1.

All about colonrectal cancer

What Is Colorectal Cancer?Colorectal cancer is a cancer that starts in the colon or the rectum. These cancers can also
be named colon cancer or rectal cancer, depending on where they start. Colon cancer and rectal cancer are often
grouped together because they have many features in common.

Cancer starts when cells in the body start to grow out of control. Cells in nearly any part of the body can become cancer,
and can spread to other areas of the body. To learn more about how cancers start and spread, see What Is Cancer?

How does colorectal cancer start?

Polyps in the colon or rectum

Most colorectal cancers start as a growth on the inner lining of the colon or rectum. These growths are called polyps.

Some types of polyps can change into cancer over time (usually many years), but not all polyps become cancer. The
chance of a polyp changing into cancer depends on the type of polyp it is. The 2 main types of polyps are:

 Adenomatous polyps (adenomas): These polyps sometimes change into cancer. Because of this, adenomas are
called a pre-cancerous condition.
 Hyperplastic polyps and inflammatory polyps: These polyps are more common, but in general they are not
pre-cancerous.
Other factors that can make a polyp more likely to contain cancer or increase someone’s risk of developing colorectal
cancer include:

 If a polyp larger than 1 cm is found

 If more than 2 polyps are found
 If dysplasia is seen in the polyp after it's removed. Dysplasia is another pre-cancerous condition. It means there's
an area in a polyp or in the lining of the colon or rectum where the cells look abnormal, but they don't look like
true cancer cells.
For more details on the types of polyps and conditions that can lead to colorectal cancer, see Understanding Your
Pathology Report: Colon Polyps.

How colorectal cancer spreads

If cancer forms in a polyp, it can grow into the wall of the colon or rectum over time. The wall of the colon and rectum is
made up of many layers. Colorectal cancer starts in the innermost layer (the mucosa) and can grow outward through
some or all of the other layers.

When cancer cells are in the wall, they can then grow into blood vessels or lymph vessels (tiny channels that carry away
waste and fluid). From there, they can travel to nearby lymph nodes or to distant parts of the body.

The stage (extent of spread) of a colorectal cancer depends on how deeply it grows into the wall and if it has spread
outside the colon or rectum. For more on staging, see Colorectal Cancer Stages.

Where does colorectal cancer grow?

To understand colorectal cancer, it helps to understand the parts that make up the colon and rectum. The colon and
rectum make up the large intestine (or large bowel), which is part of the digestive system, also called the gastrointestinal
(GI) system (see illustration below).

Most of the large intestine is made up of the colon, a muscular tube about 5 feet long. The parts of the colon are named
by which way the food is traveling through them.

 The first section is called the ascending colon. It starts with a pouch called the cecum, where undigested food is
comes in from the small intestine. It extends upward on the right side of the abdomen (belly).
 The second section is called the transverse colon. It goes across the body from the right to the left side.
 The third section is called the descending colon because it descends (travels down) on the left side.
 The fourth section is called the sigmoid colon because of its “S” shape. The sigmoid colon joins the rectum,
which connects to the anus.
The ascending and transverse sections together are called the proximal colon. The descending and sigmoid colon are
called the distal colon.

What do the colon and rectum do?

The colon absorbs water and salt from the remaining food matter after it goes through the small intestine (small
bowel). The waste matter that's left after going through the colon goes into the rectum, the final 6 inches of the
digestive system. It's stored there until it passes out of the body through the anus. Ring-shaped sphincter (SFINK-ter)
muscles around the anus keeps stool from coming out until they relax during a bowel movement.

Types of cancer in the colon and rectum

Adenocarcinomas make up about 96% of colorectal cancers. These cancers start in cells that make mucus to lubricate
the inside of the colon and rectum. When doctors talk about colorectal cancer, they're almost always talking about this
type. Some sub-types of adenocarcinoma, such as signet ring and mucinous, may have a worse prognosis (outlook).

