What is cancer?

Cancer is a group of more than 100 different diseases. They affect the body's basic unit, the cell.
Cancer occurs when cells become abnormal and divide without control or order. Like all other
organs of the body, the colon and rectum are made up of many types of cells. Normally, cells
divide to produce more cells only when the body needs them. This orderly process helps keep us
healthy.

If cells keep dividing when new cells are not needed, a mass of tissue forms. This mass of extra
tissue, called a growth or tumor, can be benign or malignant.

Benign tumors are not cancer. They can usually be removed and, in most cases, they do not
come back. Most important, cells from benign tumors do not spread to other parts of the body.
Benign tumors are rarely a threat to life.

Malignant tumors are cancer. Cancer cells can invade and damage tissues and organs near the
tumor. Also, cancer cells can break away from a malignant tumor and enter the bloodstream or
lymphatic system. This is how cancer spreads from the original (primary) tumor to form new
tumors in other parts of the body. The spread of cancer is called metastasis.

When cancer spreads to another part of the body, the new tumor has the same kind of abnormal
cells and the same name as the primary tumor. For example, if colon cancer spreads to the liver,
the cancer cells in the liver are colon cancer cells. The disease is metastatic colon cancer (it is
not liver cancer).

What is cancer of the colon and rectum?

The colon is the part of the digestive system where the waste material is stored. The rectum is
the end of the colon adjacent to the anus. Together, they form a long, muscular tube called the
large intestine (also known as the large bowel). Tumors of the colon and rectum are growths
arising from the inner wall of the large intestine. Benign tumors of the large intestine are called
polyps. Malignant tumors of the large intestine are called cancers. Benign polyps do not invade
nearby tissue or spread to other parts of the body. Benign polyps can be easily removed during
colonoscopy, and are not life threatening. If benign polyps are not removed from the large
intestine, they can become malignant (cancerous) over time. Most of the cancers of the large
intestine are believed to have developed from polyps. Cancer of the colon and rectum (also
referred to as colorectal cancer) can invade and damage adjacent tissues and organs. Cancer
cells can also break away and spread to other parts of the body (such as liver and lung) where
new tumors form. The spread of colon cancer to distant organs is called metastasis of the colon
cancer. Once metastasis has occurred in colorectal cancer, a complete cure of the cancer is
unlikely.
Globally, cancer of the colon and rectum is the third leading cause of cancer in males and the
fourth leading cause of cancer in females. The frequency of colorectal cancer varies around the
world. It is common in the Western world, and is rare in Asia and Africa. In countries where the
people have adopted western diets, the incidence of colorectal cancer is increasing.

General Information About Colon Cancer

Colon cancer is a disease in which malignant (cancer) cells form in the tissues of the
colon.

The colon is part of the body’s digestive system. The digestive system removes and
processes nutrients (vitamins, minerals, carbohydrates, fats, proteins, and water) from
foods and helps pass waste material out of the body. The digestive system is made up of
the esophagus, stomach, and the small and large intestines. The first 6 feet of the large
intestine are called the large bowel or colon. The last 6 inches are the rectum and the anal
canal. The anal canal ends at the anus (the opening of the large intestine to the outside of
the body).

Anatomy of the lower digestive system, showing the colon and other organs.

Age and health history can affect the risk of developing colon cancer.

Risk factors include the following:

  Age 50 or older.
 A family history of cancer of the colon or rectum.
 A personal history of cancer of the colon, rectum, ovary, endometrium, or breast.
 A history of polyps in the colon.

Polyps in the colon. Some polyps have a stalk and others do not. Inset shows
a photo of a polyp with a stalk.

 A history of ulcerative colitis (ulcers in the lining of the large intestine) or Crohn's
disease.
 Certain hereditary conditions, such as familial adenomatous polyposis and
hereditary nonpolyposis colon cancer (HNPCC; Lynch Syndrome).

Possible signs of colon cancer include a change in bowel habits or blood in the stool.

These and other symptoms may be caused by colon cancer. Other conditions may cause
the same symptoms. A doctor should be consulted if any of the following problems
occur:

 A change in bowel habits.

 Blood (either bright red or very dark) in the stool.
 Diarrhea, constipation, or feeling that the bowel does not empty completely.
 Stools that are narrower than usual.
 Frequent gas pains, bloating, fullness, or cramps.
 Weight loss for no known reason.
 Feeling very tired.
 Vomiting.

Tests that examine the rectum, rectal tissue, and blood are used to detect (find) and
diagnose colon cancer.

The following tests and procedures may be used:

 Physical exam and history: An exam of the body to check general signs of health,
including checking for signs of disease, such as lumps or anything else that seems
unusual. A history of the patient’s health habits and past illnesses and treatments
will also be taken.
 Fecal occult blood test: A test to check stool (solid waste) for blood that can only
be seen with a microscope. Small samples of stool are placed on special cards and
returned to the doctor or laboratory for testing.

Fecal Occult Blood Test (FOBT) kit to check for blood in stool.
  Digital rectal exam: An exam of the rectum. The doctor or nurse inserts a
lubricated, gloved finger into the rectum to feel for lumps or anything else that
seems unusual.
 Barium enema: A series of x-rays of the lower gastrointestinal tract. A liquid that
contains barium (a silver-white metallic compound) is put into the rectum. The
barium coats the lower gastrointestinal tract and x-rays are taken. This procedure
is also called a lower GI series.

