Excluding skin cancers, colorectal cancer is the third most common cancer in women and men in the United States. The American Cancer Society’s estimates for the number of colorectal cancers in the United States for 2023 are:

• 106,970 new cases of colon cancer
• 46,050 new cases of rectal cancer

The rate of colorectal cancer diagnoses has dropped annually since the mid-1980s, largely because more people are getting screened and changing lifestyle-related risk factors.

Colorectal Cancer is Rising Among the Young

From 2011 to 2019, colorectal cancer incidence rates dropped by about one percent annually. However, this downward trend is mostly in older adults. For those under 50, rates have been increasing by one to two percent each year since the mid-1990s.

Colorectal cancer is a significant health concern worldwide, accounting for many cancer-related deaths. As researchers continue to investigate potential preventive strategies, one intriguing area of study is aspirin.

While we lack sufficient data to recommend aspirin to reduce colorectal cancer risk routinely, a new study is encouraging.

Aspirin, a widely available non-steroidal anti-inflammatory drug (NSAID), has been the subject of numerous studies examining its potential role in reducing the risk of colorectal cancer.

This essay delves into the relationship between aspirin use and the risk of colorectal cancer, exploring the evidence, mechanisms, and potential benefits of this medication.

Aspirin and Colorectal Cancer — Background

Multiple studies have suggested a potential link between aspirin use and a reduced risk of developing colorectal cancer. The evidence originates from observational studies and randomized controlled trials.

First, observational studies (such as the Nurses’ Health Study and the Health Professionals Follow-up Study) show a consistent association between long-term aspirin use and a reduced incidence of colorectal cancer.

Second, a meta-analysis published in The Lancet in 2010 found a one-quarter (24 percent) reduction in colorectal cancer incidence among individuals who took aspirin regularly.

How Might Aspirin Reduce Colorectal Cancer Risk?

We have not yet fully elucidated the mechanisms by which aspirin might reduce colorectal cancer risk. There are likely several biological pathways.

For example, aspirin exerts anti-inflammatory effects by blocking the cyclooxygenase (COX) enzymes, especially COX-1 and -2. These enzymes are critical to prostaglandin production, substances known to promote inflammation and cancer development.

Aspirin inhibits COX enzymes, dropping prostaglandin production and attenuating the inflammatory response.

Aspirin — Cancer and Cardiovascular Benefits?

While the evidence suggests a potential protective effect of aspirin against colorectal cancer, it is important to consider the benefits and the potential risks associated with its use.

Aside from reducing the incidence of colorectal cancer, aspirin has also been linked to a lower risk of other gastrointestinal cancers, including the esophagus, stomach, and pancreas.

Additionally, aspirin has well-established cardiovascular benefits, including preventing heart attacks and strokes, further enhancing its potential value.

However, it is important to acknowledge the potential risks of aspirin use, such as gastrointestinal bleeding and hemorrhagic stroke. These risks tend to increase with higher doses and long-term use.

Therefore, individuals considering aspirin for colorectal cancer prevention should consult their healthcare providers to evaluate their risk factors and discuss the potential benefits and risks.

Colon Polyps and Adenomas

A colon polyp is a small clump of cells that forms on the colon’s lining. Most colon polyps are harmless. But over time, some colon polyps can develop into colon cancer. Colon cancer can be fatal when found in its later stages.

Anybody can develop colon polyps. The risk is higher for those 50 or older. Smokers and overweight individuals also have a higher risk. Those with a personal or family history of colon polyps or colon cancer also are at higher risk of developing a polyp.

Colon polyps don’t usually cause symptoms. It’s important to have regular screening tests because the doctor can usually remove early colon polyps safely and completely. The best prevention for colon cancer is regular screening for and removing polyps.

Adenomas are non-cancerous tumors. Tubular adenomas are pre-cancerous polyps in your colon (or rectum), typically found during colonoscopies. Such polyps are your body’s early warning system for colorectal cancer. While approximately half of us will develop tubular adenomas, less than one in ten tubular adenomas, become cancer.

Aspirin and Colorectal Cancer — A New Study

Aspirin is a compelling research area in the context of colorectal cancer risk reduction. A new study assessed the association between regular aspirin or NSAID (non-steroidal anti-inflammatory drugs such as ibuprofen) use at least twice weekly with the risk of developing early-onset adenoma.

A new study demonstrates the following:

Regular use of aspirin or other nonsteroidal anti-inflammatory drugs was associated with a lower risk of early-onset conventional and advanced adenomas.

The researchers explain that aspirin could be an effective strategy in preventing early-onset colorectal cancer.

One of the study authors, Dr. Cassandra Fritz of Washington University (USA), offers a “15 percent reduction for all adenomas and a one-third drop for those with more concerning forms of adenoma.

