Colorectal Cancer 3.pdfColon and rectal cancer is the third most common cancer in both men and women in the United States, and the second leading cancer killer in men and women.

Division of Colon and Rectal Surgery PennStateHershey.org/colonandrectal

Colorectal CancerA Patient Guide

Colon and rectal cancer is the third mostcommon cancer in both men and womenin the United States, and the secondleading cancer killer in men and women.More that 140,000 new cases arediagnosed each year, and more than50,000 men and women die each yearfrom colon and rectal cancer. Earlyscreening, advances in chemotherapyand radiation along with surgicaltechniques that can preserve the musclesof continence have improved the qualityof life for patients with colorectal cancer.

The board-certified physicians at PennState Milton S. Hershey Medical Centerhave been providing treatment topatients with colon and rectal cancer for over ten years. Our skilled surgeonsutilize state-of-the-art diagnosticcapabilities, the latest drug therapies and leading-edge surgical techniques to provide the most advanced andeffective medical care available.

1 Penn State Hershey Colon and Rectal Surgery (717) 531-5164

Comprehensive Colon & Rectal Care

PennStateHershey.org/colonandrectal 2

To our patients and families:

This booklet was written for you bymembers of your healthcare team toeducate you about colorectal cancer, the surgical options for its treatmentand the associated medical managementof the disease.

We know that surgery is a stressful event,and we believe that an understanding of the process can help reduce thesefears. We encourage you to share thisinformation with your families andsignificant others.

This booklet will discuss many aspectsof colon and rectal cancer, includingsphincter sparing surgical procedures.

This booklet describes the following:

• Normal anatomy • Explanation of colon and rectal cancer• Staging of colon and rectal cancer• Surgical procedures involved• Pre- and postoperative care• Chemotherapy and radiation• Stoma care—ileostomy and colostomy• Postoperative surveillance• Risk for family members

We believe that patients are critical to the recovery process, so yourparticipation is important. Please cometo us with your questions and concerns.

Sincerely, Your healthcare team:

Introduction

Walter Koltun, M.D.,F.A.C.S., F.A.S.C.R.S.Chief, Division of Colon andRectal Surgery; Peter andMarshia Carlino Professor inInflammatory Bowel Disease

Lisa Poritz, M.D., F.A.C.S.,F.A.S.C.R.S.Associate Professor ofSurgery

David Stewart, M.D.Assistant Professor ofSurgery

Kevin McKenna, M.D.,F.A.S.C.R.S.Assistant Professor of Surgery

Marjorie Lebo, M.S.N.,C.R.N.P.Certified Registered NursePractitioner

Amy Sheranko, M.A.Medical Assistant

Table of Contents

4 Normal Anatomy & Function of the Colon and Rectum

5 Overview of Colon and Rectal Cancer

5 Colon Cancer

5 Operation for Colon Cancer

6 Rectal Cancer

6 Types of Operations for Rectal Cancer

8 Colon and Rectal Cancer Staging

9 Risk of Colon Cancer for Your Family Members

10 What To Expect During Your Hospitalization

14 Follow-Up After Surgery for Colon and Rectal Cancer

15 Stoma (Ostomy)

16 Second Stage Surgery – Ileostomy Closure If You Have One

18 Chemotherapy and Radiation

19 Glossary

20 Resources – Who To Contact

Penn State Hershey Colon and Rectal Surgery (717) 531-5164

esophagus

stomach

small bowel

large bowel orcolon

rectum

anal sphinctersanus

Normal Anatomy & Function of the Colon and Rectum


The gastrointestinal (GI) tract begins atthe mouth and ends at the anus. The GItract digests and stores food, absorbsvitamins and nutrients and eliminateswastes. The small bowel absorbs muchof the nutrients and then passes thematerial into the colon.

Large Bowel or ColonThe large bowel has two major functions—absorption of water and storage of stool.As water is absorbed from the paste-likeliquid passed from the small intestine,the material that remains becomes semi-solid stool. The stool is stored in thelarge bowel until it is

passed (defecated) through the anus. An adult’s colon is approximately five to six feet long.

RectumThe rectum is the last part of the colonand extends about 15-20 cm from theanus. When your rectum becomes filledwith stool, you feel an urge to defecate.As the anal sphincters relax, the rectumsqueezes and expels stool.

