Colorectal Cancer

What is colorectal cancer?

Colorectal cancer is cancer that starts in either the colon or the rectum. Colon cancer and rectal cancer have many features in common. They are discussed together here except for the section about treatment, where they are discussed separately.

The normal digestive system

Colon and rectal cancers begin in the digestive system, also called the GI (gastrointestinal) system (see the picture below). This is where food is processed to create energy and rid the body of solid waste matter (stool). In order to understand colorectal cancer, it helps to know something about the structure of the digestive system and how it works.

After food is chewed and swallowed, it travels to the stomach. There it is partly broken down and sent to the small intestine. The word “small” refers to the width of the small intestine. In fact, the small intestine is the longest part of the digestive system — about 20 feet.

The small intestine also breaks down the food and absorbs most of the nutrients. The small intestine leads to the large intestine (also called the large bowel or colon), a muscular tube about 5 feet long. The colon absorbs water and nutrients from the food and also serves as a storage place for waste matter. The waste matter (stool) moves from the colon into the rectum, the last 6 inches of the digestive system. From there the waste passes out of the body through the opening called the anus.

The wall of the colon and rectum has several layers of tissues. Colorectal cancer starts in the inner layer and can grow through some or all of the other layers. The stage (extent of spread) of a cancer depends to a great degree on how deep the cancer goes into these layers.

Abnormal growths in the colon or rectum

Cancer that starts in these different areas may cause different symptoms. But colon cancer and rectal cancer have many things in common. In most cases, colorectal cancers develop slowly over many years. We now know that most of these cancers begin as a polyp — a growth of tissue that starts in the lining and grows into the center of the colon or rectum. This tissue may or may not be cancer. A type of polyp known as an adenoma can become cancer. Removing a polyp early may keep it from becoming cancer.

Over 95% of colon and rectal cancers are adenocarcinomas. These are cancers that start in the cells that line the inside of the colon and rectum. There are some other, more rare, types of tumors of the colon and rectum, but the facts given here refer only to adenocarcinomas.

How many people get colorectal cancer?

The American Cancer Society’s most recent estimates for colorectal cancer in the United States are for 2009:

• 106,100 new cases of colon cancer
• 40,870 new cases of rectal cancer
• 49,920 deaths from colorectal cancer

Not counting skin cancers, colorectal cancer is the third most common cancer found in men and women in this country. The risk of a person having colorectal cancer in their lifetime is about 1 in 19.

The death rate from colorectal cancer has been going down for the past 15 years. One reason is that there are fewer cases. Thanks to colorectal cancer screening, polyps can be found and removed before they turn into cancer. And colorectal cancer can also be found earlier when it is easier to cure. Treatments have improved, too.

What causes colorectal cancer?

While we do not know the exact cause of most colorectal cancers, there are certain known risk factors. A risk factor is something that affects a person’s chance of getting a disease. Some risk factors, like smoking, can be controlled. Others, such as a person’s age, can’t bechanged. But risk factors don’t tell us everything. Having a risk factor, or even several risk factors, does not mean that you will get the disease. And some people who get the disease may nothave any known risk factors. Even if a person with colorectal cancer has a risk factor, it isoften very hard to know what part that risk factor may have contributed to the cancer.

Researchers have found some risk factors that may increase a person’s chance of gettingpolyps or colorectal cancer.

Risk factors you cannot change

Age: The chances of having colorectal cancer go up after age 50. More than 9 out of 10 people with colorectal cancer are older than 50.

Having had polyps or colorectal cancer before: Some types of polyps increase the risk of colorectal cancer, especially if they are large or if there are many of them. If you have had colorectal cancer (even if it has been completely removed), you are more likely to have new cancers start in other areas of your colon and rectum. The chances of this happening are greater if you had your first colorectal cancer when you were younger.

Having a history of bowel disease: Two bowel diseases, called ulcerative colitis and Crohn’s disease, increase the risk of colon cancer. In these diseases, the colon is inflamed over a long period of time. If you have either of these diseases your doctor may want you to have colon screening testing more often. (These diseases are different than irritable bowel syndrome (IBS), which does not carry an increased risk for colorectal cancer.)

Family history of colorectal cancer: If you have close relatives (parents, brothers/sisters, or children) who have had this cancer, your risk might be increased. This is especially true if the family member got the cancer before age 60. People with a family history of colorectal cancer should talk to their doctors about when and how often to have screening tests.

Certain family syndromes: A syndrome is a group of symptoms. The 2 most common inherited syndromes linked with colorectal cancers are familial adenomatous polyposis (FAP) and hereditary non-polyposis colorectal cancer (HNPCC).

If your doctor tells you that you have a condition that makes you or your family members more likely to get colorectal cancer, you will probably need to begin colon cancer testing at a younger age, and you might want to talk about genetic counseling.

Race or ethnic background: Some racial and ethnic groups such as African Americans and Jews of Eastern European descent (Ashkenazi Jews) have a higher colorectal cancer risk. Among Ashkenazi Jews, several gene mutations have been found that lead to an increased risk of colorectal cancer.

Risk factors linked to things you do

Several lifestyle-related factors have been linked to colorectal cancer. In fact, the links between diet, weight, and exercise and colorectal cancer risk are some of the strongest for any type of cancer.

Certain types of diets: A diet that is high in red meats (beef, lamb, or liver) and processed meats such as hot dogs, bologna, and lunch meat can increase your colorectal cancer risk. Cooking meats at very high heat (frying, broiling, or grilling) can create chemicals that might increase cancer risk. Diets high in vegetables and fruits have been linked with a lower risk of colorectal cancer.

Lack of exercise: Getting more exercise may help reduce your risk.

Overweight: Being very overweight increases a person’s risk of having and dying from colorectal cancer.

Smoking: Most people know that smoking causes lung cancer, but long-time smokers are more likely than non-smokers to have and die from colorectal cancer. Smoking increases the risk of many other cancers, too.

Alcohol: Heavy use of alcohol has been linked to colorectal cancer.

Diabetes: People with type 2 diabetes have an increased chance of getting colorectal cancer. They also tend to have a worse outlook (prognosis).

Risk factors that are less certain

Night-shift work: One study suggested that working a night shift at least 3 nights a month for at least 15 years might increase the risk of colorectal cancer in women. More research is needed to check out this finding.

Other cancers and their treatment: A recent report on testicular cancer survivors found that these men had a higher rate of colorectal cancer. Men who get radiation therapy for prostate cancer have been reported to have a higher risk of rectal cancer, too.

The American Cancer Society and several other medical organizations recommend earlier testing for people with increased colorectal cancer risk. These recommendations differ from those for people at average risk. For more information, talk with your doctor.

Can colorectal cancer be prevented?

Even though we don’t know exactly what causes colorectal cancer, there are some steps you can take to reduce your risk.

Screening tests: Regular colorectal cancer screening or testing is one of the best ways to help prevent colorectal cancer. Screening is the process of looking for cancer in people who don’t have any symptoms of the disease. Some polyps, or growths, can be found and removed before they have the chance to turn into cancer. Screening can also help find colorectal cancer early, when it is small and more likely to be cured.

People who have a history of colorectal cancer in their family should talk with a doctor about when and how often to have screening tests.