The analysis focused on data from the Nurses’ Health Study II. The study included more than 32,000 women with at least one colonoscopy before age 50 (1991–2015).

For the clinicians amongst you: High-risk adenomas included those at least one centimeter with tubulovillous/villous histology or high-grade dysplasia or at least three adenomas.

Aspirin Risks: The Drug is Not for Everyone

For selected individuals, daily aspirin is helpful to lower heart attack, clot-related stroke, and other blood flow risks in patients with cardiovascular disease or who have already had a heart attack or stroke. Many medical professionals prescribe aspirin for these uses.

There may be a benefit to daily aspirin use if you have some kind of heart or blood vessel disease or if you have poor blood flow to the brain. However, long-term aspirin use risks may be greater than the benefits if there are no signs of, or risk factors for, heart or blood vessel disease.

The US Food and Drug Administration (FDA) reminds us that every prescription and over-the-counter medication has risks and benefits — even aspirin, a common medicine. Aspirin can cause serious toxicities, such as brain or stomach bleeding and kidney failure.

No medicine is completely safe. By carefully reviewing many factors, your health professional can help you make the best choice.

Please Don’t Forget Colorectal Screening

Colorectal cancer screening plays a crucial role in the early detection and prevention of one of the most common types of cancer worldwide.

Colorectal cancer is highly treatable when caught early. However, it often develops without noticeable symptoms in its initial stages, underscoring the significance of regular screening.

Screening for colorectal cancer is recommended for both men and women starting at the age of 45 or earlier for individuals with a family history of the disease or other risk factors.

Various screening methods are available, including colonoscopy, sigmoidoscopy, fecal occult blood tests (FOBT), and fecal immunochemical tests (FIT).

Colorectal Cancer Screening Benefits

These screening tests help identify precancerous polyps or early-stage cancers that may not yet be causing symptoms. Detecting and removing these abnormal growths during screening can significantly reduce the risk of developing colorectal cancer.

Regular colorectal cancer screening has several important benefits. Firstly, it reduces mortality rates by detecting cancer early when it is more treatable. Early detection often leads to less invasive treatment options, higher survival rates, and better patient outcomes.

Secondly, screening can help identify and remove polyps before they become cancerous, preventing colorectal cancer altogether. This observation highlights the preventive aspect of screening, as it can potentially eliminate or catch the disease at its most treatable stage.

Lastly, screening can provide peace of mind for individuals by assuring them that their colorectal health is being monitored and any issues can be addressed promptly.

Regular screening, combined with a healthy lifestyle that includes a balanced diet, regular exercise, and avoidance of known risk factors such as smoking and excessive alcohol consumption, significantly contributes to the overall prevention and early detection of colorectal cancer.

Here are the US Preventative Services Task Force guidelines:

Colorectal Cancer: Screening Guidelines

www.uspreventiveservicestaskforce.org

Key points — Unveiling the Power of Aspirin: Game-Changer for Colon Cancer Prevention?

Question. Does aspirin have the potential to be a game changer for colon cancer prevention?

Findings. A new study shows that the regular use of aspirin or other nonsteroidal anti-inflammatory drugs is associated with a lower risk of early-onset conventional and advanced adenomas.

Meaning. While confirmatory research is needed, the one-seventh (15 percent) reduction with aspirin/NSAIDS in early-onset adenoma — and particularly for the quite substantial one-third risk-reduction in advanced adenoma with advanced histology, we need to think about a precision-based chemoprevention strategy for early-onset precursors of colorectal cancer.

This study does not give us high-level evidence to recommend aspirin for all. Individuals at high risk for colorectal cancer should consult an expert healthcare provider. Of course, screening remains a cornerstone of reducing our risk of dying from colorectal cancer.

The US Food and Drug Administration reminds us that if you use aspirin daily to prevent a heart attack, stroke, or any use not listed on the label — without guidance from your health professional — you could be doing your body more harm than good.

Potential conflicts. One of the study authors (Dr. Cao) consults for Geneoscopy, a non-invasive colorectal cancer screening company.

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The headlines have been jarring:

“Screening Procedure Fails to Prevent Colon Cancer Deaths in Large Study,” offered Bloomberg.

“In a Gold-Standard Trial, an Invitation to Colonoscopy Reduced Cancer Incidence but Not Death,” observed Statnews.

“Colonoscopy Fails to Reduce Rate of Cancer Deaths in Trial” volunteers realclearscience.com.

Have you heard about the 10-year follow-up of the large, multicenter, randomized Northern-European Initiative on Colorectal Cancer (NordICC) trial?

Researchers recruited healthy individuals in Poland, Norway, Sweden, and the Netherlands between 2009 and 2014. Most came from Poland (54,258), followed by Norway (26,411) and Sweden (3,646). The study authors did not include data from the Netherlands because of data protection law.

