Overview:

What Is Cancer?
Cancer occurs when cells in a part of the body begin to grow out of control. Normal cells divide
and grow in an orderly way. Cancer cells do not. Cancer cells keep growing and crowd out
normal cells. There are many kinds of cancer. But they all have this out-of-control cell growth in
common.

Different kinds of cancer can act very differently. For example, lung cancer and breast cancer are
very different diseases. They grow at different rates. They also respond to different treatments.
That’s why people with cancer need treatment that is aimed at their kind of cancer.

Sometimes cancer cells break away from a tumor and spread to other parts of the body through
the blood or lymph system. They can settle in new places and form new tumors. When this
happens, it is called metastasis (meh-TAS-teh-sis). Cancer that has spread in this way is called
metastatic cancer.

Even when cancer has spread to a new place in the body, it is still named after the part of the
body where it started. For example, if prostate cancer spreads to the bones, it is still called
prostate cancer. If breast cancer spreads to the lungs, it is still breast cancer. When cancer
comes back in a person who appeared to be free of the disease after treatment, it is called a
recurrence.

Revised 11/8/2004
Overview: Colon and Rectum Cancer

What Is Colorectal Cancer?

Most kinds of cancer are named after the part of the body where the cancer first starts. Colon and
rectal cancers begin in the digestive system, also called the GI (gastrointestinal) system. This is
where food is changed to create energy and rid the body of waste matter.

After food is chewed and swallowed, it travels down to the stomach. There it is partly broken
down and sent to the small intestine.The word "small" refers to the diameter of the small
intestine. The small intestine is really the longest segment of the digestive system. It is about 20
feet long.

The small intestine continues breaking down the food and absorbs most of the nutrients. The
small intestine joins the large intestine (large bowel), a muscular tube about five feet long. The
first part of the large bowel, called the colon, absorbs water and nutrients from the food and also
serves as a storage place for waste matter. The waste matter moves from the colon into the
rectum, the final 6 inches of the large bowel. From there the waste passes out of the body
through the opening called the anus during a bowel movement.
The colon has four sections, as shown in the picture above. Cancer can start in any of the four
sections or in the rectum. The wall of each of these sections (and rectum) has several layers of
tissues. Cancer starts in the inner layer and can grow through some or all of the other layers.
Knowing a little about these layers is helpful because the stage (extent of spread) of a cancer
depends to a great degree on which of these layers it affects.

Cancer that starts in the different areas may cause different symptoms. Colon and rectum
cancers probably develop slowly over a period of several years. We now know that most of these
cancers begin as a polyp--a growth of tissue into the center of the colon or rectum. Polyps are
also known as adenomas. Removing the polyp early may prevent it from becoming cancer.

Over 95% of colon and rectal cancers are adenocarcinomas. These are cancers of the cells that
line the inside of the colon and rectum. There are some other, more rare, types of tumors of the
colon and rectum, but the facts given here refer only to adenocarcinomas.

Colon and rectal cancer have many features in common and are often referred to together as
colorectal cancer. They are discussed together here except for the section about treatment. At
that point they will be discussed separately.

Revised 5-04
Overview: Colon and Rectum Cancer

What Causes Colorectal Cancer?

While we do not know the exact cause of most colorectal cancer, there are certain known risk
factors. A risk factor is something that increases a person's chance of getting a disease.
Some risk factors, like smoking, can be controlled. Others, such as a person's age, can't
be changed. Researchers have found several risk factors that increase a person's chance
of getting colorectal cancer.
 Risk Factors for Colorectal Cancer
If you have close relatives (parent, brother or sister,or child) who have had this
cancer, your risk is increased. Some people with colorectal cancer have a
gene defect that causes the cancer. But colorectal cancer is more common in
Family history
families that do not have a gene defect. People with a family history of
colorectal cancer should talk to their doctors about how often to have
screening tests.

Ethnic Jews of Eastern European descent (Ashkenazi Jews) may have a higher rate
background of colon cancer.

Personal
history of Even if a colorectal cancer has been completely removed, new cancers may
colorectal start in other areas of colon and rectum.
cancer

Personal
Some types of polyps increase the risk of colorectal cancer, especially if they
history of
are large or if there are many of them.
polyps

Personal A disease called ulcerative colitis (Crohn’s colitis) increases the risk of colon
history of cancer. The colon is inflamed over a long period of time and may have ulcers
bowel in its lining. If you have this problem, you should start being screened at a
disease young age and have the tests often.

Age Your chances of having colorectal cancer go up after age 50.

A diet made up mostly of foods that are high in fat, especially from animal
sources, can increase the risk of colorectal cancer. The American Cancer
Diet
Society recommends choosing most of your foods from plant sources and
limiting the amount of high-fat foods you eat.

Lack of
People who are not active have a higher risk of colorectal cancer.
exercise

Being very overweight increases a person's colorectal cancer risk. Having

Overweight extra fat in the waist area increases this risk more than having fat in the thighs
or hips.

Most people know that smoking causes lung cancer, but recent studies show
Smoking that smokers are 30% to 40% more likely than nonsmokers to die of colorectal
cancer.

