Gastroenterology involves the health of the digestive system. This includes the colorectal, gallbladder and bile duct, stomach, pancreatic and liver.
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- What is colorectal cancer?
- What are the types of cancer in the colon and rectum?
- What are the symptoms of colorectal cancer?
- How is colorectal cancer diagnosed?
- What are the stages of colorectal cancer?
- The TNM system for colorectal cancer
- Stage groupings
- Colorectal Cancer: Treatment Choices
- Types of treatment for colorectal cancer
- Clinical trials for new treatments
What is cancer?
Cancer is when cells in the body change and grow out of control. Your body is made up of tiny building blocks called cells. Normal cells grow when your body needs them, and die when your body does not need them any longer.
Cancer is made up of abnormal cells that grow even though your body doesn't need them. In most cancers, the abnormal cells grow to form a lump or mass called a tumor. If cancer cells are in the body long enough, they can grow into (invade) nearby areas. They can even spread to other parts of the body (metastasis).
Colorectal cancer is cancer that starts in either your colon or your rectum. These make up the lower part of your digestive tract. In most cases cancer does not start in both the colon and rectum. But both types of cancer have a lot in common. So they are often called colorectal cancer.
Understanding the colon and rectum
The colon is a muscular tube about 5 feet long that forms the last part of the digestive tract. It absorbs water from the remaining food matter. The rectum is the last 6 inches of the digestive tract. It acts as a storage space before waste (feces or stool) leaves the body through the anus. Together, the colon and rectum make up the large intestine. This is sometimes called the large bowel. The colon and rectum have an inner lining made of millions of cells. Changes in these cells can lead to growths in the colon that can become cancer.
Here is an overview of the types of cancer that can start in the colon and rectum:
- Adenocarcinoma. The most common type of colorectal cancer. More than 95% of colorectal cancers are adenocarcinoma. This cancer starts in the lining of internal organs. The tumors start in gland cells that release, or secrete, fluids.
Other types of cancer that can start in the colon or rectum are much less common:
- Gastrointestinal stromal tumor (GIST). These tumors start in special cells in the wall of the digestive tract. They may be found anywhere in the digestive tract. But they rarely appear in the colon. They may be benign, or not cancer, at first. But many do turn into cancer.
- Lymphoma. This cancer starts in a type of immune cell called a lymphocyte. Lymphomas often start in bean-sized groups of lymphocytes, called lymph nodes. But they can also start in the colon, rectum, or other organs.
- Carcinoid. This cancer starts in special hormone-making cells in the intestine.
- Sarcoma. These tumors start in blood vessels, muscle, or connective tissue in the colon and rectum wall.
How colorectal cancer starts and grows
Changes that occur in the cells that line the inside of the colon or rectum can lead to growths called polyps. Over time, some types of polyps can become cancer. Removing polyps early may stop cancer from ever forming.
- Polyps are fleshy clumps of tissue that form on the inner lining of the colon or rectum. Small polyps are usually not cancer. But over time, the cells in a type of polyp known as an adenomatous polyp, or adenoma, can change and become cancer. The longer a polyp is there and the larger it grows, the more likely this is to happen.
- Colorectal cancers most often start when cells in a polyp begin growing abnormally. As a cancer tumor grows, it can invade into the deeper layers of the colon or rectal wall. Over time, the cancer can grow beyond the colon or rectum and into nearby organs. Or it can spread to nearby lymph nodes. The cancer cells can also travel to other parts of the body, where they can form new tumors. This is known as metastasis. If colorectal cancer spreads, it most often goes to the liver first. But it can also spread to other organs.
Talk with your healthcare provider
If you have questions about colorectal cancer, talk with your healthcare provider. Your healthcare provider can help you understand more about this cancer.
People with colorectal cancer often do not have symptoms right away. By the time symptoms appear, the cancer may have grown or spread to other organs, which may make treating it harder. That’s why routine screening is important.
As cancers in the colon and rectum grow, warning signs may arise. You should tell your health care provider and get prompt medical attention if you notice any of these symptoms:
- A change in bowel habits that lasts for more than a few days, including diarrhea, constipation, or a sensation that your bowel is still not empty after a bowel movement
- Bright red or very dark blood in your stool
- Constant tiredness
- Pica (unusual food cravings), such as for ice
- Stools that are thinner than usual
- Stools that appear slimy or that have a mucous film on them
- Persistent gas pains, bloating, fullness, or cramps
- Unexplained weight loss
These symptoms may be caused by colorectal cancer or by other, less serious conditions. It is important to check with your healthcare provider to be sure.