Should we ditch colon cancer screening?

Let’s get right to the recent report published in the New England Journal of Medicine:

The real-world risk of colorectal cancer and associated death rates appeared lower among people who had a single screening colonoscopy (compared with those not having the procedure), although only modestly so.

The researchers determined that the number needed to invite to undergo screening to prevent one case of colorectal cancer is 455. This number gives us an estimate of the effect of screening colonoscopy in the general population. Or does it?

The researchers determined outcomes based on intention-to-screen. In other words, they compared all subjects invited to have a colonoscopy screening with those who received no invitation or screening.

Here are some other study outcomes:

• The 10-year colorectal cancer risk was 0.98 percent for the screened individuals, compared with 1.2 percent for the unscreened subjects. While this 18 percent risk reduction sounds great, the absolute difference is small.
• The risk of death appeared similar in the invited group (0.28 percent) versus 0.31 percent in the usual care drop. Again, a nice relative drop (10 percent) but not particularly different in absolute numbers.
• The risk of death from any cause appeared similar in the invited and usual-care group members, at 11.03 percent and 11.04 percent, respectively.

My take — Colon cancer screening

The colonoscopy benefits would have been greater had more individuals had colorectal screening. Only 42 percent of those invited had a colonoscopy.

When the scientists adjusted for this low participation level, they discovered this:

Had all those invited to undergo screening had it, the 10-year risk of colorectal cancer would have dropped from 1.22 percent to 0.84 percent, and the risk of colorectal cancer–related death would have fallen from 0.30 percent to 0.15.

The NordICC is the first randomized trial to quantify the possible benefits of colonoscopy screening on the risk of colorectal cancer and related death.

Longer follow-up is needed to understand better whether colonoscopy is effective in this real-world analysis. Drs. Jason Dominitz and Douglas Robertson comment on the possible reasons for the low reduction in incident cancer and deaths observed in the NordICC study.

In an editorial that accompanied the study publication, they note that other studies suggest an approximate halving (40 to 69 percent) in the incidence of colorectal cancer and an up to seven-eighths (29 to 88 percent) decrease in the risk of death with colonoscopy.

We must take such observations in context: Historical non-randomized studies likely overestimate the real-world effectiveness of colonoscopy, given a lack of adjustment for incomplete adherence to testing. In addition, there is a tendency for healthier individuals to seek preventative care.

In the United States, colonoscopy is the main screening tool for colorectal cancer. In other places, participation rates may be quite different. In this sense, the real-world results in the USA may be closer to the results seen in the per-protocol analysis of this study.

I look forward to seeing if greater improvements in outcome emerge when the NordICC state has a 15-year follow-up. Finally, if the modest effectiveness of screening colonoscopy is real, can we afford to use this expensive screening tool? Or should we turn to less-invasive tactics such as FIT (fecal immunochemical testing)?

But Dr. Maas said that “around half of the patients in the study did not undergo colonoscopy, which may have negatively impacted the results. I will end with this observation about this study: Colonoscopy cannot possibly work if an individual does not have it. We need more evidence to guide us about the use of colonoscopy.

Thank you for joining me in the exploration of the effectiveness of colonoscopy.

The post Is Colonoscopy Effective? A New Study Raises Questions appeared first on Medika Life.

Today we explore the growing problem of colorectal cancer occurring at a young age. We will then look at a new study suggesting a later stage presentation for the younger folks.

Early-onset colorectal cancer — A growing problem

First, age is a significant risk factor for colon or rectal cancer development. Large bowel (colon) cancer is relatively uncommon before age 40. The disease incidence increases significantly between 40 and 50, and the age-specific incidence increases in each subsequent decade.

You can see from this US government-provided graph that age is a significant risk factor for colorectal cancer. A recent look at the Surveillance, Epidemiology, and End Results database shows that while colorectal cancer has recently decreased among older folks, the disease is rising among those under age 50.

The rate of increase among younger individuals is striking: In the USA, the incidence of colorectal cancer under age 50 steadily increased at two percent per year from 1995 through 2016.

Even the group under 40 appear to have experienced a rising risk of colorectal cancer (even as we recognize that the absolute numbers are low).

Interestingly, the increases in colorectal cancer risk are predominantly in cancers in the left side of the colon and the rectum. The left side means the right side of the picture above, as the patient is facing us; the increased risk is in the descending colon and rectum.

Over 86 percent of those with colorectal cancer under age 50 have symptoms. We don’t fully understand why young individuals are experiencing an increased risk of developing colon or rectal cancer, but we have some hints:

Up to 35 percent of young adult colorectal cancer is associated with inherited genetics.