Alcohol Heavy use of alcohol has been linked to colorectal cancer.

Revised 5-04
Overview: Colon and Rectum Cancer

Can Colorectal Cancer Be Prevented?

Even though we don't know exactly what causes colorectal cancer, there are some steps you can
take to reduce your risk. First, you should follow the screening guidelines mentioned below to
help find colon or rectal cancer. When these cancers are found and treated early, they can often
be cured. Screening can also find polyps. Removing these polyps helps prevent some cancers.

People who have a history of colorectal cancer in their family should check with their doctor for
advice about screening tests or other tests to find cancer early.

It is important to eat plenty of fruits, vegetables, and whole grain foods and to limit high-fat foods.
Some studies suggest that taking a daily multivitamin containing folic acid or folate can lower
colorectal cancer risk. Other studies suggest that getting more calcium with supplements or low-
fat dairy products can help. Getting enough exercise is important as well. The American Cancer
Society recommends at least 30 minutes of physical activity on five or more days of the week.

Combined hormone replacement therapy (HRT) for women after menopause may slightly reduce
the risk of colorectal cancer and osteoporosis (thinning of the bones). But HRT may increase the
risk of heart disease, blood clots, and breast and uterine cancer. Whether or not to use HRT is
something women should discuss with their doctors.

People with a family history of colorectal cancer may benefit from starting screening tests when
they are younger and having them done more often than people without this risk factor.

Revised 5-04
Overview: Colon and Rectum Cancer

How Is Colorectal Cancer Found?

Screening tests are used to look for disease in people who do not have any symptoms. In many
cases, these tests can find colorectal cancers at an early stage and greatly improve the chances
of successful treatment. Screening tests can also help prevent some cancers by allowing doctors
to find and remove polyps that might become cancer. There are several tests used to screen for
colorectal cancer.

Stool Blood Test (Fecal Occult Blood Test or FOBT): This test is used to find small amounts
of hidden (occult) blood in the stool. A sample of stool is tested for traces of blood. People having
this test will receive a kit with instructions that explain how to take stool samples at home. The kit
is then sent to a lab for testing. If the test is positive, further tests will be done to pinpoint the
exact cause of the bleeding.

Flexible Sigmoidoscopy (flex-sig): A sigmoidoscope is a slender, lighted tube about the

thickeness of a finger. It is placed into the lower part of the colon through the rectum. This allows
the doctor to look at the inside of the rectum and part of the colon for cancer or polyps. Because
the tube is only about 2 feet long, the doctor is only able to see about half of the colon. The test
can be uncomfortable but it should not be painful. Before the test, you will need to take an enema
to clean out the lower colon.

Colonoscopy: The colonoscope is a longer version of the sigmoidoscope. It allows the doctor to
see the entire colon. If a polyp is found, the doctor may remove it. If anything else looks
abnormal, a biopsy might be done. To do this, a small piece of tissue is taken out through the
colonoscope. The tissue is sent to the lab to see if cancer cells are present. This test can be
uncomfortable. To avoid this, you will be given medicine through a vein to make you feel relaxed
and sleepy.

Medicare now covers this test for people at average risk. More information about this coverage is
given in the section, "Medicare Coverage."

Barium enema with air contrast: A chalky substance is used to partly fill and open up the colon.
Air is then pumped in to cause the colon to expand. This allows good x-ray films to be taken. You
will need to use laxatives the night before the exam and have an enema the morning of the exam.

Virtual colonoscopy: You might think of this as a super x-ray of the colon. Air is pumped into the
colon to cause it to expand, then a special CT scan is done. Right now, this test is not among
those recommended by the ACS for finding colon cancer early. More studies are needed to find
out if it is as good as or better than other methods of finding colon cancer early.

American Cancer Society Colorectal Cancer Screening Guidelines

Beginning at age 50, both men and women should follow one of the screening options below:

1. Yearly stool blood test (FOBT)

2. Flexible sigmoidoscopy every 5 years
3. Yearly stool blood test plus flexible sigmoidoscopy every 5 years
(Of the first three options, the ACS recommends the third option, that is, stool blood test
every year plus flexible sigmoidoscopy every five years.)
4. Or you may have:
5. Double contrast barium enema every 5 to 10 years
6. Colonoscopy every 10 years