Genetic testing, screening, and treatment for those with a strong family history: People with a strong family history of colorectal polyps or cancer should think about getting genetic counseling to help them decide whether genetic testing or earlier screening may be right for them. Before getting genetic testing, it’s good to know ahead of time what the results may or may not tell you about your risk. These tests are not perfect, and in some cases may not be able to give you solid answers. This is why meeting with a genetic counselor before testing is crucial in deciding whether or not testing is right for you.

Diet and exercise: People can lower their risk of getting colorectal cancer by taking charge of the risk factors that they can control, such as diet and exercise. It is important to eat plenty of fruits, vegetables, and whole grain foods and to limit intake of high-fat foods. Getting enough exercise is also important. The American Cancer Society recommends at least 30 minutes of physical activity on 5 or more days of the week. Forty-five to 60 minutes of exercise on 5 or more days of the week is even better.

Avoiding too much alcohol may also help lower your risk of colorectal cancer. The American Cancer Society recommends no more than 1 drink per day for women or 2 per day for men.

Weight: Being overweight or obese raises the risk of colon cancer in both men and women, but the link seems to be stronger in men. The American Cancer Society recommends that people try to stay at a healthy weight throughout life by balancing what they eat with physical activity. If you are overweight, you can ask your doctor about a weight loss plan that will work for you.

Vitamins and minerals: Some studies suggest that taking a daily multivitamin containing folic acid or folate can lower colorectal cancer risk. Other studies suggest that getting more calcium and vitamin D can help. One recent study suggested that a diet high in magnesium may also reduce colorectal cancer risk in women. But not all studies have found these supplements to reduce risk. More research is needed in this area.

Aspirin and other drugs: Aspirin and drugs such as ibuprofen (Motrin®, Advil®) or naproxen (Aleve®), seem to prevent the growth of polyps. A drug called Celebrex® also reduces polyps for some people with FAP. But these medicines can have serious or even life-threatening side effects such as stomach bleeding. For this reason, experts do not advise the general public to take them to try to prevent colorectal cancer. If you are at high risk for colorectal cancer, talk to your doctor about what you should do.

Female hormones: Hormone replacement therapy (HRT) in women after menopause may reduce their risk of getting colorectal cancer. But those women on HRT who do get colorectal cancer may have a faster growing cancer. The decision to use HRT should be based on a careful discussion of benefits and risks with your doctor.

Some studies have found that the use of birth control pills may lower the risk of colorectal cancer in women. More research is needed to confirm this link.

How is colorectal cancer found?

Colorectal cancer screening tests

Screening tests are used to look for disease in people who do not have any symptoms. In many cases, these tests can find colorectal cancers at an early stage and greatly improve the chances of successful treatment. Screening tests can also help prevent some cancers by allowing doctors to find and remove polyps that might become cancer. The tests used to screen for polyps and colorectal cancer can be divided into 2 broad groups:

• Tests that can find both colorectal polyps and cancer: These tests are done either by looking at the colon using a scope that is put into the rectum, or with special x-ray tests. Polyps found before they become cancer can be removed, so these tests may prevent colorectal cancer. Because of this, these tests are preferred if they are available and you are willing to have them.

• Tests that mainly find cancer: These involve testing the stool (feces) for signs of cancer. These tests are easier to have done, but they are less likely to find polyps.

Tests that can find both colorectal polyps and cancer

Flexible sigmoidoscopy (flex-sig): A sigmoidoscope is a thin, flexible, lighted tube about the thickness of a finger. It is placed into the lower part of the colon through the rectum. This allows the doctor to look at the inside of the rectum and part of the colon for cancer or polyps. Because the tube is only about 2 feet long, the doctor is only able to see about half of the colon. The test can be uncomfortable, but it should not be painful. Be sure your doctor is aware of any medicines you are taking, as you may need to change how you take them before the test.

Before the test, you will need to take some medicine to clean out your colon and rectum. This is so the doctor can clearly see the lining. If a small polyp is found your doctor may remove it during this test. This can be done with tools used through the scope. If an adenoma polyp or colorectal cancer is found during the flex-sig, you will need to have a colonoscopy to look for polyps or cancer in the rest of the colon.

A sigmoidoscopy usually takes 10 to 20 minutes. Most people do not need to be sedated for this test, but this may be an option you can discuss with your doctor. Sedation may make the test easier, but you will need some time to recover, as well as someone with you to take you home after the test.

Colonoscopy: A colonoscope is a longer version of the sigmoidoscope. It is used the same way but allows the doctor to see the entire colon. If a polyp is found, the doctor may remove it. If anything else looks abnormal, a biopsy might be done. To do this, a small piece of tissue is taken out through the colonoscope. The tissue is sent to the lab to see if cancer cells are present.

Colonoscopy may be done in a hospital outpatient department, in a clinic, or in a doctor’s office.

Before the test: The colon and rectum must be empty and clean. You will take some medicine to clean out your colon the day before the test and maybe an enema that morning. Your doctor will give you exact instructions. Be sure to read these carefully a few days ahead of time, since you may need to shop for special supplies and get laxatives from a drug store. If you are not sure about anything, call the doctor’s office and go over things step by step with the nurse.

Be sure your doctor is aware of any medicines you are taking, as you may need to change how you take them before the test. Many people find the bowel preparation to be the most unpleasant part of the test, as you will most likely be in the bathroom quite a bit. You may be given other instructions, too, such as foods to avoid for a certain amount of time before the test.

During the test: The test itself usually takes about 30 minutes, but it may take longer if a polyp is found and removed. Before the test begins, you will be given medicine through your vein to make you feel comfortable and sleepy. You may be awake, but you will not be aware of what is going on and may not remember the test afterward. Most people will be fully awake by the time they get home from the test.

If a small polyp is found, the doctor may remove it. If your doctor sees a larger polyp or tumor or anything else not normal, a biopsy may be done. To do this, a small piece of tissue is taken out through the colonoscope. The tissue is looked at under a microscope to see whether it is a cancer, a benign (non-cancer) growth, or a result of inflammation.

After the test: You may need to have someone drive you home from the test because the medicine used can affect your ability to drive. Your doctor will tell you if you need someone to drive you home. Some people may have gas pains or cramping for a while after the test, but most feel fine once the drugs wear off.

Double contrast barium enema (DCBE): To do this test a chalky substance is used to partly fill and open up the colon. Air is then pumped in to cause the colon to expand. This allows good x-ray pictures to be taken. If an area does not look normal you will need to have a colonoscopy.

The preparation for this test is much like that for the colonoscopy (above), but for the DCBE you will not be given drugs to make you sleepy. It takes about 30 to 45 minutes to do this test. A small, flexible tube is put into the rectum, and barium sulfate is pumped in to partly fill and open up the colon. When the colon is about half-full of barium, you are turned on the x-ray table so the barium spreads throughout the colon. Then air is pumped into the colon through the same tube. This may cause discomfort and you may feel like you have to have a bowel movement. You may have bloating or cramping after the test, and will likely feel the need to empty your bowels soon after the test is done. The barium can cause constipation for a few days, and your stool may look grey or white until all the barium is out.

Virtual colonoscopy: You might think of this as a super x-ray or an advanced CT scan of the colon. The CT scanner takes many pictures as it rotates around you while you lie on a table. A computer then combines these pictures into images of slices of the colon and rectum. Virtual colonoscopy (also called CT colonography) involves the use of special computer programs to create both 2 dimensional x-ray pictures and a 3-D “fly-through” view of the inside of the colon and rectum, which allows the doctor to look for polyps or cancer.

