Colon Cancer

What are the causes of colon cancer?

Doctors are certain that colorectal cancer is not contagious (a person cannot catch the disease
from a cancer patient). Some people are more likely to develop colorectal cancer than others.
Factors that increase a person's risk of colorectal cancer include high fat intake, a family history
of colorectal cancer and polyps, the presence of polyps in the large intestine, and chronic
ulcerative colitis.

Diet and colon cancer

Diets high in fat are believed to predispose humans to colorectal cancer. In countries with high
colorectal cancer rates, the fat intake by the population is much higher than in countries with
low cancer rates. It is believed that the breakdown products of fat metabolism lead to the
formation of cancer-causing chemicals (carcinogens). Diets high in vegetables and high-fiber
foods such as whole-grain breads and cereals may rid the bowel of these carcinogens and help
reduce the risk of cancer.

Colon polyps and colon cancer

Doctors believe that most colon cancers develop in colon polyps. Therefore, removing benign
colon polyps can prevent colorectal cancer. Colon polyps develop when chromosome damage
occurs in cells of the inner lining of the colon. Chromosomes contain genetic information
inherited from each parent. Normally, healthy chromosomes control the growth of cells in an
orderly manner. When chromosomes are damaged, cell growth becomes uncontrolled,
resulting in masses of extra tissue (polyps). Colon polyps are initially benign. Over years, benign
colon polyps can acquire additional chromosome damage to become cancerous.

Ulcerative colitis and colon cancer

Chronic ulcerative colitis causes inflammation of the inner lining of the colon. For further
information, please read the Ulcerative Colitis article. Colon cancer is a recognized complication
of chronic ulcerative colitis. The risk for cancer begins to rise after eight to 10 years of colitis.
The risk of developing colon cancer in a patient with ulcerative colitis also is related to the
location and the extent of his or her disease.

Current estimates of the cumulative incidence of colon cancer associated with ulcerative colitis
are 2.5% at 10 years, 7.6% at 30 years, and 10.8% at 50 years. Patients at higher risk of cancer
are those with a family history of colon cancer, a long duration of colitis, extensive colon
involvement, and those with primary sclerosing cholangitis (PSC).

Since the cancers associated with ulcerative colitis have a more favorable outcome when
caught at an earlier stage, yearly examinations of the colon often are recommended after eight
years of known extensive disease. During these examinations, samples of tissue (biopsies) can
be taken to search for precancerous changes in the lining cells of the colon. When precancerous
changes are found, removal of the colon may be necessary to prevent colon cancer.

Genetics and colon cancer

A person's genetic background is an important factor in colon cancer risk. Among first-degree
relatives of colon cancer patients, the lifetime risk of developing colon cancer is 18% (a
threefold increase over the general population in the United States).

Even though family history of colon cancer is an important risk factor, majority (80%) of colon
cancers occur sporadically in patients with no family history of colon cancer. Approximately
20% of cancers are associated with a family history of colon cancer. And 5 % of colon cancers
are due to hereditary colon cancer syndromes. Hereditary colon caner syndromes are disorders
where affected family members have inherited cancer-causing genetic defects from one or
both of the parents.

Chromosomes contain genetic information, and chromosome damages cause genetic defects
that lead to the formation of colon polyps and later colon cancer. In sporadic polyps and
cancers (polyps and cancers that develop in the absence of family history), the chromosome
damages are acquired (develop in a cell during adult life). The damaged chromosomes can only
be found in the polyps and the cancers that develop from that cell. But in hereditary colon
cancer syndromes, the chromosome defects are inherited at birth and are present in every cell
in the body. Patients who have inherited the hereditary colon cancer syndrome genes are at
risk of developing large number of colon polyps, usually at young ages, and are at very high risk
of developing colon cancer early in life, and also are at risk of developing cancers in other
organs.

FAP (familial adenomatous polyposis) is a hereditary colon cancer syndrome where the affected
family members will develop countless numbers (hundreds, sometimes thousands) of colon
polyps starting during the teens. Unless the condition is detected and treated (treatment
involves removal of the colon) early, a person affected by familial polyposis syndrome is almost
sure to develop colon cancer from these polyps. Cancers usually develop in the 40s. These
patients are also at risk of developing other cancers such as cancers in the thyroid gland,
stomach, and the ampulla (the part where the bile ducts drain into the duodenum just beyond
the stomach).