When to see your healthcare provider
Many of these symptoms may be caused by other, more common health problems. But it is important to see your healthcare provider if you have these symptoms. Only a healthcare provider can tell if you have colorectal cancer.
Your doctor might suspect you have colorectal cancer based on the results of a screening test to look for the cancer early. Or you might have symptoms that could be caused by colorectal cancer. If your healthcare provider thinks you might have colorectal cancer, you will need certain exams and tests to be sure. Diagnosing colorectal cancer starts with your healthcare provider asking you questions. He or she will ask you about your health history, your symptoms, risk factors, and family history of disease. Your healthcare provider will also give you a physical exam.
What is a biopsy?
A biopsy is the removal of cells or tissue to be examined under a microscope. This exam can show whether the tissue is cancerous. For colorectal cancer, a biopsy is needed to be sure of the diagnosis. The most common type of biopsy is an endoscopic biopsy, which is usually done during a colonoscopy. Other types of biopsies that your healthcare provider may use include a needle biopsy and a surgical biopsy. But these are not often used to diagnose colorectal cancer. Needle biopsies are sometimes used in other parts of the body to see if the cancer has spread. Surgical biopsies are used to take samples of large tumors. They are also used for tumors in hard-to-reach places.
Once your healthcare provider removes the tissue, he or she sends it to a lab. There a doctor called a pathologist looks at the tissue under a microscope to check for cancer cells. It usually takes several days for the results of your biopsy to come back. A biopsy is the only sure way to tell if you have cancer and the only way to tell what kind of cancer it is.
Here are descriptions of the three types of biopsies your health care provider may do:
The most common biopsy done to diagnose colorectal cancer is done during a colonoscopy or a sigmoidoscopy. These are screening and diagnostic tests that use an endoscope. An endoscope is a tube with a small video camera on the end used to look inside your rectum and colon. There are specific types of endoscopes used depending on what part of your body the healthcare provider is looking at. For a colonoscopy, the healthcare provider uses a colonoscope. For a sigmoidoscopy, a sigmoidoscope is used. It is shorter and can only reach about one-third of the colon. If the healthcare provider finds a polyp or growth in the colon or rectum during one of these tests, he or she most likely will remove it using instruments passed down the endoscope. After cutting it from your colon wall, the healthcare provider will take it out through the tube being used to see inside you. The removal is called a polypectomy. Your healthcare provider then sends the polyp to the lab to be checked for cancer. If the healthcare provider sees a mass or some other type of unusual tissue, he or she will remove a portion of it through the tube and send it to the lab. The lab will then be able to determine whether it is cancer.
There are two types of needle biopsies. One is a fine needle biopsy. For it, the health care provider uses a fine needle and syringe to remove liquid and a very small sample of tissue. The other is a core needle biopsy. The needle for this procedure is slightly larger. The health care provider takes out a small sample of tissue about one-sixteenth of an inch in diameter. These biopsies are sometimes done to examine tissue from a tumor or a mass the healthcare provider has found in some other part of your body such as the liver. They can help the healthcare provider know whether the cancer has spread. To perform a needle biopsy, the healthcare provider inserts a needle into the tumor and withdraws a sample of tissue. The biopsy can be done in the healthcare provider's office using a local anesthetic for tumors the doctor can feel. For tumors that can't be felt, the healthcare provider may use a CT scan to help guide the placing of the needle. CT scans are very accurate X-rays that take detailed pictures of the inside of your body. Sometimes healthcare providers use an ultrasound image to help guide the insertion of the needle. These types of biopsies are done in a special operating room. A needle biopsy usually takes only a few minutes. It doesn't require you to stay in the hospital overnight.
Most biopsies can be performed with one of the above techniques. However, if the polyp or the mass the health care provider wants to examine is large or in a hard-to-reach spot, you may need to have surgery. You'll be given general anesthesia so that you fall asleep and don't feel anything. You will also probably have to stay overnight in the hospital. It may take several days before you can go back to your normal routine. Sometimes you need a formal surgical procedure even for a biopsy.
Most polyps are benign. That means they are not cancerous. Microscopic exam will reveal the nature of the polyps and whether dysplasia, which is abnormal cell growth, or carcinoma, which is cancer, is present. If you do not have cancer but do have a dysplastic polyp, you are at higher risk for developing more polyps or even cancer.
Getting your test results
When your healthcare provider has the results of your biopsy, he or she will contact you with the results. Your provider will talk with you about other tests you may need if colorectal cancer is found. Make sure you understand the results and what follow-up you need.
What does stage of cancer mean?