This test may be useful for some people who can’t have or don’t want to have tests where a tube or scope is put in the colon or rectum. It can be done fairly quickly and you do not need drugs to make you sleepy. But while this test does not mean a scope will be put into your colon like colonoscopy, you still need to do the same type of bowel preparation. If polyps or other problems are seen on this test, a colonoscopy will likely be needed to remove them or to get a better look at them.

Tests that mainly find colorectal cancer

These tests are used to find small amounts of hidden (occult) blood in the stool. Most people find these tests are easier because they can often be done at home. But they are not as good at finding polyps as the tests described above, and a positive result on one of these screening tests will likely mean you will need a test like a colonoscopy.

These tests have different names such as FOBT (fecal occult blood test), FIT (fecal immunochemical test), and iFOBT (immunochemical fecal occult blood test). They are all alike in that you will need to collect samples of your stool (bowel movement) to be sent to a lab for testing. They differ in the exact way in which you collect the samples and in how the samples are studied in the lab.

If you are having one of these tests, the doctor or nurse will give you a kit with exact instructions on what to do ahead of time (there may be some limits on what you can eat or drink or medicines that you take) and how to collect the samples.

Some people who are given the kits never do the test or don’t give it to their doctor because they worry that they might not have followed the instructions right. Be sure to talk to your doctor or nurse if you have any questions about what you should do or how to collect the samples. The most important thing is to get the test done.

Most of these tests need to be done every year, and, as mentioned before, if the lab spots any problems, you will need to have more tests such as a colonoscopy. For more detailed information about these tests, please see, Colorectal Cancer: Early Detection.

Preventing colorectal cancer or finding it early

Colon cancer begins with a growth (a polyp) that is not yet cancer. Testing can help your doctor tell whether there is a problem, and some tests can find polyps before they become cancer. Most people who have polyps removed never get colon cancer. If colon cancer is found, you have a good chance of beating it with treatment if it is found early. Testing can find it early.

The American Cancer Society believes that preventing colorectal cancer (and not just finding it early) should be a major reason for getting tested. Finding and removing polyps keeps some people from getting colorectal cancer. Tests that have the best chance of finding both polyps and cancer should be your first choice if these tests are available to you and you are willing to have them.

Doctors will take into account a number of factors when they recommend the tests you should have, how often you should have them, and when you should begin testing. These factors include whether you are at average, increased, or high risk for colorectal cancer. If you are at increased or high risk, the type of test used and how often it is done will further depend on whether you have had polyps, cancer, or certain other diseases, as well as your family history.

In general, both men and women at average risk of colorectal cancer should begin screening tests at age 50. But you should talk with your doctor about your own health and your family history so that you can choose the best screening plan for you. For more detailed information about the American Cancer Society’s recommendations for screening, please see our document, Colorectal Cancer: Early Detection.

Insurance coverage for colorectal cancer screening

There are good colorectal cancer screening tests, but not enough people have them done. Some of the reasons could include not knowing about screening tests, costs, and lack of health insurance.

Laws regarding insurance coverage for colorectal cancer screening tests vary by state. The same is true of state Medicaid programs. For people with Medicare, coverage begins at age 50 for the most common colorectal cancer screening tests.

For more information on insurance coverage for colorectal cancer screening tests, please see the our document, Colorectal Cancer: Early Detection.

How is colorectal cancer diagnosed?

Most people with early colon cancer don’t have symptoms. Symptoms usually are seen with more advanced disease. If something of concern turns up as a result of screening or if you have symptoms, you will need more tests.

Signs and symptoms of colorectal cancer

If you have any of the following you should see your doctor:

• a change in bowel habits such as diarrhea, constipation, or narrow stool that lasts for more than a few days
• a feeling that you need to have a bowel movement that doesn’t go away after doing so
• rectal bleeding, dark stools, or blood in the stool (often, though, the stool will look normal)
• cramping or stomach pain
• weakness and tiredness

Most of these symptoms are more likely caused by something other than colorectal cancer. Still, if you have any of these problems, it’s important to see a doctor right away so the cause can be found and treated, if needed.

If there is any reason to suspect colon or rectal cancer you will need to have more tests to find out if the disease is really present and, if so, to see how far it has spread. Some of these tests are the same ones that are used for screening people who do not have symptoms. (See the section, “Tests to look for colorectal polyps and cancer.”)

Medical history and physical exam

Your doctor will ask you questions about your health, your family history, and do a complete physical exam.

Blood tests

Your doctor may order certain blood tests to help find out if you have colorectal cancer. People with colorectal cancer often have low red blood cell counts (become anemic) because of bleeding from the tumor. You might also have blood tests to check your liver function because colorectal cancer can spread to the liver. There are other substances (tumor markers) in the blood that can help tell how well treatment is working. But these tumor markers are not used to find cancer in people who have not had cancer and who seem to be healthy. They are most often used for follow-up of people who have already been treated for colorectal cancer.

Tests to look for colorectal polyps or cancer

If symptoms or the results of the physical exam or blood tests suggest that you might have colorectal cancer, your doctor may want to do some more tests. These tests might include those described earlier in the section “Tests to look for colorectal polyps and cancer.”

A biopsy will be done on any part of the colon or rectum that does not look normal. For a biopsy, the doctor removes a small piece of the tissue from the area of concern. This is done during a colonoscopy. The tissue is sent to the lab where it is looked at under a microscope to see if cancer is present. While other tests may suggest colorectal cancer, a biopsy is the only way to know this for sure.

Imaging tests

The tests described below make pictures of the inside of your body. Imaging tests may be done for many reasons, such as to help find out whether a changed area might be cancer, to learn how far cancer may have spread, and to help learn whether treatment is working.

Computed tomography (CT or CAT) scan

A CT scan uses x-rays to take many pictures of the body that are then combined by a computer to give a detailed picture. A CT scan can often show whether the cancer has spread to the liver, lungs, or other organs. CT scans take longer than regular x-rays. The patient has to lie still on a table while the CT scan is being done. A contrast “dye” may be put into a vein or a special drink used to help outline the area being looked at. The dye can cause some flushing (redness and warm feeling). Some people are allergic and get hives or, rarely, more serious reactions like trouble breathing and low blood pressure. Be sure to tell the doctor if you have ever had a reaction to any contrast dye used for x-rays.

CT scans can also be used to guide a biopsy needle into a tumor. For this to be done, the patient remains on the CT table while a radiologist moves a biopsy needle through the skin and toward the mass. A tiny piece of tissue or a thin cylinder of tissue about 1/2 inch long and less than 1/8 inch wide is then removed and looked at under a microscope.

A new way to use a CT scan is to do a “virtual colonoscopy.” After stool is cleaned from the colon and the colon is filled with air, a computer can put together a picture of the inside of the colon. This method requires the same preparation as for a colonoscopy and there is some discomfort from the bowel being filled with air. If anything looks like it is not normal, a follow-up colonoscopy will be needed.

Ultrasound

Ultrasound uses sound waves to make a picture of the inside of the body. Most people know about ultrasound because it is often used to look at a baby during pregnancy. This is an easy test to have. The patient simply lies on a table while a kind of wand is moved over the skin of the belly.

Two special types of ultrasound might be used for people with colon or rectal cancer. In one, the wand that gives off sound waves is placed into the rectum to look for cancer there and to see if it has spread to nearby organs or tissues. In the other test, used during surgery, the wand is placed against the surface of the liver to see if the cancer has spread there.

