Third Edition. What you need to know. RICHARD PAZDUR, MD US Food and Drug Administration Rockville, Maryland

Transcription

1 Third Edition Myths & Facts about colorectal cancer What you need to know RICHARD PAZDUR, MD US Food and Drug Administration Rockville, Maryland MELANIE E ROYCE, MD, PhD University of New Mexico Cancer Research and Treatment Center Albuquerque, New Mexico Text illustrations by Ronald Futral

2 Clinical opinions expressed in this book are those of the authors and do not necessarily reflect the opinions of the sponsor, editors, or the publisher and officers of the Oncology Publishing Group of CMP Healthcare Media. Copyright 2004 by CMP Healthcare Media. All rights reserved. This book is protected by copyright. No part of it may be reproduced in any manner or by any means, electronic or mechanical, without the written permission of the publisher. Library of Congress Catalog Card Number ISBN x Single copies of this book are available at $10.95 each. For information on bulk quantities or purchases, contact the publishers: CMP Healthcare Media, Oncology Publishing Group, 600 Community Drive, Manhasset, NY Telephone: (212) Printed in the U.S.A. The views expressed are the result of independent work and do not necessarily represent the views or findings of the Food and Drug Administration of the United States. Publishers of: ONCOLOGY Oncology News International Cancer Management: A Multidisciplinary Approach

3 About the Authors Richard Pazdur, MD, is currently Director of Oncology Drug Products, Center for Drug Evaluation and Research (CDER) in the United States Food and Drug Administration. Prior to these activities, Dr. Pazdur was Professor of Medicine at The University of Texas M. D. Anderson Cancer Center in Houston, Texas. He was a faculty member for 12 years in the Department of Gastrointestinal Oncology and Digestive Diseases, specializing in the treatment of colorectal cancer. Dr. Pazdur received his medical degree from Loyola Stritch School of Medicine and completed his internship and residency training at Loyola University, Foster G. McGaw Hospital. He performed fellowship training in medical oncology at Rush- Presbyterian-St. Luke s Medical Center, and in Oncology/Hematology at the University of Chicago Medical Center. Dr. Pazdur currently serves on the Editorial Boards of ONCOLOGY and Clinical Cancer Research, and is widely published in the medical literature. Melanie E Royce, MD, PhD, is currently Associate Professor of Medicine at the University of New Mexico and is actively involved in the care of cancer patients at the UNM Cancer Research and Treatment Center and its allied institutions. Dr. Royce received her PhD in 1991 and her medical degree in 1994 from the University of Cincinnati Medical Center in Ohio. While in medical school, she was elected into the Alpha Omega Alpha Honor Society and was awarded the Upjohn Achievement Award for outstanding academic achievement. Dr. Royce completed her residency at the Yale-New Haven Hospital in Connecticut, then Medical Oncology Fellowship training at The University of Texas M. D. Anderson Cancer Center in Houston, Texas. She was awarded the C.D. Howe Award for Clinical Excellence her first year of fellowship and later served as Chief Fellow. She received both the Outstanding Achievement in Research Award and Pharmacia-Upjohn Award for Outstanding Fellow. Upon completion of her training, she joined the faculty at the University of Texas M. D. Anderson Cancer Center as Assistant Professor in the Division of Cancer Medicine. She is certified by the American Board of Internal Medicine and the American Board of Medical Specialties in Oncology. Dr. Royce was recognized as one of America s Top Physicians in 2003.

