All About Colon Cancer

Carolyn Vachani, RN, MSN, AOCN
Updated by: Elizabeth Prechtel-Dunphy, MSN, CRNP and Christina Bach, MSW, LCSW, OSW-C
Last Modified: February 28, 2015

What is the colon?

The colon is the longest portion of the large intestine, also known as the large bowel. The large intestine is the last part of the digestive tract. It is a tube that is about 5 to 6 feet in length; the first 5 feet make up the colon, which then connects to about 6 inches of rectum, and finally ends with the anus. By the time food reaches the colon (about 3 to 8 hours after eating), the nutrients have been absorbed and the remainder is liquid waste product. The colon's function is to change this liquid waste into solid stool. The stool can spend anywhere from 10 hours to several days in the colon before being expelled through the anus. It has been suggested that the longer stool remains in the colon, the higher the risk for colon cancer, but this has not been proven.

What is colon cancer?

Colon cancer is malignant tissue that grows in the wall of the colon. The majority of tumors begin when normal tissue in the colon wall forms an adenomatous polyp, or pre-cancerous growth projecting from the colon wall. As this polyp grows larger, the tumor is formed. This process can take many years, which allows time for early detection with screening tests.

Am I at Risk for Colon Cancer?

Colon cancer is the fourth most common type of cancer, in both males and females, in the United States. The incidence is highest in African Americans, who are also more likely to die of the disease. It was estimated that in the United States in 2016 there were 95,270 new cases of colon cancer.

Certain factors put people at higher risk. The risk of colon cancer rises substantially after age 50, but every year there are numerous cases reported in younger people. Individuals with a personal or family history of colon cancer, polyps, or inherited colon cancer syndromes (i.e., FAP and HNPCC/Lynch syndrome), as well as patients with ulcerative colitis or Crohn's disease, are all at higher risk and may require screening at an earlier age than the general population. A person with one first degree relative (parent, sibling or child) with colon cancer is 2 to 3 times as likely to develop the cancer as someone who does not have an affected relative.

However, this does not mean that people without a family history are not at risk. In fact, about 80% of new colon cancer cases are diagnosed in people who would not be identified as "high risk". Studies of colon cancer cases found that lifestyle factors may put a person at higher risk. These factors include: a diet high in fat and red meat but low in fruits and vegetables, high caloric intake, low levels of physical activity, and obesity. In addition, smoking and excessive alcohol intake may play a role in colon cancer development. Despite avoiding all of these factors, some people will still develop colon cancer. With screening and early detection, these patients can be effectively treated in a majority of the cases.

How Can I Prevent Colon Cancer?

Given the things that put a person at higher risk, a low-fat diet high in fruits and vegetables and low in red meat, together with regular exercise and maintaining a healthy body weight, may aide in prevention. The term chemoprevention can be defined as 'the use of a chemical compound to prevent, inhibit, or reverse the formation of the cancer'. There are ongoing studies looking at vitamins A, E, D, and C, folic acid, calcium, selenium, aspirin, cox-2 inhibitors, statin medications (traditionally used to lower cholesterol) and hormone replacement therapy as potential chemopreventive agents that may prevent or reverse the formation of polyps and colon cancer. Thus far, these studies have been inconclusive, so no specific recommendations can be made for the general population. Some of these agents continue to be evaluated in clinical trials.

What Screening Tests are Available?

Some tumors and polyps may bleed intermittently, and this blood can be detected in stool samples by a test called fecal occult blood testing (FOBT). By itself, FOBT only finds about 24% of cancers. The U.S. Preventive Services Task Force (USPSTF) recommends screening using fecal occult blood testing, and sigmoidoscopy/colonscopy every 5 years for adults, from the ages of 50-75. 

 The sigmoidoscope is a slender, flexible tube that has the ability to view about 1/3 of the colon. If a polyp or tumor is detected with this test, the patient must be referred for a full colonoscopy to have the polyp removed and tested for cancer. The colonoscope is similar to the sigmoidoscope, but is longer and thus can view the entire colon. If a polyp is found, the physician can remove it and send it to a pathology lab to determine if it is adenomatous (cancerous). The USPSTF does not have enough evidence to recommend alternative methods of screening including CT colonography (virtual colonoscopy) or fecal DNA testing at this time.

Patients with a family or personal history should have more frequent screenings; beginning at an earlier age than their relative was when he or she was diagnosed. Patients with a history of inflammatory bowel disease, including ulcerative colitis, are also at increased risk and should have more frequent screening than the general public. No screening modality is perfect. For colonoscopy, the rate of missed lesions is 2-12%.