Magnetic resonance imaging (MRI) scans

Like CT scans, MRIs show a cross-section of the body. But MRI uses radio waves and strong magnets instead of radiation to take pictures. As with CT scans, a contrast dye may be used, but this is not common. MRI scans are sometimes useful in looking at places in the liver that might have cancer spread. They can also help the doctor learn the extent of rectal cancers. MRIs take longer than CT scans and the patient may have to be placed inside a narrow tube for the test. This can feel confining and upset people with a fear of closed spaces. The machine also makes a thumping noise, but some places will provide headphones with music to block this out.

Chest X-ray

This test may be done to see whether colorectal cancer has spread to the lungs.

Positron emission tomography (PET) scan

In this test, a type of radioactive sugar is put into a vein. Over a certain amount of time the sugar moves through the body and is taken in by the cancer cells. Then the patient is put into the PET machine where a special camera can detect the radioactivity. Because the cancer cells absorb large amounts of the sugar they show up on the pictures as dark “hot spots.” PET is useful when the doctor thinks the cancer has spread, but doesn’t know where. PET scans are now more accurate because they can be done along with a CT scan.

Angiography

Angiography is an x-ray done to look at blood vessels. For this test, a thin tube (called a catheter) is put into a blood vessel and moved until it reaches the area to be studied. (The skin is numbed before the tube is put in.) Then a dye is pushed through the catheter and x-ray pictures are taken. When the pictures are done, the catheter is taken out. Surgeons sometimes use this test to show blood vessels next to cancer that has spread to the liver. The cancer can then be removed without causing a lot of bleeding.

After the tests: Staging

Staging is the process of finding out how far the cancer has spread. This is very important because your treatment and the outlook for your recovery depend on the stage of your cancer. For early cancer, surgery may be all that is needed. For more advanced cancer, other treatments like chemotherapy or radiation therapy may be used.

There is more than one system for staging colorectal cancer. Some use numbers and others use letters. But all systems describe the spread of the cancer through the layers of the wall of the colon or rectum. They also take into account whether the cancer has spread to nearby organs or to organs farther away.

Stages are often labeled using Roman numerals I through IV (1-4). As a rule, the lower the number, the less the cancer has spread. A higher number, such as stage IV (4), means a more serious cancer.

There are really 2 types of staging for colorectal cancer. The clinical stage is your doctor’s best guess of the extent of your disease, based on the results of the physical exam, biopsy, and any other tests you have had. If you have surgery, your doctors can also figure out the pathologic stage. This stage is based on the same factors as the clinical stage plus what is found during surgery and a biopsy of the tissue.

Because most patients with colorectal cancer have surgery, the pathologic stage is most often used to describe the extent of this cancer. Pathologic staging is likely to be more accurate than clinical staging, as it allows your doctor to get a good look at the extent of your disease.

Grade of colorectal cancer

Another factor that can affect the outlook for survival is the grade of the cancer. Grade is a description of how closely the cancer looks like normal colorectal tissue under a microscope. Low-grade means the tissue looks more normal; high-grade means the tissue looks less normal. Most of the time, the outlook is not as good for high-grade cancers as it is for low-grade cancers.

How is colorectal cancer treated?

This information represents the views of the doctors and nurses serving on the American Cancer Society’s Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.

The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.

Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don’t hesitate to ask him or her questions about your treatment options.

The 4 main types of treatment for colorectal cancer are:

• surgery
• radiation therapy
• chemotherapy (often called just “chemo”)
• targeted therapies (called monoclonal antibodies)

Depending on the stage of your cancer, 2 or more types of treatment may be used at the same time, or used one after the other.

Take your time and think about all of your treatment choices. You may want to get a second opinion. This can give you more information and help you feel better about the treatment plan you choose. Your chances of having a good outcome are highest in the hands of a medical team that has experience in treating colorectal cancer.

Surgery

The types of surgery used to treat colon and rectal cancers differ and are described separately.

Colon surgery

Surgery is often the main treatment for earlier stage colon cancer. The surgery is called a colectomy or a segmental resection. Usually the cancer and a piece of normal colon on either side of the cancer (as well as nearby lymph nodes) are removed. The 2 ends of the colon are then sewn back together. For colon cancer, a colostomy (an opening on the belly for getting rid of body wastes) is not usually needed, although sometimes a short-term colostomy may be done to let the colon heal. The normal hospital stay for this surgery is 4 to 7 days, depending on your overall health.

Most often, surgery is done through a cut (incision) in the belly (abdomen), but for some earlier stage cancers a different approach might be an option. In laparoscopic-assisted colectomy, instead of one long incision in the abdomen, the surgeon makes several small ones. Special long instruments are put into these small openings and used to remove part of the colon and lymph nodes. This method seems to be about as likely to cure the cancer as the standard approach for earlier stage cancers, and patients usually recover faster than they do after the usual operations. But the surgery calls for special skill. If you are thinking about laproscopic surgery, be sure to look for a skilled surgeon who has done a lot of these operations.

Some very early colon cancers (stage 0 and some early stage I tumors) or polyps can be removed using a colonoscope (the same thin, flexible scope used to do a colonoscopy). When this is done, the surgeon does not have to cut into the abdomen. Early stage cancers that are only on the surface of the colon lining can be removed along with a small amount of nearby tissue. For a polypectomy, the cancer is cut out across the base of the polyp’s stalk, the area that looks like the stem of a mushroom.

Rectal surgery

Surgery is usually the main treatment for rectal cancer, too, although radiation and chemo will often be given before or after surgery. There are several types of surgery for rectal cancer.

Some operations (such as polypectomy, local excision, and local transanal resection) can be done with instruments placed into the anus, without having to cut through the skin. One of these methods might be used to remove stage I cancers that are fairly small and not too far from the anus.

For some stage I, and most stage II or III rectal cancers, other types of surgery may be done. These are described here:

Low anterior resection: This approach is used for cancers near the upper part of the rectum, close to where it connects with the colon. The surgeon makes the cut in the belly. Then he removes the cancer and a small amount of normal tissue on either side of the cancer, along with nearby lymph nodes and a large amount of fatty and fibrous tissue around the rectum. The anus is not affected. After the surgery, the colon is reattached to the anus and waste leaves the body in the usual way. The normal hospital stay for this surgery is 4 to 7 days, depending on your overall health.

Proctectomy with colo-anal anastomosis: For some stage I and most stage II and III rectal cancers in the middle and lower third of the rectum, the entire rectum and the colon attached to the anus will need to be removed. This is called a colo-anal anastomosis (anastomosis means connection). This is a harder operation to do. For a short time, an ostomy (an opening on the belly for getting rid of body wastes) is needed to allow healing after surgery. The usual hospital stay is 4 to 7 days, depending on your overall health. A second operation is needed later to close the ostomy opening.

Abdominoperineal (AP) resection: For cancers in the lower part of the rectum, close to its outer connection to the anus, an abdominoperineal (AP) resection is done. For this the surgeon makes 1 cut in the belly (abdomen), and another in the area around the anus. Because the anus is removed, a colostomy is needed. A colostomy is an opening of the colon in the front of the abdomen. It is used as a way for the body to get rid of solid body waste (feces or stool). The usual hospital stay for an AP resection is 4 to 7 days, depending on your overall health.