The trends are seen in both developing and developed countries, even as the former has historically had lower risks of colon cancer in general. Moreover, early- to late-onset colorectal cancer ratios in several low-resource countries are much higher than in the West.

Early-onset colorectal cancer — Risk factors

Here are some risk factors for early-onset colorectal cancer, as identified by an analysis of a collection of studies (a meta-analysis):

• A first-degree relative with colorectal cancer increases risk by 4.2-times.
• Hyperlipidemia (high cholesterol) raises the risk by 1.6-times.
• Obesity is associated with a 1.5-times increase in risk.
• Alcohol consumption lifts risk by 1.7-fold.

Other potential risk factors are being explored, including sedentary behavior and diet. I previously wrote about some dietary elements:The Perils of Colorful SweetsEARLY-ONSET COLORECTAL CANCER INCIDENCE IS rising, with more disease cases among those under age 50 years. The risk has…medium.com.

Early-onset colorectal cancer — More advanced

Now comes this recent news: Younger individuals who develop colon or rectal cancer appear more likely to present with advanced-stage disease, with cancer spread to distant body sites.

Disturbingly, people in their 20s and 30s had the most pronounced increases in distant-stage colorectal cancer from 2000 to 2016. The increase appears most great among young Black and Hispanic people.

Let’s look at the numbers. Overall, distant-stage disease represented an increasing proportion of colorectal cancer.

Distant-stage disease among those 20 to 29 years old who presented with rectal cancer increased from 18 percent to 31 percent between 2000–2002 and 2014–2016. For those ages 30 to 39, the risk of late disease increased from 20 to 29 percent.

Early-onset colorectal cancer — My take

I have two takeaway messages:

• This new analysis of US SEER data supports the shifting of screening (for those at average risk for the disease) from 50 to 45.
• Young people should be vigilant about reporting symptoms such as rectal bleeding.
• We all should try to get a sense of our family history and get genetic counseling and testing as appropriate.
• The study is only observational, so it doesn’t answer why the increase in colorectal incidence and mortality is on the rise.

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We do not have a handle on why this incidence rise among young people is rising, at the same time as the risk for older folks is decreasing. Some speculate that the cause is increased consumption of a Westernized diet (think lots of added sugar, red and processed meat, and refined grains).

Suboptimal diet

Even though I am aware of the numerous problems with the American diet, this statistic rocked me: Sixty percent of the Standard American Diet is made of ultra-processed foods such as industrial baked sweets, soft drinks, and processed meat.

This suboptimal diet is associated with a higher risk of colon and rectal cancer. However, I don’t believe we have high-level evidence, and the studies are inconsistent.

Look at the picture above, and you see pretty colorful and ultra-processed food. My office break room is chock full of delicious-appearing treats this holiday season. Alas, many of the beautiful colors I see are from artificial dyes.

Dietary synthetic dyes and colon cancer

Could these colorings be problematic when it comes to colorectal cancer? I recently came across the work of Lorne Hofseth. Ph.D. The Director of the Center for Colon Cancer Research at the University of South Carolina (USA) has been looking at the effects of these synthetic food dyes on colorectal cancer development.

He appropriately observes that research into a potential connection between cancer risk and synthetic food dyes is in its infancy.

Let’s keep going, even as we recognize there is no high-level evidence to say, with certainty, that colorful unprocessed food consumption increases colon cancer risk.

Food dyes make our food appear tastier. Did you know that people used a variety of substances to add color to foods in ancient times? The ancients used everything from plants and herb extracts to fruit and vegetable peelings.

Other food additives used to enhance color included saffron, carrots, grapes, berries, and pomegranates. Here are other color enhancers: Beets, parsley, indigo, spinach, marigold, turmeric, red saunders (a powdered wood), and more.

People used natural ingredients like plant and herb extracts and vegetable and fruit peelings to add rich color in ancient times. You may have encountered saffron, carrots, pomegranates, grapes, berries, beets, parsley, spinach, indigo, turnsole, alkanet (borage root), red saunders (a powdered wood), marigold, and turmeric were all used as food coloring agents.

Our ancestors also mixed in some natural substances: People incorporated minerals and ores such as azure, silver, and gold. Put aside the fact that some of these substances are poisonous.

Natural dyes for diet

As an aside, if you want to color some food naturally, here is your guide:How To Make Your Own Natural Food DyeDitch artificial food dyes. It’s easy to make your own in a snap with these commonly available fruits and vegetables…www.thespruceeats.com.

Let’s look at things from Dr. Hofseth’s point of view:

• Gut bacteria can break down synthetic dyes into cancer-causing molecules. We need more research on how the microbiome interacts with synthetic food coloring and potential cancer risk.
• Artificial food dyes can bind to cellular DNA and proteins. These dyes can stimulate our inflammatory machinery, creating problems for colorectal health.
• Synthetic food dyes are associated with cancer, at least in rodents.