Patients should talk with their physicians about which screening method is best for them, and how often it should be performed.

What are the Signs of Colon Cancer?

Unfortunately, the early stages of colon cancer may not have any symptoms. This is why it is important to have screening tests done even though you may feel well. As the polyp grows into a tumor, it may bleed or obstruct the colon, causing symptoms. These symptoms include:

  • Bleeding from the rectum
  • Blood in the stool or toilet after a bowel movement
  • A change in the shape of the stool (i.e. thinning)
  • Cramping pain in the abdomen
  • Feeling the need to have a bowel movement when you don't actually have to

As you can see, these symptoms can also be caused by conditions other than cancer. If you experience these symptoms, you should be checked by a doctor.

How is Colon Cancer Diagnosed and Staged?

Once colon cancer is found by the screening tests, further tests are needed to determine the extent of the tumor. The tests used to determine spread of the tumor are CT scans, MRIs, PET/CT scan and lab work. Positron Emission tomography (PET) provides a whole body evaluation and highlight active tumors in the body. Malignant tumors have an increased rate of glycolysis shown by an increase uptake of glucose tracer. PET/CT scan is used to evaluate potential resectable metastasis in the lung and liver. Carcinoembryonic antigen (CEA) level is a marker for colon cancer that is found in the blood and which is elevated in 95% of cases. With these tests, a stage is determined to help dictate the necessary treatment. The TNM staging system assesses the extent of the tumor, nodal involvement, and distant metastases.

After the tumor and lymph nodes are removed by a surgeon, they are examined by a pathologist, who determines how much of the colon wall and lymph nodes have been invaded by tumor. This is reported on your pathology report – you may want to ask for a copy of this report for your personal files.

Using the results from these tests and reports, a stage is determined, which is used to determine the necessary treatment. The TNM staging system assesses the extent of the Tumor, Nodal involvement, and distant Metastases. The stage tells how far the tumor has invaded into the colon wall, and if it has spread to other parts of the body, and is an important piece to deciding on further treatment.

The American Joint Committee on Cancer (AJCC) publishes the TNM staging system for colon cancer, which is as follows:

Primary Tumor:

Primary Tumor (T):

  • Tx- Primary tumor cannot be assessed
  • T0- No evidence of primary tumor
  • T1s- Carcinoma in situ
  • T1 – Tumor invades submucosa
  • T2 – Tumor invades muscularis propria
  • T3 – Tumor invades through muscularis propria into pericolorectal tissues
  • T4
    • T4a – Tumor penetrates to the surface of the visceral peritoneum
    • T4b – Tumor directly invades or is adherent to other organs or structures

Lymph Nodes (N):

  • Nx- Lymph nodes cannot be assessed
  • N0- No lymph nodes metastasis (spread)
  • N1–Metastasis to 1 to 3 lymph nodes
    • N1a – Metastasis to 1 regional lymph node
    • N1b – Metastasis to 2-3 regional lymph nodes
    • N1c - Tumor deposits in the subserosa, mesentery, or nonperitonealized pericolic or perirectal tissues without regional nodal metastasis
  • N2 – Metastasis in four or more regional lymph nodes
    • N2a – Metastasis to 4-6 regiona lymph nodes
    • N2b – Metastasis to 7 or more regional lymph nodes

Distant Metastasis

  • M0 - No distant metastasis
  • M1 – Distant metastasis
    • M1a - metastasis confined to one organ or site
    • M1b - metastasis in more than one organ/site or the peritoneum

The TNM groupings are combined to give a stage of 0 through IVB. TNM Stage Groupings:

  • 0- Tis N0 M0
  • I - T1-2 N0 M0
  • IIA - T3 N0 M0
  • IIB - T4a N0 M0
  • IIC - T4b N0 M0
  • IIIA - T1-2 N1/1c M0, T1 N2a M0
  • IIIB - T3-T4a N1/1c M0, T2-T3 N2a M0, T1-T2 N2b M0
  • IIIC - T4a N2a M0, T3-T4a N2b M0, T4b N1-N2 M0
  • IVA – Any T Any N M1a
  • IVB – Any T Any N M1b

Because the staging system is relatively detailed, a more simplified way of understanding the stage groupings is:

  • Stage 0 (also called carcinoma in situ) - the cancer is confined to the outermost portion of the colon wall.
  • Stage I - the cancer has spread to the second and third layer of the colon wall, but not to the outer colon wall or beyond. This is also called Dukes' A colon cancer.
  • Stage II - the cancer has spread through the colon wall, but has not invaded any lymph nodes (these are small structures that help in fighting infection and disease). This is also called Dukes' B colon cancer.
  • Stage III - the cancer has spread through the colon wall and into lymph nodes, but has not spread to other areas of the body. This is also called Dukes' C colon cancer.
  • Stage IV - the cancer has spread to other areas of the body (i.e. liver and lungs). This is also called Dukes' D colon cancer.