Pelvic exenteration: If the rectal cancer is growing into nearby organs, more extensive surgery is needed. In a pelvic exenteration the surgeon removes the rectum as well as nearby organs such as the bladder, prostate, or uterus if the cancer has spread to these organs. A colostomy is needed after this operation. If the bladder is removed, a urostomy (an opening to collect urine) is also needed.

Side effects of colorectal surgery

Side effects of surgery depend on many things, such as the extent of the operation and a person’s general health before surgery. Most people will have at least some pain after the operation, but this can usually be controlled with medicines if needed. Eating problems usually get better within a few days of surgery.

Possible side effects of surgery include bleeding, blood clots in the legs, and damage to nearby organs during the operation. Rarely, the connections between the ends of the intestine may not hold together completely and leak, which can lead to infection. If an infection occurs, it is possible that the incision might open up, causing an open wound. Later, after the surgery, you might develop scar tissue in your abdomen (called adhesions) that could block the bowel.

Some people may need a short-term or permanent colostomy (or ileostomy) after surgery. If so, you will need help in learning how to manage it. Specially trained nurses or enterostomal therapists can do this. They will usually see you before your operation and again afterwards for more training. To learn more, please see our documents, Colostomy: A Guide and Ileostomy: A Guide.

Colorectal surgery and sex

If you are a man, an AP resection can cause you to have “dry” orgasms. That is, the feeling of pleasure will most likely still be there, but no semen comes out. In some cases an AP resection may make you unable to have erections or reach orgasm. In other cases your pleasure at orgasm may become less intense. Normal aging may cause some of these changes, but surgery can make them worse.

For some men, the surgery causes the semen to go backward into the bladder. This is not harmful. But if you still want to father a child, you should talk to your doctor about how the surgery will affect you and what might be done to achieve a pregnancy.

If you are a woman having colorectal surgery, you should not normally find any loss of sexual function. Scar tissue may sometimes cause pain or discomfort during sex. And if the uterus is removed, pregnancy will not be possible.

For men and women, a colostomy can affect your body image and your sexual comfort level. While you may need to make some adjustments, it should not keep you from having an enjoyable sex life.

For more information on dealing with the sexual impact of cancer and its treatment please see the American Cancer Society documents, Sexuality for the Man With Cancer and Sexuality for the Woman With Cancer.

Surgery for colorectal cancer that has spread

Sometimes surgery for cancer that has spread to other organs can help you to live longer or, depending on the extent of the disease, may even cure you. If the colorectal cancer has spread to a few areas in liver or lungs (and nowhere else), the cancer can sometimes be removed by surgery.

For spread to the liver, there are other methods besides surgery which might be used to destroy the cancer. These include methods to block the blood supply to the tumor or to destroy the cancer by freezing it or killing it with high-energy radio waves. These methods are not meant to cure the cancer.

Radiation treatment for colon and rectal cancer

Radiation treatment is the use of high-energy rays (such as x-rays) to kill cancer cells or shrink tumors. The radiation may come from outside the body (external radiation) or from radioactive materials put right in the tumor (brachytherapy or internal or implant radiation).

After surgery, radiation can kill small areas of cancer that may be missed during surgery. If the size or place of a tumor makes surgery hard, radiation may be used before the surgery to shrink the tumor. Radiation can also be used to ease symptoms of advanced cancer such as intestinal blockage, bleeding, or pain.

The main use for radiation treatment in people with colon cancer is when the cancer has attached to an internal organ or the lining of the abdomen. If this happens, the doctor can’t be sure that all the cancer has been removed, and radiation is used to kill the cancer cells left behind after surgery. For rectal cancer, radiation is also given to prevent the cancer from coming back in the place where it started and to treat local recurrences that are causing symptoms such as pain. Radiation is seldom used to treat metastatic colon cancer.

External-beam radiation therapy: In this treatment, radiation is focused on the cancer from a machine outside the body. This type is most often used for people with colon or rectal cancer. Treatments are given 5 days a week for many weeks. Each treatment lasts only a few minutes, but the setup time — getting you into place for treatment — usually takes longer.

A different approach may be used for some cases of rectal cancer with small tumors. A small device can be put into the anus to deliver the radiation. This way the radiation reaches the rectum without passing through the skin and other tissues of the abdomen. This means it is less likely to damage nearby tissues and cause side effects.

Brachytherapy (internal radiation therapy): In this method, small pellets or seeds of radioactive material are placed next to or right into the cancer. The radiation travels only a short distance, limiting the effects on nearby healthy tissues. This method is sometimes used in treating people with rectal cancer, particularly sick or older people who would not be able to go through surgery.

Side effects of radiation therapy

Side effects of radiation therapy for colon or rectal cancer include skin irritation, nausea, diarrhea, trouble controlling your bowels, rectal or bladder irritation, and tiredness. Sexual problems may also occur. Side effects often go away after treatment is over. If you have these or other side effects, talk to your doctor. There are often ways to reduce or relieve many of these problems.

To learn more about radiation therapy, please see the American Cancer Society document, Understanding Radiation Therapy: A Guide for Patients and Families.

Chemotherapy

Chemo is the use of drugs to fight cancer. The drugs may be put into a vein or given by mouth. These drugs enter the bloodstream and spread throughout the body, making the treatment useful for cancers that have spread to distant organs.

Chemo is sometimes used before surgery to try to shrink the cancer and make surgery easier. It may also be given after surgery because it can increase the survival rate for patients with some stages of colorectal cancer. Chemo can also help relieve symptoms of advanced cancer and help people live longer.

In some cases, chemo drugs can be put into an artery leading to the part of the body with the tumor. This approach is called regional chemotherapy. Since the drugs go straight to the cancer cells, there may be fewer side effects. Regional chemotherapy is sometimes used for colon cancer that has spread to the liver

Side effects of chemo

While chemo kills cancer cells, it also damages some normal cells and this can cause side effects. These side effects will depend on the type of drugs given, the amount given, and how long treatment lasts. Side effects could include the following:

• diarrhea
• nausea and vomiting
• loss of appetite
• hair loss
• hand and foot rashes and swelling
• mouth sores
• increased chance of infection
• easy bleeding or bruising after minor cuts or injuries
• severe tiredness (fatigue)

Most of the side effects go away when treatment is over. For example, hair will grow back after treatment ends, though it may look different. Anyone who has problems with side effects should talk with their doctor or nurse, as there are often ways to help.

To learn more about chemotherapy, please see our document, Understanding Chemotherapy: A Guide for Patients and Families.

Targeted therapies

Targeted therapies are drugs that attack parts of cancer cells that make them different from normal cells. Because these drugs affect only cancer cells, they often cause fewer side effects than chemo. Man-made proteins called monoclonal antibodies have been approved for use, along with chemo, to treat colorectal cancer.

Colorectal cancer survival rates

The 5-year survival rate is the percentage of patients who are alive 5 years after their cancer is found (leaving out those who die of other causes). Many of these patients live much longer than 5 years. While the numbers below are among the most current we have, they are from people who were first treated many years ago. Because cancer treatment continues to improve, the survival rates for people now may be higher.

Survival rates for colon cancer by stage
Stage I	93%
Stage IIA	85%
Stage IIB	72%
Stage IIIA	83%*
Stage IIIB	64%
Stage IIIC	44%
Stage IV	8%

*In this study, survival was better for stage IIIA than for stage IIB. The reasons for this are not clear, and it is not known if this is still the case.

