Colorectal Cancer
Volume 4, Number 2 - February/March, 2000
Editors: Carol A. Rice, Ph.D., RN, Professor and Extension Health Specialist, and Janet M. Pollard, MPH, Extension Associate-Health
Inside HealthHints....
- Colorectal Cancer
- Understanding the Anatomy
- Who is at Risk?
- Prevention: Reducing Your Risk
- Early Detection
- Screening Tests
- Colorectal Cancer Warning Signs
- Understanding Colorectal Cancer Formation
- Treatment Options
- Seeking Care: The Barriers
- Seeking Care: Being a Good Health Care Consumer
- Ongoing Colorectal Cancer Projects in Your Area
- Want to Get Information on Cancer Rates in Your County?
- Websites with Reliable Information
- References
Colorectal Cancer
Colorectal cancer, or cancer of the colon or rectum, is the second-leading cause of cancer-related death in the United States. Among cancers that kill both men and women, only lung cancer takes more lives than colorectal cancer. - Centers for Disease Control and Prevention, 1999
The American Cancer Society estimates 94,700 new cases of colon cancer and 34,700 new cases of rectal cancer this year. Colon cancer deaths are estimated to be responsible for 47,900 deaths and rectal cancer for 8,700 deaths this year (American Cancer Society, 1999).
Understanding the Anatomy
The colon and rectum are part of the digestive system. Together they form a long, muscular tube known as the large intestine or large bowel. The colon is the upper five or six feet of the large intestine; the rectum is the last five to eight inches of the large intestine (M. D. Anderson, 2000c; Schatzkin, 1996.)
Due to the anatomic and physiologic similarities of tissue in the colon and rectum, and the occasional difficulty in determining in which region a tumor has arisen, malignancies (cancerous cells/tissue) in these two bowel segments are often lumped together and called colorectal cancer (Schatzkin,1996).
In this issue of HealthHints we will look at colorectal cancer -- prevention, early detection, risk factors, warning signs and symptoms, an overview of treatments and more.
Who is at Risk?
Researchers have found several risk factors that increase a person's chance of having colorectal cancer.
- Hereditary -- Certain inherited conditions, including Familial adenomatous polyps (FAP) and Gardner's syndrome, two conditions that result in a person having many polyps (mushroom-like growths of abnormal cells) in the colon and rectum. These polyps usually develop at a young age with cancer nearly always developing in one or more of the polyps between ages 30 to 50. Another inherited condition, known as Hereditary nonpolyposis is a condition in which colorectal cancer develops at a young age without first having many polyps.
- Family history -- Close relatives of a person who has had colorectal cancer are also at increased risk. The risk is highest for those where several close relatives have had colorectal cancer.
- Polyps -- In addition to hereditary polyps, certain sporadic (not inherited) intestinal polyps are a risk factor -- mainly those classified as adenomas (growths with gland-like characteristics).
- Personal history -- A personal history of certain types of sporadic intestinal polyps, chronic inflammatory bowel disease (also called ulcerative colitis or Chron's colitis in which the colon is inflamed for a long period of time and may contain ulcers), or previous colorectal cancer increases the risk for developing colorectal cancer.
- Age -- Colorectal cancers occur most often in individuals older than age 50. Nine out of ten cases, in fact, are in people older than 50 years of age.
- Diet -- A diet high in fat, especially from animal sources, low in fruits and vegetables, and low in high-fiber foods such as breads and cereals seems to increase colorectal cancer risk.
- Physical inactivity -- A sedentary lifestyle also increases risk. Being even somewhat active lowers the risk of colorectal cancer (American Cancer Society, 1999; M. D. Anderson, Cause and prevention, 2000a; National Cancer Institute, 1991).
Prevention: Reducing Your Risk
Though we don't know exactly what causes colorectal cancer, there are steps you can take to reduce your risk.
- Diet -- Eat a diet rich in fiber (such as whole grains) and low in fat (especially animal fats). Also, eat plenty of fruits and vegetables. Take a multi-vitamin with folate every day. Limit alcohol intake. Maintain a healthy weight.
- Exercise -- Get plenty of exercise. Even small amounts of physical activity on a regular basis can be helpful. Try to be physically active for at least 30 minutes every day.
- Hormone Replacement Therapy (HRT) -- Some studies show that HRT for women after menopause may reduce the risk of colorectal cancer.
- Aspirin intake -- Some studies indicate that aspirin intake may be beneficial in reducing colorectal cancer risk. Consult your doctor for advice on your individual situation.
- Screening -- Most importantly, follow the screening guidelines described below. When found and treated early, colorectal cancer can often be cured (American Cancer Society, 1999; Harvard Center for Cancer Prevention, 2000).
Early Detection
Most health problems respond best to treatment when they are diagnosed and treated as early as possible. This is especially true for colorectal cancer. Treatment is most effective before the disease spreads (M. D. Anderson, early detection, 2000b).
