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An In-Depth Review of Colorectal Cancer

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Dignity Health Education and Outreach

We hope you enjoy and learn from our presentation of the Annual Cancer Program Report on Colorectal Cancer. Colorectal cancer continues to impact the lives of our patients. We are proud of the continuous efforts made to provide comprehensive care to our cancer patients. Dignity Health of the Central Coast cancer programs in Arroyo Grande, San Luis Obispo, and Santa Maria have demonstrated results in successful prevention, screening, diagnosis, treatment, survivorship, community education and outreach. Our cancer committees are multidisciplinary teams that represent physicians from the diagnostic and treatment specialties and non-physicians from administrative and support services. They meet monthly/quarterly to provide leadership in the cancer activities at Arroyo Grande Community Hospital, French Hospital Medical Center and Marian Regional Medical Center. The Cancer Committees are involved in evaluating new technologies, establishing new programs, and improving all cancer-related activities in the region. We are committed to working with our oncology and primary care partners to continue to improve results and the lives of the patients we serve. On behalf of our cancer committees we extend our thanks to our outstanding communities, medical staff, employees, administration and volunteers for the continued support of our cancer programs.

Get Educated About Colorectal Cancer

What is Colorectal Cancer?
Colorectal cancer is one of the most common forms of cancer. Colorectal cancer is the second leading cause of cancer deaths in the United States. But no one likes to talk about it. Understanding the disease is important for anyone who has been diagnosed with colorectal cancer, but it is also essential for those who are trying to prevent it.

The Difference Between Colon Cancer and Colorectal Cancer
Colon cancer is a malignancy that begins in the colon, or large intestine. The large intestine is a long tube-like organ near the end of the digestive system. After food passes through the stomach and small intestine, the colon is responsible for removing fluid and some nutrients from the food that you eat. The colon then pushes the remaining solid waste into the rectum where it can be expelled from the body.

Colorectal cancer is another commonly used term that includes not only cancers of the colon, but also cancers that form in the rectum. The rectum is the last part of the large intestine where stool, the body’s waste product, is expelled through the anus.

How Does Colorectal Cancer Start?
Most colorectal cancers begin as benign polyps. These are either flat or knob-like growths on the lining of the large intestine. Occasionally, the growths produce symptoms such as bleeding, constipation or blood in the stool. But often, the polyps produce no symptoms at all, so people may not know that they have them. The best way to detect the presence of polyps is with a procedure called a colonoscopy.

Who Gets Colorectal Cancer?
Anyone can get colorectal cancer but there are some people who are at higher risk. If you have a family history of colon cancer, physicians generally recommend that you get screened for colon cancer at an earlier age because your risk of getting the disease may be higher. For those who have no family history of the disease, recommended screenings generally begin at age 50. This is when the risk of getting colon cancer begins to increase.

However, even if you are under the age of 50 and have no family history of colon cancer, if you experience symptoms including abdominal pain, blood in the stool, narrowing stools, or a change in bowel habits, you should speak to your health care provider about getting the proper screening tests. Be sure to provide as much information as possible, including when the pain or discomfort started and the severity and/or frequency of symptoms.

What You Need to Know…

Colon Cancer Facts
Colorectal cancer, or cancer of the colon or rectum, is the second-leading cause of cancer-related deaths in the United States claiming more than 51,500 lives each year or 140 lives each day. An estimated 145,000 men and women will be diagnosed with colon cancer this year alone. However, colon and rectal cancers can often be prevented with proper screening. Colorectal cancer is highly treatable. Found in its earliest stages, colon cancer is survived by almost 90 percent of patients. If everyone aged 50 years old or older were screened regularly, as many as 60% of these deaths could be prevented.

Getting Screened
Colon cancer starts with polyps, small growths on the inner wall of the colon or rectum that in time can turn cancerous. Most polyps are benign (not cancerous), but some polyps (adenomas) can become cancer. Finding and removing polyps may reduce the risk of colorectal cancer. For this reason, when a physician finds one or more polyps during the colonoscopy, they are generally removed during the procedure. It can take as many as 10 to 15 years for a polyp to develop into colorectal cancer.