Thank you for allowing me to introduce the potential food dye — colorectal cancer risk association. While I offer you no high-level evidence regarding the connection, I wanted to give you a heads-up on the recent findings in rodent models. I suspect most of us have bigger fish to fry for cancer risk reduction.

Colorectal cancer — reduce your risk

Let’s look at some other potential risk-reducing maneuvers you can consider:

• Get some physical activity: A 2016 meta-analysis of 126 studies showed that individuals who did the highest level of physical activity had a one-fifth lower risk of colon cancer than those who were the least physically active.
• Get colorectal screening
• Avoid being overweight
• Avoid a low-fiber (and high-fat) diet or one high in processed meats.
• Watch the alcohol consumption.
• Avoid tobacco use

Thank you.

The post The Perils of Colorful Sweets appeared first on Medika Life.

• Colon cancer is a disease in which malignant (cancer) cells form in the tissues of the colon.
• Health history affects the risk of developing colon cancer.
• Signs of colon cancer include blood in the stool or a change in bowel habits.
• Tests that examine the colon and rectum are used to detect (find) and diagnose colon cancer.
• Certain factors affect prognosis (chance of recovery) and treatment options.

Colon cancer is a disease in which malignant (cancer) cells form in the tissues of the colon.

The colon is part of the body’s digestive system. The digestive system removes and processes nutrients (vitamins, minerals, carbohydrates, fats, proteins, and water) from foods and helps pass waste material out of the body. The digestive system is made up of the esophagus, stomach, and the small and large intestines. The colon (large bowel) is the first part of the large intestine and is about 5 feet long. Together, the rectum and anal canal make up the last part of the large intestine and are about 6-8 inches long. The anal canal ends at the anus (the opening of the large intestine to the outside of the body).

Health history affects the risk of developing colon cancer

Anything that increases your chance of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn’t mean that you will not get cancer. Talk to your doctor if you think you may be at risk for colorectal cancer.

Risk factors for colorectal cancer include the following:

• Having a family history of colon or rectal cancer in a first-degree relative (parent, sibling, or child).
• Having a personal history of cancer of the colon, rectum, or ovary.
• Having a personal history of high-risk adenomas (colorectal polyps that are 1 centimeter or larger in size or that have cells that look abnormal under a microscope).
• Having inherited changes in certain genes that increase the risk of familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary nonpolyposis colorectal cancer).
• Having a personal history of chronic ulcerative colitis or Crohn disease for 8 years or more.
• Having three or more alcoholic drinks per day.
• Smoking cigarettes.
• Being black.
• Being obese.

Older age is a main risk factor for most cancers. The chance of getting cancer increases as you get older.

Signs of colon cancer include blood in the stool or a change in bowel habits.

These and other signs and symptoms may be caused by colon cancer or by other conditions. Check with your doctor if you have any of the following:

• A change in bowel habits.
• Blood (either bright red or very dark) in the stool.
• Diarrhea, constipation, or feeling that the bowel does not empty all the way.
• Stools that are narrower than usual.
• Frequent gas pains, bloating, fullness, or cramps.
• Weight loss for no known reason.
• Feeling very tired.
• Vomiting.

Tests that examine the colon and rectum are used to detect (find) and diagnose colon cancer.

The following tests and procedures may be used:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Digital rectal exam: An exam of the rectum. The doctor or nurse inserts a lubricated, gloved finger into the rectum to feel for lumps or anything else that seems unusual.
• Fecal occult blood test (FOBT): A test to check stool (solid waste) for blood that can only be seen with a microscope. A small sample of stool is placed on a special card or in a special container and returned to the doctor or laboratory for testing. Blood in the stool may be a sign of polyps, cancer, or other conditions.There are two types of FOBTs:
  • Guaiac FOBT: The sample of stool on the special card is tested with a chemical. If there is blood in the stool, the special card changes color. A guaiac fecal occult blood test (FOBT) checks for occult (hidden) blood in the stool. Small samples of stool are placed on a special card and returned to a doctor or laboratory for testing.
  • Immunochemical FOBT: A liquid is added to the stool sample. This mixture is injected into a machine that contains antibodies that can detect blood in the stool. If there is blood in the stool, a line appears in a window in the machine. This test is also called fecal immunochemical test or FIT.A fecal immunochemical test (FIT) checks for occult (hidden) blood in the stool. A small sample of stool is placed in a special collection tube or on special cards and returned to a doctor or laboratory for testing.
• Barium enema: A series of x-rays of the lower gastrointestinal tract. A liquid that contains barium (a silver-white metallic compound) is put into the rectum. The barium coats the lower gastrointestinal tract and x-rays are taken. This procedure is also called a lower GI series.Barium enema procedure. The patient lies on an x-ray table. Barium liquid is put into the rectum and flows through the colon. X-rays are taken to look for abnormal areas.
• Sigmoidoscopy: A procedure to look inside the rectum and sigmoid (lower) colon for polyps (small areas of bulging tissue), other abnormal areas, or cancer. A sigmoidoscope is inserted through the rectum into the sigmoid colon. A sigmoidoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer.Sigmoidoscopy. A thin, lighted tube is inserted through the anus and rectum and into the lower part of the colon to look for abnormal areas.
• Colonoscopy: A procedure to look inside the rectum and colon for polyps, abnormal areas, or cancer. A colonoscope is inserted through the rectum into the colon. A colonoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer.Colonoscopy. A thin, lighted tube is inserted through the anus and rectum and into the colon to look for abnormal areas.
• Virtual colonoscopy: A procedure that uses a series of x-rays called computed tomography to make a series of pictures of the colon. A computer puts the pictures together to create detailed images that may show polyps and anything else that seems unusual on the inside surface of the colon. This test is also called colonography or CT colonography.
• Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