Take an active role in your health by following the American Cancer Society's guidelines for early detection of colorectal cancer below (for descriptions of each test, see the Screening tests box below).
Starting at age 50, men and women should have:
- Yearly fecal occult blood test, and flexible sigmoidoscopy and digital rectal exam every five years
OR - Colonscopy and a digital rectal exam every 10 years
OR - Double contrast barium enema (DCBE) and a digital rectal exam every 5 to 10 years.
Individuals should start screenings earlier and more often if they have any of the following risk factors:
- A strong family history of colon or rectal cancer (mother, father, sister or brother)
- A family history of hereditary colorectal cancer syndromes (see Hereditary under Who is at risk? above for further details)
- A personal history of colon or rectal cancer or chronic inflammatory bowel disease (see Personal History under Who is at risk? above for further details) (American Cancer Society, 1999).
Screening Tests
Digital rectal exam (DRE): For a DRE, the physician inserts a lubricated, gloved finger into the rectum to feel for abnormal areas.
Fecal occult blood test: This test is usually done with a home kit. You follow the simple instructions and provide a stool sample to your health provider. The sample is then tested for blood.
Sigmoidoscopy: During this test, the doctor looks through a thin, lighted tube inserted into the rectum to check for tumors, polyps, or other abnormalities.
Colonscopy: In this procedure, a flexible tube, long enough to reach the full length of the colon, is inserted through the rectum. The tube is hooked to a video camera and display which allows the doctor to see abnormalities. Through this tube, a wire can be inserted which allows the doctor to remove polyps, pieces of a polyp, or other tissue on which he may want to do a biopsy to detect cancerous cells.
Double contrast barium enema: This test is done by injecting a chalky substance to partly fill up and open the colon. Air is then added to expand the colon and x-ray films are taken (American Cancer Society, 1999; National Cancer Institute, 1996).
Colorectal Cancer Warning Signs
Early detection is especially important because colorectal cancer can exist without any symptoms. Some warning signs, however, may exist.
The most common warning signs are:
- Changes in bowel habits, such as diarrhea, constipation, or narrowing of the stool that persists for more than a few days.
- Very dark mahogany red, or bright red blood in or on the stool, or bleeding from the rectum.
- Abnormal discomfort (cramping or gnawing stomach pain).
Other symptoms may include:
- An urgent, painful need to defecate (called tenesmus)
- Feeling of incomplete emptying after a bowel movement
- Decreased appetite or unexplained weight loss
- Anemia
- Unusual paleness
- Jaundice (yellow-green color to the skin and whites of the eyes
- Persistent weakness and fatigue (American Cancer Society, 1999; National Cancer Institute, 1991).
Understanding Colorectal Cancer Formation
The colon and rectum (large bowel) are formed mostly from muscle with an inside lining layer (mucosa). The mucosa lining is able to absorb water so that the bowel can perform it's main functions of absorbing water and retaining waste products until they are evacuated. Underneath the mucosa and muscle layers exist the underlying tissue and lymph nodes.
The formation of colorectal cancer initiates in the mucosa lining of the bowel. In most cases, the first step in the formation of colon cancer is the appearance of a polyp. A polyp looks like a mushroom projecting out of the wall of the large bowel. This happens because the cells in the polyp tend to grow faster than the cells in the surrounding skin, so they become heaped up.
Under a microscope, you can see that the cells in the polyp are abnormal, however, the abnormal cells are, at first, confined to the polyp and do not spread to the polyp stalk (from which the polyp protrudes) or into the bowel wall.
Thus, polyps start out benign (non-cancerous), but if left long enough about one in 20 will become malignant (cancerous).
Polyps only become cancers when the abnormal cells spread beyond the skin and muscular structure of the bowel wall to reach the underlying tissue. Polyps can be removed at the time of colonscopy (see Screening tests above), helping to prevent cancer formation (Mulcahy, 1999). Successful treatment options diminish as cancer penetrates the bowel wall into underlying tissue, and becomes further complicated if the cancer spreads to the lymph nodes, which can carry it to other parts of the body.
Thus, colorectal cancer screening is essential for early detection and the best possible treatment options.
Treatment Options
Because colorectal cancer may exist at different stages (e.g., only in the mucosa lining or spread to the underlying tissues or lymph nodes), health care providers must develop treatment plans to meet the needs of each patient. Your doctor may recommend one or a combination of the following treatments:
- Chemotherapy -- using drugs to kill cancer cells.
- Radiation therapy -- using high-energy rays to damage or destroy cancer cells.
- Biological therapy -- using natural or synthetic substances to boost, direct, or restore the immune system (the bodily system that normally defends against disease) (National Cancer Institute, 1991).
