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Fighting and Killing Colon Cancer Cells

Prepared by: Prof. Ped SalvadorMarch 11, 2009


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Good News:Survivor Experience

Terry Colon Cancer Hearing the words "you have cancer" is bad enough, but after the operation that

removed the tumor and part of my colon, I was informed that they also removed asmall tumor from my liver, which meant the cancer had metastasized. The oncologistdid not look too happy when he told me I was in stage 4. I must have been in totaldenial because I really didn't believe this was happening to me. I had it all - a goodmarriage - two great kids a job I liked - good friends and about to become agrandmother. Maybe life was a little too good. The chemotherapy that was selected formy cancer was infused through a port-acath. I received about a teaspoon daily for 4months.

The side effects were minimal no hair loss or nausea but other small inconveniences which were bearable. You can imagine the anxiety I felt when I went for my first CTscan but the news was good and it has been good for the past 14 years. I had onedoctor tell me he did not believe that I had this type of cancer and was still living untilhe saw the reports. Why am I a survivor? I ask myself that question everyday when Ithank God. Maybe I needed to see my first granddaughter who was born later thatyear, or her sister born 4 years later - or to see my two little grandsons, one of which

was just born or maybe I am still needed. I don't know the answer but if I did I would wish it for all the cancer patients. It's been 14 years - I still think about it everyday andam so grateful to the doctors who treated me and my family for their support. Courageand hope to all the cancer patients. You are in my thoughts and prayers.


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Good News:Survivor ExperienceScott Hamilton A survivor!

I remember I was tired. I thought I was just overworked, I mean I was ontour, skating, traveling, doing a million things. But then I had trouble standing up straight. I have to say I was in pain, but I still thought it

was from indigestion or something minor. I never imagined what was in storefor me. I went to a physician in Peoria, Illinois, and suddenly I was having allthese tests, scary tests. It all happened really fast, but one thing Iremember so clearly. I'll never forget when I first heard the words "You havecancer." At first, I was petrified. I was in shock. I couldn't believe it. A lot of things go through your mind, and sometimes all the thoughts aren't so good.But then, I made up my mind that I would fight and that I could do it. That's

when I first said, "The only disability in life is a bad attitude." I really believethat. I had so much support from my friends and family and the great folks at

The Cleveland Clinic. There were some tough times, but the chemotherapy wasn't as bad as I thought it was going to be. I was able to manage it andmake it and I know that other people can too.I have learned a lot from my experience going through testicular cancer, but Iguess what I want to say is that the experience wasn't as bad as what I feared.

The fear was worse. If people can get information, they can overcome theirfear and make it through. I did it and you can too.


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Greg - 6 Lessons I learned from my cancer Lesson #1: Many more people genuinely care about you than you can possibly know -

and they are ready to do everything in their power to help you through your treatment. Lesson #2: God is NOT mean - sometimes bad things happen to good people. Lesson #3: All big words have simple explanations - you just have to keep asking

until you get it. Lesson #4: Not all doctors are very good; but some doctors are outstanding; and

personally dedicated to making you get well again. The same can be said for Nurses,Radiation Techs, and Receptionists. Take the time to find the really good ones.

Lesson #5: It's OK to have a bad day. You're sick; you don't have to happy about it. Lesson #6: You're a LOT tougher than you think you are - you CAN DO this.


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Benjamin - Lung CancerI am 76 years old and I have one foot in the grave and the other is on a banana

peel, but life is a ball. In 1998 when I was a young man of 70, I was informed that Ihad a growth in my left lung. After a few examinations and a needle biopsy, I wasinformed it was a cancerous growth. After consultation with an Internist, a

Pulmonologist, a Cardiothoracic Sugeon and an Oncologist (here I would like to wishthat you all would have as wonderful a group of doctors and nurses as I had), it wasdecided that chemotherapy and surgery would be our course of action. This wasaccomplished. In January of 2002, it was discovered that I had a tumor in the upperportion of my left lung. A biopsy indicated it was cancerous.

This time chemo and radiation was the prescribed treatment and it wassuccessful in eliminating the tumor. I mention this only to indicate I know of what I

speak. Do no let Cancer end your Life. Wade in with Faith, Humor, and Resolve tosurvive and enjoy what ever length of time you have left on this green earth. We will alldie at some point, it is the living that we must face, conquer and manage. Faith is astrong ally and is never to be overlooked. Humor is the lubricant for an enjoyable Life,both for you and those around you. Resolve is the determination to fight for every moment of enjoyment life has to offer. Let no one "rain on your parade."


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What is cancer?

Cancer is a group of more than 100 differentdiseases.

They affect the body'sbasic unit, the cell.

Cancer occurs whencells become abnormaland divide withoutcontrol or order.
http://www.medicinenet.com/script/main/art.asp?articlekey=13931http://www.medicinenet.com/script/main/art.asp?articlekey=13931


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Colon and Rectum Like all other organs of

the body, the colon andrectum are made up of many types of cells.Normally, cells divide toproduce more cells only

when the body needsthem. This orderly process helps keep thebody healthy.


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What is cancer?

If cells keep dividing when new cells are not needed, amass of tissue forms. This mass of extra tissue, called agrowth or tumor, can be benign or malignant.

Benign tumors are not cancer. They can usually beremoved and, in most cases, they do not come back.Most important, cells from benign tumors do not

spread to other parts of the body. Benign tumors arerarely a threat to life.


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What is cancer?

Malignant tumors are cancer. Cancer cells can invade anddamage tissues and organs near the tumor. Also, cancer cells canbreak away from a malignant tumor and enter the bloodstreamor lymphatic system. This is how cancer spreads from the

original (primary) tumor to form new tumors in other parts of the body. The spread of cancer is called metastasis.

When cancer spreads to another part of the body, the new tumorhas the same kind of abnormal cells and the same name as theprimary tumor. For example, if colon cancer spreads to the liver,the cancer cells in the liver are colon cancer cells. The disease ismetastatic colon cancer (it is not liver cancer ).


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What is cancer of the colon ?

The colon is the part of the digestive system where the wastematerial is stored. The rectum is the end of the colon adjacent tothe anus.

Together, they form a long, muscular tube called the large

intestine (also known as the large bowel). Tumors of the colon and rectum are growths arising from the

inner wall of the large intestine. Benign tumors of the large intestine are called polyps. Malignant

tumors of the large intestine are called cancers. Benign polyps do not invade nearby tissue or spread to other

parts of the body.


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Colon Anatomy

The colon is the lastportion of the digestivesystem in most

vertebrates; it extracts water and salt from solid wastes before they areeliminated from thebody.
http://en.wikipedia.org/wiki/Digestive_systemhttp://en.wikipedia.org/wiki/Digestive_systemhttp://en.wikipedia.org/wiki/Vertebrateshttp://en.wikipedia.org/wiki/Waterhttp://en.wikipedia.org/wiki/Salthttp://en.wikipedia.org/wiki/Feceshttp://en.wikipedia.org/wiki/Feceshttp://en.wikipedia.org/wiki/Defecationhttp://en.wikipedia.org/wiki/File:Intestine.pnghttp://en.wikipedia.org/wiki/Defecationhttp://en.wikipedia.org/wiki/Feceshttp://en.wikipedia.org/wiki/Feceshttp://en.wikipedia.org/wiki/Salthttp://en.wikipedia.org/wiki/Waterhttp://en.wikipedia.org/wiki/Vertebrateshttp://en.wikipedia.org/wiki/Digestive_systemhttp://en.wikipedia.org/wiki/Digestive_system


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Colorectal Cancer

Colorectal cancer , also called colon cancer orlarge bowel cancer , includes cancerous growths in the colon, rectum and appendix.

It is the third most common form of cancerand the second leading cause of cancer-relateddisease in the Western world.
http://en.wikipedia.org/wiki/Cancerhttp://en.wikipedia.org/wiki/Colon_%28anatomy%29http://en.wikipedia.org/wiki/Rectumhttp://en.wikipedia.org/wiki/Vermiform_appendixhttp://en.wikipedia.org/wiki/Vermiform_appendixhttp://en.wikipedia.org/wiki/Rectumhttp://en.wikipedia.org/wiki/Colon_%28anatomy%29http://en.wikipedia.org/wiki/Cancer


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Colorectal Cancer

Many colorectal cancers are thought to arisefrom adenomatous polyps in the colon. Thesemushroom-like growths are usually benign, butsome may develop into cancer over time.