What are the Treatments for Colon Cancer?

Surgery

Surgery is the most common treatment for colon cancer. If the cancer is limited to a polyp, the patient can undergo a polypectomy (removal of the polyp), or a local excision, where a small amount of surrounding tissue is also removed. If the tumor invades the bowel wall or surrounding tissues, the patient will require a partial resection (removal of the cancer and a portion of the bowel) and removal of local lymph nodes to determine if the cancer has spread into them. After the tumor is removed, the two ends of the remaining colon are reconnected, allowing normal bowel function. In some situations, it may not be possible to reconnect the colon, and a colostomy (an opening in the abdominal wall to allow passage of stool) is needed, which may be temporary or permanent.

Chemotherapy

Despite the fact that a majority of patients have the entire tumor removed by surgery, as many as 50 to 60% will develop a recurrence without further treatment. Chemotherapy is given to reduce this chance of recurrence, particularly when initiated within 4 week of surgery. There is some controversy over whether or not patients with stage II disease should receive chemotherapy. Studies have not consistently shown a benefit in treating these patients or have shown only a very small benefit. Many patients with stage II disease are followed closely, but receive no chemotherapy. Generally, patients with stage II disease who present with a bowel perforation or obstruction, or who have large or poorly differentiated tumors (determined by a pathologist looking at the tumor under a microscope), are considered at higher risk for recurrence and are treated with 6 months of fluorouracil (5-FU), leucovorin (LV), with or without oxaliplatin chemotherapy. Genomic testing can also be utilized after surgery in identifying patients with high risk for recurrence

Patients who present with stage III colon cancer are treated with a regimen of chemotherapy, including some combination of fluorouracil (5-FU), leucovorin, and oxaliplatin for 6 months, resulting in improved survival rates when compared with surgery alone. The addition of other agents, including irinotecan and bevacizumab, in combination with 5-FU/LV has not been shown to benefit stage III patients. After completion of this therapy, they are monitored for recurrence of the disease. Capecitabine (Xeloda) is an oral form of fluorouracil, that is used frequently as a replacement for intravenous 5-FU.

Forty to fifty percent of patients have metastatic disease (cancer that has spread to other organs, also called stage IV) at the time of diagnosis, or have a recurrence of the disease after therapy. Unfortunately, with the exception of selected patients who have limited liver/lung metastases, stage IV disease is not considered cureable. Nevertheless, patients can have improved quality of life and longer survival with chemotherapy treatment. The standard therapy for patients with advanced disease is some combination of fluorouracil, leucovorin, irinotecan (CPT-11 or Camptosar), oxaliplatin (Eloxitin), bevacizumab (Avastin), cetuximab (Erbitux), and capecitabine. Regimens adding either irinotecan or oxaliplatin to fluorouracil and leucovorin were found to be more effective than using the fluorouracil and leucovorin alone.

Treatment recommendations for patients with metastatic disease depend on whether the patient is appropriate for intensive therapy. Chemotherapy options for patients with metastatic disease depend on what treatment they initially received. Clinical trial participation may be recommended before standard therapy.

Targeted therapies are also used in the treatment of some colon cancers.  Targeted therapies are drug treatments that target specific abnormalities found in the cancer cells. These abnormalities contribute to the growth, spread, and progression of cancer. In many cases, your healthcare provider will have to test your tumor to determine if a specific target is present.  One such target is epidermal growth factor receptor (EGFR).  EGFR is abnormally over expressed in many cancers (including those of the colon and rectum), so inhibition of EGFR can result in a decrease in tumor cell growth and decreased production of other factors responsible for metastasis (tumor spread). Panitumumab and cetuximab are monoclonal antibodies that inhibit binding of epidermal growth factor to EGFR, which prevents epidermal growth factor from working, slowing cancer growth. These agents are generally used for patients who tumor type is deemed "KRAS wild-type". This means that there is no mutation with the KRAS protein.

