What Screening Tests Are Available For Colon Cancer?

Screening for colorectal cancer involves special tests performed on people who have no symptoms of a particular illness.

Good screening tests are:

• Safe
• Relatively inexpensive
• Proven effective in detecting the disease at an early stage and reducing the death rate from that disease

Current screening tests for colorectal cancer meet these four requirements and include:

• Digital rectal exam
• Fecal occult blood test (FOBT)
• Flexible sigmoidoscopy
• Colonoscopy

Digital Rectal Exam

During a digital rectal examination (DRE) the doctor inserts a gloved, lubricated finger into the rectum to check for abnormalities. This is a routine part of a physical examination and commonly used to screen for colorectal cancer.

This test is effective in detecting rectal cancer; however, doctors are able to detect only 7 to 10 percent of colorectal cancers since most of the colon cannot be felt by the examiner's finger. The goal of colorectal cancer screening is to detect the cancer before it grows large enough to be felt during such an exam.

By itself, the digital rectal exam is not considered an ideal screening test for colorectal cancer, but rather is used along with other screening tests.

Fecal Occult Blood Test (FOBT)

The fecal occult blood test (FOBT), also called the stool blood test or the guaiac test, is used to detect tiny amounts of blood in a stool sample. This test detects small amounts of blood in the stool that would not be visible.

Stool samples are smeared onto special cards and dropped off at the doctor's office or a laboratory. This is done because tumors may bleed on one day and not the next; therefore, blood may be present in stool on one day and not the next. When colorectal cancer is present, the blood may be dark, or mixed with stool, but you often can't see it. For this reason, the FOBT is important.

Need To Know: Blood in the stool does not always mean you have colorectal cancer. Other causes include: Bleeding ulcers Inflammation of the stomach or gastritis Inflammatory bowel disease (IBD) Hemorrhoids If fecal blood is found, additional tests are done to rule out cancer. Cancer can still be present if the FOBT is negative. This can happen if there was no bleeding when the test was performed. The results may come back negative but cancer is present. This is known as a false negative test.

Flexible Sigmoidoscopy Procedure

During a sigmoidoscopy procedure the doctor inserts a soft flexible, fiberoptic scope into the anus. The walls of the rectum and sigmoid portion of the colon are checked for tumors. A flexible sigmoidoscopy procedure may detect:

• About half of all colon tumors
• Nearly all rectal tumors

If doctors discover a growth or tumor during this procedure, a biopsy will be performed. During a biopsy, a small tissue sample is removed and then prepared for examination under a microscope. The biopsy procedure does not hurt.

Colonoscopy

A colonoscopy is similar to a sigmoidoscopy but is a more thorough examination of the entire colon. Patients receive medications that help them relax during the procedure. A flexible scope with a tiny camera attached is gently guided from the anus through the colon. Looking at the images provided by the camera on a monitor, the doctor examines the inside of the colon for any signs of inflammation, disease, or polyps. During the procedure, the doctor can take a sample of any suspicious areas for further testing, and can remove any polyps that are discovered.

How-To Information: Colon Cancer Screening Guidelines Seventy to 80 percent of all colon cancers occur in adults without known risk factors. The American Cancer Society guidelines recommend adults should begin colon cancer screening by age 50 years, either with: Annual stool occult blood stool tests, sigmoidoscopy, and digital rectal exam every five years, or Colonoscopy and digital rectal exam every 10 years, or Double-contrast barium enema and DRE every five to 10 years. Some experts recommend beginning blood stool tests and a digital rectal exam at age 40. For those who undergo periodic evaluation of the entire colon, no annual FOBT is needed. Those at higher-than-average risk for colon cancer should consult their doctor to begin screening at an earlier age. Their doctors will probably recommend more thorough screening tests, including a colonoscopy or barium enema rather than sigmoidoscopy. People are considered at higher-than-average risk if they have Had colon polyps removed Relatives who developed the disease Inherited colon cancer syndrome A family history of this syndrome

What Are The Symptoms Of Colon Cancer?

The symptoms of colon cancer can be confused with those of a number of digestive disorders. Having one or more of these symptoms does not mean you have cancer. In all cases, people with the following symptoms should contact their doctor:

• Bleeding from the rectum. Sometimes blood can be seen on the toilet tissue or in the toilet bowl after a bowel movement. Other things can cause rectal bleeding other than cancer, but rectal bleeding should never be ignored.

• Changes in bowel habits. These are not usually caused by cancer; however, be sure to discuss such changes with a doctor. If diarrhea or constipation lasts for more than two weeks or bowel habits go back and forth between diarrhea and constipation, or if the stool is unusually narrow, consultation should be made with a doctor.

• Pain in the abdomen or rectum. Discomfort or dull, vague, or sharp pain in the abdomen or rectum may have a number of possible causes. It does not mean that cancer is present but you should make an appointment with your physician.

• A feeling that a bowel movement cannot be completed.

• Unexplained weight loss, unusually low red blood cell counts or anemia, paleness, fatigue, or a yellowish coloring of the skin or whites of the eyes.

Need To Know:

There are many common causes for bleeding from the rectumh such as:

• Hemorrhoids may produce bright red blood from the anus.
• Diverticulosis, in which tiny "pockets" in the wall of the intestine can form and bleed when inflamed or irritated.

Always get checked by a doctor to determine the cause of rectal bleeding and to obtain treatment for the underlying cause of bleeding.

What Are The Symptoms Of Colon Cancer?