Anal Canal and SphinctersThe anal canal is surrounded by twosphincter muscles, the internal analsphincter and the external anal sphincter,that help to maintain continence.

Sixty-five percent of patients havecancer limited to the colon, higher than 15-20 cm from the anal opening.When the cancer is limited to the colon,the section of the colon containing thecancer can be removed and the twohealthy ends of the bowel reconnected,

usually without the need for a colostomyor “bag”. The patient resumes normalbowel movements and does not noticethat they have less colon. Depending onthe size of your cancer, you may needchemotherapy following surgery.


The majority of colon and rectal cancersbegin as benign polyps. Benign polypsare non-cancerous growths of the liningof the colon and rectum that, with time,get larger and can grow into cancers.Removal of polyps helps to preventcolon and rectal cancers. Colonoscopyand barium enema are two proceduresthat help to find polyps before they cangrow into cancers.

Cancers are also growths of the lining of the colon and rectum but differ in

that they have the ability to spread toother organs. Polyps do not spread buteventually turn into cancers that canspread. We attempt to find polyps orcancers early before they grow too bigor have spread too far.

Nearly all colon and rectal cancers willneed surgery of some type. The type ofoperation you will have for your cancerdepends on the size of your cancer andits location in the colon or rectum.

Overview of Colonand Rectal Cancer

colon cancer

resection

anastomosis

Before: Colon with cancer After: Colon with segment removed

Colon Cancer

Operation for Colon Cancer


Before: Colon with cancer in mid-rectum After: Colon with segment removed

Twenty to thirty percent of patients have cancer in the rectum. The goal of surgery for rectal cancer is to removeall the cancer and surrounding tissuesthat may contain cancer cells, but at the same time give patients as much“normal” rectal function as possible.The location of the tumor in the rectum,including the distance from the analopening, and the size and depth of thetumor determines the type of operationthat is needed.

Rectal Cancer

rectum

Types of Operations for Rectal Cancer

Low Anterior Resection or Colo-AnalAnastomosisThe majority of rectal cancers areremoved this way. A segment of therectum is removed through an incision

in the abdomen and the colon ishooked up to the remaining healthyrectum. This can usually be donewithout a colostomy or an ileostomy.


Before: Colon with cancer in lower-rectum After: Colon with rectum removed and colostomy in place

Types of Operations for Rectal Cancer (cont.)

Abdomino-Perineal Resection (APR)Five to ten percent of patients havecancer very close to the anal openingand require this operation. In thisoperation the entire rectum, anal canal,

and anal sphincter complex are removed.Because the sphincter muscles controlthe release of bowel movements, youwill need a permanent colostomy.

Transanal ExcisionVery small cancers that are near theanus can often be completely removedthrough the anus. This preserves analfunction and normal stool elimination.There is no skin incision since all thesurgery is done through the anus.

Transsacral ExcisionSmall cancers, a little higher in therectum, may sometimes be removedthrough the tailbone area. Again, thispreserves normal elimination but canonly be done for small or early cancers.The operation does have an incisionnext to the tailbone near the anus.


You may hear your physician talkingabout the stage of your cancer. Stagingof colon and rectal cancer helps todetermine prognosis and to decidewhich patients should receive additionaltherapy in the form of chemotherapyand possibly radiation.

This is dependent on a microscopicexamination of the tumor removed atthe operation. There are two stagingsystems: the older system is calledDukes’ Classification and the newersystem is the TNM Staging System.

Colon and Rectal Cancer Staging

D U K E S ’ C L A S S I F I C A T I O N

A Tumor is confined to the mucosa of the colon or rectum

B1 Tumor is confined to the bowel wall, but deeper than the mucosa

B2 Tumor goes all the way through the bowel wall

C1 Same as B1, but with cancer in the draining lymph nodes

C2 Same as B2, but with cancer in the draining lymph nodes

D Cancer has spread to other organs (liver or lung)

T N M S T A G I N G

Stage 1 Tumor is confined to the mucosa of the colon or rectum

Stage 2 Tumor is confined to the bowel wall

Stage 3 Tumor is in the lymph nodes

Stage 4 Cancer has spread to other organs (liver or lungs)


Although it is not completelyunderstood, family history (or genetics)plays a role in determining who is atrisk for colon cancer. Your familymembers are at increased risk fordeveloping colon and rectal cancer—especially if you are under the age of 50when you get your cancer. They shouldnotify their family physician that theyhave a relative with colon and rectalcancer so that the doctor can decide if they need to have a colonoscopy.