Other, much less common types of tumors can start in the colon and rectum, too. These include:

 Carcinoid tumors. These start from special hormone-making cells in the intestine. They're covered
in Gastrointestinal Carcinoid Tumors.
 Gastrointestinal stromal tumors (GISTs) start from special cells in the wall of the colon called the interstitial
cells of Cajal. Some are not cancer (benign). These tumors can be found anywhere in the digestive tract, but are
not common in the colon. They're discussed in Gastrointestinal Stromal Tumor (GIST).
 Lymphomas are cancers of immune system cells. They mostly start in lymph nodes, but they can also start in
the colon, rectum, or other organs. Information on lymphomas of the digestive system can be found in Non-
Hodgkin Lymphoma.
 Sarcomas can start in blood vessels, muscle layers, or other connective tissues in the wall of the colon and
rectum. Sarcomas of the colon or rectum are rare. They're discussed in Soft Tissue Sarcoma.
The signs and symptoms of colorectal cancer depend on the location of the tumor in the bowel, and whether it
has spread elsewhere in the body (metastasis). The classic warning signs include: worsening constipation,
blood in the stool, decrease in stool caliber (thickness), loss of appetite, loss of weight,
and nausea or vomiting in someone over 50 years old.[14] Around 50% of individuals with colorectal cancer do
not report any symptoms.[15]
Rectal bleeding or anemia are high-risk symptoms in people over the age of 50.[16] Weight loss and changes in
a person's bowel habit are typically only concerning if they are associated with rectal bleeding.[16][17]

Cause[edit]
Greater than 75–95% of colorectal cancer occurs in people with little or no genetic risk.[18][19] Risk factors include
older age, male sex,[19] high intake of fat, alcohol, red meat, processed meats, obesity, smoking, and a lack
of physical exercise.[18][20] Approximately 10% of cases are linked to insufficient activity.[21] The risk from alcohol
appears to increase at greater than one drink per day.[22] Drinking 5 glasses of water a day is linked to a
decrease in the risk of colorectal cancer and adenomatous polyps.[23] Streptococcus gallolyticus is associated
with colorectal cancer.[24] Some strains of Streptococcus bovis/Streptococcus equinuscomplex are consumed by
millions of people daily and thus may be safe.[25] 25 to 80% of people with Streptococcus
bovis/gallolyticusbacteremia have concomitant colorectal tumors.[26] Seroprevalence of Streptococcus
bovis/gallolyticus is considered as a candidate practical marker for the early prediction of an underlying bowel
lesion at high risk population.[26] It has been suggested that the presence of antibodies to Streptococcus
bovis/gallolyticus antigens or the antigens themselves in the bloodstream may act as markers for the
carcinogenesis in the colon.[26]
Inflammatory bowel disease[edit]
People with inflammatory bowel disease (ulcerative colitis and Crohn's disease) are at increased risk of colon
cancer.[27][28] The risk increases the longer a person has the disease, and the worse the severity of
inflammation.[29] In these high risk groups, both prevention with aspirinand regular colonoscopies are
recommended.[30] Endoscopic surveillance in this high-risk population may reduce the development of colorectal
cancer through early diagnosis and may also reduce the chances of dying from colon cancer.[30] People with
inflammatory bowel disease account for less than 2% of colon cancer cases yearly.[29] In those with Crohn's
disease, 2% get colorectal cancer after 10 years, 8% after 20 years, and 18% after 30 years.[29] In people who
have ulcerative colitis, approximately 16% develop either a cancer precursor or cancer of the colon over
30 years.[29]
Genetics[edit]
Those with a family history in two or more first-degree relatives (such as a parent or sibling) have a two to
threefold greater risk of disease and this group accounts for about 20% of all cases. A number of genetic
syndromes are also associated with higher rates of colorectal cancer. The most common of these is hereditary
nonpolyposis colorectal cancer(HNPCC or Lynch syndrome) which is present in about 3% of people with
colorectal cancer.[19] Other syndromes that are strongly associated with colorectal cancer include Gardner
syndrome,[31] and familial adenomatous polyposis (FAP). For people with these syndromes, cancer almost
always occurs and makes up 1% of the cancer cases.[32] A total proctocolectomy may be recommended for
people with FAP as a preventative measure due to the high risk of malignancy. Colectomy, removal of the
colon, may not suffice as a preventative measure because of the high risk of rectal cancer if the rectum
remains.[33]
Most deaths due to colon cancer are associated with metastatic disease. A gene that appears to contribute to
the potential for metastatic disease, metastasis associated in colon cancer 1 (MACC1), has been isolated.[34]It is
a transcriptional factor that influences the expression of hepatocyte growth factor. This gene is associated with
the proliferation, invasion and scattering of colon cancer cells in cell culture, and tumor growth and metastasis in
mice. MACC1 may be a potential target for cancer intervention, but this possibility needs to be confirmed with
clinical studies.[35]
Epigenetic factors, such as abnormal DNA methylation of tumor suppressor promoters play a role in the
development of colorectal cancer.[36]

