Colorectal Cancer

Aka: Colorectal Cancer, Colon Cancer, Colon Carcinoma, Colorectal Carcinoma

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II. Epidemiology

  1. Accounts for 8.5% of all new cancer cases
    1. Third most common cancer in the U.S.
  2. In U.S. (2014)
    1. Prevalence: 1.2 Million
    2. Incidence: 137,000/year
    3. Mortality: 50,000/year
  3. Highest Incidence of Colon Cancer
    1. North America
    2. Western Europe
    3. Australia and New Zealand
    4. Japan

III. Risk Factors

  1. See Colon Cancer Risk Factors

IV. Management: Non-resectable hepatic metastases

  1. Radiofrequency Ablation
    1. Small trials suggest prolonged survival or cure
    2. Wong (2001) Am J Surg 182:552-7 [PubMed]

V. Prevention

  1. Primary prevention
    1. See Colorectal Cancer Prevention
    2. See Colorectal Cancer Screening
  2. Secondary prevention
    1. Routine screening for other cancers
    2. Tobacco Cessation
    3. Obesity Management and Healthy Diet (Colorectal Cancer risk factors)
    4. Exercise improves quality of life and decreases overall mortality (goal: 150 min/week)
    5. Daily low dose Aspirin

VI. Course

  1. Five-year survival: 65%
  2. Recurrence risk
    1. Highest risk within first 5 years post-resection (17 to 42%)

VII. Complications: General

  1. Colorectal Cancer recurrence (typically in first 5 years after treatment)
  2. Second primary Colorectal Cancer
  3. Urinary symptoms
    1. Stress Incontinence
    2. Urge Incontinence
    3. Urology Consultation indications
      1. Persistent Urinary Retention (pelvic nerve injury is common in initial post-operative period)
      2. Persistent Hematuria
  4. Neuropsychiatric
    1. Cognitive dysfunction (Chemotherapy associated)
      1. Typically mild and transient
    2. Major Depression
    3. Anxiety Disorder
    4. Insomnia
    5. Sexual Dysfunction
      1. Vaginal Dryness and Dyspareunia in women
      2. Erectile Dysfunction (pelvic radiation, platinum-based Chemotherapy)
      3. Ostomy-related concerns
    6. Neuropathy (esp. platinum-based Chemotherapy such as Oxaliplatin)
      1. Duloxetine (Cymbalta)
      2. Gabapentin (Neurontin) or Pregabalin (Lyrica)
      3. Tricyclic Antidepressant
    7. Fatigue
      1. Common in Colorectal Cancer survivors
      2. Consider evaluating for alternative Fatigue cause (e.g Anemia, Hypothyroidism)

VIII. Complications: Gastrointestinal adverse effects

  1. Ostomy care
  2. Diarrhea
    1. Dietary Fiber supplementation
    2. Probiotic supplementation
    3. Periodic Loperamide (Imodium) use
  3. Fecal Incontinence
    1. Periodic Loperamide (Imodium) use
    2. Methylcellulose and Dietary Fiber
    3. Biofeedback
  4. Radiation Proctitis (Diarrhea, bleeding)
    1. Endoscopic argon plasma coagulation
    2. Sucralfate enemas
    3. Hanson (2012) Dis Colon Rectum 55(10): 1081-95 [PubMed]
  5. Abdominal Pain
    1. Acute pain (esp. RUQ Pain, Pelvic Pain)
      1. Evaluate for cancer recurrence
    2. Chronic Pain
      1. Radiation Proctitis
      2. Incisional Hernia
  6. Pelvic Fracture
    1. Higher risk in women who undergo pelvic radiation

IX. Protocol: Cancer Survivor Monitoring (post-Resection)

  1. See Cancer Survivor Care
  2. Oncology may often establish a survivorship care plan
  3. Follow-up visits (starting 4-5 weeks after curative resection)
    1. Visit every 3-6 months for 2-3 years, then every 6 months until 5 years post-resection
    2. May avoid in Stage I at low risk of recurrence
    3. Focus areas
      1. Ostomy problems or Stool Incontinence
      2. Radiation Proctitis
      3. Bowel adhesions
  4. Carcinoembryonic Antigen (CEA-125)
    1. Perform at each visit (every 3-6 months for 2-3 years, then every 6 months until 5 years post-resection)
    2. May avoid in Stage I at low risk of recurrence
    3. Other labs (e.g. CBC, Comprehensive panel) are not routinely indicated (unless other concerns)
  5. Colonoscopy
    1. Perform at one year post resection and resect new polyps
    2. Normal Colonoscopy
      1. Repeat at 3 years post-resection, and then every 5 years
    3. Advanced adenomatous polyp (>1 cm, high grade dysplasia or villous component)
      1. Repeat Colonoscopy in 1 year
    4. Obstructing lesion prevented Colonoscopy before resection
      1. Colonoscopy in 3 to 6 months, and then as above
    5. Rectal cancer at high risk of recurrence
      1. Flexible Sigmoidoscopy every 3-6 months for first 2-3 years post-resection
  6. Imaging
    1. PET scan is not recommended for recurrence monitoring
    2. CT Chest, Abdomen and Pelvis Indications (every 12 months for 5 years post-resection)
      1. Stage I or II if high risk for recurrence
      2. Stage III disease
      3. Stage IV disease (CT interval may be increased to coincide with CEA and visit timing)
  7. References
    1. Carek (2024) Am Fam Physician 110(1): 37-44 [PubMed]
    2. Wilbur (2014) Am Fam Physician 91(1):29-36 [PubMed]

X. References

  1. Burgers (2018) Am Fam Physician 97(5):331-6 [PubMed]
  2. Short (2014) Am Fam Physician 91(2): 93-100 [PubMed]
  3. Sunga (2005) Am Fam Physician 71:699-714 [PubMed]

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