There are two known genetic familialsyndromes that predispose patients to develop colon and rectal cancers at a young age. They are FamilialAdenomatous Polyposis (FAP) andHereditary Non-Polyposis Colon Cancer(HNPCC). If your doctor thinks youhave one of these syndromes, he/shemay suggest that you undergo genetictesting and possibly have furtherscreening tests for other types ofcancers.

Risk of Colon Cancer forYour Family Members


What to Expect During Your Hospitalization

The Preoperative VisitAfter you have been seen by one of ourcolon and rectal surgeons and havedecided upon surgery, you will bescheduled to have a preoperative visit to prepare for surgery. You will be givenprescriptions and instructions to followthe day before surgery, including “bowelprep” instructions. Blood will be drawnfor laboratory tests and a urine samplewill be taken; you may also have a chestX-ray and an EKG. Medications to takethe morning of surgery will bereviewed.

If necessary, you will be seen by anenterostomal therapy nurse whospecializes in caring for ostomy patients. This nurse will teach youabout ileostomies or colostomies,answer your questions, and mark alocation on your abdomen where sherecommends that the surgeon place the stoma. If this marking is not doneduring the preoperative visit, it will be done the morning of surgery.

The Day Before SurgeryMost patients are admitted on the dayof surgery. The day before surgery, youwill be contacted at home by a nursefrom the Same Day Unit (SDU). Ifsurgery is scheduled for Monday, theSDU nurse will contact you on Friday.The nurse will tell you what time tocome to the hospital and where to gofor admission.

Bowel prepBefore surgery, it is essential that thebowel be as clean as possible to preventinfection. To do this, you will follow astandard “bowel prep.” You will beinstructed to drink a solution that has astrong laxative effect (such as CoLyte,GoLytlely, NuLytely), to take someantibiotics and to follow a liquid diet.(Do not eat solid foods). The antibioticsdecrease the amount of bacteria in thebowel to lessen the risk of infection.

You should not eat or drink anythingafter midnight.


What to Expect During Your Hospitalization (cont.)

The Day of SurgeryUsual medicationsIf you have been told to take anymedications at home before surgery,take them with small sips of water.

You will be admitted to the hospital the day of the operation. Patients areusually hospitalized for four to six days after the surgery.

The surgery will take between two andfour hours. With preparation beforesurgery and time in the recovery room,it will be approximately six hours beforeyou are admitted to your hospital room.

Family members may wait in thesurgical waiting area. The surgeon willeither call or visit with family membersafter the surgery, so they should sign inand out with the volunteer if they leavethe waiting area.

Recovery RoomAfter surgery, you will be taken to thePost-Anesthesia Care Unit (recoveryroom), where you will be monitoredclosely until you awaken fully from theanesthesia. No visitors are allowed inthe recovery room. You will then beadmitted to an inpatient unit.

Intravenous Line(s)You will have at least one intravenous(IV) line. An IV is a long, flexible tubingconnected to a small catheter that isinserted into the top of a hand or

an arm. It is used to give fluids andmedications. The IV will be used untilyou are taking enough fluid by mouthto prevent dehydration, usually about 4 days.

Drainage TubesWhile you are asleep in the operatingroom, the following tubes and drainsmay be placed:

The nasogastric (NG) tube is used todrain stomach fluids. It is placedthrough the nose into the stomach.Usually this tube is removed in therecovery room, and patients do notremember having it. Sometimes thetube is left in place to be removed later.

A urinary catheter is placed in thebladder to collect urine. It is painlesslyremoved several days after surgery. One or two pieces of soft rubber tubingmay be left in the abdomen to drainaccumulated fluid coming out throughsmall incisions. These will be removed a few days after surgery.

Pain ControlBefore surgery, you will talk with thesurgeon and anesthesiologist about paincontrol. The three of you will decidewhich method of pain control will bethe best choice. Two of the possiblemethods that can be used after colonand rectal surgery are epidural analgesiaor patient controlled analgesia (PCA).


Epidural analgesia consists of placing asmall, thin catheter into the patient’s back,outside the spinal cord. The epiduralcatheter is inserted while the patient is in the operating room. When medi -cations are given through this catheter, a patient feels numb in the general areaof the abdominal surgery. This catheteris left in for three to four days after thesurgery to control pain.