Relative survival rates for rectal cancer by stage

Stage	Relative 5-year Survival Rate
I	90%
II	70%
III	56%
IV	7%

These numbers provide an overall picture, but keep in mind that every person is unique and statistics can’t predict exactly what will happen in your case. Talk with your cancer care team if you have questions about your own chances of a cure, or how long you might survive your cancer. They know your situation best.

Clinical trials

You may have had to make a lot of decisions since you’ve been told you have cancer. One of the most important decisions you will make is deciding which treatment is best for you. You may have heard about clinical trials being done for your type of cancer. Or maybe someone on your health care team has mentioned a clinical trial to you.

Clinical trials are carefully controlled research studies that are done with patients who volunteer for them. They are done to get a closer look at promising new treatments or procedures.

If you would like to take part in a clinical trial, you should start by asking your doctor if your clinic or hospital conducts clinical trials. You can also call our clinical trials matching service for a list of clinical trials that meet your medical needs. You can reach this service at 1-800-303-5691 or on our Web site at http://clinicaltrials.cancer.org. You can also get a list of current clinical trials by calling the National Cancer Institute’s Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) or by visiting the NCI clinical trials Web site at www.cancer.gov/clinicaltrials.

There are requirements you must meet to take part in any clinical trial. If you do qualify for a clinical trial, it is up to you whether or not to enter (enroll in) it.

Clinical trials are one way to get state-of-the art cancer treatment. They are the only way for doctors to learn better methods to treat cancer. Still, they are not right for everyone.

You can get a lot more information on clinical trials, in our document called Clinical Trials: What You Need to Know. You can read it on our Web site or call our toll-free number and have it sent to you.

Complementary and alternative therapies

When you have cancer you are likely to hear about ways to treat your cancer or relieve symptoms that your doctor hasn’t mentioned. Everyone from friends and family to Internet groups and Web sites offer ideas for what might help you. These methods can include vitamins, herbs, and special diets, or other methods such as acupuncture or massage, to name a few.

What are complementary and alternative therapies?

It can be confusing because not everyone uses these terms the same way, and they are used to refer to many different methods. We use complementary to refer to treatments that are used along with your regular medical care. Alternative treatments are used instead of a doctor’s medical treatment.

Complementary methods: Most complementary treatment methods are not offered as cures for cancer. Mainly, they are used to help you feel better. Some examples of methods that are used along with regular treatment are meditation to reduce stress, acupuncture to help relieve pain, or peppermint tea to relieve nausea. Some complementary methods are known to help, while others have not been tested. Some have been proven not be helpful, and a few are even harmful.

Alternative treatments: Alternative treatments may be offered as cancer cures. These treatments have not been proven safe and effective in clinical trials. Some of these methods may be harmful, or have life-threatening side effects. But the biggest danger in most cases is that you may lose the chance to be helped by standard medical treatment. Delays or interruptions in your medical treatments may give the cancer more time to grow and make it less likely that treatment will help.

Finding out more

It is easy to see why people with cancer think about alternative methods. You want to do all you can to fight the cancer, and the idea of a treatment with no side effects sounds great. Sometimes medical treatments like chemotherapy can be hard to take, or they may no longer be working. But the truth is that most of these alternative methods have not been tested and proven to work in treating cancer.

As you think about your options, here are 3 important steps you can take:

• Look for “red flags” that suggest fraud. Does the method promise to cure all or mostcancers? Are you told not to have regular medical treatments? Is the treatment a”secret” that requires you to visit certain providers or travel to another country?

• Talk to your doctor or nurse about any method you are thinking of using.

• Contact us at 1-800-ACS-2345 to learn more about complementary and alternative methods in general and to find out about the specific methods you are looking at.

The choice is yours

Decisions about how to treat or manage your cancer are always yours to make. If you want to use a non-standard treatment, learn all you can about the method and talk to your doctor about it. With good information and the support of your health care team, you may be able to safely use the methods that can help you while avoiding those that could be harmful.

What are some questions I can ask my doctor?

As you cope with cancer and cancer treatment, you need to have honest, open talks with your doctor. You should feel free to ask any question that’s on your mind, no matter how small it might seem. Here are some questions you might want to ask. Be sure to add your own questions as you think of them. Nurses, social workers, and other members of the treatment team may also be able to answer many of your questions.

• Would you please write down the exact kind of cancer I have.
• Where is my cancer?
• Has it spread beyond the place where it began?
• What is the stage of my cancer, and what does that mean in my case?
• Are there other tests that need to be done before we can decide on treatment?
• What treatment choices do I have?
• What treatment do you suggest and why?
• How long will treatment last? What will it involve? Where will it be done?
• What is the goal of this treatment?
• What risks or side effects are there to the treatments you suggest?
• What can I do to reduce the side effects of treatment?
• Will I need a colostomy? Will it be permanent?
• What are the chances my cancer will come back with these treatment plans? What would we do if that happens?
• If I lose my hair, what can I do about it?
• What should I do to be ready for treatment?
• Should I follow a special diet?
• What type of follow-up will I need after treatment?

Moving on after treatment

Completing treatment can be both stressful and exciting. You will be relieved to finish treatment, yet it is hard not to worry about cancer coming back. (When cancer returns, it is called recurrence.) This is a very common concern among those who have had cancer. Even with no recurrences, people who have had cancer learn to live with uncertainty. You can learn more about what to look for and how to learn to live with the chance that cancer could come back in the American Cancer Society document, Living with Uncertainty: The Fear of Cancer Recurrence, available at our toll-free number.

Follow-up care

For years after treatment ends, regular follow-up exams will be very important for you. These exams, which will include a physical exam, blood tests, and maybe imaging tests, can tell if the cancer has come back. This is the time for you to ask your health care team any questions or concerns you might have. Almost any cancer treatment can have side effects. Some may last for a few weeks to several months, but others can be forever. Tell your cancer care team about any symptoms or side effects that bother you so they can help you manage them. How often you will need follow-up visits and tests will depend on the stage of your cancer and the chances of its coming back.

Almost any cancer treatment can have side effects. Some may last for a few weeks to several months, but others can be long-term. Don’t hesitate to tell your cancer care team about any symptoms or side effects that bother you so they can help you manage them.

Seeing a new doctor

At some point after your cancer diagnosis and treatment, you may find yourself in the office of a new doctor. It is important that you be able to give your new doctor the exact details of your diagnosis and treatment. Make sure you have the following information handy and always keep copies for yourself:

• a copy of your pathology report from any biopsy or surgery
• CT and MRI images on a DVD
• if you had surgery, a copy of your operative report
• if you were hospitalized, a copy of the discharge summary that every doctor must prepare when patients are sent home from the hospital
• if you had radiation therapy, a summary of the type and dose of radiation and when and where it was given
• if you had chemotherapy, a list of your drugs, drug doses, and when you took them

It is also important to keep medical insurance. Even though no one wants to think of their cancer coming back, it is always a possibility. If it happens, the last thing you want is to have to worry about paying for treatment.

Lifestyle changes to consider during and after treatment

Having cancer and dealing with treatment can take up a lot of your time and be emotionally draining, but it can also be a time to look at your life in new ways. Maybe you are thinking about how to improve your health over the long term. Some people even begin this process during cancer treatment.

Make healthier choices

Think about your life before you learned you had cancer. Were there things you did that might have made you less healthy? Maybe you drank too much alcohol, ate more than you needed, smoked, or didn’t exercise very often. Emotionally, maybe you kept your feelings bottled up, or maybe you let stressful situations go on too long.