Regorafenib is another medication that targets both VEGFR2 and TIE2. Bevacizumab (Avastin) is a type of treatment called anti-angiogenic therapy. Tumors need nutrients to survive and are able to get these nutrients by growing new blood vessels. This medication works by attacking the new blood vessels the tumor has formed -- in other words, by cutting off its food source. Bevacizumab is used in combination with chemotherapy for patients with metastatic disease.

Immunotherapy is also being used in the treatment of certain colon cancers.  Immunotherapy is a method of treating cancer that uses the body’s own capabilities to identify and kill cancer cells.  Immunotherapy medications currently being used in the treatment of colon cancer include nivolumab and pembrolizumab

Epidermal growth factor receptor (EGFR) is abnormally over expressed in many cancers (including those of the colon and rectum), so inhibition of EGFR can result in a decrease in tumor cell growth and decreased production of other factors responsible for metastasis (tumor spread). Panitumumab and cetuximab are monoclonal antibodies that exert cancer fighting properties by competitively inhibiting the binding of epidermal growth factor to EGFR, which prevents epidermal growth factor from working, and hence not allowing cancer growth to occur. These agents are generally used for patients who tumor type is deemed "KRAS wild-type". This means that there is no mutation with the KRAS protein.

Treatment recommendations for patients with metastatic disease depend on whether the patient is appropriate for intensive therapy. Chemotherapy options for patients with metastatic disease depend on what treatment they initially received. Clinical trial participation may be recommended before standard therapy.

Radiotherapy

Colon cancer is not typically treated with radiation therapy. If the cancer has invaded another organ, or attached itself to the abdominal wall, radiation therapy may be a treatment option. One reason for the limited role of radiation is that it is a local treatment typically aimed at a "target." Once the colon cancer has been surgically resected, the "target" or high-risk area for disease recurrence is not very easy to define. Furthermore, if the cancer has spread to other organs, chemotherapy (rather than radiation therapy) is able to reach distant areas of spread of tumor cells.

Interventional Radiology

Interventional radiologists are specialists who use radiology techniques, such as CT scan, to access areas of the body and treat diseases without traditional surgery. These techniques are sometimes called "minimally invasive". In some cases, these physicians are able to help patients with colon cancer that has metastasized to the liver or lung. The techniques currently being used by these specialists include: CT directed biopsies, chemoembolization, radiofrequency ablation and radioembolization. By entering a patient's blood vessels, the physician can thread a catheter all the way to the liver and give treatment directly to the tumor.

Radiofrequency ablation (RFA) is a local treatment that kills the tumor cells with heat, while sparing healthy liver tissue. When the tumor is too large or in a location not amenable to RFA, embolization may be used to cut off the blood supply to the tumor, deliver radiation to a tumor (called radioembolization), or combine this technique with chemotherapy to deliver the cancer drug directly to the tumor (called chemoembolization). These therapies are not considered curative, but can provide improved quality of life and extend survival.

Some patients may benefit from having an infusion pump inserted to infuse chemotherapy directly into the liver. IR physicians can also perform palliative procedures, such as inserting a stent to relieve an obstruction, treating certain types of pain, inserting central catheters or treating blood clots.

Clinical Trials

Clinical trials have played and continue to play an important role in the treatment of colon cancer. In the past 20 years, considerable improvements have been made in colon cancer therapy, with overall survival rates increasing from 45 to 75 percent. The treatments we have today were refined through clinical trials, and many new avenues continue to be explored. Talk with your physician about current clinical trials for colon cancer in your area or use the OncoLink Clinical Trials Matching Service.

Follow-Up Care and Survivorship

Once a patient has completed chemotherapy, they must be followed closely for recurrence. The guidelines for follow-up surveillance, written by the National Comprehensive Cancer Network (NCCN) are: physical exam (including digital rectal exam) every 3 months for 2 years, then every 6 months for 3 years; CEA level (if elevated preoperatively) checked every 3 months for 2 years, then every 6 months for 3 years; and colonoscopy in 1 year, with a repeat in 1 year if abnormal, or every 2-3 years if no polyps are found. Patients who are at high risk of developing colon cancer recurrence, a yearly CT scan is recommended.

Fear of recurrence, relationships and sexual health, financial impact of cancer treatment, employment issues, and coping strategies are common emotional and practical issues experienced by colon cancer survivors. Your healthcare team can identify resources for support and management of these challenges faced during and after cancer.

Cancer survivorship is a relatively new focus of oncology care. With some 15 million cancer survivors in the US alone, there is a need to help patients transition from active treatment to survivorship. What happens next, how do you get back to normal, what should you know and do to live healthy going forward? A survivorship care plan can be a first step in educating yourself about navigating life after cancer and helping you communicate knowledgeably with your healthcare providers. Create a survivorship care plan today on OncoLink.