AFAP (attenuated familial adenomatous polyposis) is a milder version of FAP. Affected

members develop less than 100 colon polyps. Nevertheless, they are still at very high risk of
developing colon cancers at young ages. They are also at risk of having gastric polyps and
duodenal polyps.

HNPCC (hereditary nonpolyposis colon cancer) is a hereditary colon cancer syndrome where
affected family members can develop colon polyps and cancers, usually in the right colon, in
their 30s to 40s. Certain HNPCC patients are also at risk of developing uterine cancer, stomach
cancer, ovarian cancer, and cancers of the ureters (the tubes that connect the kidneys to the
bladder), and the biliary tract (the ducts that drain bile from the liver to the intestines).

MYH polyposis syndrome is a recently discovered hereditary colon cancer syndrome. Affected
members typically develop 10-100 polyps occurring at around 40 years of age, and are at high
risk of developing colon cancer

What are the symptoms of colon cancer?

Symptoms of colon cancer are numerous and nonspecific. They include fatigue, weakness,
shortness of breath, change in bowel habits, narrow stools, diarrhea or constipation, red or
dark blood in stool, weight loss, abdominal pain, cramps, or bloating. Other conditions such as
irritable bowel syndrome (spastic colon), ulcerative colitis, Crohn's disease, diverticulosis, and
peptic ulcer disease can have symptoms that mimic colorectal cancer. For more information on
these conditions, please read the following articles: Irritable Bowel Syndrome, Ulcerative
Colitis, Crohn's Disease, Diverticulosis, and Peptic Ulcer Disease.

Colon cancer can be present for several years before symptoms develop. Symptoms vary
according to where in the large bowel the tumor is located. The right colon is spacious, and
cancers of the right colon can grow to large sizes before they cause any abdominal symptoms.
Typically, right-sided cancers cause iron deficiency anemia due to the slow loss of blood over a
long period of time. Iron deficiency anemia causes fatigue, weakness, and shortness of breath.
The left colon is narrower than the right colon. Therefore, cancers of the left colon are more
likely to cause partial or complete bowel obstruction. Cancers causing partial bowel obstruction
can cause symptoms of constipation, narrowed stool, diarrhea, abdominal pains, cramps, and
bloating. Bright red blood in the stool may also indicate a growth near the end of the left colon
or rectum.

What tests can be done to detect colon cancer?

When colon cancer is suspected, either a lower GI series (barium enema x-ray) or colonoscopy
is performed to confirm the diagnosis and to localize the tumor.

A barium enema involves taking x-rays of the colon and the rectum after the patient is given an
enema with a white, chalky liquid containing barium. The barium outlines the large intestines
on the x-rays. Tumors and other abnormalities appear as dark shadows on the x-rays. For more
information, please read the Lower Gastrointestinal Series (Barium Enema) article.

Colonoscopy is a procedure whereby a doctor inserts a long, flexible viewing tube into the
rectum for the purpose of inspecting the inside of the entire colon. Colonoscopy is generally
considered more accurate than barium enema x-rays, especially in detecting small polyps. If
colon polyps are found, they are usually removed through the colonoscope and sent to the
pathologist. The pathologist examines the polyps under the microscope to check for cancer.
While the majority of the polyps removed through the colonoscopes are benign, many are
precancerous. Removal of precancerous polyps prevents the future development of colon
cancer from these polyps. For more information, please read the Colonoscopy article.

If cancerous growths are found during colonoscopy, small tissue samples (biopsies) can be
obtained and examined under the microscope to confirm the diagnosis. If colon cancer is
confirmed by a biopsy, staging examinations are performed to determine whether the cancer
has already spread to other organs. Since colorectal cancer tends to spread to the lungs and the
liver, staging tests usually include chest x-rays, ultrasonography, or a CAT scan of the lungs,
liver, and abdomen.