The PCA is a small pump attached to theIV line by a hand-held control button.The patient can receive medication tocontrol pain by pushing this button as needed.

Pain ScaleNurses will frequently ask you to rateyour pain on a scale of 0 to 10, with 10being the worst pain you have ever felt.If you have significant pain, tell a nurse sothat your medications may be modified.You may not be totally pain-free, butyour pain should be at a tolerable levelthat will allow you to breathe deeply,get out of bed and walk.

ActivityIt is essential to begin moving as soonas possible after surgery to preventcomplications from bed rest. Thesecomplications include blood clots in legveins and respiratory infections. On theday of surgery, you will get out of bedand sit in a chair (with the assistance of

a nurse) at least once. The first day aftersurgery, a nurse will help you get upand walk.

Breathing ExercisesNurses will also encourage you tocough and deep breathe to preventpneumonia. You will be taughtbreathing exercises called incentivespirometry breathing (ISB). For theseexercises, you will use a small, hand-held machine kept at the bedside.



DietInitially, you will not have anything to eator drink. As normal bowel function returns,your diet will be advanced in steps.

Clear liquidsYou will begin with small sips of clearliquids (water, fruit juices)—onemedicine cup full of liquid per hour.When you tolerate this without nausea,vomiting, or increase in pain, you mayhave as many clear liquids as you like.You will get a tray of liquids at mealtime (juices, tea, broth, Jell-O). You maynot have carbonated liquids.

Full liquidsWhen you tolerate clear liquids withoutany difficulty, your diet will be advancedto full liquids. This diet includes clearliquids as well as creamy soups, milk,eggnog, ice cream, and cream of wheat.If you have lactose intolerance, pleasetell the surgeon before being placed onfull liquids.

Low-fiber dietAfter you are able to tolerate full liquids,you will be advanced to a low-fiber dietfor approximately one to two weeks.

This mostly consists of avoiding rawfruits and vegetables. The low-fiber diet helps avoid difficulties with stoolpassing through your anastomosis. You will be given a phone number you can call after discharge in case youhave any questions about the diet.

DischargePatients who have had abdominalsurgery are usually discharged four to six days after surgery. Dischargeinstructions include information about caring for the incision, activityguidelines, signs and problems to watchfor, and how to reach a physician if youneed advice at home.

At the time of discharge, you should be walking independently, tolerating atleast a liquid diet without difficulty, andbe urinating without any difficulty.

Follow-Up CareBefore discharge, a clinic appointmentwill be scheduled with the surgeon(usually one to four weeks afterdischarge). Follow-up appointmentswill be scheduled with Oncology andRadiation Therapy if needed.



Physician VisitsYou should schedule a checkup withyour surgeon, the oncologist, or yourfamily doctor every three months for thefirst two years following your surgery.

TestsBlood tests may be ordered at each visit depending on your type of cancer.A chest X-ray and CT scan of yourabdomen may be ordered one year after your surgery.

ColonoscopyYou will need to have a follow-upcolonoscopy one year after your surgery.If there are no signs of new polyps, youwill require another colonoscopy threeyears later and then five years after that,although this is variable based on yourtype of cancer.

Follow-Up After Surgery forColon and Rectal Cancer


Stoma (Ostomy)

An ileostomy is when an end of thesmall intestine is brought up to the skinby surgery and wastes are eliminatedinto a bag. Wastes are usually liquid.

A colostomy is when the end of thecolon is brought up to the skin bysurgery and wastes are eliminated into a bag. These wastes are more solid thanan ileostomy.

Managing Your Stoma (if you have one)For three to four weeks after surgery,the drainage from an ileostomy iswatery. The consistency becomes athicker liquid, or semi-solid, as thesmall bowel begins to take over theprocess of absorbing water. Colostomydrainage is usually thick from thebeginning.

Learning to care for a stoma may seemoverwhelming and time-consuming at first, but most patients soon findthemselves caring for it with ease. The enterostomal therapy nurses willteach you how to change the appliancecovering your ostomy, how to emptyand rinse it, and how to purchasesupplies for ostomy care. These nurseswill also tell you how to get assistance if you have any problems with yourostomy after discharge.

