obtained using a special needle under local anesthesia .
Once a diagnosis of colon cancer has been established by biopsy, in addition to the physical exam, studies are performed to assess the extent of the disease. Blood studies include a complete blood count , liver function tests , and a CEA. Imaging studies include a chest x ray and a computed tomography scan (CAT scan) of the abdomen. The chest x ray deter-mines if the cancer has spread to the lung; the CAT scan evaluate potential spread to the liver as well as any local spread of the primary tumor. If the patient has any neurologic symptoms, a CAT scan of the brain is performed, and if the patient is experiencing bone pain , a bone scan is also performed.
Once the diagnosis has been confirmed by biopsy, the clinical stage of the cancer is assigned. Using the characteristics of the primary tumor, its depth of penetration through the bowel, and the presence or absence of regional or distant metastases, stage is derived. Often, the depth of penetration through the bowel or the presence of regional lymph nodes cannot be assigned before surgery.
Colon cancer is assigned stages I through IV, based on the following general criteria:
- Stage I: The tumor is confined to the epithelium or has not penetrated through the first layer of muscle in the bowel wall.
- Stage II: The tumor has penetrated through to the outer wall of the colon or has gone through it, possibly invading other local tissue. However, the cancer has not yet spread to the lymph nodes.
- Stage III: Any depth or size of tumor associated with regional lymph node involvement.
- Stage IV: Any of previous criteria associated with distant metastasis.
With many cancers other than colon cancer, staging plays an important pre-treatment role in determining treatment options. Almost all colon cancers are treated with surgery first, regardless of stage. Colon cancers through stage III, and even some stage IV colon cancers, are treated with surgery first, before any other treatments are considered.
Surgical removal of the involved segment of colon (colectomy) along with its blood supply and regional lymph nodes is the primary therapy for colon cancer. Usually, the partial colectomies are separated into right, left, transverse, or sigmoid sections based on the blood supply. The removal of the blood supply at its origin along with the regional lymph nodes that accompany it ensures an adequate margin of normal colon on either side of the primary tumor. When the cancer lies in a position such that the blood supply and lymph drainage between two of the major vessels, both vessels are taken to assure complete radical resection or removal (extended radical right or left colectomy). If the primary tumor penetrates through the bowel wall, any tissue adjacent to the tumor extension is also taken if feasible.
Surgery is used as primary therapy for stages I through III colon cancer unless there are signs that local invasion will not permit complete removal of the tumor, as may occur in advanced stage III tumors.However, this circumstance is rare, occurring in less than 2% of all colon cancer cases.
After the resection is completed, the ends of the remaining colon are reconstructed; the hook-up is called an anastomosis. Once healing has occurred, there may be a slight increase in the frequency of bowel movements. This effect usually lasts only for several weeks. Most patients go on to develop completely normal bowel function.
Occasionally, the anastomosis is risky and cannot be performed. When the anastomosis cannot be performed, a colostomy is performed instead. A colostomy is performed by bringing the end of the colon through the abdominal wall and sewing it to the skin. The patient will have to wear an appliance (a bag) to manage the stool. The colostomy may be temporary and the patient may undergo a hook-up at a later, safer date, or the colostomy may be permanent. In most cases, emergent colostomies are not reversed and are permanent.
Radiation therapy is used as an adjunct to surgery if there is concern about potential for local recurrence post-operatively and the area of concern will tolerate the radiation. For instance, if the tumor invaded muscle of the abdominal wall but was not completely removed, this area would be considered for radiation. Radiation has significant dose limits when residual bowel is exposed to it because the small and large intestine do not tolerate radiation well.
Radiation also is used in the treatment of patients with metastatic disease. It is particularly useful in shrinking metastatic colon cancer to the brain.
Chemotherapy is useful for patients who have had all identifiable tumor removed and are at risk for recurrence (adjuvant chemotherapy). Chemotherapymay also be used when the cancer is stage IV and is beyond the scope of regional therapy, but this use is rare.
Adjuvant therapy is considered in stage II disease with deep penetration or in stage III patients. In 2008, although chemotherapy was not considered standard therapy for stage II disease, some doctors recommended chemotherapy if the risk of recurrence of the cancer seemed high. Clinical trials were in progress to determine which chemotherapy regimen might be the most effective in this stage. Some of the chemotherapy agents that may be used include FOLFOX (5-FU, leucovorin, and oxaliplatin), 5-FU and leucovorin
alone, or capecitabine. The FOLFOX regimen is the most common chemotherapy regimen administered in stage III colon cancer. Other agents that may be used are 5-FU and leucovorin, capecitabine, and oxaliplatin (CapeOX regimen) or capecitabine alone.
QUESTIONS TO ASK YOUR DOCTOR
- What stage of colon cancer do I have
- How will my cancer be treated?
- Will I need a colostomy? If so, will it be permanent?
- How long will my treatments last?
- What side effects can I expect as a result of my treatment?
- Will I need to make changes to my diet?
- Am I a candidate for a clinical trial?
- What type of follow-up care will I require?
- What is my prognosis?