The majority of the time, the diagnosis of localized colon cancer is through colonoscopy .

Therapy is usually through surgery, which inmany cases is followed by chemotherapy .
http://en.wikipedia.org/wiki/Adenomahttp://en.wikipedia.org/wiki/Colorectal_polyphttp://en.wikipedia.org/wiki/Benignhttp://en.wikipedia.org/wiki/Colonoscopyhttp://en.wikipedia.org/wiki/Chemotherapyhttp://en.wikipedia.org/wiki/Chemotherapyhttp://en.wikipedia.org/wiki/Colonoscopyhttp://en.wikipedia.org/wiki/Benignhttp://en.wikipedia.org/wiki/Colorectal_polyphttp://en.wikipedia.org/wiki/Adenoma


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Causes In general, cancer occurs when healthy cells become altered.

Healthy cells grow and divide in an orderly way to keep yourbody functioning normally.

But sometimes this growth gets out of control cells continuedividing even when new cells aren't needed. In the colon and

rectum, this exaggerated growth may cause precancerous cells toform in the lining of your intestine. Over a long period of time spanning up to several years

some of these areas of abnormal cells may become cancerous.

In later stages of the disease, colon cancer may penetrate thecolon walls and spread (metastasize) to nearby lymph nodes orother organs.


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Precancerous growths in the colon Precancerous cells can occur anywhere in your large intestine,

the muscular tube that forms the last part of your gastrointestinaltract. The colon comprises the upper 4 to 5 feet of your largeintestine, and the rectum makes up the lower 6 inches.

Precancerous growths most commonly occur as clumps of cells(polyps) that extend from the wall of the colon. Polyps canappear mushroom-shaped. Precancerous growths can also be flator recessed into the wall of the colon (nonpolypoid lesions).Nonpolypoid lesions are more difficult to detect, but are lesscommon.


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Polyps


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Several types of colon polyps

Among the most common are: Adenomas. These polyps have the potential to become

cancerous and are usually removed during screening

tests such as flexible sigmoidoscopy or colonoscopy. Hyperplastic polyps. These polyps are rarely, if ever,a risk factor for colorectal cancer.

Inflammatory polyps. These polyps may follow a

bout of ulcerative colitis. Some inflammatory polypsmay become cancerous, so having ulcerative colitisincreases your overall risk of colon cancer


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Polyps
http://en.wikipedia.org/wiki/Image:Colon_cancer.jpg


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Symptons

Colon cancer can be present for several years beforesymptoms develop.

Colon cancer often causes no symptoms until it hasreached a relatively advanced stage. Thus, many organizations recommend periodic screening for thedisease with fecal occult blood testing and colonoscopy
http://en.wikipedia.org/wiki/Fecal_occult_bloodhttp://en.wikipedia.org/wiki/Fecal_occult_blood


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Symptons Symptoms vary according to where in the large bowel the tumor

is located. The right colon is spacious, and cancers of the rightcolon can grow to large sizes before they cause any abdominalsymptoms.

Typically, right-sided cancers cause iron deficiency anemia due tothe slow loss of blood over a long period of time. Iron deficiency anemia causes fatigue, weakness, and shortness of breath. Theleft colon is narrower than the right colon. Therefore, cancers of the left colon are more likely to cause partial or complete bowelobstruction.

Cancers causing partial bowel obstruction can cause symptomsof constipation, narrowed stool, diarrhea, abdominal pains,cramps, and bloating. Bright red blood in the stool may alsoindicate a growth near the end of the left colon or rectum.


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Bowel Symptoms Details

Change in bowel habits change in frequency ( constipation and/or diarrhea ), change in the quality of stools change in consistency of stools

Bloody stools or rectal bleeding Stools with mucus Tarry stools ( melena ) (more likely related to upper

gastrointestinal i.e. stomach or duodenal disease)

Feeling of incomplete defecation ( tenesmus ) (usually associated with rectal cancer) Reduction in diameter of feces Bowel obstruction (rare)
http://en.wikipedia.org/wiki/Constipationhttp://en.wikipedia.org/wiki/Diarrheahttp://en.wikipedia.org/wiki/Hematocheziahttp://en.wikipedia.org/wiki/Mucushttp://en.wikipedia.org/wiki/Melenahttp://en.wikipedia.org/wiki/Tenesmushttp://en.wikipedia.org/wiki/Bowel_obstructionhttp://en.wikipedia.org/wiki/Bowel_obstructionhttp://en.wikipedia.org/wiki/Tenesmushttp://en.wikipedia.org/wiki/Melenahttp://en.wikipedia.org/wiki/Mucushttp://en.wikipedia.org/wiki/Hematocheziahttp://en.wikipedia.org/wiki/Diarrheahttp://en.wikipedia.org/wiki/Constipation


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Constitutional Symptoms Details

Especially in the cases of cancer in the ascending colon,sometimes only the less specific constitutionalsymptoms will be found:

Anemia, with symptoms such as dizziness, malaise andpalpitations. Clinically there will bepallor and acomplete blood picture will confirm the low hemoglobin level.

Anorexia Asthenia, weakness Unexplained weight loss.
http://en.wikipedia.org/wiki/Anemiahttp://en.wikipedia.org/wiki/Pallorhttp://en.wikipedia.org/wiki/Anorexia_%28symptom%29http://en.wikipedia.org/wiki/Astheniahttp://en.wikipedia.org/wiki/Astheniahttp://en.wikipedia.org/wiki/Anorexia_%28symptom%29http://en.wikipedia.org/wiki/Pallorhttp://en.wikipedia.org/wiki/Anemia


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Metastatic SymptomsDetails

There may also be symptoms attributed to distantmetastasis:

Shortness of breath as in lung metastasis

Epigastric or right upper quadrant pain, as in livermetastasis. Rarely there can be jaundice if the outflow of bile is blocked. Clinically there might beliverenlargement.
http://en.wikipedia.org/wiki/Metastasishttp://en.wikipedia.org/wiki/Jaundicehttp://en.wikipedia.org/wiki/Bilehttp://en.wikipedia.org/wiki/Hepatomegalyhttp://en.wikipedia.org/wiki/Hepatomegalyhttp://en.wikipedia.org/wiki/Hepatomegalyhttp://en.wikipedia.org/wiki/Hepatomegalyhttp://en.wikipedia.org/wiki/Bilehttp://en.wikipedia.org/wiki/Jaundicehttp://en.wikipedia.org/wiki/Metastasis


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Tumor

The term tumor is derived from the Latin term tumor or"swelling". It originally meant an abnormal swelling of the flesh. In contemporary English, tumor issynonymous with solid neoplasm (abnormal

proliferation of cells), while all other forms of swelling are called swelling . Furthermore, this usage is common in medical

literature where the nouns tumefaction andtumescence derived from the adjective tumefied .

These nouns are also the current medical terms fornon-neoplastic swelling.
http://en.wikipedia.org/wiki/Latinhttp://en.wikipedia.org/wiki/Neoplasmhttp://en.wikipedia.org/wiki/Swelling_(medical)http://en.wikipedia.org/wiki/Tumescencehttp://en.wikipedia.org/wiki/Tumescencehttp://en.wikipedia.org/wiki/Swelling_(medical)http://en.wikipedia.org/wiki/Neoplasmhttp://en.wikipedia.org/wiki/Latin


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Diagnosis

Specific and correct diagnosis can only berendered by a biopsy or skin biopsy . The biopsy is submitted to a laboratory and a pathology report is generated.