Pathogenesis[edit]
Colorectal cancer is a disease originating from the epithelial cells lining the colon or rectum of
the gastrointestinal tract, most frequently as a result of mutations in the Wnt signaling pathway that increase
signaling activity. The mutations can be inherited or acquired, and most probably occur in the intestinal
crypt stem cell.[37][38][39] The most commonly mutated gene in all colorectal cancer is the APC gene, which
produces the APC protein. The APC protein prevents the accumulation of β-catenin protein. Without APC, β-
catenin accumulates to high levels and translocates (moves) into the nucleus, binds to DNA, and activates
the transcription of proto-oncogenes. These genes are normally important for stem cell renewal and
differentiation, but when inappropriately expressed at high levels, they can cause cancer. While APC is mutated
in most colon cancers, some cancers have increased β-catenin because of mutations in β-catenin (CTNNB1)
that block its own breakdown, or have mutations in other genes with function similar to APC such
as AXIN1, AXIN2, TCF7L2, or NKD1.[40]
Beyond the defects in the Wnt signaling pathway, other mutations must occur for the cell to become cancerous.
The p53 protein, produced by the TP53 gene, normally monitors cell division and kills cells if they have Wnt
pathway defects. Eventually, a cell line acquires a mutation in the TP53 gene and transforms the tissue from
a benign epithelial tumor into an invasive epithelial cell cancer. Sometimes the gene encoding p53 is not
mutated, but another protective protein named BAX is mutated instead.[40]
Other proteins responsible for programmed cell death that are commonly deactivated in colorectal cancers
are TGF-β and DCC (Deleted in Colorectal Cancer). TGF-β has a deactivating mutation in at least half of
colorectal cancers. Sometimes TGF-β is not deactivated, but a downstream protein named SMAD is
deactivated.[40] DCC commonly has a deleted segment of a chromosome in colorectal cancer.[41]
Approximately 70% of all human genes are expressed in colorectal cancer, with just over 1% of having
increased expression in colorectal cancer compared to other forms of cancer.[42] Some genes are oncogenes:
they are overexpressed in colorectal cancer. For example, genes encoding the proteins KRAS, RAF, and PI3K,
which normally stimulate the cell to divide in response to growth factors, can acquire mutations that result in
over-activation of cell proliferation. The chronological order of mutations is sometimes important. If a previous
APC mutation occurred, a primary KRAS mutation often progresses to cancer rather than a self-limiting
hyperplastic or borderline lesion.[43]PTEN, a tumor suppressor, normally inhibits PI3K, but can sometimes
become mutated and deactivated.[40]
Comprehensive, genome-scale analysis has revealed that colorectal carcinomas can be categorized into
hypermutated and non-hypermutated tumor types.[44] In addition to the oncogenic and inactivating mutations
described for the genes above, non-hypermutated samples also contain
mutated CTNNB1, FAM123B, SOX9, ATM, and ARID1A. Progressing through a distinct set of genetic events,
hypermutated tumors display mutated forms of ACVR2A, TGFBR2, MSH3, MSH6, SLC9A9, TCF7L2,
and BRAF. The common theme among these genes, across both tumor types, is their involvement in WNT and
TGF-β signaling pathways, which results in increased activity of MYC, a central player in colorectal cancer.[44]
Mismatch repair (MMR) deficient tumours are characterized by a deficiency in MMR proteins – which are
typically caused by epigeneticsilencing and or inherited mutations (e.g. Lynch syndrome).[45] 15 to 18 percent of
colorectal cancer tumours have MMR deficiencies, with 3 percent developing due to Lynch syndrome.[46] The
role of the mismatch repair system is to protect the integrity of the genetic material within cells (i.e.: error
detecting and correcting).[45] Consequently, a deficiency in MMR deficiency may lead to an inability to detect and
repair genetic damage, allowing for further cancer-causing mutations to occur and colorectal cancer to
progress.[45]
The polyp to cancer progression sequence is the classical model of colorectal cancer pathogenesis.[47] The
polyp to cancer sequence describes the phases of transition from benign tumours into colorectal cancer over
many years.[47] Central to the polyp to CRC sequence are gene mutations, epigenetic alterations and local
inflammatory changes.[47] The polyp to CRC sequence can be used as an underlying framework to illustrate how
specific molecular changes lead to various cancer subtypes.[47]
Field defects[edit]
Longitudinally opened freshly resected colon segment showing a cancer and four polyps. Plus a schematic
diagram indicating a likely field defect (a region of tissue that precedes and predisposes to the development of
cancer) in this colon segment. The diagram indicates sub-clones and sub-sub-clones that were precursors to
the tumors.
The term "field cancerization" was first used in 1953 to describe an area or "field" of epithelium that has been
preconditioned (by what were largely unknown processes at the time) to predispose it towards development of
cancer.[48] Since then, the terms "field cancerization", "field carcinogenesis", "field defect", and "field effect" have
been used to describe pre-malignant or pre-neoplastic tissue in which new cancers are likely to arise.[49]
Field defects are important in progression to colon cancer.[50][51][52]
However, in most cancer research, as pointed out by Rubin[53] "The vast majority of studies in cancer research
has been done on well-defined tumors in vivo, or on discrete neoplastic foci in vitro. Yet there is evidence that
more than 80% of the somatic mutations found in mutator phenotype human colorectal tumors occur before the
onset of terminal clonal expansion."[54] Similarly, Vogelstein et al.[55] pointed out that more than half of somatic
mutations identified in tumors occurred in a pre-neoplastic phase (in a field defect), during growth of apparently
normal cells. Likewise, epigenetic alterations present in tumors may have occurred in pre-neoplastic field
defects.
An expanded view of field effect has been termed "etiologic field effect", which encompasses not only molecular
and pathologic changes in pre-neoplastic cells but also influences of exogenous environmental factors and
molecular changes in the local microenvironment on neoplastic evolution from tumor initiation to death.[56]
Epigenetics[edit]
Epigenetic alterations are much more frequent in colon cancer than genetic (mutational) alterations. As
described by Vogelstein et al.,[55] an average cancer of the colon has only 1 or 2 oncogene mutations and 1 to 5
tumor suppressor mutations (together designated “driver mutations”), with about 60 further “passenger”
mutations. The oncogenes and tumor suppressor genes are well studied and are described above
under Pathogenesis.
In addition to epigenetic alteration of expression of miRNAs, other common types of epigenetic alterations in
cancers that change gene expression levels include direct hypermethylation or hypomethylation of CpG islands
of protein-encoding genes and alterations in histones and chromosomal architecture that influence gene
expression.[57] As an example, 147 hypermethylations and 27 hypomethylations of protein coding genes were
frequently associated with colorectal cancers. Of the hypermethylated genes, 10 were hypermethylated in 100%
of colon cancers, and many others were hypermethylated in more than 50% of colon cancers.[58] In addition, 11
hypermethylations and 96 hypomethylations of miRNAs were also associated with colorectal
cancers.[58] Abnormal (abberant) methylation occurs as a normal consequence of normal aging and the risk of
colorectal cancer increases as a person gets older.[59] The source and trigger of this age-related methylation is
unknown.[59][60] Approximately half of the genes that show age-related methylation changes are the same genes
that have been identified to be involved in the development of colorectal cancer.[59]These findings may suggest
a reason for age being associated with the increased risk of developing colorectal cancer. [59]
Epigenetic reductions of DNA repair enzyme expression may likely lead to the genomic and epigenomic
instability characteristic of cancer.[50][61][62][63] As summarized in the articles Carcinogenesis and Neoplasm, for
sporadic cancers in general, a deficiency in DNA repair is occasionally due to a mutation in a DNA repair gene,
but is much more frequently due to epigenetic alterations that reduce or silence expression of DNA repair
genes.[citation needed]
Epigenetic alterations involved in the development of colorectal cancer may affect a person's response to
chemotherapy.[64]