Similar chemotherapy may be administered for stage IV disease or if a patient progresses and develops metastases. Targeted therapies, such as the monoclonal antibodies cetuximab and panitumumab, may also be used. Unfortunately, these patients eventually succumb to the disease, and this chemotherapy may not prolong survival or improve quality of life in stage IV patients.
Clinical trials are scientific studies in which new therapies are compared to current standards in an effort to identify therapies that give better results. As of 2008, there were many clinical trials in progress to determine the most effective treatment options in all stages of colon cancer. Information is available from the National Cancer Institute regarding these clinical trials.
Alternative and complementary therapies
Alternative therapies have not been studied in a large-scale, scientific way. Large doses of vitamins , fiber, and green tea are among therapies tried. Avoiding cigarettes and alcohol may be helpful. Before initiating any alternative therapies, patients are wise to consult their physician to be sure that these therapies do not complicate or interfere with the established therapy.
Adenocarcinoma —Type of cancer beginning in glandular epithelium.
Adjuvant therapy —Treatment involving radiation, chemotherapy (drug treatment), or hormone therapy, or a combination of all three given after the primary treatment for the possibility of residual microscopic disease.
Anastomosis —Surgical reconnection of the ends of the bowel after removal of a portion of the bowel.
Anemia —The condition caused by too few circulating red blood cells, often manifested in part by fatigue.
Carcinogens —Substances in the environment that cause cancer, presumably by inducing mutations, with prolonged exposure.
Electrolytes —Ions or chemicals such as sodium and chloride.
Epithelium —Cells composing the lining of an organ.
Lymphatics —Channels that are conduits for lymph.
Lymph nodes —Cellular filters through which lymphatics flow.
Malignant —Cells that have been altered such that they have lost normal control mechanisms and are capable of local invasion and spread to other areas of the body.
Metastasis —Site of invasive tumor growth that originated from a malignancy elsewhere in the body.
Mutation —A change in the genetic makeup of a cell that may occur spontaneously or be environmentally induced.
Occult blood —Presence of blood that cannot be seen with the naked eye.
Polyps —Localized growths of the epithelium that can be benign, precancerous, or harbor malignancy.
Radical resection —Surgical resection that takes the blood supply and lymph system supplying the organ along with the organ.
Resect —To remove surgically.
Sacrum —Posterior bony wall of the pelvis.
Systemic —Throughout the body.
Initially some patients may be seen by the doctor for a bowel obstruction. If the obstruction lasts for longer than a few days a gastrostomy tube may be inserted to relieve pressure. The tube may also relieve any nausea and vomiting present due to the obstruction.
Patients with more advanced disease may develop nausea, anorexia, and cachexia, or physical wasting with muscle loss. Nausea may be treated with antiemetics. A dietician may be consulted to help the patient deal with loss of appetite and resultant weight loss. The dietician may recommend a diet of small, frequent meals and fluids that are calorie dense. The physician may prescribe an appetite stimulant as well.
Prognosis is the long-term outlook or survival after therapy. As expected, the survival rates are dependent upon the stage of the cancer at the time of diagnosis, making early detection crucial.
According the American Cancer Society in 2008, five-year survival rates for colon cancer by stage of diagnosis were as follows:
- Stage I: 93%
- Stage IIA: 85%
- Stage IIB: 72%
- Stage IIIA: 83%
- Stage IIIB: 64%
- Stage IIIC: 44%
- Stage IV: 8%
There is not an absolute method for preventing colon cancer. Still, there are steps individuals can take to dramatically lessen the risk or to identify the precursors of colon cancer so that it does not manifest itself. Patient with a familial history can enter screening and surveillance programs earlier than the general population. High-fiber diets and vitamins, avoiding obesity , and staying active lessen the risk. Avoiding cigarettes and alcohol may be helpful. By controlling these environmental factors, individuals can lessen risk and to this degree prevent the disease.
People who turn age 50, and all of those with a history of colon cancer in their families, should speak with their physicians about the most recent screening recommendations from physician and cancer organizations. They should watch for symptoms and attend all recommended screenings to increase the likelihood of catching colon cancer early.
For those with familial syndromes causing colon cancer, genetic counseling may be appropriate. Psychological counseling may be appropriate for anyone having trouble coping with a potentially fatal disease. Local cancer support groups may be helpful and are often identified by contacting local hospitals or the American Cancer Society. Patients with colon cancer may have to cope with changes to the diet. They may also be faced with learning how to cope with either a temporary or permanent colostomy.
The Colon Cancer Alliance offers Internet online support at the following Web page: http://www.ccalliance.org/connect/support.html.
Cancer Information Service of the NCI. (800) 4-CANCER. http://wwwicic.nci.nih.gov.
Colon Cancer Alliance. http://www.ccalliance.org.
National Cancer Institute, 6116 Executive Blvd., Room 3036A, Bethesda, MD, 20892-8322, (800) 422-6237, http://www.cancer.gov/.
Richard A. McCartney M.D.
Teresa G. Odle
Melinda Oberleitner R.N., D.N.S.