Clinical diagnosis is by clinical history, visualdiagnosis often with dermatoscopy , andpalpation. But clinical diagnosis can only beconfirmed by a biopsy.
http://en.wikipedia.org/wiki/Biopsyhttp://en.wikipedia.org/wiki/Skin_biopsyhttp://en.wikipedia.org/wiki/Pathologyhttp://en.wikipedia.org/wiki/Dermatoscopyhttp://en.wikipedia.org/wiki/Dermatoscopyhttp://en.wikipedia.org/wiki/Pathologyhttp://en.wikipedia.org/wiki/Skin_biopsyhttp://en.wikipedia.org/wiki/Biopsy


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Cause A neoplasm is an abnormal proliferation of tissues, usually

caused by genetic mutations. Most neoplasms cause a tumor, with a few exceptions like leukemia or carcinoma in situ.

Other causes of tumor development include exposure tochemicals and toxins like benzene, excessive alcohol and tobaccoconsumption, excessive exposure to sunlight and/or radiation, oran inactive sedentary lifestyle and obesity.

Certain viruses can also play a role in the development of tumors, such as cervical cancer (human papillomavirus) andhepatocellular carcinoma (hepatitis B virus).

Tumors may be benign, pre-malignant or malignant. The natureof the tumor is determined by a pathologist after examination of the tumor tissues from a biopsy or a surgical excisionspecimen
http://en.wikipedia.org/wiki/Mutationhttp://en.wikipedia.org/wiki/Leukemiahttp://en.wikipedia.org/wiki/Carcinoma_in_situhttp://en.wikipedia.org/wiki/Benign_tumorhttp://en.wikipedia.org/wiki/Anatomical_pathologyhttp://en.wikipedia.org/wiki/Biopsyhttp://en.wikipedia.org/wiki/Surgeryhttp://en.wikipedia.org/wiki/Surgeryhttp://en.wikipedia.org/wiki/Biopsyhttp://en.wikipedia.org/wiki/Anatomical_pathologyhttp://en.wikipedia.org/wiki/Benign_tumorhttp://en.wikipedia.org/wiki/Carcinoma_in_situhttp://en.wikipedia.org/wiki/Leukemiahttp://en.wikipedia.org/wiki/Mutation


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Infectiousness of tumor cells

Tumor cells are generally not infective to individualsother than the host.

The reason behind this is the presence of MHCproteins which are host-specific and help the immunesystem distinguish between the self and non-self.

These proteins are present on the surface of the cellsand produces vigorous immune response if a foreign

cell is found in the body. However, tumor can be transplanted in an individual if its immune system is compromised.


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Treatment

Treatment depends on the size and type of the tumor, the initiallocation of the tumor, and the general health of the person. Thegoals of treatment may be relief of symptoms, improved comfortor functioning.

Tumor treatment also varies based on whether it is in benign ormalignant condition. If the tumor is benign (has no potential tospread) and is located in a area where it will not cause any symptoms or disrupt the proper functioning of the organ, mostoften no treatment is needed.

However, benign tumors may be removed for cosmetic reasons.If a tumor is malignant, possible treatments include surgery,chemotherapy , radiation, or a combination of these procedures.
http://en.wikipedia.org/wiki/Malignanthttp://en.wikipedia.org/wiki/Benignhttp://en.wikipedia.org/wiki/Malignanthttp://en.wikipedia.org/wiki/Chemotherapyhttp://en.wikipedia.org/wiki/Radiation_therapyhttp://en.wikipedia.org/wiki/Radiation_therapyhttp://en.wikipedia.org/wiki/Chemotherapyhttp://en.wikipedia.org/wiki/Malignanthttp://en.wikipedia.org/wiki/Benignhttp://en.wikipedia.org/wiki/Malignant


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Treatment

If the cancer is confined to only one location, the purpose of treatment is usually surgical removal of the malignant tumor andtreatment.

In some circumstances, if the malignant tumor has spread only to local lymph nodes, these may also be removed.

If all of the cancer cannot be removed with surgery, the optionsfor treatment include radiation and chemotherapy, orcombination of these methods.

In contrast, lymphoma usually is not treated with surgery andchemotherapy ; and radiation therapy may be the possibletreatment [
http://en.wikipedia.org/wiki/Malignanthttp://en.wikipedia.org/wiki/Lymph_nodeshttp://en.wikipedia.org/wiki/Lymphomahttp://en.wikipedia.org/wiki/Surgeryhttp://en.wikipedia.org/wiki/Chemotherapyhttp://en.wikipedia.org/wiki/Tumorshttp://en.wikipedia.org/wiki/Tumorshttp://en.wikipedia.org/wiki/Chemotherapyhttp://en.wikipedia.org/wiki/Surgeryhttp://en.wikipedia.org/wiki/Lymphomahttp://en.wikipedia.org/wiki/Lymph_nodeshttp://en.wikipedia.org/wiki/Malignant


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Pathology

The pathology of the tumoris usually reported from theanalysis of tissue taken froma biopsy or surgery.

A pathology report willusually contain a descriptionof cell type and grade.

The most common coloncancer cell type isadenocarcinoma whichaccounts for 95% of cases.

Other, rarer types includelymphoma and squamous cellcarcinoma.

Histopathologic image of colonic carcinoid stained by hematoxylin and eosin.
http://en.wikipedia.org/wiki/Pathologyhttp://en.wikipedia.org/wiki/Histologyhttp://en.wikipedia.org/wiki/Adenocarcinomahttp://en.wikipedia.org/wiki/Lymphomahttp://en.wikipedia.org/wiki/Squamous_cell_carcinomahttp://en.wikipedia.org/wiki/Squamous_cell_carcinomahttp://en.wikipedia.org/wiki/Image:Colonic_carcinoid_%281%29_Endoscopic_resection.jpghttp://en.wikipedia.org/wiki/Image:Colonic_carcinoid_%281%29_Endoscopic_resection.jpghttp://en.wikipedia.org/wiki/Image:Colonic_carcinoid_%281%29_Endoscopic_resection.jpghttp://en.wikipedia.org/wiki/Image:Colonic_carcinoid_%281%29_Endoscopic_resection.jpghttp://en.wikipedia.org/wiki/Image:Colonic_carcinoid_%281%29_Endoscopic_resection.jpghttp://en.wikipedia.org/wiki/Squamous_cell_carcinomahttp://en.wikipedia.org/wiki/Squamous_cell_carcinomahttp://en.wikipedia.org/wiki/Lymphomahttp://en.wikipedia.org/wiki/Adenocarcinomahttp://en.wikipedia.org/wiki/Histologyhttp://en.wikipedia.org/wiki/Pathology


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Pathology

Cancers on the right side (ascending colon andcecum ) tend to be exophytic, that is, the tumorgrows outwards from one location in the bowel

wall. This very rarely causes obstruction of feces, and

presents with symptoms such as anemia.

Left-sided tumors tend to be circumferential,and can obstruct the bowel much like a napkinring.
http://en.wikipedia.org/wiki/Image:Colonic_carcinoid_%281%29_Endoscopic_resection.jpghttp://en.wikipedia.org/wiki/Image:Colonic_carcinoid_%281%29_Endoscopic_resection.jpghttp://en.wikipedia.org/wiki/Image:Colonic_carcinoid_%281%29_Endoscopic_resection.jpghttp://en.wikipedia.org/wiki/Image:Colonic_carcinoid_%281%29_Endoscopic_resection.jpghttp://en.wikipedia.org/wiki/Cecumhttp://en.wikipedia.org/wiki/Feceshttp://en.wikipedia.org/wiki/Anemiahttp://en.wikipedia.org/wiki/Anemiahttp://en.wikipedia.org/wiki/Feceshttp://en.wikipedia.org/wiki/Cecum


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Histopathology :

Adenocarcinoma is a malignant epithelial tumor,originating from glandular epithelium of thecolorectal mucosa.

It invades the wall, infiltrating the muscularismucosae, the submucosa and thence themuscularis propria.

Tumor cells describe irregular tubular structures,harboring pluristratification, multiple lumens,reduced stroma ("back to back" aspect).
http://en.wikipedia.org/wiki/Muscularis_mucosaehttp://en.wikipedia.org/wiki/Muscularis_mucosaehttp://en.wikipedia.org/wiki/Submucosahttp://en.wikipedia.org/wiki/Submucosahttp://en.wikipedia.org/wiki/Muscularis_mucosaehttp://en.wikipedia.org/wiki/Muscularis_mucosae


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Histopathology :

Sometimes, tumor cells are discohesive and secretemucus, which invades the interstitium producing largepools of mucus/colloid (optically "empty" spaces) -mucinous (colloid)adenocarcinoma, poorly differentiated.

