Colorectal Cancer is a malignancy of the colon and rectum. The colon is the large intestine and is composed of three sections. The last 8 to 10 inches of the large intestine is the rectum. These cancers are the second leading cause of cancer deaths in the United States. Commonly colon cancer begins as small benign groups of polyps that are small nodules of cells referred to as adenomatous polyps. After some time the polyps become malignant or cancerous.
The number of polyps can be small and produce no symptoms, making it important to get regular colonoscopies to prevent colon cancer.
Like many other cancers there are usually no symptoms in the beginning stages of the cancer. Symptoms that do develop will depend upon the side of the cancer and where it is located in the small intestine. Symptoms can be the result of co-existing conditions such as inflammatory bowel disease (IBD), irritable bowel syndrome (IBS) and possibly diverticulitis or diverticulosis. All of these conditions are treatable.
The most common symptoms for colorectal cancer are change in bowel movements or habits, which include diarrhea, constipation or a consistency of the stool for more than a couple of weeks. Other symptoms are narrow stools, rectal bleeding or bloody stool, persistent pain, cramps or gas, abdominal pain with bowel movement or a feeling of fullness in the bowel even after a bowel movement or unexplained weight loss.
Blood in the stool can mimic other conditions. Blood that is bright red on tissue paper can be from hemorrhoids or fissures in the anus. Fissures are minor tears that heal on their own caused by straining. Iron supplements and anti-diarrhea medication can cause stools to appear black. Other foods such as licorice and beets can turn stools red. It is important, though that whenever blood is suspected in stools an exam is important to determine the source.
Colon cancer mainly develops from adenomatous polyps. Screening for polyps is very important to monitor their growth, before they become cancerous. If colorectal cancer is discovered early, recovery rates improve dramatically.
Common screening and diagnostic tests are:
A digital rectal exam involves checking the first few inches of the rectum for large polyps. The doctor used lubricant and rubber gloves for comfort and the exam only takes a few seconds. The exam is painless and safe but can only check the lower rectum and small polyps are difficult to detect.
A fecal occult blood test checks for blood in the stool that is not visible with typical vision. This test can be performed in the doctor’s office but a kit is usually sent home to get a stool sample for testing. Not all cancers will bleed and sometimes they bleed occasionally. Polyps do not usually bleed and the test can be a false negative. Sometimes blood in the stool is due to hemorrhoids or conditions of the intestine that are not malignant. A fecal occult blood test is typically part of a group of diagnostic tests, since the results are ambiguous.
A flexible sigmoidoscopy is an exam which checks the last two feet of the colon. A flexible slender tube is inserted in the anus and pushed up the rectum and into the sigmoid. The test takes a few minutes and can be a little uncomfortable. The risk with this exam is slight, and that is that the colon wall can be torn. Of a polyp or colon cancer is found, then a colonoscopy will be recommended to exam the entire colon.
Barium enema is a test that uses a radioactive tracer with medical imaging to create detailed images for examination. An enema with barium is administered before a series of x-rays are taken. A double contrast enema involves placing air in the colon to expand it for better images. Sometimes a flexible sigmoidoscopy is performed with a barium enema to detect small polyps, that could be missed in a barium enema x-ray.
A colonoscopy is by far the most effective diagnostic test for colorectal cancer. A colonoscopy uses a similar device that is used in a sigmoidoscopy, but a longer tubing attached to a monitor. The entire colon and rectum can be viewed and examined. If polyps are discovered during the exam, the doctor can remove them and sent them for analysis. If the polyps are larger than 5 mm, then annual, careful screening is recommended. The most challenging part of this procedure is the preparation that must take place the day before. A strong laxative is used to clean out the colon before the test. The most significant risks of this diagnostic test are perforation of the colon and hemorrhaging, but they rarely occur.
If the patient has a family history of colorectal cancer, genetic testing could be recommended. A blood test can help determine if a significant risk of developing colorectal cancer is present. The test results do not indicate that colorectal cancer will definitely develop, just that the patient has a predisposition to develop colorectal cancer.