Links

Colon Cancer Alliance - The Colon Cancer Alliance brings the voice of survivors to battle colorectal cancer through patient support, education, research and advocacy.

Fight Colorectal Cancer - Provides advocacy, education and support.

Chris 4 Life Colon Cancer Foundation - Provides education, support and funds research.

The Colon Club - Promotes education and awareness in interesting and out of the box ways.

American Society of Colon and Rectal Surgeons - Society for colon and rectal surgeons and other surgeons dedicated to the treatment of patients with diseases and disorders affecting the colon, rectum and anus.

Colon-Rectal.com - Physicians with decades of experience and specialized training in caring for these types of problems have contributed text and images to this website.

References

Cancer.net (2016), Colorectal Cancer-Statistics. http://www.cancer.net/cancer-types/colorectal-cancer/statistics, retrieved 2/1/17

NCCN Clinical Practice Guidelines: Colon Cancer (V.1.2017). www.nccn.org (log in required).

Burt, R. W., Cannon, J. A., David, D. S., Early, D. S., Ford, J. M., Giardiello, F. M., ... & Jasperson, K. (2013). Colorectal cancer screening. Journal of the National Comprehensive Cancer Network, 11(12), 1538-1575.

Douillard, J. Y., Oliner, K. S., Siena, S., Tabernero, J., Burkes, R., Barugel, M., ... & Rivera, F. (2013). Panitumumab–FOLFOX4 treatment and RAS mutations in colorectal cancer. New England Journal of Medicine, 369(11), 1023-1034.

Edge SB, Byrd DR, Compton CC, et al., eds. (2010). AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer.

Grothey, A., Van Cutsem, E., Sobrero, A., Siena, S., Falcone, A., Ychou, M., ... & Adenis, A. (2013). Regorafenib monotherapy for previously treated metastatic colorectal cancer: an international, multicentre, randomised, placebo-controlled, phase 3 trial. The Lancet, 381(9863), 303-312.

Gustavsson, B., Carlsson, G., Machover, D., Petrelli, N., Roth, A., Schmoll, H. J., ... & Gibson, F. (2015). A review of the evolution of systemic chemotherapy in the management of colorectal cancer. Clinical Colorectal Cancer, 14(1), 1-10.

Heiken, J. P. (2015). CT colonography (‘virtual colonoscopy’): Is it ready for colorectal cancer screening? Cancer Imaging, 3(2), 146.

Heinemann, V., Douillard, J. Y., Ducreux, M., & Peeters, M. (2013). Targeted therapy in metastatic colorectal cancer–an example of personalized medicine in action. Cancer Treatment Reviews, 39(6), 592-601.

Imperiale, T. F., Ransohoff, D. F., Itzkowitz, S. H., Levin, T. R., Lavin, P., Lidgard, G. P., ... & Berger, B. M. (2014). Multitarget stool DNA testing for colorectal-cancer screening. New England Journal of Medicine, 370(14), 1287-1297.

Loupakis, F., Cremolini, C., Masi, G., Lonardi, S., Zagonel, V., Salvatore, L., ... & Zaniboni, A. (2014). Initial therapy with FOLFOXIRI and bevacizumab for metastatic colorectal cancer. New England Journal of Medicine, 371(17), 1609-1618.

Nordlinger, B., Sorbye, H., Glimelius, B., Poston, G. J., Schlag, P. M., Rougier, P., ... & Jaeck, D. (2013). Perioperative FOLFOX4 chemotherapy and surgery versus surgery alone for resectable liver metastases from colorectal cancer (EORTC 40983): long-term results of a randomised, controlled, phase 3 trial. The Lancet Oncology, 14(12), 1208-1215.

Regenbogen, S. E., & Hardiman, K. M. (2016). Colorectal Cancer: Surveillance After Curative-Intent Therapy. In The ASCRS Textbook of Colon and Rectal Surgery (pp. 555-570). Springer International Publishing.

Stoffel, E. M., Mangu, P. B., Gruber, S. B., Hamilton, S. R., Kalady, M. F., Lau, M. W. Y., ... & Limburg, P. J. (2014). Hereditary colorectal cancer syndromes: American society of clinical oncology clinical practice guideline endorsement of the familial risk–colorectal cancer: European society for medical oncology clinical practice guidelines. Journal of Clinical Oncology, 33(2), 209-217.

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