If the mucus remains inside the tumor cell, it pushesthe nucleus at the periphery - "signet-ring cell."

Depending on glandular architecture, cellular

pleomorphism, and mucosecretion of the predominantpattern, adenocarcinoma may present three degrees of differentiation: well, moderately, and poorly differentiated.


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Tumor Growth


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Colorectal Cancer


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Colon polyps and colon cancer

Doctors believe that most colon cancers develop in colonpolyps. Therefore, removing benign colon polyps can preventcolorectal cancer.

Colon polyps develop when chromosome damage occurs in cells

of the inner lining of the colon. Chromosomes contain geneticinformation inherited from each parent. Normally, healthy chromosomes control the growth of cells in

an orderly manner. When chromosomes are damaged, cellgrowth becomes uncontrolled, resulting in masses of extra tissue(polyps). Colon polyps are initially benign.

Over years, benign colon polyps can acquire additionalchromosome damage to become cancerous.
http://www.medicinenet.com/script/main/art.asp?articlekey=7761http://www.medicinenet.com/script/main/art.asp?articlekey=7761http://www.medicinenet.com/script/main/art.asp?articlekey=7761http://www.medicinenet.com/script/main/art.asp?articlekey=7761


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Risk Factor: Growing Polyps

Adenomatous polyps, area risk factor for coloncancer. The removal of colon polyps at the timeof colonoscopy reducesthe subsequent risk of colon cancer.

This polyps carries a near100% risk of developing colorectal cancer by theage of 40 if untreated.


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Risk Factor: Diet

Studies show that a diet high in red meat and low infresh fruit, vegetables, poultry and fish increases therisk of colorectal cancer. In June 2005, a study by the

European Prospective Investigation into Cancer andNutrition suggested that diets high in red and processedmeat, as well as those low in fiber, are associated withan increased risk of colorectal cancer.

Individuals who frequently ate fish showed a decreasedrisk.
http://en.wikipedia.org/wiki/European_Prospective_Investigation_into_Cancer_and_Nutritionhttp://en.wikipedia.org/wiki/European_Prospective_Investigation_into_Cancer_and_Nutritionhttp://en.wikipedia.org/wiki/European_Prospective_Investigation_into_Cancer_and_Nutritionhttp://en.wikipedia.org/wiki/European_Prospective_Investigation_into_Cancer_and_Nutrition


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Diet and colon cancer

Diets high in fat are believed to predispose humans tocolorectal cancer. In countries with high colorectalcancer rates, the fat intake by the population is muchhigher than in countries with low cancer rates.

It is believed that the breakdown products of fatmetabolism lead to the formation of cancer-causing chemicals (carcinogens).

Diets high in vegetables and high-fiber foods such as whole-grain breads and cereals may rid the bowel of these carcinogens and help reduce the risk of cancer.


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Risk Factor: Ulcerative colitis andcolon cancer

Chronic ulcerative colitis causes inflammation of the inner lining of the colon. Colon cancer is a recognized complication of chronic ulcerative colitis. The risk for cancer begins to rise aftereight to 10 years of colitis. The risk of developing colon cancerin a patient with ulcerative colitis also is related to the locationand the extent of his or her disease.

Current estimates of the cumulative incidence of colon cancerassociated with ulcerative colitis are 2.5% at 10 years, 7.6% at 30years, and 10.8% at 50 years. Patients at higher risk of cancer are

those with a family history of colon cancer, a long duration of colitis, extensive colon involvement, and those with primary sclerosing cholangitis (PSC).
http://www.medicinenet.com/script/main/art.asp?articlekey=8572http://www.medicinenet.com/script/main/art.asp?articlekey=8572http://www.medicinenet.com/script/main/art.asp?articlekey=8572http://www.medicinenet.com/script/main/art.asp?articlekey=8572


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Ulcerative colitis and colon cancer

Since the cancers associated with ulcerative colitis havea more favorable outcome when caught at an earlierstage, yearly examinations of the colon often are

recommended after eight years of known extensivedisease. During these examinations, samples of tissue (biopsies)

can be taken to search for precancerous changes in thelining cells of the colon. When precancerous changesare found, removal of the colon may be necessary toprevent colon cancer.


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Risk Factor: Genetics and coloncancer

A person's genetic background is an important factor in coloncancer risk. Among first-degree relatives of colon cancerpatients, the lifetime risk of developing colon cancer is 18% (athreefold increase over the general population in the UnitedStates).

Even though family history of colon cancer is an important risk factor, majority (80%) of colon cancers occur sporadically inpatients with no family history of colon cancer. Approximately 20% of cancers are associated with a family history of coloncancer.

And 5 % of colon cancers are due to hereditary colon cancersyndromes. Hereditary colon cancer syndromes are disorders where affected family members have inherited cancer-causing genetic defects from one or both of the parents.


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Genetics and colon cancer

Chromosomes contain genetic information, and chromosomedamages cause genetic defects that lead to the formation of colon polyps and later colon cancer.

In sporadic polyps and cancers (polyps and cancers that developin the absence of family history), the chromosome damages areacquired (develop in a cell during adult life).

The damaged chromosomes can only be found in the polyps andthe cancers that develop from that cell. But in hereditary coloncancer syndromes, the chromosome defects are inherited at birthand are present in every cell in the body.

Patients who have inherited the hereditary colon cancersyndrome genes are at risk of developing large number of colonpolyps, usually at young ages, and are at very high risk of developing colon cancer early in life, and also are at risk of developing cancers in other organs.


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Genetics and colon cancer

FAP (familial adenomatous polyposis) is a hereditary coloncancer syndrome where the affected family members willdevelop countless numbers (hundreds, sometimes thousands) of colon polyps starting during the teens.

Unless the condition is detected and treated (treatment involvesremoval of the colon) early, a person affected by familialpolyposis syndrome is almost sure to develop colon cancer fromthese polyps.

Cancers usually develop in the 40s. These patients are also at risk of developing other cancers such as cancers in the thyroid gland,stomach, and the ampulla (the part where the bile ducts draininto the duodenum just beyond the stomach).
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Genetics and colon cancer AFAP (attenuated familial adenomatous polyposis) is a milder version of

FAP. Affected members develop less than 100 colon polyps. Nevertheless,they are still at very high risk of developing colon cancers at young ages. They are also at risk of having gastric polyps and duodenal polyps.

HNPCC (hereditary nonpolyposis colon cancer) is a hereditary coloncancer syndrome where affected family members can develop colon polypsand cancers, usually in the right colon, in their 30s to 40s. Certain HNPCCpatients are also at risk of developing uterine cancer, stomach cancer, ovariancancer, and cancers of the ureters (the tubes that connect the kidneys to thebladder), and the biliary tract (the ducts that drain bile from the liver to theintestines).

MYH polyposis syndrome is a recently discovered hereditary colon cancersyndrome. Affected members typically develop 10-100 polyps occurring ataround 40 years of age, and are at high risk of developing colon cancer.

What tests can be done to detect
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What tests can be done to detectcolon cancer?

When colon cancer is suspected, either a lower GIseries ( barium enema x-ray) or colonoscopy isperformed to confirm the diagnosis and to localize the

tumor. A barium enema involves taking x-rays of the colon and

the rectum after the patient is given an enema with a white, chalky liquid containing barium. The bariumoutlines the large intestines on the x-rays. Tumors andother abnormalities appear as dark shadows on the x-rays.



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Colonoscopy is a procedure whereby a doctor inserts a long,flexible viewing tube into the rectum for the purpose of inspecting the inside of the entire colon.