The stage of a cancer is how much and how far the cancer has spread in your body. Your healthcare provider uses exams and tests to find out the size of the cancer and where it is. He or she can also see if the cancer has grown into nearby areas, and if it has spread to other parts of your body. The stage of a cancer is one of the most important things to know when deciding how to treat the cancer.
Colorectal cancer starts in the inner lining of the colon or rectum. As colorectal cancer grows, it can grow through the layers of the wall of the colon or rectum. Then, like all cancers, it can spread, or metastasize, to other parts of the body.
The most commonly used system to stage colorectal cancer is the TNM system from the American Joint Committee on Cancer. Staging is very important for deciding what treatment to use. Be sure to ask your healthcare provider to explain the stage of your cancer to you in terms you can understand.
The first step in staging your cancer is to decide the value for each part of the TNM system. Here's what the letters stand for in the TNM system:
- T tells how far the main tumor has spread into the lining of your colon or rectum and nearby tissue.
- N tells whether or not the lymph nodes in the area of the original tumor have become cancer.
- M tells whether or not the cancer has spread to other distant organs in the body, such as the liver, lung, or lining of your belly or abdomen.
Number values are assigned to the T, N, and M categories. There are also 2 other values that can be assigned:
- X means the provider does not have enough information to assess the tumor size, lymph node involvement, or spread of the cancer. This value is often assigned before surgery.
- In situ means the cancer is in its earliest stages and has not spread beyond the first layer of the colon or rectum wall.
Stage groupings are determined by combining the T, N, and M values from the TNM system. These groupings give an overall description of how advanced your cancer is. A stage grouping can have a value of 0 or of Roman numerals I through IV. The higher the number, the more advanced your cancer is.
These are the stage groupings of colorectal cancer and what they mean:
Stage 0. Cancer is only in the innermost lining of your colon or rectum. It has not spread and is in its earliest stage. This stage is also called carcinoma in situ.
Stage I. The cancer has spread to the middle layers of the lining of your colon or rectum. It has not spread to the lymph nodes or distant sites
Stage II. This stage is divided into 3 groups:
- Stage IIA. The cancer has grown into the outermost layers of the colon or rectum but has not gone through them. It still has not spread to the lymph nodes or to distant sites.
- Stage IIB. The cancer has grown through the wall of the colon or rectum but has not grown into nearby organs. It has not spread to nearby lymph nodes or distant sites.
- Stage IIC. The cancer has grown outside your colon to nearby tissues or organs. But it has still not spread to the lymph nodes or to distant sites.
Stage III. This stage is divided into 3 groups:
- Stage IIIA. One of the following applies:
- The cancer has spread to the first or middle layers of your colon or rectum wall. It has also spread to 1 to 3 lymph nodes. It hasn't spread to distant sites.
- The cancer has grown into the first layer of the colon or rectum wall. It has also spread to 4 to 6 nearby lymph nodes. It hasn't spread to distant sites.
- Stage IIIB. One of the following applies:
- The cancer has grown into or through the outer layers of the colon or rectum. But it hasn't spread to nearby organs. It has spread to 1 to 3 nearby lymph nodes. It has not spread to distant sites.
- The cancer has grown into the middle or outer layers of the colon or rectum. It has spread to 4 to 6 nearby lymph nodes. It hasn't spread to distant sites.
- The cancer has grown into the first or middle layers of the colon or rectum. It has spread to 7 or more nearby lymph nodes. It hasn't spread to distant sites.
- Stage IIIC. One of the following applies:
- The cancer has grown through the outer layers of the colon or rectum but hasn't reached nearby organs. It has spread to 4 to 6 nearby lymph nodes. But it hasn’t spread to distant sites.
- The cancer has grown into or through the outer layers of the colon or rectum but hasn't reached nearby organs. It has spread to 7 or more nearby lymph nodes. But it hasn’t spread to distant sites.
- The cancer has grown through the outer layers of the colon or rectum and has reached nearby organs. It has spread to 1 or more nearby lymph nodes or into areas of fat near the lymph nodes. But it hasn’t spread to distant sites.
Stage IV. This stage is divided into 2 sub-stages:
- Stage IVA. The cancer may or may not have grown through the wall of the colon or rectum. It may or may not have reached nearby lymph nodes. It has spread to 1 distant organ, such as the lungs or liver. Or it has spread to 1 distant set of lymph nodes.
- Stage IVB. The cancer may or may not have grown through the wall of the colon or rectum. It may or may not have reached nearby lymph nodes. It has spread to more than 1 distant organ, such as the liver or the lungs. Or it has spread to a set of distant lymph nodes. Or it has spread to distant parts of the lining of the abdomen.
