Colon Cancer

Healthy diet, healthy colon

Cancer of colon is the second most common noncutaneous (non-skin) cancer in the United States and the second leading cause of death resulting from cancer. About 138,000 new cases are diagnosed each year, and approximately 55,000 people die of the disease. Still, death rates have fallen in recent years as more is learned about causes, treatment, and prevention. Older people are particularly at risk. Around 90% of individuals with colon cancer are over age 50.

Genetic factors account for about one in every seven cases of colon cancer. However, nutrition also plays a major role. Colon cancer remains most prevalent in Western countries and countries that have adopted a Western-style, high-fat diet. A diet rich in vegetables and high-fiber foods like whole-grain breads and cereals may possibly help reduce the risk of colon cancer. So remember to eat healthfully and get regular checkups.

Pronunciation

KO-lon KAN-ser

Synonyms

  • Colorectal cancer
  • Colorectal malignancy
  • Adenocarcinoma of the colon

Detailed Description

The colon is a 5-foot-long lower segment of the intestinal tract where water is reabsorbed and waste material is stored. It's divided into several segments, and cancer of the colon can affect any one of them. The condition often starts from polyps, or precancerous growths, and cancer occurs when cells become abnormal and divide out of control, resulting in a tumor.

Factors increasing your risk of colon cancer include a high-fat, low-fiber diet; a family history of colon cancer; a family or personal history of having polyps; having ulcerative colitis; having Crohn's disease; and being over age 50.

Because colon cancer can be present for several years before symptoms develop, early detection is critical to successful treatment. The American Cancer Society recommends that both men and women have a digital rectal examination and fecal occult blood stool test each year, beginning at age 50. A sigmoidoscopy, in which the rectum and lower part of the colon are viewed with an optical tube, should be done every five years after age 50. The ACS also recommends screening colonoscopy, in which a flexible tube is used to visualize the entire colon, every 10 years, beginning at age 50.

People with known risk factors should talk to their doctors about beginning screening before age 50.

Surgery is the most common treatment for colon cancer. Chances for success depend largely upon whether the cancer has spread to other organs (metastasis). Follow-up testing is important after treatment to check for recurrence of the cancer. Also, having had colon cancer places men at greater risk for prostate cancer and women at greater risk for cancer of the breast and ovary.

Evidence continues to mount that a low-fat, high-fiber diet rich in fruits, vegetable, whole grains, and legumes can significantly reduce your chance of developing colon cancer.

Characteristics of Colon Cancer

  • Cancer of the large intestine
  • Family history and personal medical history determine risk
  • Diet also influences risk
  • Early detection is critical for treatment

How Common Is Colon Cancer?

This disease is the second most common noncutaneous (non-skin) cancer in the United States. It is also the second-leading cause of cancer death. Approximately 155,000 new cases are diagnosed per year. The risk for developing colon cancer begins to increase at age 40. Most cases occur in people between ages 60 and 70. Equal numbers of males and females are affected.

What You Can Expect

Because colon cancer can be present for several years before symptoms develop, early detection is critical to successful treatment. When the disease remains localized, the five-year survival rate is over 80%. However, once the cancer has spread to other organs, the five-year survival rate drops to less than 35%.

There are several staging systems for colon cancer. Here's one representative example:

Stage 0: Also called carcinoma in situ. Cancer is localized on surface cells, or polyps.

Stage I: Tumor invades the muscle layer of the colon and extends along one segment of the colon without spreading to the lymph nodes and without metastasis. The five-year survival rate is 80% to 100%.

Stage II: Tumor penetrates all layers of colon wall and extends along one segment of the colon, without spreading to the lymph nodes and without metastasis. The five-year survival rate is 50% to 75%.

Stage III: Tumor of any size, spreading to regional lymph nodes, without metastasis. The five-year survival rate is 30% to 50%.

Stage IV: Tumor of any size, spreading to regional lymph nodes and distant metastasis to liver, lung, and other organs. The five-year survival rate is five percent to 20%.

Your doctor will use a staging system to gauge prognosis and treatment.


Established Causes

The cause of colon cancer has not yet been identified.

Theoretical Causes

It is believed that both genetics and environmental factors, such as a diet rich in animal protein and low in fiber, play a role in the onset of the disease.