Diagnosis[edit]
Colorectal cancer diagnosis is performed by sampling of areas of the colon suspicious for possible tumor
development, typically during colonoscopy or sigmoidoscopy, depending on the location of the lesion.[19] It is
confirmed by microscopical examination of a tissue sample.
Presence of metastases is determined by a CT scan of the chest, abdomen and pelvis.[19]Other potential
imaging tests such as PET and MRI may be used in certain cases.[19] Staging of the cancer is based on both
radiological and pathological findings. As for most other forms of cancer, tumor staging is based on the TNM
system which considers how much the initial tumor has spread and the presence of metastases in lymph nodes
and more distant organs.[19]
The microscopic cellular characteristics of the tumor are reported from the analysis of tissue taken from a
biopsy or surgery. A pathology report contains a description of the microscopical characteristics of the tumor
tissue, including both tumor cells and how the tumor invades into healthy tissues and finally if the tumor appears
to be completely removed. The most common form of colon cancer is adenocarcinoma. Other, rarer types
include lymphoma, adenosquamous and squamous cell carcinoma. Some subtypes have been found to be
more aggressive.[65]
Macroscopy[edit]
Cancers on the right side of the large intestine (ascending colon and cecum) tend to be exophytic, that is, the
tumor grows 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 lumen, much like a napkin ring, and results in thinner caliber stools.
Microscopy[edit]
Adenocarcinoma is a malignant epithelial tumor, originating from superficial glandular epithelial cells lining the
colon and rectum. It invades the wall, infiltrating the muscularis mucosae layer, the submucosa, and then the
muscularis propria. Tumor cells describe irregular tubular structures, harboring pluristratification, multiple
lumens, reduced stroma ("back to back" aspect). Sometimes, tumor cells are discohesive and secrete mucus,
which invades the interstitium producing large pools of mucus. This occurs in mucinousadenocarcinoma, in
which cells are poorly differentiated. If the mucus remains inside the tumor cell, it pushes the nucleus at the
periphery, this occurs in "signet-ring cell." Depending on glandular architecture, cellular pleomorphism, and
mucosecretion of the predominant pattern, adenocarcinoma may present three degrees of differentiation: well,
moderately, and poorly differentiated.[66]
Tumor budding[edit]
Tumor budding in colorectal cancer is loosely defined by the presence of individual cells and small clusters of
tumor cells at the invasive front of carcinomas. It has been postulated to represent an epithelial–mesenchymal
transition (EMT). Tumor budding is a well-established independent marker of a potentially poor outcome in
colorectal carcinoma that may allow for dividing people into risk categories more meaningful than those defined
by TNM staging, and also potentially guide treatment decisions, especially in T1 and T3 N0 (Stage II, Dukes’ B)
colorectal carcinoma. Unfortunately, its universal acceptance as a reportable factor has been held back by a
lack of definitional uniformity with respect to both qualitative and quantitative aspects of tumor budding. [71]