Seeking Care: The Barriers
Screenings for early detection and seeking care for colorectal cancer symptoms are often delayed for some of the following reasons:
- Fear that the detection of colorectal cancer would necessarily mean extensive surgery and colostomy (American Cancer Society, 1993).
- Embarrassment in discussing symptoms with a care provider.
- Discussion about getting colorectal cancer screenings never initiated by the health care provider.
For these reasons it is important that all of us learn to be consumers of our own health care.
According to a Centers for Disease Control and Prevention study comparing health behaviors in each state, fewer than 1/3 of adults over age 50 report having completed a home blood stool test, with 18% the median response. Maine led the country in such screening with 28.5%; only 9.3% of Mississippi residents had performed such a test (Centers for Disease Control and Prevention, 2000).
The prognosis for colorectal cancer is directly related to the extent of disease when it is detected early. When detected in an early localized stage, the five-year survival rate is 91% for colon cancer and 83% for rectal cancer. After cancer has spread to regional areas of the body, the survival rate falls to 60% for colon cancer and 50% for rectal cancer....Early detection [also] reduces the likelihood of major surgery. (American Cancer Society, 1993).
Seeking Care: Being a Good Health Care Consumer
The American public and the medical profession must be alert to the signs of early cancer and the need for prompt diagnosis and treatment (American Cancer Society, 1993).
You can help care for you and your family by learning to be a good health care consumer. Three ways you can help are to:
- Learn and follow the guidelines for screenings and early detection (see Early detection). Initiate conversation about these screenings with your care provider if your provider does not mention them.
- Observe any health problems and make notes about what you observe.
- Prepare for your doctors' visits. Be clear and concise about your problems when leaving messages with a nurse or other care professional.
Observing the Problem
When you observe a health problem, try to make note of the following details:
- When did it start?
- What are the symptoms?
- Where is the pain?
- Dull aches or stabbing pain?
- What are your vital signs?
- temperature
- pulse per minute
- blood pressure
- Have you had this problem before? If so, what did you do for it? Does your self care treatment help?
- Any lifestyle changes (stress, medication, food, exercise, etc.)?
- Does anyone else at home or work have these symptoms?
- Does any close relative have these symptoms (Kemper, 1997)?
Making note of these details and reading a credible self-care health guide, such as the Healthwise Handbook, can help you to:
- make a "tentative diagnosis,"
- plan for any appropriate home care, and
- know when to call your doctor (Kemper, 1997).
Preparing for Doctors' Visits
When it's time to consult your doctor, being your own health care advocate is important. By being prepared with precise information, you can help your doctor provide you the best care.
When preparing for your visit, have the following on hand:
- Written observations from above.
- List of any medications you are using.
- Accounts of previous visits for the same problem.
During your visit:
- State your main problem or concern first. Be as clear as possible. Be specific, yet concise if you can. Most care providers naturally hear and act upon these things they hear first assuming they are the most important observations.
- Describe your symptoms (refer to your written observations).
- Describe past experiences with the same problem.
At the visit, write down the following information for your reference:
- Temperature
- Blood pressure
- Diagnosis (what's wrong)
- Prognosis (what might happen next)
- Self-care recommendations (what you can do at home).
If medications, tests, or treatments are suggested, be sure to ask the following questions:
- What is its name?
- Why is it needed?
- What are the costs and risks?
- Are there alternatives?
- What if I do nothing?
- How do I take this (for medications)?
- How do I prepare (for tests or treatments)?
At the end of your visit, be sure to get answers to the following questions:
- Am I to return for another visit?
- Am I to phone in for test results?
- What danger signs should I look for?
- When do I need to report back or follow up?
- What else do I need to know (Kemper, 1997)?
Be sure to record answers to all the applicable questions so that you have them available when you return home.
Questions About Colorectal Cancer?
For any type of information on colorectal or other cancers, call the National Cancer Institute's Cancer Information Service at 1-800-4CANCER.
Ongoing Colorectal Cancer Project in Your Area
Did you know that there are Texas Cancer Council funded projects addressing colorectal cancer in your area?
West Texas Colon Cancer Project
The West Texas Colon Cancer Project at Hendrick Medical Center in Abilene has a 3-year plan to cover the following counties: Brown, Callahan, Coleman, Comanche, Eastland, Fisher, Haskell, Jones, Kent, Knox, Mitchell, Nolan, Runnels, Scurry, Shackleford, Stephens, Stonewall, Taylor, and Throckmorton.
The mission of the West Texas Colon Cancer Project is "To improve awareness and early detection of colon cancer for underserved, rural individuals."
They are meeting this goal by:
- Providing community educational programs, health fairs, and resource booths.
- Having participants fill out a pre-screening form to determine their level of colorectal cancer risk.
- Partnering with local hospitals to help provide screenings for early detection.