The symptoms of colon cancer can be confused with those of a number of digestive disorders. Having one or more of these symptoms does not mean you have cancer. In all cases, people with the following symptoms should contact their doctor:

• Bleeding from the rectum. Sometimes blood can be seen on the toilet tissue or in the toilet bowl after a bowel movement. Other things can cause rectal bleeding other than cancer, but rectal bleeding should never be ignored.
• Changes in bowel habits. These are not usually caused by cancer; however, be sure to discuss such changes with a doctor. If diarrhea or constipation lasts for more than two weeks or bowel habits go back and forth between diarrhea and constipation, or if the stool is unusually narrow, consultation should be made with a doctor.
• Pain in the abdomen or rectum. Discomfort or dull, vague, or sharp pain in the abdomen or rectum may have a number of possible causes. It does not mean that cancer is present but you should make an appointment with your physician.
• A feeling that a bowel movement cannot be completed.
• Unexplained weight loss, unusually low red blood cell counts or anemia, paleness, fatigue, or a yellowish coloring of the skin or whites of the eyes.

Need To Know: There are many common causes for bleeding from the rectum such as: Hemorrhoids may produce bright red blood from the anus. Diverticulosis, in which tiny "pockets" in the wall of the intestine can form and bleed when inflamed or irritated. Always get checked by a doctor to determine the cause of rectal bleeding and to obtain treatment for the underlying cause of bleeding.

What Causes Colon Cancer?

There are several causes for colorectal cancer as well as factors that place certain individuals at increased risk for the disease. There are known genetic and environmental factors.

People at risk for colorectal cancer:

• The biggest risk factor is age. Colon cancer is rare in those under 40 years. The rate of colorectal cancer detection begins to increase after age 40. Most colorectal cancer is diagnosed in those over 60 years.

• Have a mother, father, sister, or brother who developed colorectal cancer or polyps. When more than one family member has had colorectal cancer, the risk to other members may be three-to-four times higher of developing the disease. This higher risk may be due to an inherited gene.

• Have history of benign growths, such as polyps, that have been surgically removed.

• Have a prior history of colon or rectal cancer.

• Have disease or condition linked with increased risk.

• Have a diet high in fat and low in fiber.

Need To Know: Who is at risk for inherited forms of colorectal cancer? People whose relatives developed colorectal cancer before age 60. Those with relatives who have other forms of cancer, particularly breast or ovarian cancer. Those with a family history of stomach, abdominal, bowel, bone, or liver cancer. In the past, colorectal cancer was misdiagnosed as stomach, abdominal, or bowel cancer, or, in later stages, the cancer may have spread to the bone or liver. Distant relatives, such as cousins, aunts, uncles, etc., who develop colorectal cancer may raise the risk of colorectal cancer for other distant family members. The relative increase in risk is not as high as in those who have first-degree relatives, such as parents or siblings with colorectal cancer.

Having certain diseases or conditions may place people at increased risk for colorectal cancer. These include

• Chronic ulcerative colitis, an inflammatory condition of the colon. People in this risk category have long-term disease, most for ten years or more.
• Crohn's disease, which is an inflammatory disease of the gastrointestinal tract. This disease may increase colorectal cancer risk, although not as much ulcerative colitis.
• A history of breast, uterine, or ovarian cancer in women.
• Inherited a specific colorectal cancer syndrome. Those with an inherited syndromes may develop colorectal cancer at a much younger age, in their 30s or even younger.

Inherited Colon Cancer Syndromes

Inherited colon cancer syndromes is a name given to a group of different types of colon cancer found to be directly inherited, or passed down from one generation to the next. Over the past several years, genetic forms of colon cancer have been identified and genetic tests developed.

Need To Know: Genetic forms of colon cancer represent a smaller percentage of all colon cancer cases. However, those with a strong family history of colon cancer may consider talking to a genetic counselor. Those at high risk may choose to undergo screening at an earlier age.

There are two basic forms of colon cancers recognized as having a genetic basis:

• Familial adenomatous polyposis (FAP) is a rare genetic disorder of the colon characterized by the development of hundreds of polyps on the inner walls of the colon. People with FAP are at a higher risk for developing colon cancer at an early age (in their early 30s).

  The treatment of choice is to have an operation to remove the diseased colon to avoid the eventual development of colon cancer. This operation can be done without the need for a colostomy.

• Hereditary nonpolyposis colon cancer (HNPCC) is a form of colon cancer that runs in certain families. HNPCC is divided into two types:
  • Type I: People with this form of HNPCC can develop colon cancer before age 50.
  • Type II: People with this disorder are not only at higher risk for colon cancer before age 50 but are also at high risk for uterine, ovarian, thyroid, bladder, and other cancers.

Nice To Know: Reliable blood tests can now determine if a person has certain genes responsible for inherited colon cancer. Inherited colon cancer makes up about 20 percent of colon cancer cases.

Gastrointestinal Carcinoid Tumors

Gastrointestinal carcinoid tumors are a rare form of cancer affecting the intestinal tract, including the stomach, small intestine, appendix, colon, or rectum. Carcinoid tumors do not usually cause major, recognizable symptoms and can take years to develop. In most cases, these tumors are accidentally discovered during abdominal surgery. These tumors secrete hormones - groups of chemicals released into the bloodstream that have an effect elsewhere in the body.