Sometimes, the doctor may obtain a blood test for CEA (carcinoembyonic antigen). CEA is a
substance produced by some cancer cells. It is sometimes found in high levels in patients with
colorectal cancer, especially when the disease has spread.

Unfortunately, colon cancers can be well advanced before they are detected. The most
effective prevention of colon cancer is early detection and removal of precancerous colon
polyps before they turn cancerous. Even in cases where cancer has already developed, early
detection still significantly improves the chances of a cure by surgically removing the cancer
before the disease spreads to other organs. Multiple world health organizations have suggested
general screening guidelines.

Digital rectal examination and stool occult blood testing

It is recommended that all individuals over the age of 40 have yearly digital examinations of the
rectum and their stool tested for hidden or "occult" blood. During digital examination of the
rectum, the doctor inserts a gloved finger into the rectum to feel for abnormal growths. Stool
samples can be obtained to test for occult blood (see below). The prostate gland can be
examined at the same time.

An important screening test for colorectal cancers and polyps is the stool occult blood test.
Tumors of the colon and rectum tend to bleed slowly into the stool. The small amount of blood
mixed into the stool is usually not visible to the naked eye. The commonly used stool occult
blood tests rely on chemical color conversions to detect microscopic amounts of blood. These
tests are both convenient and inexpensive. A small amount of stool sample is smeared on a
special card for occult blood testing. Usually, three consecutive stool cards are collected. A
person who tests positive for stool occult blood has a 30% to 45% chance of having a colon
polyp and a 3% to 5% chance of having a colon cancer. Colon cancers found under these
circumstances tend to be early and have a better long-term prognosis.

It is important to remember that having stool tested positive for occult blood does not
necessarily mean the person has colon cancer. Many other conditions can cause occult blood in
the stool. However, patients with a positive stool occult blood should undergo further
evaluations involving barium enema x-rays, colonoscopies, and other tests to exclude colon
cancer, and to explain the source of the bleeding. It is also important to realize that stool which
has tested negative for occult blood does not mean the absence of colorectal cancer or polyps.
Even under ideal testing conditions, at least 20% of colon cancers can be missed by stool occult
blood screening. Many patients with colon polyps are tested negative for stool occult blood. In
patients suspected of having colon tumors, and in those with high risk factors for developing
colorectal polyps and cancer, flexible sigmoidoscopies or screening colonoscopies are
performed even if the stool occult blood tests are negative.

Flexible sigmoidoscopy and colonoscopy

Beginning at age 50, a flexible sigmoidoscopy screening tests is recommended every three to
five years. Flexible sigmoidoscopy is an exam of the rectum and the lower colon using a viewing
tube (a short version of colonoscopy). Recent studies have shown that the use of screening
flexible sigmoidoscopy can reduce mortality from colon cancer. This is a result of the detection
of polyps or early cancers in people with no symptoms. If a polyp or cancer is found, a complete
colonoscopy is recommended. The majority of colon polyps can be completely removed by
colonoscopy without open surgery. Recently doctors are recommending screening
colonoscopies instead of screening flexible sigmoidoscopies for healthy individuals starting at
ages 50-55. Please read the Colon Cancer Screening article.
Patients with a high risk of developing colorectal cancer may undergo colonoscopies starting at
earlier ages than 50. For example, patients with family history of colon cancer are
recommended to start screening colonoscopies at an age 10 years before the earliest colon
caner diagnosed in a first-degree relative, or five years earlier than the earliest precancerous
colon polyp discovered in a first-degree relative. Patients with hereditary colon cancer
syndromes such as FAP, AFAP, HNPCC, and MYH are recommended to begin colonoscopies
early. The recommendations differ depending on the genetic defect, for example in FAP;
colonoscopies may begin during teenage years to look for the development of colon polyps.
Patients with a prior history of polyps or colon cancer may also undergo colonoscopies to
exclude recurrence. Patients with a long history (greater than 10 years) of chronic ulcerative
colitis have an increased risk of colon cancer, and should have regular colonoscopies to look for
precancerous changes in the colon lining.