A large, long-term study found that 40% of all colorectal cancers might be prevented if people underwent regular colonoscopy screenings. This new research supports guidelines that recommend that people at average risk for colorectal cancer should have a colonoscopy every 10 years.

How to Prevent Colon Cancer
Colon Cancer is preventable!
Did you know that you can stop this cancer before it starts?

  • Colon cancers almost always develop from precancerous polyps (abnormal growths) in the colon or rectum
  • Screening tests find polyps, so they can be removed before they become cancerous
  • Screening tests find colon cancer early, when treatment works best and the chance for a full recovery is very high
  • The most effective way to reduce your risk of colon cancer is by having colon cancer screening tests beginning at age 50

Who is at Risk?

Both men and women are equally at risk for colon cancer and the risk of developing colorectal cancer increases with age. Screening tests for colorectal cancer should begin soon after turning 50 and continue at regular intervals or at the recommendation of your physician. It should be noted however, that although the cancer is most common among people aged 50 and older, it can occur in patients as young as teenagers. Over 75 percent of colon and rectal cancers happen to people with no known risk factors which is why regular screening is so important.

What Are the Risk Factors for Colorectal Cancer?
Risks You CANNOT CONTROL:

AGE: Age puts you at increased risk for colorectal cancer. Over 90% of those diagnosed with colorectal cancer are over age 50. As we age, we are more likely to grow polyps which have the gene changes that turn normal tissue into cancer.

PERSONAL HISTORY OF POLYPS OR COLORECTAL CANCER: If you have a personal cancer history of colon polyps or colon cancer, rectal cancer, ovarian cancer, endometrial cancer or breast cancer—you are at increased risk for colorectal cancer. You may also want to talk with your doctor about whether genetic testing is appropriate for you.

RACE: African-American and Hispanic men and women are at increased risk for colorectal cancer. They are also often diagnosed at a later stage of the disease. ETHNICITY: Jews of eastern European descent are at increased risk for developing colorectal cancer. About 6% of American Jews who are of eastern European descent have DNA changes that increase their risk. I

NFLAMMATORY BOWEL DISORDERS (IBD): If you’ve been diagnosed with an inflammatory bowel disorder such as ulcerative colitis or Crohn’s Disease, you are at increased risk for colorectal cancer. Talk with your doctor about when your screening tests should begin.

GENETIC CONDITIONS: Two of the most commonly known genetic conditions put individuals at an increased risk for colon and rectal cancers: Familial Adenomatous Polyposis (FAP) and Hereditary Non-polyposis Colorectal Cancer (HNPCC), also known as Lynch Syndrome. Speak with your physician about when screening is right for you.

FAMILY HISTORY: If you or a family member has a history of colorectal cancer, or colon polyps, you may be at an increased risk for colorectal cancer. Generally, screening for family members is recommended to begin 10 years prior to the age of diagnosis of the affected person. (For example, if your loved one was diagnosed at age 52, family member screening needs to begin at age 42.) If your family has a known genetic syndrome, screening may be recommended earlier. Talk to your doctor about the best option for you.

Risks You CAN CONTROL:

LIFESTYLE: Low physical activity, obesity, smoking and heavy alcohol use are all linked to a higher incidence of colorectal cancer. DIET: A diet high in red meats (beef, pork, lamb) processed meats and fats may be linked to a higher incidence colorectal cancer.

What Are the Symptoms?

Change in Bowel Habits

While it is common for people to experience a change in their bowel habits from time to time, there are some changes that should be evaluated by a physician if the symptoms persist. If you notice any of these changes to your bowel habits take note of when the changes began to occur and what other lifestyle changes occurred at the same time. This information will help your physician determine the cause.

Diarrhea. Loose stool and diarrhea are common occurrences. The condition can be caused by intolerance to certain foods, medication, stress, or exposure to bacteria (often experienced when traveling). Most people will get at least a mild case of diarrhea several times per year. In most cases, the condition will resolve itself within two to three days. Your health care provider should investigate diarrhea that lasts more than three days.

Constipation. Lifestyle changes can also cause constipation. This symptom, defined as having less than three bowel movements in a week, is one of the most common gastrointestinal complaints. If you have constipation, it does not mean that you have colon cancer. A change in your diet, poor nutritional habits, stress, dehydration or lack of physical activity can cause constipation to occur. Physicians generally recommend that if you have constipation for more than two weeks, you should see your doctor so that the cause can be determined.