Risk Factors

Many risk factors are involved in colon cancer. Some can be prevented through changes in eating habits and lifestyle; others, unfortunately, cannot. If you believe you are at high risk for developing colon cancer, talk to your doctor about ways to improve your lifestyle or methods you can use to catch a cancerous growth early. Following are some risk factors:

  • Family history of colon cancer
  • Family history of familial polyposis
  • Existing ulcerative colitis
  • Crohn's disease
  • Existing polyposis syndrome
  • Increasing age (those over age 40 are at higher risk)
  • Diet high in animal protein, fats, and refined carbohydrates like sugars
  • Prior colorectal cancer

Risk factors are traits or behaviors that may make you statistically more likely than others in the general population to have a certain condition. They are not necessarily "causes" of the condition.

Symptoms

In many cases, colon cancer shows no signs in the early stages. As the tumor grows, symptoms may appear. If you notice any of these changes, see your doctor:

  • Blood in the stool
  • Black stools (which may point to bleeding)
  • Changes in the size or shape of the stool (for instance, narrow stools) that last more than one week
  • Constipation and diarrhea, in alternating cycles
  • A feeling of incomplete emptying of the bowel
  • Pain, cramping, discomfort, or swelling in the abdomen
  • Nausea and vomiting
  • Weight loss
  • Fatigue and weakness (from anemia caused by bleeding in the intestine)

Conditions That May Be Mistaken for Colon Cancer

Colon cancer may be confused with other problems that have similar symptoms:

  • Intestinal obstruction (blockage in the intestines can be caused by hernias, adhesion of scar tissue from a prior surgery, and other problems unrelated to cancer)
  • Vascular disorders of the bowel (these problems may cause narrowing of the colon, rectal bleeding, bloody stools, and pain in the abdomen)
  • Other cancers
  • Noncancerous masses (abscesses, cysts, pseudocysts)

How Colon Cancer Is Diagnosed

Your doctor may use several tests to check for colon cancer, among them:

  • Physical examination. Your doctor will insert a gloved finger into your rectum to check for lumps. During the rectal exam, your doctor can also check for blood in the stool through the use of hemoccult cards. He or she may also feel your abdomen for a mass or enlarged liver (colon cancer commonly spreads to that organ).
  • Laboratory tests. The most common lab test to check for colon cancer is the fecal occult blood test, which detects hidden blood in the stools. You will be asked to take stool samples at home and bring them in to your doctor's office. To improve the test's accuracy, try to eat a high-fiber diet and no red meat for three days before you provide the samples. Ask your doctor for other pre-test dietary guidelines. Your doctor may also test for anemia.
  • Sigmoidoscopy. As you lie on your side on an exam table, your doctor will insert a flexible fiber-optic tube (sigmoidoscope) into your rectum and the lower portion of your colon (sigmoid). On a nearby video monitor, your doctor can see pictures of the lining of your lower colon as he or she guides the sigmoidoscope through. The goal is to check for polyps, tumors, and other abnormal areas.

    You may be asked to refrain from eating at midnight before the test, and you may have to have one or two enemas to clear your bowel for this test, which takes about five minutes to perform. If your doctor detects a polyp or possible cancer, he or she may do a colonoscopy.
  • Colonoscopy. This test uses a fiber-optic endoscope (colonoscope) that has a longer reach than a sigmoidoscope. By gently inserting the colonoscope into your rectum and large intestine, your doctor will be able to check the entire length of the colon. One advantage of colonoscopy: your doctor can pass surgical instruments through the colonoscope to remove polyps or tissue (biopsy) to be studied under a microscope for cancer. Sometimes, "polypectomy" surgery removes a small, early-stage cancer entirely. Other cancers seen through colonoscopy will require regular surgery.

    Your doctor will instruct you to prepare for colonoscopy with special dietary instructions. You'll also receive a laxative, enema, and maybe a sedative.
  • Barium enema. You may be given an enema that contains a white, chalky substance called barium to outline your colon and rectum. Then a machine takes X-rays of the inner contours of the colon.

Staging colon cancer

If you are diagnosed with colon cancer, your doctor will determine the exact location and size of the tumor, as well as its other characteristics. He or she will also run staging tests, such as CT scans of the chest, abdomen, and pelvis, to check whether the cancer has spread to distant sites in the body, such as the lungs, liver, and ovaries. Cancer that has not spread, but remains confined to the colon, is much easier to cure than cancer that has spread to distant sites in the body. This staging of the cancer is crucial, not only to assess your chances for recovery, but also to plan your treatment.

After colon surgery, your doctor will also be able to tell from the surgical specimens whether the cancer has spread to nearby lymph nodes, and how much it has spread through the bowel wall.