Colonoscopy is generally considered more accurate than bariumenema x-rays, especially in detecting small polyps. If colon

polyps are found, they are usually removed through thecolonoscope and sent to the pathologist. The pathologist examines the polyps under the microscope to

check for cancer. While the majority of the polyps removedthrough the colonoscopes are benign, many are precancerous.Removal of precancerous polyps prevents the futuredevelopment of colon cancer from these polyps. For moreinformation, please read the Colonoscopy article.

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If cancerous growths are found during colonoscopy, small tissuesamples (biopsies) can be obtained and examined under themicroscope to confirm the diagnosis.

If colon cancer is confirmed by a biopsy, staging examinationsare performed to determine whether the cancer has already spread to other organs. Since colorectal cancer tends to spread tothe lungs and the liver, staging tests usually include chest x-rays,ultrasonography , or a CAT scan of the lungs, liver, andabdomen.

Sometimes, the doctor may obtain a blood test for CEA

(carcinoembyonic antigen). CEA is a substance produced by some cancer cells. It is sometimes found in high levels in patients with colorectal cancer, especially when the disease has spread.
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Colonoscopy

A lighted probe called acolonoscope is inserted intothe rectum and the entirecolon to look for polyps and

other abnormalities that may be caused by cancer. Acolonoscopy has theadvantage that if polyps are

found during the procedurethey can be immediately removed. Tissue can also betaken for biopsy .
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Grown Polyps


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Full Grown Tumor

S i


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Staging

Colon cancer staging is an estimate of theamount of penetration of a particular cancer.

It is performed for diagnostic and research

purposes, and to determine the best method of treatment. The systems for staging colorectal cancers

largely depend on the extent of local invasion,the degree of lymph node involvement and

whether there is distant metastasis.
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Tumor Stages


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Staging

Definitive staging can only be done after surgery hasbeen performed and pathology reports reviewed.

An exception to this principle would be after acolonoscopic polypectomy of a malignant pedunculatedpolyp with minimal invasion.

Preoperative staging of rectal cancers may be done withendoscopic ultrasound .

Adjuncts to staging of metastasis include AbdominalUltrasound, CT, PET Scanning , and other imaging studies.
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Dukes' system

Dukes' classification, first proposed by DrCuthbert E. Dukes in 1932, identifies the stagesas:

A - Tumor confined to the intestinal wall B - Tumor invading through the intestinal wall C - With lymph node(s) involvement D - With distant metastasis


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TNM system The most common current staging system is the TNM (for tumors/nodes/metastases)

system, though many doctors still use the older Dukes system. The TNM systemassigns a number:

T - The degree of invasion of the intestinal wall T0 - no evidence of tumor Tis- cancer in situ (tumor present, but no invasion) T1 - invasion through submucosa into lamina propria (basement membrane invaded) T2 - invasion into the muscularis propria (i.e. proper muscle of the bowel wall)

T3 - invasion through the subserosa T4 - invasion of surrounding structures (e.g. bladder) or with tumor cells on the free external

surface of the bowel N - the degree of lymphatic node involvement

N0 - no lymph nodes involved N1 - one to three nodes involved N2 - four or more nodes involved

M - the degree of metastasis M0 - no metastasis M1 - metastasis present
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What are the treatments and survival


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What are the treatments and survivalfor colon cancer?

The treatment depends on the staging of the cancer. When colorectal cancer is caught at early stages (withlittle spread) it can be curable. However when it is

detected at later stages (when distant metastases arepresent) it is more difficult to cure. Surgery remains the primary treatment while

chemotherapy and/or radiotherapy may be

recommended depending on the individual patient'sstaging and other medical factors.

What are the treatments and survival
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What are the treatments and survivalfor colon cancer?

Surgery is the most common treatment for colorectal cancer.During surgery, the tumor, a small margin of the surrounding healthy bowel, and adjacent lymph nodes are removed.

The surgeon then reconnects the healthy sections of the bowel.

In patients with rectal cancer, the rectum is permanently removed. The surgeon then creates an opening (colostomy) on the

abdomen wall through which solid waste in the colon is excreted.Specially trained nurses (enterostomal therapists) can help

patients adjust to colostomies, and most patients withcolostomies return to a normal lifestyle

T t t S g


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Treatment: Surgery Surgeries can be categorized into curative, palliative, bypass, fecal

diversion, or open-and-close. Curative Surgicaltreatment can be offered if the tumor is

localized. Very early cancer that develops within a polyp can often be

cured by removing the polyp (i.e., polypectomy) at the time of colonoscopy .

In colon cancer, a more advanced tumor typically requiressurgical removal of the section of colon containing the tumor

with sufficient margins, and radical en-bloc resection of mesentery and lymph nodes to reduce local recurrence (i.e.,colectomy). If possible, the remaining parts of colon areanastomosed together to create a functioning colon. In cases

when anastomosis is not possible, a stoma (artificial orifice) iscreated.

C ti d N C ti
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Curative and Non CurativeSurgery

Curative surgery on rectal cancer includes total mesorectalexcision ( lower anterior resection ) or abdominoperineal excision.

In case of multiple metastases, palliative (non curative) resection of the primary tumor is still offered in order to reduce furthermorbidity caused by tumor bleeding, invasion, and its cataboliceffect. Surgical removal of isolated liver metastases is, however,common and may be curative in selected patients; improvedchemotherapy has increased the number of patients who areoffered surgical removal of isolated liver metastases.

If the tumor invaded into adjacent vital structures which makes

excision technically difficult, the surgeons may prefer to bypass the tumor (ileotransverse bypass) or to do a proximal fecaldiversion through a stoma.
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Colon Prognosis

The long-term prognosis after surgery depends on whether thecancer has spread to other organs (metastasis).

The risk of metastasis is proportional to the depth of penetrationof the cancer into the bowel wall. In patients with early colon

cancer which is limited to the superficial layer of the bowel wall,surgery is often the only treatment needed. These patients can experience long-term survival in excess of

80%. In patients with advanced colon cancer, wherein the tumor has

penetrated beyond the bowel wall and there is evidence of metastasis to distant organs, curing will be more than difficult.

Treatment: Chemotherapy


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Treatment: Chemotherapy

Chemotherapy is used to reduce the likelihood of metastasis developing, shrink tumor size, or slow tumorgrowth.

Chemotherapy is often applied after surgery (adjuvant),before surgery (neo-adjuvant), or as the primary therapy if surgery is not indicated (palliative).

The treatments listed here have been shown in clinicaltrials to improve survival and/or reduce mortality rateand have been approved for use by the US Food andDrug Administration .
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Chemotherapy

In some patients, there is no evidence of distant metastasis at thetime of surgery, but the cancer has penetrated deeply into thecolon wall or reached adjacent lymph nodes. These patients areat risk of tumor recurrence either locally or in distant organs.

Chemotherapy in these patients may delay tumor recurrence andimprove survival.

Chemotherapy is the use of medications to kill cancer cells. It is asystemic therapy, meaning that the medication travelsthroughout the body to destroy cancer cells. After colon cancersurgery, some patients may harbor microscopic metastasis (small

foci of cancer cells that will hardly be detected).


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Chemotherapy

Chemotherapy is given shortly after surgery to destroy thesemicroscopic cells.

Chemotherapy given in this manner is called adjuvantchemotherapy. Recent studies have shown increased survival anddelay of tumor recurrence in some patients treated with adjuvantchemotherapy within five weeks of surgery.

Most drug regimens have included the use of 5-flourauracil (5-FU).

On the other hand, however, chemotherapy for shrinking orcontrolling the growth of metastatic tumors has beendisappointing.

Improvement in the overall survival for patients with widespreadmetastasis has not been convincingly demonstrated.


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Chemotherapy

Chemotherapy is usually given in a doctor's office, in the hospitalas a outpatient, or at home.

Chemotherapy is usually given in cycles of treatment periodsfollowed by recovery periods. Side effects of chemotherapy vary from person to person, and also depend on the agents given.Modern chemotherapy agents are usually well tolerated, and sideeffects are manageable.

In general, anti-cancer medications destroy cells that are rapidly growing and dividing. Therefore, red blood cells, platelets, and

white blood cells are frequently affected by chemotherapy.