Change in the Appearance of Stool

The way that your stool looks can be a good indicator of what is going on inside your body. Small, hard stool is an indicator of constipation. But if you notice one of the following changes, contact your physician for an appointment:

Change in Shape. If your stool becomes, thin, narrow or ribbon-like this could be an indication of changes inside your colon. Contact your health care provider to have the condition evaluated.

Change in Color. If you notice blood in the stool, or darkened stool this could also be an indication of changes inside the colon. Your physician can help you to determine the cause.

Bleeding

One of the most disturbing symptoms of colon cancer can be bleeding from the rectum or blood in the toilet after you have a bowel movement. Be aware, however, that conditions such as hemorrhoids or fissures (a break or tear in skin) can also cause small amounts of blood. If you notice blood, contact your physician and be sure to explain any other symptoms that you may be experiencing at the same time. A large amount of blood may warrant a visit to the emergency room.

Stomach Discomfort or Cramping

Like constipation or diarrhea, stomach discomfort is a common occurrence and can be the result of poor diet, food intolerance, stress or other factors. Be aware of discomfort that does not go away or cramping that gets worse. Additionally, if you have the constant feeling that you need to have a bowel movement and the feeling is not relieved by having one, contact your physician for an appointment.

Unexplained Fatigue, Weakness or Weight Loss

Chronic rectal bleeding can cause iron deficiency. You might feel tired all of the time and have pale skin as a result. If your energy level drops or you begin to lose weight for no reason, take note of when the changes occur and contact your physician for evaluation.

It is important to remember that most of these conditions may have causes other than colon cancer. Fear of a cancer diagnosis shouldn’t keep you away from seeing your health care provider if you are experiencing symptoms. Chances are good that your symptoms can be treated. If cancer is suspected, the earlier the cancer is detected the better off you will be. Nearly 90% of colon cancer is treatable and survivable if diagnosed in its early stages.

Not Having Any Symptoms at All?

Keep in mind that many people who are diagnosed with colon cancer report having no symptoms prior to their diagnosis. Don’t wait for symptoms to occur to get screened for colon cancer if you are over the age of 50 or if you have a family history of the disease. Talk to your physician or primary care provider to get more information about screening options.

The Colonoscopy Screening

Why is Screening for Colorectal Cancer so Important?

Many colorectal cancers can be prevented through regular screening. Screening can find precancerous polyps (abnormal growths in the colon or rectum) so that they can be removed before they become cancerous. Screening is crucial because when found early, colorectal cancer is highly treatable. Early stages of colorectal cancer usually present no symptoms; the symptoms tend to appear as the cancer progresses.

What is a Colonoscopy?

A colonoscopy is considered the gold standard for detection of colorectal cancer. It is the only screening test that also prevents many colorectal cancers. Here are a few things you should know about this test:

• The day before the procedure you will be given a “prep” to cleanse the colon. The prep is considered to be the most difficult part of the procedure by some people. There are things you can do, however, to make your prep day more tolerable.

• On the day of the colonoscopy, you will receive medication to help you relax. Most people fall asleep and do not remember much about the test when they wake up. The exam takes about 30 minutes to complete.

• Your doctor performs a colonoscopy by inserting a long, thin, flexible tube called a colonoscope into your colon through the rectum. The tube has a tiny video camera and light at the end that sends images to a video monitor.

• During a colonoscopy, your doctor examines the lining of your entire colon to check for polyps or tumors. If any polyps are found, they can be removed immediately.

• Both men and women should have a colonoscopy starting at age 50. People at increased risk of colorectal cancer may need to start earlier, depending on your doctor's instructions. Also, your doctor will tell you in how many years you will need another colonoscopy.

Since 90% of colon cancer cases are curable when diagnosed at an early stage, screening for the disease should be a top priority.

Preparing for a Colonoscopy

How Not to Dread a Colonoscopy:
Steps To Make the Test More Comfortable

• Get informed and get scheduled.
Sometimes the hardest part of getting the colonoscopy is making the decision to have the test performed in the first place. A common reason that people avoid a colonoscopy is that they think they don’t need one. If they have no symptoms or family history of colon cancer they feel that they don’t need to be screened. However, most cases are found in people with no family history of colon cancer. Often people report that they felt no symptoms prior to being diagnosed.