• The stage of the cancer (whether the cancer is in the inner lining of the colon only or has spread through the colon wall, or has spread to lymph nodes or other places in the body).
• Whether the cancer has blocked or made a hole in the colon.
• Whether there are any cancer cells left after surgery.
• Whether the cancer has recurred.
• The patient’s general health.

The prognosis also depends on the blood levels of carcinoembryonic antigen (CEA) before treatment begins. CEA is a substance in the blood that may be increased when cancer is present.

Stages of Colon Cancer

• After colon cancer has been diagnosed, tests are done to find out if cancer cells have spread within the colon or to other parts of the body.
• There are three ways that cancer spreads in the body.
• Cancer may spread from where it began to other parts of the body.
• The following stages are used for colon cancer:
  • Stage 0 (Carcinoma in Situ)
  • Stage I
  • Stage II
  • Stage III
  • Stage IV

After colon cancer has been diagnosed, tests are done to find out if cancer cells have spread within the colon or to other parts of the body.

The process used to find out if cancer has spread within the colon or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment.

The following tests and procedures may be used in the staging process:

• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, such as the abdomen, pelvis, or chest, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the colon. A substance called gadolinium is injected into the patient through a vein. The gadolinium collects around the cancer cells so they show up brighter in the picture. This procedure is also called nuclear magnetic resonance imaging (NMRI).
• PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
• Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
• Surgery: A procedure to remove the tumor and see how far it has spread through the colon.
• Lymph node biopsy: The removal of all or part of a lymph node. A pathologist views the lymph node tissue under a microscope to check for cancer cells. This may be done during surgery or by endoscopic ultrasound-guided fine needle aspiration biopsy.
• Complete blood count (CBC): A procedure in which a sample of blood is drawn and checked for the following:
  • The number of red blood cells, white blood cells, and platelets.
  • The amount of hemoglobin (the protein that carries oxygen) in the red blood cells.
  • The portion of the blood sample made up of red blood cells.
• Carcinoembryonic antigen (CEA) assay:A test that measures the level of CEA in the blood. CEA is released into the bloodstream from both cancer cells and normal cells. When found in higher than normal amounts,it can be a sign of colon cancer or other conditions.

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

• Tissue. The cancer spreads from where it began by growing into nearby areas.
• Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
• Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels  to other parts of the body.

Cancer may spread from where it began to other parts of the body.

When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.

• Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
• Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For example, if colon cancer spreads to the lung, the cancer cells in the lung are actually colon cancer cells. The disease is metastatic colon cancer, not lung cancer.

The following stages are used for colon cancer:

Stage 0 (Carcinoma in Situ)

In stage 0, abnormal cells are found in the mucosa (innermost layer) of the colon wall. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.

Stage I

In stage I colon cancer, cancer has formed in the mucosa (innermost layer) of the colon wall and has spread to the submucosa (layer of tissue next to the mucosa) or to the muscle layer of the colon wall.

Stage II

Stage II colon cancer is divided into stages IIA, IIB, and IIC.

• Stage IIA: Cancer has spread through the muscle layer of the colon wall to the serosa (outermost layer) of the colon wall.
• Stage IIB: Cancer has spread through the serosa (outermost layer) of the colon wall to the tissue that lines the organs in the abdomen (visceral peritoneum).
• Stage IIC: Cancer has spread through the serosa (outermost layer) of the colon wall to nearby organs.

Stage III

Stage III colon cancer is divided into stages IIIA, IIIB, and IIIC.