Goals of Treatment

Most cancers of the colon grow slowly, so you have a good chance of complete cure if you are diagnosed and treated while the cancer is in its early stages. If cancer is caught and treated before it spreads beyond the colon, more than 80% of people are still alive five years later. Even when a cure isn't possible, treatment can still relieve symptoms and prolong life. If you have colon cancer, effective treatment is available, mainly through surgery and chemotherapy. Another form of treatment, radiation therapy, is used much less in colon cancer cases, although radiation is often employed in cases of rectal cancer.

Treatment Overview

Surgery

Surgery, the most common treatment for colon cancer, takes several forms:

  • Polypectomy. Polypectomy removes colon polyps that may be precancerous growths or early-stage cancers. This surgery is done with instruments passed through the colonoscope during colonoscopy, so you don't need to have abdominal surgery.
  • Surgical resection or colectomy. For larger tumors that can't be removed during colonoscopy, the surgeon may perform a surgical resection (also called a colectomy). This procedure is an abdominal surgery done under anesthesia. The surgeon removes the tumor along with a nearby section of healthy colon tissue. Then the two ends of the shortened colon are sewn together to keep open a passageway for stools. In a partial colectomy, only the affected segment of the colon is removed. In a total colectomy, the surgeon removes the entire colon. In most cases, the surgeon will also remove nearby lymph nodes so that they can be checked for the spread of cancer. Nearby structures, such as the liver and ovaries, will also be checked for signs of cancer.

    If surgery leaves you with a colon that can't be sewn together and preserved all the way to the anus?-- this often happens when the rectum is removed, too?-- you may need a colostomy. After the surgeon removes the cancerous portion, he or she attaches the healthy end of the colon to a surgically created opening in the abdominal wall (this opening is called a stoma). Through the stoma, your feces will pass into a colostomy bag worn outside the body under the clothing. Some colostomies are temporary. After the colon and rectum heal from surgery, a second operation is done in which the healthy ends of the colon are joined and the stoma removed. Some colostomies, though, are permanent.

    If the colon cancer has spread to distant organs, you may also need surgery in those areas.

Chemotherapy

In early-stage cases of colon cancer, surgery alone may enough to cure the disease. But in many other cases, people will need chemotherapy after surgery. Your doctor will help you decide whether to take this route after studying the results of your staging tests and surgical specimen tests. Chemotherapy drugs are given to kill any remaining cancer cells that may have spread. Chemotherapy can also be given to reduce the chance of the tumor returning. This is called adjuvant therapy.

If cancer has spread only to the liver, the preferred treatment is surgery to remove the tumors. If this isn't possible, then chemotherapy drugs can be injected into the artery that supplies the liver.

Drugs most commonly prescribed:

New treatments in development

The use of immunotherapy (also called biological therapy) is under investigation. Immunotherapy is based on the notion of getting your own body's own immune system, which destroys foreign substances, to fight the cancer as well. The method consists mainly of treating the immune system with highly purified proteins in hopes of activating it to destroy cancer cells. Interferon and interleukin are two such proteins, but more being researched. Monoclonal antibodies, for instance, are showing promise, too.

Radiation therapy

Radiation therapy is used much less to treat colon cancer than rectal cancer. (Some people have colorectal cancer, in which both areas have tumors). Radiation doesn't work as well in the colon as it does in the rectum, and it may not combine well with chemotherapy. Radiation is used in certain select cases of colon cancer, however. In advanced colon cancer, it can also be used to control the size of tumors and to relieve pain from cancer that has spread to the liver or other sites. Radiation can be delivered from a machine outside the body, or by placing radiation materials inside the body.

Appropriate Healthcare Setting

Sigmoidoscopy and colonoscopy are typically outpatient procedures done in the office of your doctor or gastroenterologist, or they can be performed in the endoscopy suite of a hospital. Colectomy and colostomy are major surgeries that require hospitalization (an inpatient procedure).

Healthcare Professionals Who May Be Involved

Many healthcare professionals work together to treat this condition:

  • Family doctors
  • General internists
  • Gastroenterologists
  • Radiologists
  • General surgeons
  • Colon-rectal surgeons
  • Surgical oncologists
  • Pathologists
  • Medical oncologists
  • Radiation oncologists
  • Nurse oncologists
  • Enterostomal therapists
  • Psychiatrists
  • Dieticians

Activity and Diet Recommendations

For the first week or so after open abdominal surgery for colon cancer, you'll take in only broth, apple juice, applesauce and gelatin to give your colon a chance to heal without putting too much strain on it. After a week, you'll be able to return to eating solid foods. During cancer treatment, such as chemotherapy, eat several smaller meals throughout the day, emphasizing nutrient-rich foods. As you recover, you'll need adequate nutrition and sufficient calories to maintain strength, boost your immune system, and help your body heal after surgery and other treatment. A registered dietitian can help you plan menus to lessen strain on your digestive tract.