Prevention[edit]
It has been estimated that about half of colorectal cancer cases are due to lifestyle factors, and about a quarter
of all cases are preventable.[72]Increasing surveillance, engaging in physical activity, consuming a diet high in
fiber, and reducing smoking and alcohol consumption decrease the risk.[73][74]
Lifestyle[edit]
Lifestyle risk factors with strong evidence include lack of exercise, cigarette smoking, alcohol, and
obesity.[75][76] The risk of colon cancer can be reduced by maintaining a normal body weight through a
combination of sufficient exercise and eating a healthy diet.[77]
Starting in the 1970s, dietary recommendations to prevent colorectal cancer often included increasing the
consumption of whole grains, fruits and vegetables, and reducing the intake of red meat and processed meats.
This was based on animal studies and retrospective observational studies. However, large scale prospective
studies have failed to demonstrate a significant protective effect, and due to the multiple causes of cancer and
the complexity of studying correlations between diet and health, it is uncertain whether any specific dietary
interventions (outside of eating a healthy diet) will have significant protective effects.[78]:432–433[79]:125–126 In 2018
the National Cancer Institute stated that "There is no reliable evidence that a diet started in adulthood that is low
in fat and meat and high in fiber, fruits, and vegetables reduces the risk of CRC by a clinically important
degree."[75][80]
With regard to dietary fiber, the 2014 World Health Organization cancer report noted that it has been
hypothesized that fiber might help prevent colorectal cancer, but most studies have not borne this out, and
status of the science remained unclear as of 2014.[79] A 2019 review however found evidence of benefit from
dietary fiber and whole grains.[81] The World Cancer Research Fund listed the benefit of fiber for prevention of
colorectal cancer as "probable" as of 2017.[82]
Higher physical activity is recommended.[20][83] Physical exercise is associated with a modest reduction in colon
but not rectal cancer risk.[84][85] High levels of physical activity reduce the risk of colon cancer by about
21%.[86] Sitting regularly for prolonged periods is associated with higher mortality from colon cancer. The risk is
not negated by regular exercise, though it is lowered.[87]
Medication and supplements[edit]
Aspirin and celecoxib appear to decrease the risk of colorectal cancer in those at high risk.[88][89] Aspirin is
recommended in those who are 50 to 60 years old, do not have an increased risk of bleeding, and are at risk for
cardiovascular disease to prevent colorectal cancer.[90] It is not recommended in those at average risk.[91]
There is tentative evidence for calcium supplementation, but it is not sufficient to make a
recommendation.[92] Vitamin D intake and blood levels are associated with a lower risk of colon cancer.[93][94]
Screening[edit]
As more than 80% of colorectal cancers arise from adenomatous polyps, screening for this cancer is effective
for both early detection and for prevention.[19][95] Diagnosis of cases of colorectal cancer through screening
tends to occur 2–3 years before diagnosis of cases with symptoms.[19] Any polyps that are detected can be
removed, usually by colonoscopy or sigmoidoscopy, and thus prevent them from turning into cancer. Screening
has the potential to reduce colorectal cancer deaths by 60%.[96]
The three main screening tests are colonoscopy, fecal occult bloodtesting, and flexible sigmoidoscopy. Of the
three, only sigmoidoscopy cannot screen the right side of the colon where 42% of cancers are found.[97] Flexible
sigmoidoscopy, however, has the best evidence for decreasing the risk of death from any cause. [98]
Fecal occult blood testing (FOBT) of the stool is typically recommended every two years and can be
either guaiac-based or immunochemical.[19]If abnormal FOBT results are found, participants are typically
referred for a follow-up colonoscopy examination. Yearly to every two year FOBT screening reduces colorectal
cancer deaths by 16% and among those participating in screening colorectal cancer deaths can be reduced up
to 23%, although it has not been proven to reduce all-cause mortality.[99]Immunochemical tests are accurate
and do not require dietary or medication changes before testing.[100]
Other options include virtual colonoscopy and stool DNA screening testing (FIT-DNA). Virtual colonoscopy via
a CT scan appears as good as standard colonoscopy for detecting cancers and large adenomas but is
expensive, associated with radiation exposure, and cannot remove any detected abnormal growths like
standard colonoscopy can.[19] Stool DNA screening test looks for biomarkers associated with colorectal cancer
and precancerous lesions, including altered DNA and blood hemoglobin. A positive result should be followed
by colonoscopy. FIT-DNA has more false positives than FIT and thus results in more adverse effects.[5] Further
study is required as of 2016 to determine if a three year screening interval is correct.[5]
Recommendations[edit]
In the United States, screening is typically recommended between ages 50 to 75 years.[5] The American Cancer
Society recommends starting at the age of 45.[101] For those between 76 and 85 years old, the decision to
screen should be individualized.[5] Several screening methods can be used, including stool based tests every 3
years, sigmoidoscopy every 5 years and colonoscopy every 10 years. For those at high risk, screenings usually
begin at around 40.[19][102] It is unclear which of these two methods is better.[103] Colonoscopy may find more
cancers in the first part of the colon, but is associated with greater cost and more complications.[103] For people
with average risk who have had a high-quality colonoscopy with normal results, the American
Gastroenterological Association does not recommend any type of screening in the 10 years following the
colonoscopy.[104][105] For people over 75 or those with a life expectancy of less than 10 years, screening is not
recommended.[106] It takes about 10 years after screening for one out of a 1000 people to benefit.[107] The
USPSTF list seven potential strategies for screening, with the most important thing being that at least one of
these strategies is appropriately used.[5]
In Canada, among those 50 to 75 years old at normal risk, fecal immunochemical testing or FOBT is
recommended every two years or sigmoidoscopy every 10 years.[108] Colonoscopy is less preferred.[108]
Some countries have national colorectal screening programs which offer FOBT screening for all adults within a
certain age group, typically starting between ages 50 to 60. Examples of countries with organised screening
include the United Kingdom,[109] Australia,[110] and the Netherlands.[111]