In some people, carcinoid tumors may cause symptoms known as "carcinoid syndrome":

• Facial swelling with redness or flushing
• Wheezing
• Diarrhea

Carcinoid syndrome symptoms usually occur only if the cancer spreads to the liver.

Treatment for carcinoid syndrome depends on the stage of the disease and the person's overall health. Treatment may include surgery, radiation therapy, or chemotherapy.

What Is Colon Cancer?

Colon cancer is a common type of malignancy (cancer) in which there is uncontrolled growth of the cells that line the inside of the colon or rectum. Colon cancer is also called colorectal cancer.

• The colon, also known as the large intestine, is the last part of the digestive tract.
• The rectum is the very end of the large intestine that opens at the anus.

Understanding Cancer

The body is made up of different types of cells that normally divide and multiply in an orderly way. These new cells replace older cells. This process of cell birth and renewal occurs constantly in the body.

Cancer or malignant growths occur when:

• Some cells in the body begin to multiply in an uncontrolled manner.
• The body's natural defenses, such as certain parts of the immune system, cannot stop uncontrolled cell division.
• These abnormal cells become greater and greater in number.
• In some types of cancer, including colon cancer, the uncontrolled cell growth forms a mass, also called a tumor.

Some tumors are benign, which means that they are not cancerous. Cancerous or malignant tumors grow out of control and can invade, replace, and destroy normal cells near the tumor. In some cases, cancer cells spread to other areas of the body.

There are two kinds of growths that occur in the colon:

• noncancerous growths, such as polyps.
• Malignant or cancerous growths. Colon cancer usually begins with the growth of benign growths such as polyps.

Most types of colorectal cancer are adenocarcinomas. This means that the cancer cells are formed from abnormal gland cells that line the inner surface of an organ. The prefix "adeno" means "gland." In colorectal cancer, the abnormal growth begins to form in the inner lining of the large bowel.

Nice To Know: Other forms of color cancer may occur, but are not nearly as common as adenocarcinomas. Tumors that begin in connective tissue, such as sarcomas Tumors that begin in the lymphatic system, such lymphomas Rare cancers such as carcinoids and gastrointestinal stromal tumors.

If a polyp develops and is not removed, it may become cancerous. Once a cancer develops it begins to invade the intestinal wall and may spread to nearby lymph nodes. Lymph nodes are part of the lymphatic system, which carries special filtered fluids throughout the body. Through the lymphatic system, cancer cells may also be carried to areas of the body far away the original tumor.

This process of cancer cells traveling to other parts of the body is known as metastasis. The spread of cancer may also occur via the blood stream. Colon and rectal cancers that metastasize through the blood stream will travel first to the liver. There the cancerous cells may continue to grow and develop new tumors. As these new tumors continue to grow and spread further, the function of vital organs, such as the liver, may deteriorate.

About The Digestive System

The digestive system receives food, breaks it down into smaller, useful nutrients, absorbs these nutrients into the bloodstream, and eliminates the remaining waste from the body.

The digestive system is made up of

• The esophagus
• The stomach
• The small intestine
• The large intestine, also known as the colon

The colon has several parts:

• Ascending colon - Beginning in the lower right abdomen and continuing up the right side.
• Transverse colon - Beginning at the upper right side of the abdomen and continuing across to the left side of the abdomen.
• Descending colon - From the left upper abdomen straight down to the left lower side.
• Sigmoid colon - An S-shaped section that leads downward into the pelvic cavity.
• Rectum - The last six or so inches of the colon, ending at the anus.

Facts About Colon Cancer About 150,000 new cases of colorectal (colon and rectal) cancer are diagnosed each year in the U.S., making it the second most common type of cancer and the second leading cause of cancer death in the U.S. One-third of all colorectal cancers are found in the rectum; the rest are found in other parts of the colon. Screening for colorectal cancer should begin at the age of 40 in healthy adults. Seventy to 80 percent of colorectal cancer cases occur in adults without specific risk factors. Widespread screening for colorectal cancer could save up to many lives each year. Early detection reduces the probability of major surgery and increases chances of cure. Risk increases after age 40. Both men and women are equally at risk for colorectal cancer. In the U.S. the death rate for colorectal cancer is declining. This may be due to a higher rate of screening for the disease. Colon cancer may affect any racial or ethnic group; however, some studies suggest that Americans of northern European heritage have a higher-than-average risk of colon cancer.

An Inside Look at Rectal Cancer

Rectal Cancer Overview

The rectum is the lower part of the colon that connects the large bowel to the anus. The rectum’s primary function is to store formed stool in preparation for evacuation. Like the colon, the 3 layers of the rectal wall are as follows:

• Mucosa: This layer of the rectal wall lines the inner surface. The mucosa is composed of glands that secrete mucus to help the passage of stool.
  
• Muscularis propria: This middle layer of the rectal wall is composed of muscles that help the rectum keep its shape and contract in a coordinated fashion to expel stool.
  
• Mesorectum: This fatty tissue surrounds the rectum.

In addition to these 3 layers, another important component of the rectum is the surrounding lymph nodes (also called regional lymph nodes). Lymph nodes are part of the immune system and assist in conducting surveillance for harmful materials (including viruses and bacteria) that may be threatening the body. Lymph nodes surround every organ in the body, including the rectum.

Of the 150,000 cases of colorectal cancer diagnosed each year in the United States, more than 40,000 people are diagnosed with rectal cancer. The most common type of rectal cancer is adenocarcinoma, which is a cancer arising from the mucosa. Cancer cells can also spread from the rectum to the lymph nodes on their way to other parts of the body.