During a colonoscopy, your physician cannot only detect signs of colon cancer, but also remove pre-cancerous polyps that have the potential to become cancer over time. Understanding the preventative potential of the test may make scheduling a colonoscopy more tolerable. In most cases, your physician will discuss the procedure during your annual physical. But if symptoms arise, don’t hesitate to contact your health care team and ask to have the test performed.

When scheduling the procedure, keep in mind that due to the sedation you will need to take the test day off from work. On prep day, you will need to be close to a bathroom and may experience some discomfort. Some preps can be started late in the afternoon but some people choose to take this day off from work as well. On test day, your sedation will make it unsafe for you to drive or perform work duties. Be sure to have a friend or family member as transportation to and from the procedure.

• Get prepped.
On the day before your colonoscopy, your physician will ask you to perform a “prep” to cleanse the colon. A clean colon makes it easier to find and remove polyps, so doing a thorough bowel cleaning is essential. Be sure to read the instructions given to you by your physician and clarify any confusion by calling and speaking to your health care provider in advance.
In most cases, cleansing the digestive tract means consuming a clear liquid diet on the day before the exam. This means that you will avoid any solid foods and will only be drinking clear fluids that are approved by your health care team. Be sure to have a kitchen that is well stocked with products such as:
• Clear fruit juices
• Jell-O (no red, blue, or purple coloring)
• Clear soft drinks
• Coffee (no milk or creamer)
• Broth

In addition, your physician will prescribe a liquid laxative. Be sure to follow instructions and drink all of the fluid that is prescribed. Some people find the solution disagreeable to drink. Tips for getting it down include:
• Drinking through a straw placed at the back of the mouth
• Keeping the fluid cold
• Sucking on tart hard candies or lemon to mute the taste

The Colonoscopy Screening, continued

Being close to a bathroom during the prep is essential. In fact, some people drink the laxative in the bathroom because bowel movements may begin immediately after you begin drinking. You may find it more comfortable to use flushable moistened baby wipes instead of toilet paper or to apply hemorrhoid cream to protect your skin.

• Stay relaxed on test day.
A colonoscopy is an endoscopic procedure. This means that a scope is inserted through the anus to view the colon. Your gastroenterologist is skilled at moving the scope in a way that creates minimal discomfort.

Good communication between you and your health care team on test day is the key to making your experience a positive one. Increased anxiety or fear can make the scoping process less comfortable. Don’t be afraid to ask questions about sedation, about the test process, or about managing discomfort.

After the test is complete, be sure to ask questions about the results of the exam. Your physician will let you know if there were any polyps or signs of cancer. And finally, find out if there are any further steps you need to take and when you will need your next colonoscopy.

Preventing Colorectal Cancer

There is convincing evidence that the following strategies can decrease colorectal cancer risk:

• Eat nine servings of fruits and vegetables each day
• Eat foods with folate such as kale, Swiss chard and other dark leafy green vegetables
• Limit fat in your diet
• Avoid tobacco, including smokeless products
• If you do smoke, stop
• Increase your physical activity such as walking, gardening, or climbing steps for at least 20 minutes three to four times a week
• Maintain a healthy body weight
• Avoid overall body fat, especially fat around your waist
• Reduce how much red meat and processed meats you eat
• Use alcohol in moderation

There is probable evidence that these additional strategies can reduce risk:

• Increase foods that contain dietary fiber
• Include garlic in your diet
• Drink more milk if you can tolerate it
• Add foods with calcium
• Women should consume alcohol only in moderation

While over 90 percent of colon and rectal cancers are found in people over the age of 50, anyone at any age can get colorectal cancer.

People younger than 50 need to protect themselves by knowing their family cancer history as well as their own medical history. Those with a family history of certain cancers or with certain medical conditions may need to begin colonoscopy screening earlier and be tested more often.

In addition, everyone, no matter how old they are, should be aware of the symptoms of colorectal cancer. If you have any of the symptoms be sure to talk to your doctor about the appropriate colon screening to determine the cause. Don’t ignore them.