Treatment[edit]
The treatment of colorectal cancer can be aimed at cure or palliation. The decision on which aim to adopt
depends on various factors, including the person's health and preferences, as well as the stage of the
tumor.[112] When colorectal cancer is caught early, surgery can be curative. However, when it is detected at later
stages (for which metastases are present), this is less likely and treatment is often directed at palliation, to
relieve symptoms caused by the tumour and keep the person as comfortable as possible.[19]
Surgery[edit]
A diagram of local surgery for rectal cancer
If the cancer is found at a very early stage, it may be removed during a colonoscopy.[6] For people with localized
cancer, the preferred treatment is complete surgical removal with adequate margins, with the attempt of
achieving a cure. This can either be done by an open laparotomy or sometimes laparoscopically.[19] The colon
may then be reconnected or a person may have a colostomy.[6]
If there are only a few metastases in the liver or lungs they may also be removed. Sometimes chemotherapy is
used before surgery to shrink the cancer before attempting to remove it. The two most common sites of
recurrence of colorectal cancer are the liverand lungs.[19]
Chemotherapy[edit]
In both cancer of the colon and rectum, chemotherapy may be used in addition to surgery in certain cases. The
decision to add chemotherapy in management of colon and rectal cancer depends on the stage of the disease.
In Stage I colon cancer, no chemotherapy is offered, and surgery is the definitive treatment. The role of
chemotherapy in Stage II colon cancer is debatable, and is usually not offered unless risk factors such as T4
tumor, undifferentiated tumor, vascular and perineural invasion or inadequate lymph node sampling is
identified.[113] It is also known that the people who carry abnormalities of the mismatch repair genes do not
benefit from chemotherapy. For stage III and Stage IV colon cancer, chemotherapy is an integral part of
treatment.[19]
If cancer has spread to the lymph nodes or distant organs, which is the case with stage III and stage IV colon
cancer respectively, adding chemotherapy agents fluorouracil, capecitabine or oxaliplatin increases life
expectancy. If the lymph nodes do not contain cancer, the benefits of chemotherapy are controversial. If the
cancer is widely metastatic or unresectable, treatment is then palliative. Typically in this setting, a number of
different chemotherapy medications may be used.[19]Chemotherapy drugs for this condition may
include capecitabine, fluorouracil, irinotecan, oxaliplatin and UFT.[114] The drugs capecitabine and fluorouracil
are interchangeable, with capecitabine being an oral medication while fluorouracil being an intravenous
medicine. Some specific regimens used for CRC are CAPOX, FOLFOX, FOLFOXIRI,
and FOLFIRI.[115] Antiangiogenic drugs such as bevacizumab are often added in first line therapy. Another class
of drugs used in the second line setting are epidermal growth factor receptor inhibitors, of which the two FDA
approved ones are cetuximab and panitumumab.[116]
The primary difference in the approach to low stage rectal cancer is the incorporation of radiation therapy.
Often, it is used in conjunction with chemotherapy in a neoadjuvant fashion to enable surgical resection, so that
ultimately as colostomy is not required. However, it may not be possible in low lying tumors, in which case, a
permanent colostomy may be required. Stage IV rectal cancer is treated similar to stage IV colon cancer.
Radiation therapy[edit]
While a combination of radiation and chemotherapy may be useful for rectal cancer,[19] its use in colon cancer is
not routine due to the sensitivity of the bowels to radiation.[117] Just as for chemotherapy, radiotherapy can be
used in the neoadjuvant and adjuvant setting for some stages of rectal cancer.
Immunotherapy[edit]
Immunotherapy with immune checkpoint inhibitors has been found to be useful for a type of colorectal cancer
with mismatch repair deficiency and microsatellite instability.[118][119] Most people who do improve, however, still
worsen after months or years.[119] Other types of colorectal cancer as of 2017 is still being studied.[118][119]
Palliative care[edit]
Palliative care is recommended for any person who has advanced colon cancer or who has significant
symptoms.[120][121]
Involvement of palliative care may be beneficial to improve the quality of life for both the person and his or her
family, by improving symptoms, anxiety and preventing admissions to the hospital.[122]
In people with incurable colorectal cancer, palliative care can consist of procedures that relieve symptoms or
complications from the cancer but do not attempt to cure the underlying cancer, thereby improving quality of life.