Like colon cancer, the prognosis and treatment of rectal cancer depends on how deeply the cancer has invaded the rectal wall and surrounding lymph nodes. However, although the rectum is part of the colon, the location of the rectum in the pelvis poses additional challenges in treatment when compared with colon cancer.

This article only discusses issues related to rectal adenocarcinoma.

Rectal Cancer Causes

Rectal cancer usually develops over several years, first growing as a precancerous growth called a polyp. Some polyps have the ability to turn into cancer and begin to grow and penetrate the wall of the rectum.

The actual cause of rectal cancer is unclear. However, the following are risk factors for developing rectal cancer:

• Increasing age
  
• Smoking
• Family history of colon or rectal cancer
• High-fat diet and/or a diet mostly from animal sources
• Personal or family history of polyps or colorectal cancer

Family history is a factor in determining the risk of rectal cancer. If a family history of colorectal cancer is present in a first-degree relative (a parent or a sibling), then endoscopy of the colon and rectum should begin 10 years before the age of the relative’s diagnosis or at age 50 years, whichever comes first.

An often forgotten risk factor, but perhaps the most important, is the lack of screening for rectal cancer. Routine cancer screening of the colon and rectum is the best way to prevent rectal cancer.

Rectal Cancer Symptoms

Rectal cancer can cause many symptoms that require a person to seek medical care. However, rectal cancer may also be present without any symptoms, underscoring the importance of routine health screening. Symptoms to be aware of include the following:

• Bleeding
  
  • Seeing blood mixed with stool is a sign to seek immediate medical care. Although many people bleed due to hemorrhoids, a doctor should still be notified in the event of rectal bleeding.
    
  • Prolonged rectal bleeding (perhaps in small quantities that is not seen in the stool) may lead to anemia, causing fatigue, shortness of breath, light-headedness, or a fast heartbeat.
    
• Obstruction
  
  • A rectal mass may grow so large that it prevents the normal passage of stool. This blockage may lead to the feeling of severe constipation or pain when having a bowel movement. In addition, abdominal pain or cramping may occur due to the blockage.
    
  • The stool size may appear narrow so that it can be passed around the rectal mass. Therefore, pencil-thin stool may be another sign of an obstruction from rectal cancer.
    
  • A person with rectal cancer may have a sensation that the stool cannot be completely evacuated after a bowel movement.
    
• Weight loss: Cancer may cause weight loss. Unexplained weight loss (in the absence of dieting or a new exercise program) requires a medical evaluation.
  

When to Seek Medical Care - Questions to Ask the Doctor

If a person has been diagnosed with rectal cancer, the doctor should be asked the following questions:

• Where is my cancer located?
  
• How far has the cancer spread?
• What treatment options do I have?
• What is the overall goal of treatment in my case?
• What are the risks and side effects of the proposed treatment?
• Am I eligible for a clinical trial?
• How do I find out if I am eligible for a clinical trial?

Exams and Tests

Appropriate colorectal screening leading to the detection and removal of precancerous growths is the only way to prevent this disease. Screening tests for rectal cancer include the following:

• Fecal occult blood test (FOBT): Early rectal cancer may damage blood vessels of the rectal lining and cause small amounts of blood to leak into the feces. The stool appearance may not change. The fecal occult blood test requires placing a small amount of stool on a special paper that is provided by a doctor. The doctor then applies a chemical to that paper to see if blood is present in the stool sample.
  
• Endoscopy: During endoscopy, a doctor inserts a flexible tube with a camera at the end (called an endoscope) through the anus and into the rectum and colon. During this procedure, the doctor can see and remove abnormalities on the inner lining of the colon and rectum.
  

Exams and Tests continued...

If rectal cancer is suspected, the tumor can be physically detected through either digital rectal examination (DRE) or endoscopy.

• A digital rectal examination is performed by a doctor using a lubricated gloved finger inserted through the anus to feel the cancer on the rectal wall. Not all rectal cancers can be felt this way, and detection is dependent on how far the tumor is from the anus. If an abnormality is detected by a digital rectal examination, then an endoscopy is performed for further evaluation of the cancer.
  
• Flexible sigmoidoscopy is the insertion of a flexible tube with a camera on the end (called an endoscope) through the anus and into the rectum. An endoscope allows a doctor to see the entire rectum, including the lining of the rectal wall.
  
• Rigid sigmoidoscopy is the insertion of a rigid optical scope inserted through the anus and into the rectum. Rigid sigmoidoscopy is usually performed by either a gastroenterologist or a surgeon. The advantage of rigid sigmoidoscopy is that a more exact measurement of the tumor’s distance from the anus can be obtained, which may be relevant if surgery is required.
  
• A colonoscopy may be performed. For a colonoscopy, a flexible endoscope is inserted through the anus and into the rectum and colon. A colonoscopy allows a doctor to see abnormalities in the entire colon, including the rectum.

Because the depth of the cancer’s growth into the rectal wall is important in determining treatment, an endoscopic ultrasound (EUS) may be performed during endoscopy. An endoscopic ultrasound uses an ultrasound probe at the tip of an endoscope that allows a doctor to see how deeply the cancer has penetrated. In addition, a doctor can measure the size of the lymph nodes around the rectum during an endoscopic ultrasound. Based on the size of the lymph nodes, a good prediction can be made as to whether the cancer has spread to the lymph nodes.