You may need assistance with changingyour ostomy appliance at home. A familymember may help with this. We canalso arrange for a visiting nurse to assist.You may meet with an enterostomaltherapy nurse when you have a follow-up clinic appointment with the surgeon.

Pouch

Wafer


Second Stage Surgery – Ileostomy Closure If You Have One

Before the stoma is closed, you willundergo an X-ray of your rectum toensure that it has healed properly. If theX-ray is normal, the stoma closure willbe scheduled, and you will have anotherpreoperative visit similar to that of thefirst surgery.

Day Before SurgeryThe day before surgery, a nurse from theSame Day Unit will call with a time toreport to the hospital and where to gofor admission.

Bowel prepThe bowel prep for the ileostomy closureis slightly different from that of the first surgery. You will be receivingprescriptions for antibiotics anddirections for drinking a laxative,Magnesium Citrate.

FoodsOnce the bowel prep has begun, do noteat any solid foods. Your diet shouldconsist of clear liquids. After midnight,you should not eat or drink anything.

Day of SurgeryAgain, you will be admitted on the dayof your surgery. Patients are usuallyhospitalized for two days after thissurgery.

The ileostomy closure usually takes lessthan an hour. The incision is made as acircle around the stoma, and the stomais closed restoring elimination throughthe anus. The incision is then fully orpartially closed. A midline abdominalincision is rarely needed.

UrinationUrinary catheters are usually notinserted for the ileostomy closure.

Pain ControlPain after the ileostomy closure is muchless than after the first surgery. Whenyou feel you need medication for painrelief, ask a nurse. These medicationswill not be given automatically. Yourpain should be at a tolerable level,which allows you to get out of bed,walk, and do deep breathing exercises.

DietThe day after surgery, you will start on sips of clear liquids every hour andadvance to as many clear liquids as youlike, if tolerated. When you have passedgas, you will be advanced to either a fullliquid diet or a low-fiber diet. You willneed to stay on the low-fiber diet (sameas with the prior surgery) forapproximately two weeks.


Wound CareYou may have an open wound wherethe ileostomy was removed. This site isleft open and heals from the inside—out to the skin. The wound will need tobe packed two times a day. At first,most people require visiting nurses toassist with this at home. If you have afamily member who is willing to learnthe dressing change, or if you are ableto learn it yourself, you will be taught.

DischargePatients are usually discharged two daysafter surgery. At the time of discharge,you should be tolerating at least a liquiddiet and be having bowel movementswithout difficulty. You will receiveguidelines for activity, advice aboutproblems you should watch for, andhow to reach a physician if you needassistance. A clinic appointment will bemade for you to see the surgeon. If youare discharged on a weekend or holiday,a representative from Central Schedulingwill call the following business day.

Second Stage Surgery – Ileostomy Closure If You Have One (cont.)


Colon CancerThe size of your cancer and extent ofinvolvement with the lymph nodes willbe reported by the pathologists. This willdetermine whether you need chemo -therapy after surgery. Patients with smallcancers that have not spread may notneed further treatment after surgery. If you could benefit from chemotherapy,an oncologist (cancer doctor) will visityou in the hospital or you will bescheduled for an appointment afterdischarge. They will discuss chemo -therapy with you. Chemotherapy wouldnot be started for several weeks untilyou have had time to fully recover fromsurgery. Colon cancer is usually nottreated with radiation.

Rectal CancerThe size of your cancer and extent ofinvolvement with the lymph nodes willbe reported by the pathologists. This willdetermine whether you need chemo -therapy after surgery. Like colon cancer,patients with small cancers that havenot spread may not need furthertreatment after surgery. If you couldbenefit from chemotherapy, an oncologist(cancer doctor) will visit you in thehospital or you will be scheduled for an appointment after discharge. The oncologist will discuss chemotherapyand radiation with you. Rectal cancer isoften treated with radiation, in conjunctionwith chemotherapy. The radiation isgiven by a Radiation Oncologist. Youwill meet the radiation oncologist afterbeing seen by the chemotherapyoncologist, if radiation is appropriate foryou. Therapy would not be started forseveral weeks until you have had timeto fully recover from surgery.

Some patients will be treated withchemotherapy and radiation prior tosurgery to help shrink the cancer.

Chemotherapy and Radiation


Glossary

Anastomosis – The sewn connectionbetween two ends of bowel.