Part of diagnosing colorectal cancer involves a procedure known as staging. The stage of colorectal cancer is determined by the location of the malignancy, whether it has spread or not.
Stage 0 is defined as cancer that has not grown beyond the inner wall or lining of the colon or rectum, this is also referred to as carcinoma in situ.
Stage I is defined as cancer that has frown through the mucosa but has not spread beyond the wall of the colon or rectum.
Stage II is defined as cancer that has grown through the wall or the rectum or colon, but is not found in lymph nodes located nearby.
Stage III is defined as cancer that has spread to nearby lymph notes but is not found in any other part of the body.
Stage IV is defined as cancer that has spread to distant sites such as the liver, lung, peritoneal lining or ovaries.
Recurrent is defined as cancer that has returned after treatment. It may recur in the colon, rectum or other organs in the body.
Treatment options are based on the stage of the cancer. Treatments used for colorectal cancer are surgery, chemotherapy and radiation.
Surgery is the primary treatment for colorectal cancer. The amount of colon removed depends on the extent of the cancer. Sometimes, only part of the colon needs to be removed with surrounding affected lymph nodes. In many cases the surgeon is able to reconnect the remaining healthy portion of the colon to the anus. If it is not possible because the cancer is more advanced, a permanent or temporary colostomy may be created. If the colostomy is temporary, a second surgery will be performed after the colon has healed to reconnect your colon to the anus. The colostomy would be closed up and removed. There are times when the colostomy is permanent, which far outweighs the consequences of not having surgery.
There is a rare inherited syndrome called familial adenomatous polyposis. When a patient is diagnosed with colorectal cancer and has this disease or inflammatory bowel disease (such as ulcerative colitis) a prophylactic surgical procedure of removing the entire colon and rectum is ideal to avoid or cure the colorectal cancer. An ileal pouch-anal anastomosis is constructed from the end of the small intestine and directly attached to the anus. Waste can be eliminated normally, though may be several times a day and watery.
The side effects of colon cancer surgery are short term pain and soreness, diarrhea or constipation. A colostomy may cause soreness on the skin around the opening to you abdomen.
If the cancer is not significant and is localized to a single polyp and at an early stage, it may be removed completely during a colonoscopy. A pathologist will be able to determine if the cancer was close to the base of the polyp growing out of the abdominal wall. Then it means that the cancer has possibly been completely eliminated.
Larger polyps may be removed via laparoscopic surgery. This involves a series of small incisions and a variety of instruments with cameras. The colon will be viewed on video via the camera. Adjacent instruments will be guided to the polyps and affected lymph nodes. Patients who have this surgery have a smaller rate of recurrence rate and a shorter recovery time including less pain. Advanced cancer and poor health of the patient, may prevent the removal of the entire colon. This method is not as affective as removing more of the colon. This type of surgery is consider palliative care and is not a cure.
Chemotherapy involves potent drugs that kill cancer cells. Chemotherapy can be used to destroy residual cancer cells after surgery, shrink or control growth of tumors and to relieve symptoms of colorectal cancer. Chemotherapy can be used in combination with radiation therapy.
Side effects for chemotherapy are diarrhea, vomiting, mouth sores, hair loss, fatigue and nausea.
In radiation therapy high doses of radiation are used to kill any residual cancer cells after surgery. Sometimes radiation therapy is used to shrink tumors before surgery to make them easier to remove. Radiation has also been used as palliative care for advanced stages of colorectal cancer. Radiation therapy can relieve the symptoms of colorectal cancer. Therapy goal is to destroy the tumor without damaging healthy tissues. Side effects of radiation therapy are nausea, fatigue, loss of appetite, rectal bleeding, and diarrhea.
In 2004, two new drugs were approved in the United States to treat colorectal cancer. This therapy is known as monoclonal antibody therapy. The drugs inhibit the tumor cell’s growth factor. The drugs are used with standard chemotherapy in patients with advanced cancer that has spread to other organs.
When treatment has ended whether remission is achieved or not, follow-up care is very important. Regular check up s should include a colonoscopy, chest x-rays and imaging of the abdomen to make sure the caner has not returned or has not spread.
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