Once an abnormality is seen with endoscopy, a biopsy specimen is obtained using the endoscope and sent to a pathologist. The pathologist can confirm that the abnormality is a cancer and needs treatment. A person may experience small amounts of bleeding after a biopsy is performed. If this bleeding is heavy or lasts longer than a few days, a doctor should be notified immediately.

A chest x-ray and a CT scan of the abdomen and pelvis are most likely performed to see whether the cancer has spread further than the rectum or surrounding lymph nodes.

Routine blood studies are performed to assess how a person might tolerate the upcoming treatment.

In addition, a blood test called CEA (carcinoembryonic antigen) is obtained. The CEA is often produced by colorectal cancers and can be a useful gauge of how the treatment is working. After the treatment, the doctor may regularly check the CEA level as one indicator of whether the cancer has returned. However, checking the CEA level is not an absolute test for colorectal cancers, and other conditions may cause a rise in the CEA level. Likewise, a normal CEA level is not a guarantee that the cancer is no longer present.

Rectal Cancer Treatment - Medical Treatment

The treatment and prognosis of rectal cancer depend on the stage of the cancer, which is determined by the following 3 considerations:

• How deeply the tumor has invaded the wall of the rectum
• Whether the lymph nodes appear to have cancer in them
  
• Whether the cancer has spread to any other locations in the body (Organs that rectal cancer commonly spreads to include the liver and the lungs.)

The stages of rectal cancer are as follows:

• Stage I: The tumor involves only the first or second layer of the rectal wall and no lymph nodes are involved.
  
• Stage II: The tumor penetrates into the mesorectum, but no lymph nodes are involved.
  
• Stage III: Regardless of how deeply the tumor penetrates, the lymph nodes are involved with the cancer.
  
• Stage IV: Convincing evidence of the cancer exists in other parts of the body, outside of the rectal area.

Localized rectal cancer includes stages I-III. Metastatic rectal cancer is stage IV.

The goals of treating localized rectal cancer are to ensure the removal of all the cancer and to prevent a recurrence of the cancer, either near the rectum or elsewhere in the body.

If stage I rectal cancer is diagnosed, then surgery is likely to be the only necessary step in treatment. The risk of the cancer coming back after surgery is low, and, therefore, chemotherapy is not usually offered.

Sometimes, after the removal of a tumor, the doctor discovers that the tumor penetrated into the mesorectum (stage II) or that the lymph nodes contained cancer cells (stage III). In these cases, chemotherapy and radiation therapy are offered after recovery from the surgery to reduce the chance of the cancer returning. Chemotherapy and radiation therapy given after surgery is called adjuvant therapy.

If the initial exams and tests show a person to have stage II or III rectal cancer, then chemotherapy and radiation therapy should be considered before surgery. Chemotherapy and radiation given before surgery is called neoadjuvant therapy. This therapy lasts approximately 6 weeks. Neoadjuvant therapy is performed to shrink the tumor so it can be more completely removed by surgery. In addition, a person is likely to tolerate the side effects of combined chemotherapy and radiation therapy better if this therapy is administered before surgery rather than afterward. After recovery from the surgery, a person who has undergone neoadjuvant therapy should meet with the oncologist to discuss the need for more chemotherapy.

If the rectal cancer is metastatic, then surgery and radiation therapy would only be performed if persistent bleeding or bowel obstruction from the rectal mass exist. Otherwise, chemotherapy alone is the standard treatment of metastatic rectal cancer. At this time, metastatic rectal cancer is not curable. However, average survival times for people with metastatic rectal cancer have lengthened over the past several years because of the introduction of new medications.

Medications

The following chemotherapy drugs may be used at various points during therapy:

• 5-Fluorouracil (5-FU): This drug is given intravenously either as a continuous infusion using a medication pump or as quick injections on a routine schedule. This drug has direct effects on the cancer cells and is often used in combination with radiation therapy because it makes cancer cells more sensitive to the effects of radiation. Side effects include fatigue, diarrhea, mouth sores, and hand-and-foot syndrome (redness, peeling, and pain in the palms of the hands and the soles of the feet).
  
• Capecitabine (Xeloda): This drug is given orally and is converted by the body to a compound similar to 5-FU. Capecitabine has similar effects on cancer cells as 5-FU and can be used either alone or in combination with radiation therapy. Side effects are similar to intravenous 5-FU.
  
• Oxaliplatin (Eloxatin): This drug is given intravenously once every 2 or 3 weeks. Oxaliplatin has recently become the most common drug to use in combination with 5-FU for the treatment of metastatic rectal cancer. Side effects include fatigue, nausea, increased risk of infection, anemia, and peripheral neuropathy (tingling or numbness of the fingers and toes). This drug may also cause a temporary sensitivity to cold temperatures up to 2 days after administration. Inhaling cold air or drinking cold liquids should be avoided if possible after receiving oxaliplatin.
  
• Irinotecan (Camptosar, CPT-11): This drug is given intravenously once every 1-2 weeks. Irinotecan is also commonly combined with 5-FU. Side effects include fatigue, diarrhea, increased risk of infection, and anemia. Because both irinotecan and 5-FU cause diarrhea, this symptom can be severe and should be reported immediately to a doctor.
  