Surgical options may include non-curative surgical removal of some of the cancer tissue, bypassing part of the
intestines, or stent placement. These procedures can be considered to improve symptoms and reduce
complications such as bleeding from the tumor, abdominal pain and intestinal obstruction.[123] Non-operative
methods of symptomatic treatment include radiation therapy to decrease tumor size as well as pain
medications.[124]
Follow-up[edit]
The aims of follow-up are to diagnose, in the earliest possible stage, any metastasis or tumors that develop
later, but did not originate from the original cancer (metachronous lesions).
The U.S. National Comprehensive Cancer Network and American Society of Clinical Oncology provide
guidelines for the follow-up of colon cancer.[125][126] A medical history and physical examination are
recommended every 3 to 6 months for 2 years, then every 6 months for 5 years. Carcinoembryonic
antigen blood level measurements follow the same timing, but are only advised for people with T2 or greater
lesions who are candidates for intervention. A CT-scan of the chest, abdomen and pelvis can be considered
annually for the first 3 years for people who are at high risk of recurrence (for example, those who had poorly
differentiated tumors or venous or lymphatic invasion) and are candidates for curative surgery (with the aim to
cure). A colonoscopycan be done after 1 year, except if it could not be done during the initial staging because of
an obstructing mass, in which case it should be performed after 3 to 6 months. If a villous polyp, a polyp >1
centimeter or high grade dysplasia is found, it can be repeated after 3 years, then every 5 years. For other
abnormalities, the colonoscopy can be repeated after 1 year.
Routine PET or ultrasound scanning, chest X-rays, complete blood count or liver function tests are not
recommended.[125][126] A 2016 systematic review concluded that more intense surveillance and close follow-up
does not provide additional survival benefits in non-metastatic colorectal cancers.[127]
Exercise[edit]
Exercise may be recommended in the future as secondary therapy to cancer survivors. In epidemiological
studies, exercise may decrease colorectal cancer-specific mortality and all-cause mortality. Results for the
specific amounts of exercise needed to observe a benefit were conflicting. These differences may reflect
differences in tumour biology and expression of biomarkers. Patients with tumors that
lacked CTNNB1expression (β-catenin), involved in Wnt signalling pathway, required more than 18 Metabolic
equivalent (MET) hours per week, a measure of exercise, to observe a reduction in colorectal cancer mortality.
The mechanism of how exercise benefits survival may be involved in immune surveillance and inflammation
pathways. In clinical studies, a pro-inflammatory response was found in patients with stage II-III colorectal
cancer who underwent 2 weeks of moderate exercise after completing their primary therapy. Oxidative balance
may be another possible mechanism for benefits observed. A significant decrease in 8-oxo-dG was found in the
urine of patients who underwent 2 weeks of moderate exercise after primary therapy. Other possible
mechanisms may involve metabolic hormone and sex-steroid hormones, although these pathways may be
involved in other types of cancers[128][129]
Another potential biomarker may be p27. Survivors with tumors that expressed p27 and performed greater and
equal to 18 MET hours per week were found to have reduced colorectal-cancer mortality survival compared to
those with less than 18 MET hours per week. Survivors without p27 expression who exercised were shown to
have worse outcomes. The constitutive activation of PI3K/AKT/mTOR pathway may explain the loss of p27 and
excess energy balance may up-regulate p27 to stop cancer cells from dividing.[129]
90%. Those with a more invasive tumor yet without node involvement (T3-4, N0, M0) have an average five-year
survival rate of approximately 70%. Patients with positive regional lymph nodes (any T, N1-3, M0) have an
average five-year survival rate of approximately 40%, while those with distant metastases (any T, any N, M1)
have an average five-year survival rate of approximately 5%.[130]
The average five-year recurrence rate in people where surgery is successful is 5% for stage I cancers, 12% in
stage II and 33% in stage III. However, depending on the number of risk factors it ranges from 9 – 22% in stage
II and 17 – 44% in stage III.[131]
Less than 600 genes are linked to outcomes in colorectal cancer.[42]These include both unfavorable genes,
where high expression is related to poor outcome, for example the heat shock 70 kDa protein 1 (HSPA1A), and
favorable genes where high expression is associated with better survival, for example the putative RNA-binding
protein 3 (RBM3).[42]