In stage IIIA, cancer has spread:

• through the mucosa (innermost layer) of the colon wall to the submucosa (layer of tissue next to the mucosa) or to the muscle layer of the colon wall. Cancer has spread to one to three nearby lymph nodes or cancer cells have formed in tissue near the lymph nodes; or
• through the mucosa (innermost layer) of the colon wall to the submucosa (layer of tissue next to the mucosa). Cancer has spread to four to six nearby lymph nodes.

In stage IIIB, cancer has spread:

• through the muscle layer of the colon wall to the serosa (outermost layer) of the colon wall or has spread through the serosa to the tissue that lines the organs in the abdomen (visceral peritoneum). Cancer has spread to one to three nearby lymph nodes or cancer cells have formed in tissue near the lymph nodes; or
• to the muscle layer or to the serosa (outermost layer) of the colon wall. Cancer has spread to four to six nearby lymph nodes; or
• through the mucosa (innermost layer) of the colon wall to the submucosa (layer of tissue next to the mucosa) or to the muscle layer of the colon wall. Cancer has spread to seven or more nearby lymph nodes.

In stage IIIC, cancer has spread:

• through the serosa (outermost layer) of the colon wall to the tissue that lines the organs in the abdomen (visceral peritoneum). Cancer has spread to four to six nearby lymph nodes; or
• through the muscle layer of the colon wall to the serosa (outermost layer) of the colon wall or has spread through the serosa to the tissue that lines the organs in the abdomen (visceral peritoneum). Cancer has spread to seven or more nearby lymph nodes; or
• through the serosa (outermost layer) of the colon wall to nearby organs. Cancer has spread to one or more nearby lymph nodes or cancer cells have formed in tissue near the lymph nodes.

Stage IV

Stage IV colon cancer is divided into stages IVA, IVB, and IVC.

• Stage IVA: Cancer has spread to one area or organ that is not near the colon, such as the liver, lung, ovary, or a distant lymph node.
• Stage IVB: Cancer has spread to more than one area or organ that is not near the colon, such as the liver, lung, ovary, or a distant lymph node.
• Stage IVC: Cancer has spread to the tissue that lines the wall of the abdomen and may have spread to other areas or organs.

Recurrent Colon Cancer

Recurrent colon cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the colon or in other parts of the body, such as the liver, lungs, or both.

Treatment Option Overview

• There are different types of treatment for patients with colon cancer.
• Seven types of standard treatment are used:
  • Surgery
  • Radiofrequency ablation
  • Cryosurgery
  • Chemotherapy
  • Radiation therapy
  • Targeted therapy
  • Immunotherapy
• New types of treatment are being tested in clinical trials.
• Treatment for colon cancer may cause side effects.
• Patients may want to think about taking part in a clinical trial.
• Patients can enter clinical trials before, during, or after starting their cancer treatment.
• Follow-up tests may be needed.

There are different types of treatment for patients with colon cancer.

Different types of treatment are available for patients with colon cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Seven types of standard treatment are used:

Surgery

Surgery (removing the cancer in an operation) is the most common treatment for all stages of colon cancer. A doctor may remove the cancer using one of the following types of surgery:

• Local excision: If the cancer is found at a very early stage, the doctor may remove it without cutting through the abdominal wall. Instead, the doctor may put a tube with a cutting tool through the rectum into the colon and cut the cancer out. This is called a local excision. If the cancer is found in a polyp (a small bulging area of tissue), the operation is called a polypectomy.
• Resection of the colon with anastomosis: If the cancer is larger, the doctor will perform a partial colectomy (removing the cancer and a small amount of healthy tissue around it). The doctor may then perform an anastomosis (sewing the healthy parts of the colon together). The doctor will also usually remove lymph nodes near the colon and examine them under a microscope to see whether they contain cancer.Resection of the colon with anastomosis. Part of the colon containing the cancer and nearby healthy tissue is removed, and then the cut ends of the colon are joined.
• Resection of the colon with colostomy: If the doctor is not able to sew the 2 ends of the colon back together, a stoma (an opening) is made on the outside of the body for waste to pass through. This procedure is called a colostomy. A bag is placed around the stoma to collect the waste. Sometimes the colostomy is needed only until the lower colon has healed, and then it can be reversed. If the doctor needs to remove the entire lower colon, however, the colostomy may be permanent.Colon cancer surgery with colostomy. Part of the colon containing the cancer and nearby healthy tissue is removed, a stoma is created, and a colostomy bag is attached to the stoma.

After the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy or radiation therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that the cancer will come back, is called adjuvant therapy.

Radiofrequency ablation

Radiofrequency ablation is the use of a special probe with tiny electrodes that kill cancer cells. Sometimes the probe is inserted directly through the skin and only local anesthesia is needed. In other cases, the probe is inserted through an incision in the abdomen. This is done in the hospital with general anesthesia.

Cryosurgery

Cryosurgery is a treatment that uses an instrument to freeze and destroy abnormal tissue. This type of treatment is also called cryotherapy.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy).