• Bevacizumab (Avastin): This drug is given intravenously once every 2-3 weeks. Bevacizumab is an antibody to vascular endothelial growth factor (VEGF) and is given to reduce blood flow to the cancer. Bevacizumab is used in combination with 5-FU and irinotecan or oxaliplatin for the treatment of metastatic rectal cancer. Side effects include high blood pressure, nose bleeding, blood clots, and bowel perforation.
  
• Cetuximab (Erbitux): This drug is given intravenously once every week. Cetuximab is an antibody to epidermal growth factor receptor (EGFR) and is given because rectal cancer has large amounts of EGFR on the cell surface. Cetuximab is used alone or in combination with irinotecan for the treatment of metastatic rectal cancer. Side effects include an allergic reaction to the medication and an acnelike rash on the skin. Clinical trials are underway to evaluate this antibody for the treatment of localized rectal cancer.

Medications are available to alleviate the side effects of chemotherapy and antibody treatments. If side effects occur, an oncologist should be notified so that they can be addressed promptly.

Surgery

Surgical removal of a tumor is the cornerstone of curative therapy for localized rectal cancer. In addition to removing the rectal tumor, removing the fat and lymph nodes in the area of a rectal tumor is also necessary to minimize the chance that any cancer cells might be left behind.

Surgery continued...

However, because the rectum is in the pelvis and is close to the anal sphincter (the muscle that controls the ability to hold stool in the rectum), rectal surgery can be difficult. With more deeply invading tumors and when the lymph nodes are involved, chemotherapy and radiation therapy are usually included in the treatment course to increase the chance that all microscopic cancer cells are removed or killed.

Four types of surgeries are possible, depending on the location of the tumor in relation to the anus.

• Transanal excision: If the tumor is small, located close to the anus, and confined only to the mucosa (innermost layer), then performing a transanal excision, where the tumor is removed through the anus, may be possible. No lymph nodes are removed with this procedure. No incisions are made in the skin.
  
• Mesorectal surgery: This surgical procedure involves the careful dissection of the tumor from the healthy tissue. Mesorectal surgery is being performed mostly in Europe.
  
• Low anterior resection (LAR): When the cancer is in the upper part of the rectum, then a low anterior resection is performed. This surgical procedure requires an abdominal incision, and the lymph nodes are typically removed along with the segment of the rectum containing the tumor. The two ends of the colon and rectum that are left behind can be joined, and normal bowel function can resume after surgery.
  
• Abdominoperineal resection (APR): If the tumor is located close to the anus (usually within 5 cm), performing an abdominoperineal resection and removing the anal sphincter may be necessary. Lymph nodes are also removed during this procedure. With an abdominoperineal resection, a colostomy is necessary. A colostomy is an opening of the colon to the front of the abdomen, where feces are eliminated into a bag.

Other Therapy

Radiation therapy uses high-energy rays that are aimed at the cancer cells to kill or shrink them. For rectal cancer, radiation therapy may be used either before surgery (neoadjuvant therapy) or after surgery (adjuvant therapy), usually in conjunction with chemotherapy.

The goals of radiation therapy are as follows:

• Shrink the tumor to make its surgical removal easier (if given before surgery).
  
• Kill the remaining cancer cells after surgery to reduce the risk of the cancer returning or spreading.
  
• Treat any local recurrences that are causing symptoms, such as abdominal pain or bowel obstruction.

Typically, radiation treatments are given daily, 5 days a week, for up to 6 weeks. Each treatment lasts only a few minutes and is completely painless; it is similar to having an x-ray film taken.

The main side effects of radiation therapy for rectal cancer include mild skin irritation, diarrhea, rectal or bladder irritation, and fatigue. These side effects usually resolve soon after the treatment is complete.

Chemoradiation is often given for stages II and III rectal cancer. Preoperative chemoradiation is sometimes performed to decrease the size of the tumor.

Next Steps - Follow-up

Because a risk exists of rectal cancer coming back after treatment, routine follow-up care is necessary. Follow-up care usually consists of regular visits to the doctor’s office for physical exams, blood studies, and imaging studies.

In addition, a colonoscopy is recommended 1 year after a diagnosis of rectal cancer. If the findings from the colonoscopy are normal, then the procedure can be repeated every 3 years.

Prevention

Appropriate colorectal screening leading to the detection and removal of precancerous growths is the only way to prevent this disease. Screening tests for rectal cancer include fecal occult blood test and endoscopy.

If a family history of colorectal cancer is present in a first-degree relative (a parent or a sibling), then endoscopy of the colon and rectum should begin 10 years before the age of the relative’s diagnosis or at age 50 years, whichever comes first.

Outlook

The outlook for recovery from rectal cancer is unique for each individual. Many factors are involved when considering the chance of survival after rectal cancer treatment.

Long-term survival generally depends upon the stage of the cancer at the time of diagnosis and treatment.

According to stage, the following approximations of the likelihood of survival 5 years after treatment are as follows:

• Stage I: The probability of being alive in 5 years is approximately 70-80%.
  
• Stage II: The probability of being alive in 5 years is approximately 50-60%.
  
• Stage III: The probability of being alive in 5 years is approximately 30-40%.
  
• Stage IV: The probability of being alive in 5 years is less than 10%.

Support Groups and Counseling

Being diagnosed with cancer is a physically and emotionally trying experience. Many avenues of support exist within the local community and beyond, both for people diagnosed with cancer and for their family and friends. The American Cancer Society provides information on local support groups. In addition, social workers, counselors, psychiatrists, and clergy can also be helpful in providing information and companionship through the difficult times caused by a cancer diagnosis

Via: http://www.webmd.com/

New Ways to Diagnose Colon Cancer

New advances in colonoscopy promise faster and easier screenings.