Now is not the time to feel guilty or to blame yourself. However, you can start making changes today that can have positive effects for the rest of your life. Not only will you feel better but you will also be healthier. What better time than now to take advantage of the motivation you have as a result of going through a life-changing experience like having cancer?

You can start by working on those things that you feel most concerned about. Get help with those that are harder for you. For instance, if you are thinking about quitting smoking and need help, call the ACS’ Quitline® program at 1-800-227-2345.

Diet and nutrition

Eating right can be a challenge for anyone, but it can get even tougher during and after cancer treatment. For instance, treatment often may change your sense of taste. Nausea can be a problem. You may lose your appetite for a while and lose weight when you don’t want to. On the other hand, some people gain weight even without eating more. This can be frustrating, too.

If you are losing weight or have taste problems during treatment, do the best you can with eating and remember that these problems usually improve over time. You may want to ask your cancer team for a referral to a dietitian, an expert in nutrition who can give you ideas on how to fight some of the side effects of your treatment. You may also find it helps to eat small portions every 2 to 3 hours until you feel better and can go back to a more normal schedule.

One of the best things you can do after treatment is to put healthy eating habits into place. You will be surprised at the long-term benefits of some simple changes, like increasing the variety of healthy foods you eat. Try to eat 5 or more servings of vegetables and fruits each day. Choose whole grain foods instead of white flour and sugars. Try to limit meats that are high in fat. Cut back on processed meats like hot dogs, bologna, and bacon. Get rid of them altogether if you can. If you drink alcohol, limit yourself to 1 or 2 drinks a day at the most. And don’t forget to get some type of regular exercise. The combination of a good diet and regular exercise will help you maintain a healthy weight and keep you feeling more energetic.

Rest, fatigue, work, and exercise

Fatigue is a very common symptom in people being treated for cancer. This is often not an ordinary type of tiredness but a “bone-weary” exhaustion that doesn’t get better with rest. For some, this fatigue lasts a long time after treatment, and can discourage them from physical activity.

But exercise can actually help you reduce fatigue. Studies have shown that patients who follow an exercise program tailored to their personal needs feel better physically and emotionally and can cope better, too.

If you are ill and need to be on bed rest during treatment, it is normal to expect your fitness, endurance, and muscle strength to decline some. Physical therapy can help you maintain strength and range of motion in your muscles, which can help fight fatigue and the sense of depression that sometimes comes with feeling so tired.

Any program of physical activity should fit your own situation. An older person who has never exercised will not be able to take on the same amount of exercise as a 20-year-old who plays tennis 3 times a week. If you haven’t exercised in a few years but can still get around, you may want to think about taking short walks.

Talk with your health care team before starting, and get their opinion about your exercise plans. Then, try to get an exercise buddy so that you’re not doing it alone. Having family or friends involved when starting a new exercise program can give you that extra boost of support to keep you going when the push just isn’t there.

If you are very tired, though, you will need to balance activity with rest. It is okay to rest when you need to. Sometimes it’s really hard for some people to allow themselves to do that when they are used to working all day or taking care of a household. (For more information about fatigue, please see the publication, Fatigue in People with Cancer.)

Exercise can improve your physical and emotional health.

• It improves your cardiovascular (heart and circulation) fitness.
• It strengthens your muscles.
• It reduces fatigue.
• It lowers anxiety and depression.
• It makes you feel generally happier.
• It helps you feel better about yourself.

Anyone who has been treated for colorectal cancer may also be at risk for a second colorectal cancer or even for other types of cancer. We know that exercise plays a role in preventing some cancers. The American Cancer Society recommends that adults take part in at least 1 physical activity for 30 minutes or more on 5 days or more of the week.

Can you reduce your risk of the cancer coming back?

Most people want to know if there is anything they can do to reduce their risk of cancer coming back. For most cancers, there is little solid evidence that can guide people in this direction. This doesn’t mean that nothing will help — it’s just that for the most part this is an area that hasn’t been well-studied. Most studies have looked at ways of preventing cancer in the first place, not preventing its return.

However, some studies have pointed to things people can do that might help reduce the risk of colorectal cancer returning.

Exercise: Two recent studies of people with earlier stage (I, II, or III) colorectal cancers showed that about 4 to 5 hours of brisk walking per week might reduce the chance of dying from cancer (or from other causes). More studies are needed to see if this is true.

Diet: In a large study of patients with stage III colon cancer, those who ate the most meat, fat, refined grains, and desserts were about 3 times more likely to have a return of their cancer than those who ate the lowest levels. More research is needed to confirm these results.

How about your emotional health?

Once your treatment ends, you may find yourself overwhelmed by emotions. This happens to a lot of people. You may have been going through so much during treatment that you could only focus on getting through your treatment.

Now you may find that you think about the potential of your own death, or the effect of your cancer on your family, friends, and career. You may also begin to re-evaluate your relationship with your spouse or partner. Unexpected issues may also cause concern — for instance, as you become healthier and have fewer doctor visits, you will see your health care team less often. That can be a source of anxiety for some.

This is an ideal time to seek out emotional and social support. You need people you can turn to for strength and comfort. Support can come in many forms: family, friends, cancer support groups, church or spiritual groups, online support communities, or individual counselors.

Almost everyone who has been through cancer can benefit from getting some type of support. What’s best for you depends on your situation and personality. Some people feel safe in peer-support groups or education groups. Others would rather talk in an informal setting, such as church. Others may feel more at ease talking one-on-one with a trusted friend or counselor. Whatever your source of strength or comfort, make sure you have a place to go with your concerns.

The cancer journey can feel very lonely. It is not necessary or realistic to go it all by yourself. And your friends and family may feel shut out if you decide not include them. Let them in — and let in anyone else who you feel may help. If you aren’t sure who can help, call your American Cancer Society at 1-800-227-2345 and we can put you in touch with a group or resource that might work for you.

You can’t change the fact that you have had cancer. What you can change is how you live the rest of your life — making healthy choices and feeling as well as possible, physically and emotionally.

What happens if treatment is no longer working?

If cancer continues to grow after one kind of treatment, or if it returns, it is often possible to try another treatment plan that might still cure the cancer, or at least shrink the tumors enough to help you live longer and feel better. On the other hand, when a person has had several different treatments and the cancer has not been cured, over time the cancer tends to become resistant to all treatment. At this time it’s important to weigh the possible limited benefit of a new treatment against the possible downsides, including continued doctor visits and treatment side effects. Should your cancer come back the American Cancer Society document, When Your Cancer Comes Back: Cancer Recurrence, gives you information on how to manage and cope with this phase of your treatment.

This is likely to be the most difficult time in your battle with cancer — when you have tried everything medically within reason and it’s just not working anymore. Although your doctor may offer you new treatment, you need to consider that at some point, continuing treatment is not likely to improve your health or change your prognosis or survival.

If you want to continue treatment to fight your cancer as long as you can, you still need to consider the odds of more treatment having any benefit. In many cases, your doctor can estimate the response rate for the treatment you are considering. Some people are tempted to try more chemotherapy or radiation, for example, even when their doctors say that the odds of benefit are less than 1%. In this situation, you need to think about and understand your reasons for choosing this plan.

Everyone has his or her own way of looking at recurrence. Some people may want to focus on remaining comfortable during their limited time left.

