1. Cancer of the Digestive System Colorectal Cancer

2. Digestive System – Anatomy/Physiology Purpose of digestive system: to change food (nutrients) into energy for storage or body use Primary Organs: esophagus, stomach, small/large intestine Other digestive system organs assist in digestion - liver, gallbladder, pancreas Colon (large intestine), rectum and anus carry waste products (non-nutrients) through to excretion ADAM and Medline Plus.

3. Purpose of colon: Water absorption from indigestible food Parts of colon in order of passage: ascending, transverse, descending, sigmoid Ileocecal valve of small intestine passes waste into large intestine at cecum. Waste excreted from rectum through anal canal - anus ADAM, Medline Plus

4. Large intestine - long hollow organ lined with mucous membrane Muscle wraps around length of large intestine, assisting the passage of food through organ to rectum, anal canal, and anus Adam, Medline Plus

5. What is Colon Cancer or Colorectal Cancer (CRC)? Disease in which malignant cells form in tissues of colon Colon – first 6 feet of large bowel/intestine Rectum – last 6 inches of anal canal Appendix – also a part of colon Usually adenocarcinoma – 95% of all cases Other types Lymphoma Carcinoid tumors Melanoms Sarcoma Medline Plus, ACS

6. Epidemiology of CRC Third most common form of cancer in males and females 2 nd most common cause of death among US males and females combined 10% of male cancer deaths annually Greater proportion of cancer deaths - only in lung/bronchus (31%) 10% of female cancer deaths annually Greater proportion of cancer deaths - only in lung/bronchus (26%) & breast (15%) Second leading cause of cancer deaths in Western world 655,000 deaths per year worldwide 148,540 will develop annually (2008 estimate) 108,070 in colon; 40,740 in rectum 49,960 deaths per year in US Medline Plus, ACS

7. Symptoms Depends on location of tumor in bowel Whether cancer has metastasized Many symptoms may also occur in other diseases, so symptoms are not definitive Three kinds of symptoms Local Constitutional Metastatic Medline Plus, ACS

8. Local Symptoms More likely if growth near end of anal canal Change in bowel habits Constipation or diarrhea of new onset & unrelated to another cause Feeling of incomplete evacuation of bowel (rectal cancer) Reduction in stool size (diameter) (rectal cancer) Change in shape of stool (pencil thin) Bleeding from rectum (frank, bright red) (CRC) Tarry or black stools (beginning of large intestine) Mucus in stools (CRC) Medline Plus, ACS

9. Local symptoms (continued) Tumor large enough to fully occlude opening of bowel – bowel obstruction Constipation Abdominal pain Tenderness in lower abdomen Distention of abdomen Emesis Perforation and peritonitis Low back pain Advanced Noticed on palpation Seen at physical exam Metastatic to bladder – blood or air in urine Metastatic to female reproductive organs – vaginal discharge Medline Plus, ACS

10. Constitutional Symptoms Iron deficiency anemia if chronic undetected bleeding Fatigue Irregular heart beat - palpatations Paleness of skin Weight loss Decreased appetite Fever of unknown origin Thrombosis – usually DVT Medline Plus, ACS

11. Symptoms of Metastatic CRC Usually spreads to liver Jaundice Abdominal pain Bile duct obstruction Pale stools due to biliary obstruction Medline Plus, ACS

12. Specimen showing one invasive carcinoma – on top, red, irregularly-shaped tumor Wikipedia

13. Specimen showing 2 polyps attached by stalk; one invasive carcinoma Wikipedia

14. Risk Factors Age over 50 More than 90% of CRC diagnosed in those > 50 years Most CRC appears in 60s and 70s Cases under 50 rare unless genetic predisposition among younger family members AA highest rate of all racial/ethnic groups in US; Eastern European Jews History of cancer Women with previously diagnosed/treated ovarian, uterine, or breast cancer Personal diagnosis and treatment for CRC History of polyps, especially benign polyps - adenomatous Inflammatory bowel disease – History of chronic ulcerative colitis in 1%; Chron’s Obesity Heavy alcohol use Family History Less than 10% caused by genetics Close relative diagnosed before 55 years of age Multiple relatives diagnosed with CRC Medline Plus

15. Risk Factors (continued) Smoking Smokers more likely to die of CRC than non-smokers Female smokers more than 40% more likely to die of CRC than non-smokers Male smokers – increased risk (30%) compared to non-smokers Diet low in fruits/vegetables, fish, poultry - possible Unclear fiber effect Diet high in fat, red and/or processed meat - possible Physical inactivity Virus – HPV Low levels of selenium Medline Plus

16. Prevention Death rate dropped in last 15 years Takes many years to develop CRC Early detection of polyps and CRC – critical Most CRC develops from easily removable polyps Undetected polyps grow through lining and layer of colon wall and rectum Early screening could significantly reduce mortality Screening rates low Almost all men and women older than 50 should screen ACS

17. Diagnosis and Screening Initial DRE – inspection of distal parts of rectum FOBT – tests for trace amounts of blood in stool - annually Guiac (chemical) Immunochemical – superior to FOBT Must be used with endoscopy False negatives and positives Endoscopy Sigmoidoscopy – inspection of rectum & lower third of colon with lighted probe and inserting air – every 5 years Colonoscopy – inspection of rectum and all parts of colon; polyp removal and biopsy – every 3 years Double contrast barium enema for detection in large intestine Complete blood count to check for anemia ACS

18. All 4 screening tests - effective in detecting cancers in early stages. ADAM

21. Prognosis Depends on stage of cancer when detected If detected and treated early, most patients survive for 5 years 5-year survival rate drops if not detected early enough and cancer has metastasized If CRC does not return in 5 years, considered cured Stages 1-3 potentially curable Stage 4 not curable in most cases ACS

22. ADAM

23. Staging Depends on size of tumor and degree of penetration Stage 0 – very early – tumor on mucosa – inner-most colon layers Stage I: Metastasized into sub-mucosa – inner layers T1N0M0 – In sub-mucosa - inner layers of the colon T2N0M0 – in muscularis propria Stage II: Metastasized into colon’s muscle wall A-T3N0M0- In sub-serosa or beyond (no organs) B-T4N0M0 – in adjacent organs after perforates peritoneum Stage III: Metastasized into nearby lymph nodes A -T1-2N1M0 – in 1-3 regional lymph nodes (T1 or T2) B- T3-4 N1M0 – in 1-3 regional lymph nodes (T3 or T4) C-Any T, N2M0- 4 or more regional lymph nodes. Any T Stage IV: Metastasized to remote organs Any T, Any N, M1 – remote metastases. Any T, any N ACS

24. Several metastatic tumors in liver and spleen originating from carcinoma of intestine ADAM

25. Cancer of large bowel (sigmoid area of colon) detected on barium enema ADAM

26. Cancer of the rectum detected with barium enema. ADAM

27. Treatment Depends on stage of cancer Choices: Surgery – primary treatment Radiation (mostly used in Stage 3 rectal cancer); also used with chemotherapy in other stages Treatment by stage Stage 0 – removal during colonoscopy Stage 1, 2, 3 – more extensive surgery Stage 4 – chemotherapy Metastatic liver cancer: surgery, chemotherapy/radiation directed to liver, cryotherapy, ablation ACS