Talking with your healthcare provider
Once your cancer is staged, your healthcare provider will talk with you about what the stage means for your treatment. Make sure to ask any questions or talk about your concerns.
There are various treatment choices for colorectal cancer. Which may work best for you? It depends on a number of factors. These include the type, size, location, and stage of your cancer. Factors also include your age, overall health, and what side effects you’ll find acceptable.
Learning about your treatment options
You may have questions and concerns about your treatment options. You may also want to know how you’ll feel and function after treatment, and if you’ll have to change your normal activities.
Your doctor is the best person to answer your questions. He or she can tell you what your treatment choices are, how successful they’re expected to be, and what the risks and side effects are. Your healthcare provider may advise a specific treatment. Or he or she may offer more than one, and ask you to decide which one you’d like to use. It can be hard to make this decision. It is important to take the time you need to make the best decision.
Deciding on the best plan may take some time. Talk with your healthcare provider about how much time you can take to explore your options. You may want to get another opinion before deciding on your treatment plan. In fact, some insurance companies may require a second opinion. In addition, you may want to involve your family and friends in this process.
Understanding the goals of treatment for colorectal cancer
For many colorectal cancers, the goal of treatment is to cure the cancer. If cure is not possible, treatment may be used to shrink the cancer or keep it under control for as long as possible. Treatment can also improve your quality of life by helping control the symptoms of the disease. The goals of colorectal cancer treatment can include:
- Remove the cancer in the colon or rectum
- Remove or destroy tumors in other parts of the body
- Kill or stop the growth or spread of colorectal cancer cells
- Prevent or delay the cancer's return
- Ease symptoms from the cancer, such as pain or pressure on organs
Several types of treatment can be used for colorectal cancer. Different combinations of treatment may be used, depending on the stage of the cancer and other factors. Each treatment has its own goals. Here is an overview of each type of treatment:
- Surgery. This is the most common treatment for most early stages of colon and rectal cancer. The goal of surgery is to remove the entire tumor and any cancer cells that may have spread to nearby tissue. Depending on the stage of the cancer, surgery may be all that's needed. Or surgery may come before or after another treatment is used.
- Chemotherapy. The goal of chemotherapy is to stop cancer from growing or spreading. It does this by using medicines to either kill the cells or stop them from dividing. If the medicines are given in a way that lets them enter the bloodstream, they treat cancer cells throughout the body. That way they can treat cancer that has spread. This type of treatment is called systemic. Medicines can also be given to attack cancer cells in specific organs, such as the liver. This treatment is called local. Chemotherapy might also be used before surgery to shrink tumors. When used before surgery, it is called neoadjuvant therapy. It might be used after surgery to kill or control any remaining cancer cells. When used after surgery, it is called an adjuvant therapy.
- Radiation therapy. The goal of radiation therapy is to kill cancer cells using high-energy X-rays. It has a major role in treating rectal cancers, but it may be used in some colon cancers as well. Like chemotherapy, it may be used before surgery to shrink tumors. This treatment is called neoadjuvant radiation therapy. This may lower the chance that a person will need a permanent colostomy. When it's used after surgery, it is called adjuvant radiation therapy. Then the goal is to reduce the chance that the cancer will come back.
- Targeted therapy. This type of therapy uses medicines that target proteins or cell functions that help cancer cells grow. Some of these medicines are given along with chemotherapy medicines, while others are used by themselves. The goal is to prevent the cancer from growing. It may also be used to help chemotherapy get inside the tumor. This can help it be more effective.
- Ablation and embolization. These methods can be used to treat tumors that have spread to other parts of the body, such as the liver or lungs. Ablation is the use of heat, cold, or other methods to destroy tumors rather than removing them. For embolization, a substance is injected into a blood vessel to try to cut off a tumor's blood supply.
- Supportive care. Your healthcare provider may advise therapies that help ease your symptoms, but don’t treat the cancer. These can sometimes be used along with other treatments. Or your healthcare provider may suggest supportive care if he or she believes that available treatments are more likely to do you more harm than good.
Researchers are also studying other treatments, such as immunologic techniques that could help the body's immune system fight the cancer.
Researchers are always looking for new ways to treat cancer. These new methods are tested in clinical trials. Talk with your doctor to find out if there are any clinical trials you should consider.
Talking with your doctor
At first, thinking about treatment options may seem overwhelming. Talk with your doctors, nurses, and loved ones. Make a list of questions. Consider the benefits and possible side effects of each option. Discuss your concerns with your doctor before making a decision.