Common side effects include anemia, loss of energy, easy bruising, and a low resistance to infections. Cells in the hair rootsand intestines also divide rapidly. Therefore, chemotherapy cancause hair loss, mouth sores, nausea, vomiting, and diarrhea.


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Chemotherapy Drugs Adjuvant (after surgery) chemotherapy. One regimen involves the combination of infusional 5-fluorouracil, leucovorin, and oxaliplatin ( FOLFOX )

5-fluorouracil (5-FU) or Capecitabine (Xeloda) Leucovorin (LV, Folinic Acid) Oxaliplatin (Eloxatin)

Chemotherapy for metastatic disease. Commonly used first line chemotherapy regimens involvethe combination of infusional 5-fluorouracil, leucovorin, and oxaliplatin ( FOLFOX ) with

bevacizumab or infusional 5-fluorouracil, leucovorin, and irinotecan ( FOLFIRI ) withbevacizumab 5-fluorouracil (5-FU) or Capecitabine Leucovorin (LV, Folinic Acid) Irinotecan (Camptosar) Oxaliplatin (Eloxatin) Bevacizumab (Avastin)

Cetuximab (Erbitux) Panitumumab (Vectibix)

In clinical trials for treated/untreated metastatic disease. [2] Bortezomib (Velcade) Oblimersen (Genasense, G3139) Gefitinib and Erlotinib (Tarceva) Topotecan (Hycamtin)
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Chemotherapy using Drug C225

Miracle Drug Thus it was with considerable delight that cancer researchers at the meeting of

the American Society of Clinical Oncology in New Orleans learned last Monday of apatient who had done the seemingly impossible. Shannon Kellum, a 30 year oldaccountant from Fort Myers, Florida, learned in 1998 that she had terminal colon cancer,and could not expect to live long. The cancer had already spread to her liver, with tumorsthe size of grapefruits, far too large to remove. Her life expectancy was nil. Today she is tumor-free, and not at all dead .

The drug C225 was administered to Kellum once a week intravenously, withchemotherapy to aid in knocking out any tumor cells weakened but not killed by lack of EGF. Her liver tumors shrank by 80% in four months. Four months later, the tumors weresmall enough to be removed surgically. Today she is tumor-free. Only time will tell if she iscured -- some cancer cells may remain that could restart tumors. But there is no denying the fact that she is very much alive and leading a normal life, a year after she should havedied.
http://www.txtwriter.com/Onscience/OSpictures/curecoloncancer.jpg


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Treatment: Radiation therapy
http://www.txtwriter.com/Onscience/OSpictures/curecoloncancer.jpg


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Treatment: Radiation therapy Radiotherapy is not used routinely in colon cancer, as it could lead to

radiation enteritis, and it is difficult to target specific portions of the colon. Itis more common for radiation to be used in rectal cancer, since the rectumdoes not move as much as the colon and is thus easier to target. Indicationsinclude:

Colon cancer pain relief and palliation - targeted at metastatic tumor deposits if they

compress vital structures and/or cause pain Rectal cancer

neoadjuvant - given before surgery in patients with tumors that extendoutside the rectum or have spread to regional lymph nodes, in order todecrease the risk of recurrence following surgery or to allow for lessinvasive surgical approaches (such as a low anterior resection instead of an abdomino-perineal resection)

adjuvant - where a tumor perforates the rectum or involves regionallymph nodes (AJCC T3 or T4 tumors or Duke's B or C tumors)

palliative - to decrease the tumor burden in order to relieve or preventsymptoms
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Radiation Therapy

Radiation therapy in colorectal cancer has been limited totreating cancer of the rectum. There is a decreased localrecurrence of rectal cancer in patients receiving radiation eitherprior to or after surgery.

Without radiation, the risk of rectal cancer recurrence is close to50%. With radiation, the risk is lowered to approximately 7%. Side effects of radiation treatment include fatigue, temporary or

permanent pelvic hair loss, and skin irritation in the treated areas. Other treatments have included the use of localized infusion of

chemotherapeutic agents into the liver, the most common site of metastasis.


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Radiation Therapy

This involves the insertion of a pump into the blood supply of the liver which can deliver high doses of medicine directly to theliver tumor.

Response rates for these treatments have been reported to be ashigh as eighty percent. Side effects, however, can be serious.

Additional experimental agents considered for the treatment of colon cancer include the use of cancer-seeking antibodies boundto cancer-fighting drugs.

Such combinations can specifically seek and destroy tumortissues in the body.


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Radiation Therapy

Other treatments attempt to boost the immune system, thebodies' own defense system, in an effort to more effectively attack and control colon cancer.

In patients who are poor surgical risks, but who have large

tumors which are causing obstruction or bleeding, lasertreatment can be used to destroy cancerous tissue and relieveassociated symptoms.

Still other experimental agents include the use of photodynamictherapy. In this treatment, a light sensitive agent is taken up by the tumor which can then be activated to cause tumordestruction.


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Others Treatment

Immunotherapy Bacillus Calmette-Gurin (BCG) is being investigated as an adjuvant mixed

with autologous tumor cells in immunotherapy for colorectal cancer.

Vaccine In November 2006, it was announced that a vaccine had been developed and

tested with very promising results. The new vaccine, called TroVax , works in a totally different way to existing

treatments by harnessing the patient's own immune system to fight thedisease.

Experts say this suggests that gene therapy vaccines could prove an effectivetreatment for a whole range of cancers. Oxford BioMedica is a British spin-out from Oxford University specializing in the development of .

Phase III trials are underway for renal cancers and planned for colon cancers.

Treatment of colorectal cancer
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metastasis to the liver

According to the American Cancer Society statistics in 2006greater than 20% of patients present with metastatic (stage IV)colorectal cancer at the time of diagnosis, and up to 25% of thisgroup will have isolated liver metastasis that is potentially resectable.

Lesions which undergo curative resection have demonstrated 5-year survival outcomes now exceeding 50%.


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Metastasis to the liver


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Metastasis to the liver

Patients with colon cancer and metastatic disease to the liver may be treatedin either a single surgery or in staged surgeries (with the colon tumortraditionally removed first) depending upon the fitness of the patient forprolonged surgery, the difficulty expected with the procedure with either thecolon or liver resection, and the comfort of the surgery performing potentially complex hepatic surgery.

Poor pronostic factors of patients with liver metastasis include Synchronous (diagnosed simultaneously) liver and primary colorectal tumors A short time between detecting the primary cancer and subsequent

development of liver mets Multiple metastatic lesions High blood levels of the tumor marker, carcino -embryonic antigen ( CEA ), in

the patient prior to resection Larger size metastatic lesions

What is the follow-up care for colon


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cancer?

Follow-up exams are important after treatment for colon cancer. The cancercan recur near the original site or in a distant organ such as the liver or lung.Follow-up exams include a physical examination by the doctor, blood tests of liver enzymes, chest x-rays, CAT scans of the abdomen and pelvis,colonoscopies, and blood CEA levels.

Abnormal liver enzymes may indicate growth of liver metastasis. CEA levels

may be elevated before surgery and become normal shortly after the cancer isremoved. Slowly rising CEA level may indicate cancer recurrence. A CATscan of the abdomen and pelvis can show tumor recurrence in the liver,pelvis, or other areas. Colonoscopy can show recurrence of polyps or cancerin the large intestine.

In addition to checking for cancer recurrence, patients who have had coloncancer may have an increased risk of cancer of the prostate, breast, and ovary.

Therefore, follow-up examinations should include these areas.

Follow-up


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Follow up

The aims of follow-up are to diagnose in the earliest possible stage any metastasis ortumors that develop later but did not originate from the original cancer (metachronouslesions).

The U.S. National Comprehensive Cancer Network and American Society of ClinicalOncology provide guidelines for the follow-up of colon cancer. A medical history andphysical examination are recommended every 3 to 6 months for 2 years, then every 6months for 5 years. Carcinoembryonic antigen blood level measurements follow thesame timing, but are only advised for patients with T2 or greater lesions who arecandidates for intervention.

A CT-scan of the chest, abdomen and pelvis can be considered annually for the first 3years for patients who are at high risk of recurrence (for example, patients who hadpoorly differentiated tumors or venous or lymphatic invasion) and are candidates forcurative surgery (with the aim to cure).