By Colette Bouchez
WebMD Feature

Reviewed by Louise Chang, MD

If you've been putting off having a colonoscopy out of fear or dread, take heart: New advances are helping make this test faster and much easier to endure.

Durado Brooks, MD, director of Colorectal Cancer for the American Cancer Society, tells WebMD that "most people no longer experience any significant discomfort during the procedure. In fact most report they are pretty comfortable," he says.

Gastroenterologist Jennifer Christie, MD, agrees. "Patients are generally much more comfortable now than in the past. And one reason is because doctors are simply getting better at performing this screening. We're better trained and we're doing more procedures, so patients reap the benefits," says Christie, director of Women's Gastrointestinal Health and Motility at Mt. Sinai Medical Center in New York City.

How a Colonoscopy Works

A colonoscopy is one option recommended for screening of colon cancer in adults at average risk. A colonoscopy is performed by inserting a lighted, flexible tube called an endoscope into the rectum to visualize the inside of the colon. The end of the tube houses a tiny camera that relays the images back to a computer screen.

During the test doctors look for lesions known as "polyps." These are small growths that can sometimes be the precursor to colon cancer. If a polyp is found, the endoscope can also be used to remove them during the same procedure.

"In this sense a colonoscopy is both diagnostic and therapeutic -- it can find a problem and treat it during the same procedure," says Brooks.

Advances in Screening Techniques

If you had a colonoscopy in the past -- and didn't find it quite so easy to endure -- chances are your screening did not include the use of a deeper type of sedation that, until recently, was saved for more complex procedures.

"Traditionally we used just a sedative and a narcotic during colonoscopy. Now we're moving towards using an anesthesiologist so that the patient can be put into a deeper sleep without risking safety. And ultimately that means the procedure can be done more quickly and the patient is really very comfortable," says Christie.

Because, however, not all insurance companies will pay for an anesthesiologist, experts say in the future more gastroenterologists will likely be trained in administering anesthesia, particularly in conjunction with a nurse anesthetist.

In addition to more generous use of anesthesia, advances in the instruments used during the test itself are also increasing the comfort level for patients. One such advance helps reduce the incidence of "looping" -- a complication that can make the exam difficult to complete.

In this instance the flexible tubing used to view the inside of the colon gets caught in the multiple internal curves, causing the scope to push against the colon allowing a "loop" to form. This can make it difficult to complete the test.

Advances in Screening Techniques continued...

However, David Lieberman, MD, says several newly designed scopes are helping doctors avoid "looping" in a variety of clever ways.

"One innovation is called a variable fitness instrument -- a scope that allows the doctor to stiffen the head of the scope, making it easier to get through the colon and complete the exam," says Lieberman, chief of gastroenterology at Oregon Health and Science University in Portland.

Additionally, Lieberman tells WebMD that other devices, including one called NeoGuide, use computer chips to remember the turn of the scope, which, he says, also reduces the likelihood of looping.

A brand-new device -- now being tested -- uses balloon technology to push the scope through the colon in a kinder, gentler way.

"It's a dual balloon system with air between them, and it's actually the air pressure that gently advances the endoscope through the colon," says Lieberman, who adds that this too can reduce the possibility of looping.

However, he cautions that most of these new devices are still considered experimental and not yet proven to work in large clinical trials.

"We are definitely heading in this direction, however, and it's all very promising," says Lieberman.

Preparing for Success

In order for a colonoscopy to be successful -- at least in terms of getting a clear visualization -- preparation must include emptying the bowels completely. Many doctors say that achieving this is tantamount to a quick, easy, and successful test.

"The single most important way to increase the success of a colonoscopy is to achieve a good prep. If it's not good, the procedure itself is longer and more difficult to perform," says Lieberman.

In the past this entailed consuming up to a gallon or more of a powerful liquid laxative all within a couple of hours, a task that Christie says many patients found hard to accomplish.

"It's generally not very palatable. Some patients find it very difficult to consume," says Christie.

Now, however, advances are making the prep easier while helping to ensure the success of the screening itself.

Among the newest is OsmoPrep, which offers much of the same bowel cleansing effects as the drink, using half the liquid and no bad taste. The down side: You have to take a lot of pills in a very short period of time.

According to its manufacturer, Salix Pharmaceuticals, the recommended dosage is 32 tablets, divided into doses of four tablets every 15 minutes, each taken with 8 ounces of clear liquid, for a total of 2 quarts. Twenty of the pills are taken the night before the exam, and 12 the day of the test.

"The hope for the future is a totally prepless exam and we are moving in that direction," says Lieberman.

Indeed, Lieberman reports that European studies utilizing an MRI are coming close to achieving this goal.

"With the MRI technology currently being studied in Europe you can theoretically subtract different densities [of material found in the colon] to differentiate between fecal matter and a colon abnormality," says Lieberman.

If the European studies turn out well he estimates the prepless colonoscopy could be a reality within several years.

The Virtual Test

While looking towards the future is promising, there is also one futuristic method of colon screening that is available right now. It's called a "Virtual Colonoscopy" -- a noninvasive screening that uses X-ray beams to look inside the colon.

Doctors say there is so little fuss and bother, the whole procedure is over in less than 10 minutes.