- Referring high-risk individuals to their physicians, and providing average-risk participants with fecal occult blood test cards and instructions for providing stool samples and returning them for testing. Results are then returned to participants and their physicians for further follow up.
The West Texas Colon Cancer Project Director is Sandi Saringer. She can be reached at 915-670-4499 or ssrange@hendrickhealth.org. Feel free to contact her. She would love to partner with you and share ideas about target audiences and how best to reach the individuals in your county with this important information and the appropriate screenings for early detection and saved lives.
Colorectal Cancer Screening for El Paso
The Colorectal Cancer Screening for El Paso project has the mission to create substantial public and private partnerships to provide colorectal screening for underserved individuals initially in El Paso County and eventually throughout the areas covered by the West Texas Community Care Consortium.
Currently the project is working primarily through the Texas Tech University Health Science Center Clinic and the R. E. Thomas General Hospital, as well as four other sites in the area, providing educational materials and personal health educators to those in need of their services.
This is a good opportunity to let your clientele in the El Paso area know about this project should a need for these services arise. You can also contact the project director, Sheila Elias, at 915-545-6995 for further information on this project.
Want to Get Information on Cancer Rates in Your County?
If you would like to have a county cancer profile for your specific county, all you have to do is go to the Texas Cancer Data Center (TCDC) website. Here's how it works:
Go to http://www.txcancer.org/.
Click on Texas Demographics and Statistics.
Click on County Cancer Profiles.
Select your county name.
It's that simple. The TCDC site will provide you a county-specific profile of all types of cancer statistics.
Websites with Reliable Information
- Cancer Gateway Texas [http://www.cancergateway.org/]
- Cancer Prevention Dietary Guidelines (University of Pennsylvania Cancer Center)
[http://www.oncolink.com/experts/article.cfm?c=2&s=8&ss=15&id=1071] - Colon and Rectum Cancer Overview (ACS)
[http://www.cancer.org/docroot/CRI/CRI_2x.asp?sitearea=LRN&dt=10] - Colorectal Cancer (MUSC)
[http://www.ddc.musc.edu/ddc_pub/
digestiveProbs/diseases/colonRectum/colorCancer.htm] - M. D. Anderson Focus on Colorectal Cancer
[http://www.mdanderson.org/diseases/colorectal/] - Your Cancer Risk (Harvard Center for Cancer Prevention)
[http://www.yourcancerrisk.harvard.edu/]
References
- American Cancer Society (1999). Colon and rectum cancer overview [on-line]. Available:
http://www.cancer.org/eprise/main/docroot/CRI/CRI_0?sitearea=. - American Cancer Society (1993). Facts on Colorectal Cancer [brochure]. No. 2004-LE.
- Centers for Disease Control and Prevention (2000). CDC compares health behavior in each state [on-line]. Available: http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/ss4902a1.htm.
- Centers for Disease Control and Prevention (1999). Screen for life: National Colorectal Cancer Action Campaign [on-line]. Available: http://www.cdc.gov/cancer/screenforlife/.
- Harvard Center for Cancer Prevention (2000). Your cancer risk [on-line]. Available: http://www.yourcancerrisk.harvard.edu.
- Kemper, D.W. (1997). Healthwise Handbook: A Self-Care Manual for You, 13th edition. Healthwise, Inc.: Boise, Idaho, pp 1-2.
- M. D. Anderson Cancer Center (2000a). What you need to know about cancer of the colon and rectum: Cause and prevention [on-line]. Available: http://www.mdanderson.org/focus/colon/ntk/cause.htm.
- M. D. Anderson Cancer Center (2000b). What you need to know about cancer of the colon and rectum: Early detection [on-line]. Available: http://www.mdanderson.org/focus/colon/ntk/early.htm.
- M. D. Anderson Cancer Center (2000c) What you need to know about cancer of the colon and rectum: The colon and rectum [on-line]. Available: http://www.mdanderson.org/focus/colon/ntk/default.htm.
- Mulcahy, H. (1999). Colorectal Cancer [on-line]. Available:
http://www.ddc.musc.edu/ddc_pub/
digestiveProbs/diseases/colonRectum/colorCancer.htm. - National Cancer Institute (1991). Cancer of the Colon and Rectum: Research Report [booklet]. NIH Publication No. 92-95.
- National Cancer Institute and James Cancer Hospital and Research Institute (1996). Colorectal Cancer [fact sheet]. For more information, call the James Line: 1-800-293-5066.
- Schatzkin, A.G. (1996). In: Cancer Rates and Risks, 4th Edition. U.S. Department of Health and Human Services, Public Health Service, and National Institutes of Health, NIH Publication No. 96-691.
Acknowledgements:
Thank you to Dr. Mickey Bielamowicz, Nutrition Specialist, for her contributions on preventative dietary guidelines regarding colorectal cancer.