Genetic counseling and testing

Blood tests are now available to test for FAP, AFAP, MYH, and HNPCC hereditary colon cancer
syndromes. Families with multiple members having colon cancers, members with multiple
colon polyps, members having cancers at young ages, and having other cancers such as cancers
of the ureters, uterus, duodenum, etc., should be referred for genetic counseling followed
possibly by genetic testing. Genetic testing without prior counseling is discouraged because of
the extensive family education that is involved and the complicated nature of interpreting the
test results.

The advantages of genetic counseling followed by genetic testing include: (1) identifying family
members at high risk of developing colon cancer to begin colonoscopies early; (2) identifying
high risk members so that screening may begin to prevent other cancers such as ultrasound
tests for uterine cancer, urine examinations for ureter cancer, and upper endoscopies for
stomach and duodenal cancers; and (3) alleviating concern for members who test negative for
the hereditary genetic defects.

Diet and colon cancer to prevent colon cancer

People can change their eating habits by reducing fat intake and increasing fiber (roughage) in
their diet. Major sources of fat are meat, eggs, dairy products, salad dressings, and oils used in
cooking. Fiber is the insoluble, nondigestible part of plant material present in fruits, vegetables,
and whole-grain breads and cereals. It is postulated that high fiber in the diet leads to the
creation of bulky stools which can rid the intestines of potential carcinogens. In addition, fiber
leads to the more rapid transit of fecal material through the intestine, thus allowing less time
for a potential carcinogen to react with the intestinal lining

What are the treatments and survival for colon cancer?

Surgery is the most common treatment for colorectal cancer. During surgery, the tumor, a small
margin of the surrounding healthy bowel, and adjacent lymph nodes are removed. The surgeon
then reconnects the healthy sections of the bowel. In patients with rectal cancer, the rectum is
permanently removed. The surgeon then creates an opening (colostomy) on the abdomen wall
through which solid waste in the colon is excreted. Specially trained nurses (enterostomal
therapists) can help patients adjust to colostomies, and most patients with colostomies return
to a normal lifestyle.

The long-term prognosis after surgery depends on whether the cancer has spread to other
organs (metastasis). The risk of metastasis is proportional to the depth of penetration of the
cancer into the bowel wall. In patients with early colon cancer which is limited to the superficial
layer of the bowel wall, surgery is often the only treatment needed. These patients can
experience long-term survival in excess of 80%. In patients with advanced colon cancer,
wherein the tumor has penetrated beyond the bowel wall and there is evidence of metastasis
to distant organs, the five-year survival rate is less than 10%.

In some patients, there is no evidence of distant metastasis at the time of surgery, but the
cancer has penetrated deeply into the colon wall or reached adjacent lymph nodes. These
patients are at risk of tumor recurrence either locally or in distant organs. Chemotherapy in
these patients may delay tumor recurrence and improve survival.

Chemotherapy is the use of medications to kill cancer cells. It is a systemic therapy, meaning
that the medication travels throughout the body to destroy cancer cells. After colon cancer
surgery, some patients may harbor microscopic metastasis (small foci of cancer cells that
cannot be detected). Chemotherapy is given shortly after surgery to destroy these microscopic
cells. Chemotherapy given in this manner is called adjuvant chemotherapy. Recent studies have
shown increased survival and delay of tumor recurrence in some patients treated with adjuvant
chemotherapy within five weeks of surgery. Most drug regimens have included the use of
5-flourauracil (5-FU). On the other hand, chemotherapy for shrinking or controlling the growth
of metastatic tumors has been disappointing. Improvement in the overall survival for patients
with widespread metastasis has not been convincingly demonstrated.

Chemotherapy is usually given in a doctor's office, in the hospital as a outpatient, or at home.

Chemotherapy is usually given in cycles of treatment periods followed by recovery periods. Side
effects of chemotherapy vary from person to person, and also depend on the agents given.
Modern chemotherapy agents are usually well tolerated, and side effects are manageable. In
general, anticancer medications destroy cells that are rapidly growing and dividing. Therefore,
red blood cells, platelets, and white blood cells are frequently affected by chemotherapy.
Common side effects include anemia, loss of energy, easy bruising, and a low resistance to
infections. Cells in the hair roots and intestines also divide rapidly. Therefore, chemotherapy
can cause hair loss, mouth sores, nausea, vomiting, and diarrhea.