If you've had abdominal surgery, take care not to strain your abdominal muscles until your incision has healed. Lifting or bending down to pick up objects can cause you to pull your abdominal muscles. Once you feel up to it, walking and regular activity can help you to feel better. After you've healed, you'll be able to return to a normal routine of work and play, even if you've had a colostomy. Ask your doctor if you're concerned about any restrictions on your activity.

Monitoring the Condition

After colon surgery and other cancer treatments, you'll need follow-up exams to check your overall health and to detect any recurrence of cancer. The schedule of appointments will vary, depending on the type and extent of your cancer. But common follow-up tests include a physical exam, chest X-ray, CT scans of the abdomen and pelvis, blood tests, a barium enema, and sigmoidoscopy or colonoscopy. Be sure to check yourself for symptoms of recurrence and to call your doctor if any changes occur.

Possible Complications

Complications that may arise from colon cancer include the following:

After surgery:

  • Infection
  • Abscess that forms after surgical removal of tumor
  • Pneumonia
  • Impotence, if sacral nerves are damaged during surgery (for low-lying tumors)

After chemotherapy:

  • Nausea and poor appetite
  • Diarrhea
  • Mucositis (inflammation of a mucous membrane)
  • Hair loss
  • Lowering of white blood cell count, which increase your risk of infection

The Quality of Your Life

Only a minority of colon cancer patients require a colostomy, which routes feces to a bag worn outside the body. If you have this surgery, nurses who are specially trained in colostomy care will counsel you on how to adapt to this change. In time, you'll be able to resume an almost normal bowel routine and return to a full range of normal activities, including work, sex, and most sports. Here are some suggestions:

  • Eat moderately and on a regular schedule.
  • Eat a healthy diet, avoiding fried foods and refined, low-fiber foods. You may want to ask your colostomy advisor for a list of gas- or odor-producing foods to avoid.
  • Use a specially formulated colostomy-pouch deodorant to control odor.
  • Don't wear belts or waistbands directly over the stoma.
  • Avoid rough contact sports and those placing strain on the abdominal muscles.
  • Empty the ostomy pouch before swimming or any sexual activity.

Joining an ostomy support group can be helpful. Contact the American Cancer Society for more information.

Considerations for Women

Colon cancer may spread to the ovaries (metastatic colon cancer). In other cases, women whose colon cancer hasn't spread to the ovaries are still at increased risk of getting primary ovarian cancer (cancer that begins in the ovary, rather than spreading from another part of the body). Some women choose to have their ovaries removed during surgical resection of the colon as a preventive measure. If you still have your ovaries, talk to your doctor about early detection of ovarian cancer.

Pregnancy

Chemotherapy and radiation treatment are not options during pregnancy.

Nursing mothers

Avoid nursing during chemotherapy. Your infant will swallow the chemicals through the breast milk. Instead, wean your baby onto formula before you undergo chemotherapy.

Preventing Colon Cancer

A diet rich in fruits, vegetables, and whole grains has been shown to reduce the risk of developing cancer in general, and colon cancer in particular. These foods are rich in complex carbohydrates, fiber, and substances that can inhibit tumor formation.

Reducing fat intake and increasing fiber intake are the two critical dietary components in reducing your risk of colon cancer. Major sources of fat are meat, eggs, dairy products, salad dressings, and cooking oils. The products of fat metabolism can lead to the formation of cancer-causing chemicals, or carcinogens. A diet high in vegetables and high-fiber foods like whole-grain breads and cereals may rid the bowel of these carcinogens and help reduce the risk of cancer.

Increasing fiber or roughage in your diet is another important component in reducing the risk of colon cancer. Fiber is the insoluble, nondigestible part of plant material present in fruits, vegetables, and whole-grain breads and cereals. A high-fiber diet leads to the creation of bulky stools that can rid the intestines of potential carcinogens. Fiber lets fecal material move more quickly through the intestine, so potential carcinogens have less time to react with the intestinal lining.

The National Cancer Institute recommends the following to help prevent colon cancer:

  • Eat fresh or dried fruits for desserts and snacks.
  • Include beans, legumes, and peas in soups, stews, casseroles, and salads.
  • Eat whole-grain cereals and breads. Eat brown rice and buckwheat instead of white rice and refined grains.
  • Increase fiber intake by leaving the skins on potatoes, fruits, and vegetables.