2. CEA ?
- Carcinoembryonic antigen > protein found in many types of cells but associated with tumors and the
developing fetus.
- benign condition that can increase CEA incl smoking, infection, IBD, pancreatitis, pregnant,cirrhosis of the
liver and some benign tumors ( not cause increase over 10 ng/ml)
- main use : tumor marker especially with intestinal cancer. The most common cancer that elevate CEA are
in the colon and rectum(70-80%) . Others : pancreas, stomach, breast, lung, bladder, certain types of thyroid
and ovarian cancer. (over 20 ng/dl > indicate cancer that has already metastasized)
- CEA is made by some cancers and by the developing fetus
- indication :
after your diagnosis to help your doctor find the right treatments
during treatment to see how well chemotherapy, radiation, surgery or other therapies have worked
after treatment to help find out whether the cancer has come back
- specimen : blood , cerebrospinal > spine, peritoneal > abdomen, pleural > area next to lung
3. Hyoscine (Scopolamine)
Antispasmodic drug indicates for the treatment of abdominal pain associated with cramps induces by GI
spasma.
 - anticholinergic drugs with high affinity for muscarinic receptors located on the smooth muscle cells of the
GI tracts.
- its cholinergic effects the smooth muscle relaxing/ spasmolytic by blocking the muscarinic receptors in the
GI tract.
- hyoscine also bind to nicotinic receptors which induces a ganglion- blocking effect
- common side effects : sleepiness, blurred vision, dilated pupils, and dry mouth, constipation, trouble
urinating, nausea
- precaution : glaucoma, heart disease, enlarged prostate, allergies, stomach or intestinal disease, bowel
obstruction
4.