Anal Sphincters – Ring-like muscularstructures that surround the anus andcontrol bowel movements.

Anus – The opening in the end of therectum that allows stool to pass out ofthe body.

Benign – A growth that cannot spreadto other organs.

Cancer (malignancy) – A growth thathas the potential to spread to otherorgans.

Clinical Case Manager – A registerednurse who will assist in coordinatingyour care during your hospitalization.

Colon (large bowel or intestine) –The portion of the gastrointestinal tractextending from the end of the smallbowel to the rectum.

Colonoscopy – A procedure when yoursurgeon or gastroenterologist looksinside your entire colon with a longscope with a light on the end.

Colostomy – When the end of the colonis brought up to the skin by surgeryand wastes are eliminated into a bag.These wastes are more solid than anileostomy.

Enterostomal Therapy Nurse – A registered nurse who specializes in ostomy care.

Epidural Analgesia – A form of paincontrol delivered through a catheter thatis placed in the lower back.

Gastrointestinal System (GI Tract) –The group of structures from the mouthto the anus that are responsible for theingestion (taking in), digestion, andabsorption of nutrients, as well as thestorage and elimination of fecal wastes.

Ileostomy – When an end of the smallintestine is brought up to the skin bysurgery and wastes are eliminated into abag. Wastes are usually liquid.

IV (intravenous) Line – A long, flexibletubing that is connected to a smallcatheter inserted in a vein used forgiving fluids.

Patient Controlled Analgesia (PCA) – A form of pain control, deliveredthrough an IV, in which the patient usesa small pump to control the timing andamount of medication received. Themaximum amount of medication thatcan be delivered is programmed intothe pump, so the patient receives a safeand effective dose.

Polyp – A benign growth in the colonor rectum.

Rectum – The last portion of intestinethat connects to the anus.

Stoma (ostomy) – An opening createdin the intestine and brought to theabdominal wall so that wastes can beeliminated.


Resources – Who To Contact

Your healthcare team at Penn StateHershey Medical Center is available torespond to your questions andconcerns. If you would like, yoursurgeon will refer you to another patientwho has undergone treatment for coloncancer and is willing to provide supportand information from a patientperspective.

Penn State Milton S. Hershey Medical Center• Medical questions or concerns, orreferral to another patient (weekdays)

n Walter A. Koltun, M.D., F.A.C.S.,F.A.S.C.R.S.

n Lisa S. Poritz, M.D.,F.A.C.S.,F.A.S.C.R.S.

n Kevin McKenna, M.D., F.A.S.C.R.S.n David Stewart, M.D.n Marjorie A. Lebo, M.S.N., C.R.N.P.n Amy Sheranko, M.A.

(717) 531-5164

• Medical questions or concerns(nights, weekends, holidays) n Surgical resident on call

(717) 531-8521

• Discharge or home-healthcarequestions or concerns (weekdays)

n Clinical Case Manager(717) 531-8521 pager 2023

• Ostomy care or nutrition questions or concerns (weekdays)

n Enterostomal Therapy Nurses(717) 531-5427

Other Resources Available forInformation and Support

• The companies that manufactureostomy supplies provide free literatureon ostomy care. They may alsoprovide free samples of theirappliances. Contact them directly.

Penn State Hershey Colon and Rectal Surgery (717) 531-5164

Notes

History

Founded in 1963 through a gift fromThe Milton S. Hershey Foundation,Penn State Milton S. HersheyMedical Center is one of the leadingteaching and research hospitals in thecountry. The 484-bed Medical Center isa provider of high-level, patient-focusedmedical care. The Medical Centercampus also includes Penn StateCollege of Medicine (Penn State’smedical school), Penn State Hershey

Cancer Institute, and Penn StateHershey Children’s Hospital—theregion’s only children’s hospital. TheMedical Center campus is part of PennState Hershey Health System, whichalso includes the PennsylvaniaPsychiatric Institute, Penn State HersheyRehabilitation Hospital, and otherspecialty facilities. On the Web atpennstatehershey.org.

PennStateHershey.org/colonandrectal

Division of Colon and Rectal Surgery 500 University Drive • PO Box 850Hershey, PA 17033-0850 • (717) 531-5164

Colorectal Cancer 3.pdfColon and rectal cancer is the third most common cancer in both men and women in the United States, and the second leading cancer killer in men and women.

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