The National Cancer Institute's dietary guidelines recommend "five a day" -- a minimum of five servings of fruits and vegetables each day -- to prevent cancer. Other guidelines include eating six to 11 servings of breads, grains, and cereals per day.

A plant-based diet

Some experts recommend eating a plant-based diet for optimum health and to help prevent colon cancer. These foods are typically:

  • Low in saturated fats -- the animal fats found in meats, butter, and cheese that are linked to increased risk of colon cancer.
  • High in fiber, which is associated with a lower risk of colon cancer. Good sources include the skins of potatoes and apples, plus whole grains and beans.
  • High in phytochemicals -- natural substances found in fruits and vegetables which seem to offer some protection against the formation of certain tumors.

While all fruits and vegetables are good for you, certain foods protect especially well against cancer-causing agents. Broccoli and other cruciferous vegetables -- like cauliflower, kale, cabbage, collards, and mustard greens -- contain phytochemicals that help block carcinogen damage. Also, tomatoes, tomato sauce, and orange and grapefruit juice all contain antioxidants that can inhibit cancer cell growth. Taking antioxidant vitamins to prevent cancer, however, has proven questionable. It's better to get your vitamins from real foods.

Chemoprevention of colon cancer is another area that's being studied. Researchers have found that aspirin and other nonsteroidal anti-inflammatory agents, as well as calcium supplements, reduce the risk of developing polyps and colon cancer. Also, estrogen replacement therapy cuts the risk of colon cancer.

Screening for Colon Cancer

Aside from preventing colon cancer, early detection is the next best option. Several early detection methods are available:

  • Annual fecal test for blood in the stool, starting at age 50 (limited accuracy)
  • Annual digital rectal examination, starting at age 50
  • Sigmoidoscopy every five years, starting at age 50
  • Colonoscopy every 10 years, starting at age 50 (more frequently for people with certain risk factors); or double contrast barium enema every five-10 years, starting at age 50

People with a family history of colon cancer (in which a first-degree relative had the disease before age 60, or two first-degree relatives had the disease at any age) may need to start screening at age 40 or earlier. Also, people with chronic inflammatory bowel diseases or a personal history of colon cancer or polyps may need earlier and more frequent screening.

Young people with a family history of familial adenomatous polyposis or hereditary nonpolyposis colon cancer are at high risk for colon cancer and may need to have colonoscopy and other tests as early as puberty or age 21.

Self-Care Measures

Dietary factors can play an important role in cancer treatment. Adequate nutrition is needed to maintain strength, boost your immune system, and help your body heal after surgery and other treatment. You will also be better able to tolerate side effects of your medications.

During cancer treatment, eat several smaller meals throughout the day, emphasizing nutrient-rich foods. Because your colon will need time to heal after surgery, a clinical dietitian will help you plan menus to minimize strain on your digestive tract.

Highly stressful situations can affect your immune system's ability to fight off disease. It's always a good idea to reduce stress in your life, especially when diagnosed with a serious, potentially life-threatening illness. The American Cancer Society recommends at least 30 minutes of exercise every day to help keep your weight down and prevent cancer.

Websites & Organizations

American Cancer Society
1599 Clifton Road NE
Atlanta, GA 30329
Phone: 800-ACS-2345 (227-2345)

American Society of Colon and Rectal Surgeons
85 W. Algonquin Road, Suite 550
Arlington Heights, IL 60005
Phone: 847-290-9184
Fax: 847-290-9203

Cancer AnswerLine
Phone: 800865-1125

Cancer Care Inc.

Comprehensive Cancer Center University of Michigan
1500 E. Medical Center Dr.
Ann Arbor, MI 48109
Cancer Information Line: 800-865-1125
Email: wwwcancer@umich.edu

M.D. Anderson Cancer Center
1515 Holcombe Boulevard
Houston, TX 77030
Phone: 713-792-3305
Fax: 713-794-1370

Medicine Online

National Cancer Institute
National Institutes of Health
Bethesda, MD 20892
Phone: 301-496-4000 or 800-4-CANCER (422-6237)

National Coalition for Cancer Survivorship
1010 Wayne Avenue, 5th Floor
Silver Springs, MD 20910
Phone: 888-837-6227 or 301-650-8868

United Ostomy Association
36 Executive Park, Suite 120
Irvine, CA 92714
Phone: 714-660-8624

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