Radiation therapy in colorectal cancer has been limited to treating cancer of the rectum. There
is a decreased local recurrence of rectal cancer in patients receiving radiation either prior to or
after surgery. Without radiation, the risk of rectal cancer recurrence is close to 50%. With
radiation, the risk is lowered to approximately 7%. Side effects of radiation treatment include
fatigue, temporary or permanent pelvic hair loss, and skin irritation in the treated areas.

Other treatments have included the use of localized infusion of chemotherapeutic agents into
the liver, the most common site of metastasis. This involves the insertion of a pump into the
blood supply of the liver which can deliver high doses of medicine directly to the liver tumor.
Response rates for these treatments have been reported to be as high as eighty percent. Side
effects, however, can be serious. Additional experimental agents considered for the treatment
of colon cancer include the use of cancer-seeking antibodies bound to cancer-fighting drugs.
Such combinations can specifically seek and destroy tumor tissues in the body. Other
treatments attempt to boost the immune system, the bodies' own defense system, in an effort
to more effectively attack and control colon cancer. In patients who are poor surgical risks, but
who have large tumors which are causing obstruction or bleeding, laser treatment can be used
to destroy cancerous tissue and relieve associated symptoms. Still other experimental agents
include the use of photodynamic therapy. In this treatment, a light sensitive agent is taken up
by the tumor which can then be activated to cause tumor destruction

Follow-up exams are important after treatment for colon cancer. The cancer can recur near the
original site or in a distant organ such as the liver or lung. Follow-up exams include a physical
examination by the doctor, blood tests of liver enzymes, chest x-rays, CAT scans of the
abdomen and pelvis, colonoscopies, and blood CEA levels. Abnormal liver enzymes may
indicate growth of liver metastasis. CEA levels may be elevated before surgery and become
normal shortly after the cancer is removed. Slowly rising CEA level may indicate cancer
recurrence. A CAT scan of the abdomen and pelvis can show tumor recurrence in the liver,
pelvis, or other areas. Colonoscopy can show recurrence of polyps or cancer in the large
intestine.

In addition to checking for cancer recurrence, patients who have had colon cancer may have an
increased risk of cancer of the prostate, breast, and ovary. Therefore, follow-up examinations
should include these areas.

What does the future hold for patients with colorectal cancer?

Colon cancer remains a major cause of death and disease, especially in the western world. A
clear understanding of the causes and course of the disease is emerging. This has allowed for
recommendations regarding screening for and prevention of this disease. The removal of colon
polyps helps prevent colon cancer. Early detection of colon cancer can improve the chances of a
cure and overall survival. Treatment remains unsatisfactory for advanced disease, but research
in this area remains strong and newer treatments continue to emerge. New and exciting
preventive measures have recently focused on the possible beneficial effects of aspirin or other
anti-inflammatory agents. In trials, the use of these agents has markedly limited colon cancer
formation in several experimental models. Other agents being evaluated to prevent colon
cancer include calcium, selenium, and vitamins A, C, and E. More studies are needed before
these agents can be recommended for widespread use by the public to prevent colon cancer.

Colon Cancer at A Glance

* Colorectal cancer is a malignant tumor arising from the inner wall of the large intestine.
 * Colorectal cancer is the third leading cause of cancer in males and fourth in females in
the U.S.

* Risk factors for colorectal cancer include heredity, colon polyps, and long-standing
ulcerative colitis.

* Most colorectal cancers develop from polyps. Removal of colon polyps can prevent
colorectal cancer.

* Colon polyps and early cancer can have no symptoms. Therefore regular screening is
important.

* Diagnosis of colorectal cancer can be made by barium enema or by colonoscopy with

biopsy confirmation of cancer tissue.

* Treatment of colorectal cancer depends on the location, size, and extent of cancer
spread, as well as the age and health of the patient.

* Surgery is the most common treatment for colorectal cancer.