Barium enema procedure. The patient lies on an x-ray table. Barium liquid is
put into the rectum and flows through the colon. X-rays are taken to look for
abnormal areas.

 Sigmoidoscopy: A procedure to look inside the rectum and sigmoid (lower) colon
for polyps, abnormal areas, or cancer. A sigmoidoscope (a thin, lighted tube) is
inserted through the rectum into the sigmoid colon. Polyps or tissue samples may
be taken for biopsy.

Sigmoidoscopy. A thin, lighted tube is inserted through the anus and rectum
and into the lower part of the colon to look for abnormal areas.

 Colonoscopy: A procedure to look inside the rectum and colon for polyps,
abnormal areas, or cancer. A colonoscope (a thin, lighted tube) is inserted through
the rectum into the colon. Polyps or tissue samples may be taken for biopsy.

Colonoscopy. A thin, lighted tube is inserted through the anus and rectum
and into the colon to look for abnormal areas.

 Biopsy: The removal of cells or tissues so they can be viewed under a microscope
to check for signs of cancer.
 Virtual colonoscopy: A procedure that uses a series of x-rays called computed
tomography to make a series of pictures of the colon. A computer puts the
pictures together to create detailed images that may show polyps and anything
else that seems unusual on the inside surface of the colon. This test is also called
colonography or CT colonography.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) depends on the following:

 The stage of the cancer (whether the cancer is in the inner lining of the colon
only, involves the whole colon, or has spread to other places in the body).
  Whether the cancer has blocked or created a hole in the colon.
 The blood levels of carcinoembryonic antigen (CEA; a substance in the blood that
may be increased when cancer is present) before treatment begins.
 Whether the cancer has recurred.
 The patient’s general health.

Treatment options depend on the following:

 The stage of the cancer.

 Whether the cancer has recurred.
 The patient’s general health.

Stages of Colon Cancer

After colon cancer has been diagnosed, tests are done to find out if cancer cells have
spread within the colon or to other parts of the body.

The process used to find out if cancer has spread within the colon or to other parts of the
body is called staging. The information gathered from the staging process determines the
stage of the disease. It is important to know the stage in order to plan treatment. The
following tests and procedures may be used in the staging process:

 CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas
inside the body, taken from different angles. The pictures are made by a computer
linked to an x-ray machine. A dye may be injected into a vein or swallowed to
help the organs or tissues show up more clearly. This procedure is also called
computed tomography, computerized tomography, or computerized axial
tomography.
 Lymph node biopsy: The removal of all or part of a lymph node. A pathologist
views the tissue under a microscope to look for cancer cells.
 Complete blood count (CBC): A procedure in which a sample of blood is drawn
and checked for the following:
o The number of red blood cells, white blood cells, and platelets.
o The amount of hemoglobin (the protein that carries oxygen) in the red
blood cells.
o The portion of the blood sample made up of red blood cells.
 Carcinoembryonic antigen (CEA) assay: A test that measures the level of CEA in
the blood. CEA is released into the bloodstream from both cancer cells and
normal cells. When found in higher than normal amounts, it can be a sign of colon
cancer or other conditions.
 MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves,
and a computer to make a series of detailed pictures of areas inside the colon. A
substance called gadolinium is injected into the patient through a vein. The
gadolinium collects around the cancer cells so they show up brighter in the
picture. This procedure is also called nuclear magnetic resonance imaging
(NMRI).
  Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type
of energy beam that can go through the body and onto film, making a picture of
areas inside the body.
 Surgery: A procedure to remove the tumor and see how far it has spread through
the colon.

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Perioperative management of colon cancer under

Medicare risk programs
S. M. Retchin, L. Penberthy, C. Desch, R. Brown, B. Jerome-D'Emilia and D. Clement
Department of Internal Medicine, Massey Cancer Center, Virginia Commonwealth
University, Richmond, USA. retchin@gems.vcu.edu

OBJECTIVE: To determine differences in perioperative care and outcomes for patients

with colon cancer enrolled in Medicare health maintenance organizations compared
with similar fee-for-service nonenrollees. METHODS: Cross-sectional evaluation of
hospital care and posthospital outcomes with data obtained from medical records.
Nineteen health maintenance organizations representing all model types were
selected from 12 states. The nonenrollee sample was drawn from the same areas.
The sample included 412 enrollees and 401 nonenrollees, representing 65 hospitals
for health maintenance organizations and 61 hospitals for fee-for-service. RESULTS:
Nonenrollees were slightly older and had higher preoperative risk. Enrollees had
shorter intervals between admission and surgery (enrollees, 1.55 days vs
nonenrollees, 2.85 days). Differences in length of stay (enrollees, 10.9 days vs
nonenrollees, 14.2 days) persisted even after controlling for preoperative health
status. Differences in admissions to intensive care units (enrollees, 36.4% vs
nonenrollees, 44.4%) were highly influenced by preoperative health status.
Nonenrollees were more significantly likely to receive preoperative antibiotics,
postoperative testing (eg, postoperative chest radiographs and electrocardiograms),
and postoperative patient-controlled analgesia. Tumor staging was similar for both
groups. Enrollees were more likely to be discharged home, while nonenrollees were
more likely to be discharged to a nursing home. There were no significant differences
in hospital deaths or postdischarge readmissions. CONCLUSIONS: Health
maintenance organization enrollees with colon cancer received less clinical services of
several types than similar patients in fee-for-service settings, had shorter hospital
stays, and were less likely to be discharged to nursing homes. However, there was
no evidence that they experienced different outcomes.

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