"For the most part, when a patient leaves here they are pleased and happy. They are on and off the table in no time, and there is no sedation. You can literally go back to work in 10 minutes," says Michael Macari, director of abdominal imaging at NYU Medical Center in New York City.

Besides the fact that the screening is noninvasive, Marcari says that prior to the test his center also uses carbon dioxide -- compared with "room air" -- to extend the colon. The difference, he says, means very little cramping and almost no residual pain after the screening is completed.

"Initially there is a little pressure but the carbon dioxide gets absorbed so fast, by the time they leave they feel fine," says Macari.

Looking to the Future

While the screening itself may be fast and easy, right now it requires the same preparation as the regular colonoscopy, so patients are not spared the pretesting discomfort.

However, Macari reports that may change in the not-too-distant future, with the advent of a process called "fecal tagging."

In this procedure, he says, patients drink an agent which -- once inside the colon -- latches onto the fecal material and helps doctors differentiate between that and polyps on the scan.

"We just completed study of 80 patients using fecal tagging and no bowel cleansing and we had a very high rate of detection of polyps over 10 millimeters, which many believe is the real threshold for removal," says Macari.

In another study published in the journal Radiology doctors from Belgium compared fecal tagging with standard colonoscopy preparation. They found that fecal tagging left behind more fecal residue, but improved differentiation of polyps. The fecal tagging also dramatically reduced patient discomfort, side effects, and sleep disturbances.

Still, Marcari says he would not routinely recommend it for virtual colonoscopy -- at least not until larger studies are done.

"Right now it's used if a patient simply cannot tolerate the standard prep, or if a medical condition precludes them from participating in the standard prep," says Macaria.

As easy as a virtual colonoscopy appears to be, Brooks cautions that should a polyp be found during the exam, the patient must still undergo a standard colonoscopy to have the growth removed.

"This requires a second prep and a second procedure whereby if you have the standard colonoscopy screening and something is found, it can be removed on the spot without the need for a second procedure," he says.

Looking to the Future continued...

Macari says that in order to avoid dual prep times some medical centers are coordinating the virtual colonoscopy with a gastroenterologist who is standing by.

"In the event the virtual colonoscopy reveals a problem, the gastroenterlogist is right there ready to perform a standard colonoscopy without the need for a second prep," says Macari.

This dual-system screening is currently being performed in a select number of major medical centers nationwide.

Via: http://www.webmd.com

5 Important Questions About Colon Polyps

Colon Polyps - Topic Overview

What are colon polyps?

Colon polyps are growths in your large intestine (colon). The cause of most colon polyps is not known, but they are common in adults.

Most colon polyps are not cancer. But some growths can turn into colon cancer. If a colon polyp is the kind that can turn into cancer, it usually takes many years for that to happen.

People over 50 are more likely than younger people to get colon cancer. So experts recommend that everyone age 50 or older have a screening test to look for colon polyps. Finding and removing colon polyps can prevent colon cancer.

What are the symptoms?

You can have colon polyps and not know it because they usually don't cause symptoms. They are usually found during routine screening tests for colon cancer. A screening test looks for signs of a disease when there are no symptoms.

If polyps get large, they can cause symptoms. You may have bleeding from your rectum or a change in your bowel habits. A change in bowel habits includes diarrhea, constipation, going to the bathroom more often or less often than usual, or a change in the way your stool looks.

How are colon polyps diagnosed?

Most polyps are found during screening tests for colon cancer. Screening is advised if you are age 50 or older or you have a higher risk for the disease. The four screening tests for colon cancer are:

• Colonoscopy. In this test, the doctor inserts a small viewing tube all the way into your colon and looks for polyps. The doctor can also take out any polyps he or she finds.
• Flexible sigmoidoscopy. This test is like a colonoscopy, except that the viewing tube is shorter so the doctor can only look at the last part of your colon.
• Fecal occult blood test. This test checks for blood in your stool. You place a small sample of stool on a special card, pad, or wipe in a kit that your doctor gives you. The sample is sent to a lab and is tested to see if it contains blood.
• Barium enema. To make it show up on an X-ray, your colon is filled with a white liquid (barium). The liquid blocks the X-rays, so your colon shows up clearly in the picture.

Doctors often recommend colonoscopy because it lets them look at the whole colon and remove any polyps they find. If polyps are found during another type of test, you may still need colonoscopy so the doctor can remove the polyps.

What increases my risk of getting colon polyps?

You are more likely to have colon polyps if:

• You are over 50.
• Colon polyps run in your family.
• You inherited a certain gene that causes you to develop polyps. People with this gene are much more likely than others to get the kind of polyps that turn into colon cancer.

How are they treated?

Doctors usually remove colon polyps because some of them can turn into colon cancer. Most polyps are removed during a colonoscopy. You may need to have surgery if you have a large polyp.

Colon polyps can grow back. If you have had polyps removed, it is important to have follow-up testing to look for more polyps. Talk to your doctor about how often you need to be tested.

Frequently Asked Questions

Learning about colon polyps:	What are colon polyps? What are the symptoms of colon polyps? What increases my risk for getting colon polyps?
Being diagnosed:	How does a fecal occult blood test show colon polyps or cancer? What happens during a barium enema? How does a sigmoidoscopy find colon polyps or cancer? How does a colonoscopy find colon polyps or cancer? What kind of screening should I have?
Getting treatment:	How are colon polyps treated? Can removing colon polyps cause any problems? What can I do to lower my risk of colon polyps and colon cancer?

WebMD Medical Reference from Healthwise