No matter what you decide to do, it is important that you be as comfortable as possible. Make sure you are asking for and getting treatment for any symptoms you might have, such as pain. This type of treatment is called “palliative” treatment.

Palliative treatment helps relieve these symptoms, but is not expected to cure the disease; its main purpose is to improve your quality of life. Sometimes, the treatments you get to control your symptoms are similar to the treatments used to treat cancer. For example, radiation therapy might be given to help relieve bone pain from bone metastasis. Or chemo might be given to help shrink a tumor and keep it from causing a bowel obstruction. But this is not the same as receiving treatment to try to cure the cancer.

At some point, you may benefit from hospice care. Most of the time, this can be given at home. Your cancer may be causing symptoms or problems that need attention, and hospice focuses on your comfort. You should know that getting hospice care doesn’t mean you can’t have treatment for the problems caused by your cancer or other health conditions. It just means that the focus of your care is on living life as fully as possible and feeling as well as you can at this difficult stage of your cancer.

Remember also that maintaining hope is important. Your hope for a cure may not be as bright, but there is still hope for good times with family and friends — times that are filled with happiness and meaning. In a way, pausing at this time in your cancer treatment is a chance to refocus on the most important things in your life. This is the time to do some things you’ve always wanted to do and to stop doing the things you no longer want to do.

What’s new in colorectal cancer research?

Research is always going on in the area of colorectal cancer. Scientists are looking for ways to prevent this cancer, as well as ways to improve treatments.

Genetics

Scientists are learning more about some of the changes in DNA that cause cells of the colon and rectum to become cancer. This knowledge is already being used in genetic tests to inform people most at risk. At some point, this knowledge could also lead to new drugs treatments to fix these gene problems.

Chemoprevention

Chemoprevention is the use of natural or man-made chemicals to lower a person’s risk of getting cancer. Researchers are testing whether certain substances such as fiber, minerals, vitamins, or drugs can lower colorectal cancer risk. Some studies have found that people who take multivitamins with folic acid (folate), vitamin D supplements, or calcium may have a lower colorectal cancer risk. Research into this question is now being done. Most experts say that people should not take large doses of vitamins or minerals unless they are part of a study or are under the care of a doctor.

Taking aspirin or some drugs much like it (called “non-steroidal anti-inflammatory drugs” or NSAIDs) is linked to a lower risk of colorectal cancer. But these drugs can cause stomach ulcers and other side effects. For this reason, taking NSAIDs just for this purpose is not recommended for people at average colorectal cancer risk. If you are at higher risk for colorectal cancer, you should talk to your doctor about whether to take these drugs as prevention measure.

Most studies have found that a diet high in fruits and vegetables may lower colorectal cancer risk, as well as the risk of some other diseases. This hasn’t been completely proven by all studies. But it is important that you eat enough servings — at least 5 a day!

Earlier detection

Studies are going on to look at how well current colorectal cancer screening methods work and to explore new ways to tell the public about the importance of using these methods. Only about half of Americans over 50 have had any colorectal cancer testing at all. If everyone were tested, tens of thousands of lives could be saved each year. Meanwhile, new tests are also being developed.

Treatment

Surgery

Surgeons continue to find better ways to operate on colorectal cancers. They now know more about what makes colorectal surgery more likely to be successful, such as making sure enough lymph nodes are removed during the operation.

Laparoscopic surgery, which is done through several small cuts (incisions) instead of one large one, is becoming more widely used for some colon cancers. This allows patients to recover faster, with less pain after the operation. This surgery is also being studied for treating some rectal cancers.

Robotic surgery, in which the surgeon sits at a control panel and operates very precise robotic arms to do the surgery, is also being studied.

Chemo

Many new chemo drugs (or drugs that are now used against other cancers) are now being tested to treat colorectal cancer. Also under study are ways to combine and improve drugs already being used against colorectal cancer. Still other studies are testing the best ways to combine chemo with other treatments.

Targeted therapy

Some targeted therapies are already used to treat colorectal cancer. Doctors are looking at the best way to give these drugs. They are also looking at dozens of new ones to increase the treatment choices for people with colorectal cancer. And newer studies are looking at using them with chemo in earlier stage cancers to reduce the risk of recurrence.

Immunotherapy

Vaccines that could treat colorectal cancer or keep it from coming back after treatment are being studied. Unlike vaccines that prevent other diseases, these vaccines are meant to boost the patient’s immune reaction to better fight colorectal cancer. At this time, such vaccines are only available in clinical trials.

How can I learn more?

From your American Cancer Society

The following related information may also be helpful to you. These materials may beordered from our toll-free number, 1-800-227-2345.

After Diagnosis: A Guide for Patients and Families (also available in Spanish)

Clinical Trials: What You Need to Know

Colostomy: A Guide (also available in Spanish)

Ileostomy: A Guide (also available in Spanish)

Nutrition for the Person With Cancer: A Guide for Patients and Families (also available in Spanish)

Sexuality for the Man With Cancer (also available in Spanish)

Sexuality for The Woman With Cancer (also available in Spanish)

Surgery (also available in Spanish)

Understanding Chemotherapy: A Guide for Patients and Families (also available in Spanish)

Understanding Radiation Therapy: A Guide for Patients and Families (also available in Spanish)

Living with Uncertainty: The Fear of Cancer Recurrence

When Your Cancer Comes Back: Cancer Recurrence

Books

The following books are available from the American Cancer Society. Call us at 1-800-227-2345 to ask about costs or to place your order.

The American Cancer Society’s Complete Guide to Colorectal Cancer

Cancer in the Family: Helping Children Cope With a Parent’s Illness

Caregiving: A Step-By-Step Resource for Caring for the Person With Cancer at Home

Couples Confronting Cancer: Keeping Your Relationship Strong

Eating Well, Staying Well During and After Cancer

What Helped Get Me Through: Cancer Survivors Share Wisdom and Hope

National organizations and Web sites*

Along with the American Cancer Society, other sources of information and support include:

American College of Gastroenterology
Web site: www.acg.gi.org

American Gastroenterological Association
Web site: www.gastro.org

American Society of Colon and Rectal Surgeons
Web site: www.fascrs.org

C3: Colorectal Cancer Coalition
Toll-free number: 1-877-4CRC-111 (1-877-427-2111)
Web site: www.fightcolorectalcancer.org

Colon Cancer Alliance
Toll-free number: 1-877-422-2030
Web site: www.ccalliance.org

National Cancer Institute
Toll-free number1-800-4-CANCER (1-800-422-6237)
TTY: 1-800-332-8615
Web site: www.cancer.gov

National Colorectal Cancer Research Alliance
Web site: www.eif.nccra.org

Other resources*

The following book describes one woman’s experience with colon cancer and the health care system. The book provides lessons about how to deal with unexpected life-threatening illnesses; how to identify and assess treatment options; how to talk with health care providers; and how to find your way through the health care system.

Kingson, Eric R. Lessons from Joan: Living and Loving with Cancer, a Husband’s Story. Syracuse University Press. Syracuse, NY. www.SyracuseUniversityPress.syr.edu

*Inclusion on this list does not imply endorsement by the American Cancer Society.

No matter who you are, we can help. Contact us anytime, day or night, for information and support. Call us at 1-800-227-2345 or visit www.cancer.org.

Last Medical Review: 6/7/2009
Last Revised: 6/7/2009
2009 Copyright American Cancer Society