Chemoembolization of the hepatic artery may be used to treat cancer that has spread to the liver. This involves blocking the hepatic artery (the main artery that supplies blood to the liver) and injecting anticancer drugs between the blockage and the liver. The liver’s arteries then deliver the drugs throughout the liver.

Only a small amount of the drug reaches other parts of the body. The blockage may be temporary or permanent, depending on what is used to block the artery. The liver continues to receive some blood from the hepatic portal vein, which carries blood from the stomach and intestine.

The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy:

• External radiation therapy uses a machine outside the body to send radiation toward the cancer.
• Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.

The way the radiation therapy is given depends on the type and stage of the cancer being treated. External radiation therapy is used as palliative therapy to relieve symptoms and improve quality of life.

Targeted therapy

Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells.

Types of targeted therapies used in the treatment of colon cancer include the following:

• Monoclonal antibodies: Monoclonal antibodies are made in the laboratory from a single type of immune system cell. These antibodies can identify substances on cancer cells or normal substances that may help cancer cells grow. The antibodies attach to the substances and kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion. They may be used alone or to carry drugs, toxins, or radioactive material directly to cancer cells.There are different types of monoclonal antibody therapy:
  • Vascular endothelial growth factor (VEGF) inhibitor therapy: Cancer cells make a substance called VEGF, which causes new blood vessels to form (angiogenesis) and helps the cancer grow. VEGF inhibitors block VEGF and stop new blood vessels from forming. This may kill cancer cells because they need new blood vessels to grow. Bevacizumab and ramucirumab are VEGF inhibitors and angiogenesis inhibitors.
  • Epidermal growth factor receptor (EGFR) inhibitor therapy: EGFRs are proteins found on the surface of certain cells, including cancer cells. Epidermal growth factor attaches to the EGFR on the surface of the cell and causes the cells to grow and divide. EGFR inhibitors block the receptor and stop the epidermal growth factor from attaching to the cancer cell. This stops the cancer cell from growing and dividing. Cetuximab and panitumumab are EGFR inhibitors.
• Angiogenesis inhibitors: Angiogenesis inhibitors stop the growth of new blood vessels that tumors need to grow.
  • Ziv-aflibercept is a vascular endothelial growth factor trap that blocks an enzyme needed for the growth of new blood vessels in tumors.
  • Regorafenib is used to treat colorectal cancer that has spread to other parts of the body and has not gotten better with other treatment. It blocks the action of certain proteins, including vascular endothelial growth factor. This may help keep cancer cells from growing and may kill them. It may also prevent the growth of new blood vessels that tumors need to grow.

Immunotherapy

Immunotherapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also called biotherapy or biologic therapy.

Immune checkpoint inhibitor therapy is a type of immunotherapy:

• Immune checkpoint inhibitor therapy: PD-1 is a protein on the surface of T cells that helps keep the body’s immune responses in check. When PD-1 attaches to another protein called PDL-1 on a cancer cell, it stops the T cell from killing the cancer cell. PD-1 inhibitors attach to PDL-1 and allow the T cells to kill cancer cells. Pembrolizumab is a type of immune checkpoint inhibitor.

Treatment Options for Colon Cancer

Stage 0 (Carcinoma in Situ)

Treatment of stage 0 (carcinoma in situ) may include the following types of surgery:

• Local excision or simple polypectomy.
• Resection and anastomosis. This is done when the tumor is too large to remove by local excision.

Stage I Colon Cancer

Treatment of stage I colon cancer usually includes the following:

• Resection and anastomosis.

Stage II Colon Cancer

Treatment of stage II colon cancer may include the following:

• Resection and anastomosis.

Stage III Colon Cancer

Treatment of stage III colon cancer may include the following:

• Resection and anastomosis which may be followed by chemotherapy.
• Clinical trials of new chemotherapy regimens after surgery.

Stage IV and Recurrent Colon Cancer

Treatment of stage IV and recurrent colon cancer may include the following:

• Local excision for tumors that have recurred.
• Resection with or without anastomosis.
• Surgery to remove parts of other organs, such as the liver, lungs, and ovaries, where the cancer may have recurred or spread. Treatment of cancer that has spread to the liver may also include the following:
  • Chemotherapy given before surgery to shrink the tumor, after surgery, or both before and after.
  • Radiofrequency ablation or cryosurgery, for patients who cannot have surgery.
  • Chemoembolization of the hepatic artery.

• Radiation therapy or chemotherapy may be offered to some patients as palliative therapy to relieve symptoms and improve quality of life.
• Chemotherapy and/or targeted therapy with a monoclonal antibody or an angiogenesis inhibitor.
• Immunotherapy.
• Clinical trials of chemotherapy and/or targeted therapy.

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