• Colorectal Cancer

     "Colorectal cancer is the second most common cancer in the United states affecting over 140,000 people annually and causing 60,000 deaths. Screening substantially decreases the risk of colorectal cancer. Advances not only in surgical techniques but in oncology and radiation oncology have improved survival and outcomes for patients."
    -Patricia L Roberts, MD, FACS, FASCRS, chair of Lahey's Department of Colon and Rectal Surgery

    Overview

    The colon, which makes up the final portion of the digestive tract, is also called the large intestine or large bowel. A long muscular tube, the colon and rectum store fecal material which then passes through the anus. In terms of size, the digestive tract is quite large: the small intestine measures 20 feet; and the colon and rectum are 4 to 6 feet.

    The majority of colorectal cancers begin in polyps-small growths on the lining of the colon and rectum. Over time, polyps can grow larger, and sometimes become cancers. The majority of colorectal cancers arise in polyps. Although colon cancer and rectal cancers may produce different symptoms, at an early stage they may be asymptomatic. More than 95 percent of colonrectal cancers are known as adenocarcinomas. The remaining 5 percent are far less common and include tumors arising from hormone-producing cells in the intestine, rare stromal tumors and lymphomas that typically arise in the lymph nodes, but may also start in the colon. More information about these less common malignancies can be found at the American Cancer Society's Web site. 

    When diagnosed early, colon cancer is often curable. With increasing awareness of the importance of colorectal cancer screening, the incidence of colorectal cancers and cancer deaths have declined over the past 15 years. Screening programs allow for detection of polyps (which can be removed to decrease the risk of cancer) or detection of cancers at an earlier stage.

    Our team of Lahey colon and rectal surgeons, radiation oncologists and medical oncologists work together in a multidisciplinary fashion to treat patients with colorectal cancer. Our team has expertise with open and laparoscopic colorectal resections, sphincter sparing procedures, and transanal endoscopic mircrosurgical resections (TEM's). Lahey's Department of Colon and Rectal Surgery is the largest group of colon and rectal surgeons in New England. At Lahey, the Department of Colorectal Surgery works closely with medical oncologists and radiologists to offer patients personalized treatment plans based on cutting-edge research and the most sophisticated techniques. 
     

    Risk Factors

    Although colorectal cancer may occur at any point in life, the risk increases with age. More than 90 percent of patients are over 50, and the risk doubles every decade after. Although colon polyps can turn cancerous for many reasons, there are some established factors that may put one at higher risk for colorectal cancer: 

    • Family history of colorectal cancer
    • Family history of colon polyps 
    • Personal history of colon polyps, inflammatory bowel disease (ulcerative colitis), Crohn's Disease or previous cancer, particularly tumors of the breast and uterus
    • Excessive consumption of alcohol, red meat, and fatty foods
    • Low intake of fruits and vegetables
    • Smoking
    • Obesity 
    • Sedentary lifestyle

    People with diabetes have a 30 percent higher risk of developing the disease. Colon cancer can also be hereditary. Although experts believe fewer than 10 percent of colon cancer cases are inherited, risk assessment is important. Familial adenomatous polyposis-which fortunately is extremely rare-begins at a very young age, causing hundreds, even thousands of polyps to grow throughout the colon. Lynch Syndrome is another common hereditary condition affecting blood relatives within one family. Given these strong family connections, many hospitals, including Lahey, have established special departments to track hereditary cases; educate patients and families about colorectal cancer risk; provide genetic counseling and testing when needed; promote early diagnosis and conduct research into family colorectal syndromes. Click here for more information about the Lahey Hereditary Colon and Rectal Cancer Registry.  

    Prevention

    The most important thing you can do to avoid colorectal cancer is to undergo regular screening exams beginning at age 50. This cannot be emphasized strongly enough: physicians estimate up to 50 percent of all colon cancers could be prevented by undergoing recommended tests, including:

    • Digital rectal exam (yearly): usually performed during your annual physical
    •  Fecal occult blood test (yearly): performed in the laboratory to detect very small amounts of blood in the stool
    •  Flexible sigmoidoscopy (every 5 years): a short in-office procedure done with a thin, lighted tube your doctor uses to examine the rectum and lower colon
    •  Colonoscopy (every 5 or 10 years): a more comprehensive evaluation of the full colon, usually performed in a hospital or clinic. Physicians use a longer tube to examine the full length of the colon and remove any polyps found during the examination.
    •  Virtual colonoscopy is a fairly new test that uses computerized tomography (CT) scanning to create a 3-D view of the colon. While somewhat more comfortable than the standard form, virtual colonoscopy does not allow the doctor to remove and biopsy polyps. Therefore, it is not ideal for every patient and must be discussed with your physician. Expert radiologists at Lahey can perform this test if standard colonoscopy is not appropriate.

    In addition to regular screenings to prevent colorectal cancer, medical experts advise you to make the following changes in your diet and lifestyle:

    • Increase your consumption of fruits and vegetables
    • Eat food with less animal fat (such as meat, particularly red meat)
    • Avoid meat, poultry, and fish that is charred, burned, or heavily browned from cooking methods such as grilling, which have been associated with development of colon cancer
    • Get regular exercise and maintain a healthy weight
    • Avoid, or stop, smoking

    Symptoms

    One of the reasons early detection of colorectal cancer is so important is that the disease produces few or no symptoms until it is advanced. If you have any of the following symptoms, talk to your doctor right away, as it may be a sign of colon cancer: 

    • Rectal bleeding or blood in the stool
    • Change in bowel habits (constipation, diarrhea, flatulence, or continued urge to evacuate even after doing so)
    • Change in stool appearance (long and narrow, floating, increased mucous, unusual smell)
    • Chronic abdominal pain or increased episodes of cramping
    • Yellowing or jaundice of the skin, eyes or tongue
    • General fatigue or weakness that could be a sign of anemia Based on your symptoms, your physician may order one of the screening tests discussed above and/or blood work to detect anemia or tumor markers-substances in the blood that can signal a return of disease in patients with previous colorectal cancer. Polyps found during colonoscopy are immediately biopsied.