A colonoscopy can be done after 1 year, except if it could not be done during theinitial staging because of an obstructing mass, in which case it should be performedafter 3 to 6 months. If a villous polyp, polyp >1 centimeter or high grade dysplasia isfound, it can be repeated after 3 years, then every 5 years. For other abnormalities, thecolonoscopy can be repeated after 1 year.

How can colon cancer be prevented?
http://en.wikipedia.org/wiki/National_Comprehensive_Cancer_Networkhttp://en.wikipedia.org/wiki/American_Society_of_Clinical_Oncologyhttp://en.wikipedia.org/wiki/American_Society_of_Clinical_Oncologyhttp://en.wikipedia.org/wiki/Medical_historyhttp://en.wikipedia.org/wiki/Physical_examinationhttp://en.wikipedia.org/wiki/Carcinoembryonic_antigenhttp://en.wikipedia.org/wiki/Computed_tomographyhttp://en.wikipedia.org/wiki/Colonoscopyhttp://en.wikipedia.org/wiki/Colonoscopyhttp://en.wikipedia.org/wiki/Computed_tomographyhttp://en.wikipedia.org/wiki/Computed_tomographyhttp://en.wikipedia.org/wiki/Computed_tomographyhttp://en.wikipedia.org/wiki/Carcinoembryonic_antigenhttp://en.wikipedia.org/wiki/Physical_examinationhttp://en.wikipedia.org/wiki/Medical_historyhttp://en.wikipedia.org/wiki/American_Society_of_Clinical_Oncologyhttp://en.wikipedia.org/wiki/American_Society_of_Clinical_Oncologyhttp://en.wikipedia.org/wiki/National_Comprehensive_Cancer_Network


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Unfortunately, colon cancers can be well advanced before they are detected. The most effective prevention of colon cancer is early detection and removalof precancerous colon polyps before they turn cancerous.

Even in cases where cancer has already developed, early detection stillsignificantly improves the chances of a cure by surgically removing the cancerbefore the disease spreads to other organs. Multiple world health

organizations have suggested general screening guidelines. Digital rectal examination and stool occult blood testing It is recommended that all individuals over the age of 40 have yearly digital

examinations of the rectum and their stool tested for hidden or "occult"blood. During digital examination of the rectum, the doctor inserts a glovedfinger into the rectum to feel for abnormal growths. Stool samples can be

obtained to test for occult blood (see below). The prostate gland can beexamined at the same time.



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Most colorectal cancers should be preventable, through increasedsurveillance, improved lifestyle, and, probably, the use of dietary chemopreventative agents.Surveillance

Most colorectal cancer arise from adenomatous polyps. These lesions can bedetected and removed during colonoscopy. Studies show this procedure

would decrease by > 80% the risk of cancer death, provided it is started by the age of 50, and repeated every 5 or 10 years.

As per current guidelines under National Comprehensive Cancer Network , inaverage risk individuals with negative family history of colon cancer andpersonal history negative for adenomas or Inflammatory Bowel diseases,

flexible sigmoidoscopy every 5 years with fecal occult blood testing annually or double contrast barium enema are other options acceptable for screening rather than colonoscopy every 10 years (which is currently the Gold-Standardof care).

http://en.wikipedia.org/wiki/National_Comprehensive_Cancer_Networkhttp://en.wikipedia.org/wiki/Adenomashttp://en.wikipedia.org/wiki/Inflammatory_Bowel_diseaseshttp://en.wikipedia.org/wiki/Inflammatory_Bowel_diseaseshttp://en.wikipedia.org/wiki/Adenomashttp://en.wikipedia.org/wiki/National_Comprehensive_Cancer_Network


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An important screening test for colorectal cancers and polyps is the stooloccult blood test. Tumors of the colon and rectum tend to bleed slowly intothe stool.

The small amount of blood mixed into the stool is usually not visible to thenaked eye. The commonly used stool occult blood tests rely on chemicalcolor conversions to detect microscopic amounts of blood.

These tests are both convenient and inexpensive. A small amount of stoolsample is smeared on a special card for occult blood testing. Usually, threeconsecutive stool cards are collected.

A person who tests positive for stool occult blood has a 30% to 45% chanceof having a colon polyp and a 3% to 5% chance of having a colon cancer.

Colon cancers found under these circumstances tend to be early and have a

better long-term prognosis.


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It is important to remember that having stool tested positive for occult blooddoes not necessarily mean the person has colon cancer. Many otherconditions can cause occult blood in the stool.

However, patients with a positive stool occult blood should undergo furtherevaluations involving barium enema x-rays, colonoscopies, and other tests toexclude colon cancer, and to explain the source of the bleeding.

It is also important to realize that stool which has tested negative for occultblood does not mean the absence of colorectal cancer or polyps. Even underideal testing conditions, at least 20% of colon cancers can be missed by stooloccult blood screening.

Many patients with colon polyps are tested negative for stool occult blood.In patients suspected of having colon tumors, and in those with high risk

factors for developing colorectal polyps and cancer, flexible sigmoidoscopiesor screening colonoscopies are performed even if the stool occult blood testsare negative.


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Flexible sigmoidoscopy and colonoscopy Beginning at age 50, aflexible sigmoidoscopy screening tests is recommended

every three to five years. Flexible sigmoidoscopy is an exam of the rectum andthe lower colon using a viewing tube (a short version of colonoscopy).

Recent studies have shown that the use of screening flexible sigmoidoscopy can reduce mortality from colon cancer. This is a result of the detection of polyps or early cancers in people with no symptoms. If a polyp or cancer isfound, a complete colonoscopy is recommended.

The majority of colon polyps can be completely removed by colonoscopy without open surgery. Recently doctors are recommending screening colonoscopies instead of screening flexible sigmoidoscopies for healthy individuals starting at ages 50-55.

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Patients with a high risk of developing colorectal cancer may undergocolonoscopies starting at earlier ages than 50. For example, patients withfamily history of colon cancer are recommended to start screening colonoscopies at an age 10 years before the earliest colon caner diagnosed in afirst-degree relative, or five years earlier than the earliest precancerous colonpolyp discovered in a first-degree relative.

Patients with hereditary colon cancer syndromes such as FAP, AFAP,HNPCC, and MYH are recommended to begin colonoscopies early. Therecommendations differ depending on the genetic defect, for example inFAP; colonoscopies may begin during teenage years to look for thedevelopment of colon polyps.

Patients with a prior history of polyps or colon cancer may also undergocolonoscopies to exclude recurrence. Patients with a long history (greater than10 years) of chronic ulcerative colitis have an increased risk of colon cancer,and should have regular colonoscopies to look for precancerous changes inthe colon lining.

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Genetic counseling and testing Blood tests are now available to test for FAP, AFAP, MYH, and HNPCC

hereditary colon cancer syndromes. Families with multiple members having colon cancers, members with multiple colon polyps, members having cancersat young ages, and having other cancers such as cancers of the ureters, uterus,duodenum, etc., should be referred for genetic counseling followed possibly

by genetic testing. Genetic testing without prior counseling is discouraged because of theextensive family education that is involved and the complicated nature of interpreting the test results.

The advantages of genetic counseling followed by genetic testing include: (1)identifying family members at high risk of developing colon cancer to begin

colonoscopies early; (2) identifying high risk members so that screening may begin to prevent other cancers such as ultrasound tests for uterine cancer,urine examinations for ureter cancer, and upper endoscopies for stomach andduodenal cancers; and (3) alleviating concern for members who test negativefor the hereditary genetic defects.

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Lifestyle The comparison of colorectal cancer incidence in

various countries strongly suggests that sedentarity,overeating (i.e., high caloric intake), and perhaps a diet

high in meat (red or processed) could increase the risk of colorectal cancer. In contrast, physical exercise, and eating plenty of

fruits and vegetables would decrease cancer risk,probably because they contain protectivephytochemicals.

Accordingly, lifestyle changes could decrease the risk of colorectal cancer as much as 60-80%.