For the stool blood test, the take-home, multiple-sample method should be used.
If something abnormal is found, a colonoscopy should be done.
While a digital rectal exam (DRE) is often done as part of a regular physical exam, it should not
be used as a stand-alone test for colorectal cancer. For a DRE, the doctor examines the patient’s
rectum with a gloved finger.
People with certain risk factors should begin screening earlier or have screening more often. For
more information, please see "ACS Guidelines for Screening and Surveillance for Early Detection
of Colorectal Polyps and Cancer," available through our toll-free number or on our web site. Talk
to your doctor about your own risk and when you should have screening tests.
Medicare Coverage
Not long ago, Medicare started paying for colonoscopy for people 50 and older. In the past,
Medicare only covered the exam for people at high risk. The American Cancer Society led the
efforts to expand coverage of this test. People on Medicare now have more choices for screening
tests.
For people on Medicare, this is what is covered:
Stool blood test (fecal occult blood test) each year for those 50 and over
Flexible sigmoidoscopy (flex-sig) every 4 years for those 50 and over at average risk
Colonoscopy every 2 years for those at high risk
Colonoscopy once every 10 years for those 50 and over at average risk
Barium enema with air contrast instead if a doctor believes that it is as good as or better than
flex-sig or colonoscopy.
What would someone on Medicare expect to pay for these tests?
Stool blood test: people over 50 pay no coinsurance and no Part B deductible
Flex-sig: Patient pays 20% of Medicare-approved amount after the yearly Part B deductible
Colonoscopy: Patient pays 20% of Medicare-approved amount after the yearly Part B deductible
Barium enema: When used instead of flex-sig or colonoscopy, patient pays 20% of Medicare-
approved amount after the yearly Part B deductible
Symptoms of Colorectal Cancer
In many cases, colorectal cancer can be found early. If you have any of these symptoms, be sure
to tell your doctor.
 A change in bowel habits such as diarrhea, constipation, or narrowing of the stool that
lasts for more than a few days
 A feeling that you need to have a bowel movement that doesn't go away after doing so
 Bleeding from the rectum or blood in the stool
 Cramping or steady stomach pain
 Weakess and tiredness

Just because you have these symptoms does not mean you have cancer. But you need to talk to
your doctor to be sure.
If there is any reason to suspect colon or rectal cancer, the doctor will look at your medical history
and do a physical exam. Then you will need to have further tests to find out if the disease is really
present and if so, to see how far it has spread. Some of these tests are the same ones that are
used for screening people who do not have symptoms.
Stool blood test, flex-sig, barium enema, and colonoscopy: your doctor may do one or more
of these tests. They were described earlier.
Blood tests: Your doctor will order a blood count to see if you have too few red blood cells (are
anemic). People with colorectal cancer often become anemic because of bleeding from the
tumor. There are other substances (tumor markers) in the blood that can help tell how well
treatment is working. But these tumor markers are not used to find cancer in people who have not
had cancer and who appear to be healthy.
Biopsy: In a biopsy, the doctor removes a small piece of tissue. The tissue is sent to the lab
where it is looked at under a microscope to see if cancer is present.
Ultrasound: Ultrasound uses sound waves to produce a picture of the inside of the body. Most
people know about ultrasound because it is often used to view a baby during pregnancy. Two
special types of ultrasound might be used for people with colon or rectal cancer. In one, the
instrument that gives off sound waves is placed into the rectum. In the other test, used during
surgery, the instrument is placed against the surface of the liver to see if the cancer has spread
there.
CT scan (computed tomography): A CT scan uses x-rays to take many pictures of the body that
are then combined by a computer to give a detailed picture. A CT scan can often show if the
cancer has spread to the liver, lungs, or other organs. CT scans can also be used to help guide a
biopsy needle into a tumor. CT scans take longer than regular x-rays. The patient has to lie still
on a table while the CT scan is being done. A contrast "dye" may be injected or a special drink
used to help outline the area being viewed.
A new way to use a CT scan is to do a “virtual colonscopy.” After cleaning the stool from the
colon and filling the colon with air, a computer assisted reconstruction of the colon from CT
images is possible. It requires the same preparation as for a colonscopy and there is some
discomfort from the bowel being filled with air. If anything not normal is seen, a follow-up
colonoscopy will be needed.
MRI (magnetic resonance imaging): Like CT scans, MRI displays a cross-section of the body.
However, MRI uses radio waves and strong magnets instead of radiation. As with CT scans, a
contrast dye may be injected, although this is used less often.
Chest x-ray: This test may be done to see whether colorectal cancer has spread to the lungs.
PET scan (positron emission tomography): In this test, a type of radioactive sugar is used. The
cancer cells absorb high amounts of the sugar. PET is useful when your doctor thinks the cancer
has spread, but doesn't know where.
Angiography: For this test, a tube is placed into a blood vessel and moved until it reaches the
area to be studied. Then a dye is injected and a series of x-ray pictures is taken. When the
pictures are complete, the tube is removed. Surgeons sometimes use this method to find blood
vessels next to cancer that has spread to the liver. The cancer can then be removed without
causing a lot of bleeding.
After the Tests: Staging
Staging is the process of finding out how far the cancer has spread. This is very important
because your treatment and the outlook for your recovery depend on the stage of your cancer.
For early cancer, surgery may be all that is needed. For more advanced cancer, other treatments
such as chemotherapy or radiation therapy may be used.
There is more than one system for staging colon or rectal cancer. Some use numbers and others
use letters. But all systems describe the spread of the cancer through the layers of the wall of the
colon or rectum. They also take into account whether the cancer has spread to nearby organs or
to organs farther away.
Stages are often labeled using Roman numerals I through IV (1-4). In general, the lower the
number, the less the cancer has spread. A higher number, such as stage IV (4), means a more
serious cancer.
For most people, the stage is not known until after surgery, so your doctor may wait until then to
assign a number. Be sure to ask your doctor to explain your stage in a way you understand. This
will help you both decide on the best treatment for you.