Colorectal Cancer: A Current Overview
Colorectal cancer is the third most common non-skin cancer and the second leading cause of cancer-related mortality in men and women in the US and other developed countries. It is estimated that approximately $14 billion is spent each year on colorectal cancer treatment. Approximately 1 million new cases of colorectal cancer are diagnosed every year, and more than half a million people die from this disease, equivalent to approximately 8% of all cancer-related deaths worldwide. Both men and women have similar incidence and mortality rates through age 50 - after 50 years, these rates are higher in men. Overall, colorectal cancer is the fourth most common cancer after skin, prostate and lung cancer in men. In women too, it is the fourth most common cancer after skin, breast and lung cancer. There were close to 150,000 new cases of colon and rectal cancer in the US in 2010 with over 50,000 deaths overall, according to the National Cancer Institute.
African Americans have higher mortality rates than all other racial and ethnic groups as well as higher incidence rates than all except American Indians and Alaska Natives. Incidence and mortality rates are lowest among Hispanics and Asians and Pacific Islanders. Overall colorectal cancer incidence and mortality rates have been declining in the US over the past two decades, which are attributed largely to increased use of screening tests.
Risk factors for colorectal cancer include increasing age, colorectal polyps, a family history of colorectal cancer as well as certain genetic mutations. Effective colorectal cancer screening tests include the fecal occult blood test, sigmoidoscopy and colonoscopy. These screening tests enable detection and removal of polyps that may eventually progress to cancer over time. Standard treatments for colorectal cancer include surgery, chemotherapy, radiation therapy and targeted therapy.
Typically, colorectal cancer cells form in the inner lining of the colon or rectum. Together, the colon and rectum make up the large bowel or large intestine. The large intestine is the last segment of the digestive system and comes after the esophagus, stomach and small intestine. The large bowel's main job is to reabsorb water from the contents of the intestine so that solid waste can be expelled. The first several feet of the large intestine make up the colon, while the last 6 inches make up the rectum.
Most colon and rectal cancers typically originate from "benign" or harmless wart-like growths on the inner lining of the large bowel, called polyps. Not all polyps become cancerous - the ones that do are called adenomas. It typically takes more than 10 years for an adenoma to develop into cancer. This means colon cancer prevention tests are effective even if done at 10-year intervals - although this interval may be too long in people who suffer from ulcerative colitis or Crohn's colitis and who have a strong family history of colorectal cancer or adenomas.
Most early colorectal cancers produce no symptoms, which is why early screening is so important. Symptoms can vary depending on the location of the cancer within the colon or rectum, although there have been cases with no symptoms at all. Overall, the prognosis tends to be worse in symptomatic as compared to asymptomatic individuals. The most common presenting symptom of colorectal cancer is rectal bleeding. Cancers arising from the left side of the colon generally cause bleeding, whereas in their late stages they may cause constipation, abdominal pain and obstructive symptoms. Right-sided colon lesions may lead to vague abdominal aching, but are unlikely to present with obstruction or altered bowel habits. Other symptoms such as weakness, weight loss or anemia resulting from chronic blood loss may accompany cancer of the right side of the colon. Anyone who experiences any of these symptoms should see their physician right away - new onset of abdominal pain, blood in or on the stool, change in stool caliber or shape, change in typical bowel habits, constipation or diarrhea.
In general, it is very important to get checked for colorectal cancer even if there are no symptoms because adenomas can grow for years and transform into cancer without producing any symptoms. By the time symptoms develop, it is often too late to cure the cancer because it may have spread to other areas. Screening identifies cancers earlier and results in cancer prevention by removal of adenomas and pre-cancerous polyps.
Who is at risk for colorectal cancer? Men tend to get colorectal cancer at an earlier age than women, but women live longer so they 'catch up' with men and thus the total number of cases in men and women is equal.
There are several categories of risk:
- Everyone aged 50 years and older - while the average age to develop colorectal cancer is 70 years, more than 90% of cases occur in people who are 50 years or older. Current recommendations are to begin screening at age 50 if there are no risk factors other than age.
- Family history - if a person has two or more first-degree relatives (parent, sibling, or child) with colorectal cancer, or any first-degree relatives diagnosed under age 60, their overall colorectal cancer risk is three to six times higher than that of the general population. For those with one first-degree relative diagnosed with colorectal cancer at age 60 or older, there is an approximate two times greater risk of colon cancer than in the general population. A well-documented family history of adenomas is also an important risk factor.
- Personal history of colorectal cancer or adenomas at any age, or cancer of endometrium (uterus) or ovary diagnosed before age 50 - people who have had colorectal cancer or adenomas removed are at increased risk of developing additional adenomas or cancers. Women diagnosed with uterine or ovarian cancer before the age of 50 years are at increased risk of colorectal cancer. These groups should be checked by colonoscopy at regular intervals, usually every three to five years. Woman with a personal history of breast cancer have only a very slight increase in risk of colorectal cancer.
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