 

Colon Cancer Stages and Treatment

A colon cancer diagnosis can be terrifying. One of the first questions that patients usually ask is, “What’s next?” The plan for treatment depends on a number of factors. Determining the best course of action is determined by your general health, whether or not the cancer is a recurrence of a cancer that was treated in the past, and on the stage of the cancer.

Cancer staging takes place after the initial diagnosis and may involve a number of tests. Each test will help your physician to determine how much of your body the cancer has affected. After determining the stage, your physician will recommend a course of treatment.

Stage 0 Colon Cancer

When abnormal cells are found in the wall, or mucosa, of the colon, it is considered stage 0 colon cancer. This is also called carcinoma in situ.

Treatment: A polypectomy (surgical removal of a polyp) is performed during a colonoscopy and may remove all of the malignant cells. If the cells have affected a larger area, an excision may be performed. An excision is simply a minor, minimally invasive surgery that can often be performed during the colonoscopy.

Stage I Colon Cancer

Cancer which has invaded the mucosa and the submucosa is considered stage I colon cancer. The submucosa is the underlining of the large intestine and it lies beneath the mucosa. In stage I colon cancer, malignant cells may have also affected the deeper muscle layer of the colon wall, but have not invaded any areas outside of the colon.

Treatment: Surgery is performed to remove the affected area. This is called a partial colectomy and may involve rejoining the parts of the colon that are still healthy.

Stage II Colon Cancer

When cancer has spread past the colon wall, but has not affected the lymph nodes, it is considered stage II colon cancer. This condition is subdivided into three stages.

• Stage IIA Cancer has spread to the serosa, or outer colon wall, but not beyond that outer barrier.
• Stage IIB Cancer has spread past the serosa but has not affected nearby organs.
• Stage IIC Cancer has affected the serosa and the nearby organs.

Treatment: Stage II cancers are treated with surgery to remove the affected areas. Chemotherapy may also be recommended in some cases. High grade or abnormal cancer cells, or tumors that have caused a blockage or perforation of the colon may warrant further treatment. If the surgeon was not able to remove all of the cancer cells, radiation may also be recommended to treat any remaining cancer cells and reduce the risk of a recurrence.

Stage III Colon Cancer

Cancer that has spread past the lining of the colon and has affected the lymph nodes is considered stage III colon cancer. In this stage, even though the lymph nodes are affected, the cancer has not yet affected other organs in the body. This stage is further divided into three categories: IIIA, IIIB and IIIC. Where your cancer is staged in these categories depends on a complex combination of which layers of the colon wall are affected and how many lymph nodes have been affected.

Treatment: The course of action for all categories of stage III colon cancer involves surgery to remove the affected areas and chemotherapy. Radiation treatment may also be recommended for patients who are not healthy enough for surgery or for patients who may still have cancer cells in their bodies after surgery has taken place.

Stage IV Colon Cancer

In stage IV colon cancer, the cancer has spread (metastasized) to other organs in the body through the blood and lymph nodes.

Treatment: Patients with stage IV colon cancer may undergo surgery to remove small areas, or metastases, in the organs which have been affected. In many cases, however, the areas are too large to be removed. Chemotherapy may help to shrink the tumors so that surgery is more effective or to prolong life.

Chemotherapy treatments for stage IV colon cancer may include:
• FOLFOX (leucovorin [folinic acid], 5-FU, and oxaliplatin)
• FOLFIRI (leucovorin, 5-FU, and irinotecan)
• CapeOX (capecitabine and oxaliplatin)
• 5-FU and leucovorin, with or without bevacizumab
• Capecitabine, with or without bevacizumab
• FOLFOXIRI (leucovorin, 5-FU, oxaliplatin, and irinotecan)
• Irinotecan, with or without cetuximab
• Cetuximab
• Panitumumab

Researchers acknowledge that even though advances in treating metastatic colon cancer are moving along at a rapid pace there is no standard recommended treatment for the disease at this level. As one study points out, “different strategies may be better for different individuals.” Patients who are faced with a stage IV diagnosis may find it helpful to be aware of clinical trials by talking with your physician or contacting our Research RN.