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Chemoprevention More than 200 agents, including the above cited phytochemicals, and other

food components like calcium or folic acid (a B vitamin), and NSAIDs likeaspirin, are able to decrease carcinogenesis in preclinical models: Some studiesshow full inhibition of carcinogen-induced tumors in the colon of rats.

Other studies show strong inhibition of spontaneous intestinal polyps in

mutated mice (Min mice). Chemoprevention clinical trials in human volunteers have shown smaller prevention, but few intervention studies havebeen completed today.

Calcium, aspirin and celecoxib supplements, given for 3 to 5 years after theremoval of a polyp, decreased the recurrence of polyps in volunteers (by 15-40%).The "chemoprevention database" shows the results of all published

scientific studies of chemopreventive agents, in people and in animals.

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http://en.wikipedia.org/wiki/NSAIDhttp://en.wikipedia.org/wiki/NSAID


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Aspirin chemoprophylaxis Aspirin should not be taken routinely to prevent colorectal cancer, even in

people with a family history of the disease, because the risk of bleeding andkidney failure from high dose aspirin (300mg or more) outweigh the possiblebenefits.

A clinical practice guidelineby the U.S. Preventive Services Task Force

(USPSTF) recommended against taking aspirin ( grade Drecommendation ).The Task Force acknowledged that aspirin may reduce theincidence of colorectal cancer, but "concluded that harms outweigh thebenefits of aspirin and NSAID use for the prevention of colorectal cancer". Asubsequent meta-analysisconcluded "300 mg or more of aspirin a day forabout 5 years is effective in primary prevention of colorectal cancer inrandomised controlled trials, with a latency of about 10 years". However,long-term doses over 81 mg per day may increase bleeding events.

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http://en.wikipedia.org/wiki/Clinical_practice_guidelinehttp://www.ahrq.gov/clinic/uspstfix.htmhttp://www.ahrq.gov/clinic/uspstfix.htmhttp://en.wikipedia.org/wiki/Aspirinhttp://www.ahrq.gov/clinic/3rduspstf/ratings.htmhttp://www.ahrq.gov/clinic/3rduspstf/ratings.htmhttp://en.wikipedia.org/wiki/Meta-analysishttp://en.wikipedia.org/wiki/Meta-analysishttp://en.wikipedia.org/wiki/Meta-analysishttp://en.wikipedia.org/wiki/Meta-analysishttp://www.ahrq.gov/clinic/3rduspstf/ratings.htmhttp://www.ahrq.gov/clinic/3rduspstf/ratings.htmhttp://en.wikipedia.org/wiki/Aspirinhttp://www.ahrq.gov/clinic/uspstfix.htmhttp://www.ahrq.gov/clinic/uspstfix.htmhttp://en.wikipedia.org/wiki/Clinical_practice_guideline


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Calcium A meta-analysisby the Cochrane Collaboration of randomized

controlled trials published through 2002 concluded "Althoughthe evidence from two RCTs suggests that calciumsupplementation might contribute to a moderate degree to theprevention of colorectal adenomatous polyps, this does notconstitute sufficient evidence to recommend the general use of calcium supplements to prevent colorectal cancer.".

Subsequently, one randomized controlled trial by the Women's

Health Initiative (WHI) reported negative results. A second randomized controlled trial reported reduction in all

cancers, but had insufficient colorectal cancers for analysis.

What does the future hold fori i h l l ?
http://en.wikipedia.org/wiki/Meta-analysishttp://en.wikipedia.org/wiki/Cochrane_Collaborationhttp://en.wikipedia.org/wiki/Randomized_controlled_trialshttp://en.wikipedia.org/wiki/Randomized_controlled_trialshttp://en.wikipedia.org/wiki/Randomized_controlled_trialhttp://en.wikipedia.org/wiki/Women%27s_Health_Initiativehttp://en.wikipedia.org/wiki/Women%27s_Health_Initiativehttp://en.wikipedia.org/wiki/Randomized_controlled_trialhttp://en.wikipedia.org/wiki/Randomized_controlled_trialhttp://en.wikipedia.org/wiki/Women%27s_Health_Initiativehttp://en.wikipedia.org/wiki/Women%27s_Health_Initiativehttp://en.wikipedia.org/wiki/Randomized_controlled_trialhttp://en.wikipedia.org/wiki/Randomized_controlled_trialshttp://en.wikipedia.org/wiki/Randomized_controlled_trialshttp://en.wikipedia.org/wiki/Cochrane_Collaborationhttp://en.wikipedia.org/wiki/Meta-analysishttp://en.wikipedia.org/wiki/Meta-analysishttp://en.wikipedia.org/wiki/Meta-analysis


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patients with colorectal cancer?

Colon cancer remains a major cause of death and disease, especially in the western world. A clear understanding of the causes and course of the diseaseis emerging. This has allowed for recommendations regarding screening forand prevention of this disease.

The removal of colon polyps helps prevent colon cancer. Early detection of colon cancer can improve the chances of a cure and overall survival.

Treatment remains unsatisfactory for advanced disease, but research in thisarea remains strong and newer treatments continue to emerge. New and exciting preventive measures have recently focused on the possible

beneficial effects of aspirin or other anti-inflammatory agents. In trials, theuse of these agents has markedly limited colon cancer formation in severalexperimental models.

Other agents being evaluated to prevent colon cancer include calcium,selenium, and vitamins A, C, and E. More studies are needed before theseagents can be recommended for widespread use by the public to preventcolon cancer.


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DIETARYMANAGEMENT

Obj i


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Objectives

Recognize the special nutritional needs of cancer survivors during active cancertreatment

Advise cancer survivors about nutritionand physical activity during the recovery phase and beyond

Resolve controversial nutritional issuesfacing cancer survivors


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NUTRITIONAL DEFICIENCIES


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The primary organ where the malignancy occurs. The severity of the cancer at the time of diagnosis. The symptoms experienced by the person with cancer. The type and frequency of the cancer treatment

being used and the side effects associated with thattreatment (surgery, radiation, or chemotherapy).

The effect of the malignancy or disease on food and

nutrient ingestion, tolerance, and utilization.

There are several factors that may contribute to the type anddegree of nutrient deficiencies:

Bod Weight Changes


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Body Weight Changes Intentional weight loss during cancer

treatment is not recommended Some cancer survivors may gain weight

during and after treatments During treatment, a healthy eating plan

that meets but does not exceed caloricneeds (along with physical activity) isadvisable

Healthy weight loss is best initiated afterthe recovery phase

Obesity is associated with increased risk and poorer prognosis of breast and coloncancers

The Phases of Cancer Survival


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The Phases of Cancer Survival

Phase 1 : Active Treatment

Phase 2 : Recovery from Treatment

Phase 3 : Preventing Cancer Recurrence,Second Primary Cancers.

Phase 4 : Living with Advanced Cancer Dietary management

Phase 1: Nutritional Issues


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During Active Treatment

Energy balance is the most important goal

ENERGY INTAKE ENERGY EXPENDITURE NUTRITIONAL SUPPLEMENTS

ENERGY INTAKE


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ENERGY INTAKE The need for caloric intake is usually increased

during cancer treatments Nausea, vomiting, taste changes, loss of

appetite, bowel changes all interfere with the

usual eating patterns. Food choices at this time should be easy to

chew, swallow, digest and absorb and shouldalso be appealing.

Adjust usual food choices and usual food patterns.

ENERGY EXPENDITURE


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ENERGY EXPENDITURE

cancer treatment can cause fatigue light regular physical activity during

treatment should be encouraged to

improve appetite, stimulate digestion, prevent constipation.

Helps to maintain energy level and

muscle mass and provide relaxation orstress reduction

NUTRITIONAL


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SUPPLEMENTSNutritional products such as Boost, Ensureetc can be helpful on a temporary basis toassist with intake of calories and nutrients.Other supplements is quite controversial . Forexample, it is counterproductive for patients totake vitamin supplements that contain highlevels of folic acid or to eat foods fortified withhigh amount of folic acid, when onMethotrexate . ( metho interferes with folatemetabolism ).

NUTRITIONAL

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