    Diagnosis and Staging

    Diagnosis of colorectal cancer is confirmed through biopsy. Following surgical removal of the polyps, additional imaging studies may be performed to evaluate affected tissues and determine how advanced the cancer is-its stage-before determining the next step in treatment. Such tests may include endorectal ultrasound, computed tomography (CT) and positron emission tomography (PET) scans, magnetic resonance imaging (MRI) and angiography.

    Physicians diagnose colorectal cancers based on their location-how far it has spread beyond the wall of the colon or rectum. While colorectal tumor staging is complex, here is a brief description of the primary categories: 

    • Stage 0: Referred to by doctors as "carcinoma in situ," this means the abnormal or malignant cells are confined to the mucosa of the colon
    • Stage 1: The cancer has spread to a second or third layer of tissue and now affects the inside wall of the colon. However, it has not spread outside the colon wall.
    • Stage 2: The cancer has progressed beyond the muscular wall of the colon and invaded the fatty or thinner skin tissues enclosing the colon and rectum
    • Stage 3: The cancer has spread to lymph nodes in the area, but not to other parts of the body
    • Stage 4: The cancer has metastasized to other parts of the body such as the liver and lungs

    Treatments

    Although colon and rectal cancers are treated somewhat differently given their different locations and characteristics, they both employ one or more of the following general treatment approaches. 

    Surgery

    Surgery, referred to as colectomy, is the primary treatment for colorectal cancer. During colectomy, the surgeon removes the tumor, surrounding colorectal tissue, and possibly the nearby lymph nodes. In most cases of colon cancer, the physician is able to reconnect the healthy portion of the colon. If this is not possible, patients may require a temporary or permanent colostomy or ileostomy-creation of a surgical opening through the abdomen into the colon to facilitate collection of bodily waste in a special bag worn outside the body. 

    Radiation Therapy

    Radiation therapy applies high-dose energy such as X-rays directly on small areas of the body, to destroy or reduce the size of any malignant tissues remaining after surgery. It may be used alone or in combination with drug therapy to treat colorectal cancer. Depending on the location and stage of the tumor, physicians may use the combined approach-called chemo-radiation-to kill cancer cells prior to surgery. 

    Chemotherapy

    Chemotherapy-a class of powerful, specialized anticancer drugs given by mouth or intravenously-is used to shrink tumors or as adjuvant (additional) therapy to help prevent cancer from returning after surgery. Because chemotherapy medications act systemically-that is, they work throughout the body-they usually have side effects. Chemotherapy's effectiveness for treating colorectal cancer has seen tremendous advances over the past decade. Survival is almost four times longer than it used to be for patients with widespread disease, and the rate of cure after surgery has increased by up to 40 percent through the use of modern chemotherapy. 

    New and emerging treatments for colorectal cancer

    New treatment approaches are continually being developed or adjusted for use in attacking every stage of colorectal cancer. What follows are some of the more innovative therapies currently available at Lahey Hospital & Medical Center. 

    Monoclonal antibody therapy

    In recent years, exciting treatment breakthroughs have been made using targeted biologic products that work directly and exclusively on cancer cells, sparing healthy tissue. One class of biologic drugs involves monoclonal antibodies-natural proteins, produced in laboratories, that work by attaching to malignant cells and blocking the specific cell receptors that promote cell growth and replication. Cetuximab and Panitumumab are monoclonal antibodies administered intravenously to block a key receptor that signals colorectal cancer cells to growth and divide. Used with standard chemotherapy agents, they have been shown to increase overall effectiveness in treating colon cancer. Another monoclonal antibody, bevacizumab, acts to prevent angiogenesis-the development of oxygen-supplying blood vessels that feed and promote growth of cancer cells. For patients with advanced colorectal disease, bevacizumab can shrink cancers and extend survival time. 

    Surgical innovations

    Laparoscopy: Since the 2004 publication of a groundbreaking study comparing laparoscopic colectomy to traditional open abdominal surgery, laparoscopy has become the surgical method of choice for patients with colon cancer. Laparoscopy allows surgeons to remove tumors and repair colorectal structures using long thin instruments passed through tiny incisions in the outer abdomen. The advantages of this minimally invasive technique are numerous: shorter recovery time, less scarring, and less potential for long-bowel obstruction. All Lahey colorectal surgeons are trained to perform laparoscopic colectomy; every year, two Lahey surgeons teach courses to outside surgeons eager to learn the new technique.
    Transanal endoscopic microsurgery (TEMS) is a special procedure designed to remove small early stage tumors in the rectum directly through the anus. Although only 10 percent of rectal cancers can be treated this way, TEMS offers new opportunities for positive, long-term results when combined with radiation or chemoradiation.

    Colorectal cancer research at Lahey

    As with most forms of cancer, colorectal cancer is a highly active area of clinical research. The Department of Hematology and Oncology at Lahey Hospital & Medical Center is working on a number of investigational protocols for patients with both early and advanced colorectal cancers. Lahey physicians participate in important studies assessing the effectiveness of new surgical techniques and chemotherapy combinations, all with the goal of improving outcomes for patients with colorectal cancer. Learn about our current trials

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