4 Contents Introduction What Is Colorectal Cancer? What Causes Colorectal Cancer? Known Risk Factors 13 History of Adenomatous Polyps 13 Inflammatory Bowel Disease 14 Prior Personal History of Cancer 14 Family History of Cancer 14 Other Possible Risk Factors 15 Environment 15 Diet 15 Tobacco Use 15 Possible Protectants 15 Aspirin and NSAIDs 15 How Is Colorectal Cancer Detected and Diagnosed? Symptoms Associated With Colorectal Cancer 16 Physical Examination 17 Diagnostic Tests 17 Fecal Occult Blood Test 17 Flexible Sigmoidoscopy and Colonoscopy 17 Double Contrast Barium Enema 20 Emerging Technologies in Screening for Colorectal Cancer 20 Recommendations for Screening Examinations 21 Average Risk 21 Increased Risk 21 High Risk 22

5 6 Contents continued How Is Colorectal Cancer Treated? Staging 27 Polyp Removal 28 Surgery 30 Chemotherapy 32 Adjuvant Chemotherapy 32 Chemotherapy Drugs 33 Side Effects of Chemotherapy 34 Biologically Targeted Therapies 35 Radiation Therapy 36 Investigational Therapies 36 Follow-up Care for Colorectal Cancer Patients Physical Examinations 38 Laboratory Tests 39 Colonoscopy 39 CT Scans, MRI, and Other Scans 40 Colostomy Care 40 Coping With Colorectal Cancer Family Relationships 42 Sexual Relationships 42 Returning to Work 43 Support Groups 43 Appendix 1 - Cooperative Groups That Conduct Research for Colorectal Cancer Appendix 2 - Resources for Cancer Patients Glossary

6 7 Introduction Colorectal Cancer is among the most common malignant diseases diagnosed each year in persons living in the United States. It is also one of the most curable types of cancer when detected at an early stage. Fortunately, screening procedures are widely available and accurate in detecting cancer early when the chance for cure is greatest, as well as in identifying polyps and removing these growths before a cancer can develop. Misconceptions about all diseases are common, and colorectal cancer is no exception. Despite a popular myth that colorectal cancer occurs more commonly in men, the fact is that its incidence is nearly equal in women. There are other widely held misconceptions about the treatment of colorectal cancer or of precancerous growths, such as colorectal polyps. Colorectal polyps usually can be removed easily during colonoscopy, avoiding the need for surgery. If surgery is required for colorectal cancer, a minority of patients will require a permanent colostomy. We realize that misconceptions about colorectal cancer can cause patients and their families unnecessary fear and confusion. Myths & Facts About Colorectal Cancer represents an attempt to provide you with practical information. This handbook is not a comprehensive guide to your treatment options, but it does offer important guidance to assist you in partnering with your doctor to identify your treatment goals and to weigh the risks, benefits, and possible outcomes of various procedures. We consider this handbook a useful reference to help answer some of the many questions you are likely to have when faced with a diagnosis of cancer. As in other books in our Myths & Facts series, words in italic print are defined in the Glossary for your convenience. In addition, there are quotes from patients with this disease and their families and friends. We would like to thank these men and women for their openness and willingness to share their thoughts with others.

7 9 What Is Colorectal Cancer? Colorectal cancer is a major public health issue, particularly in industrialized nations. In the United States, an estimated 147,000 people are newly diagnosed with colorectal cancer each year and about 57,000 people die of the disease. It is the third most common cancer, after breast and lung cancers in women, and prostate and lung cancer in men. Since the mid 1980s, the incidence of and deaths from colorectal cancer in the United States has been declining. However, the incidence among blacks has increased since the early 1970s, but the reason for this is unclear. Cancer is an abnormal, uncontrolled growth of cells. Normally, cells in the body divide at a steady pace, with new cells being formed to replace an equal number of worn-out cells or to repair injuries. In cancer, cells proliferate out of control and the abnormal growth of cancerous cells forms Myth Colon cancer is the same as rectal cancer. Fact Colon and rectal cancers are often lumped together as colorectal cancer. However, there are important differences. Rectal cancers arise in the final 6 inches of the digestive tract. Cancers that arise from areas of the bowel above the rectum are called colon cancers. Local recurrence in the pelvis is more common with rectal cancers.

8 10 FIGURE 1 The Large Colon and Surrounding Anatomy Illustration by R. Futral. Lungs Liver Stomach Spleen Transverse Colon Descending Colon Ascending Colon Small Intestine Appendix Sigmoid Colon Rectum Anus

9 11 tumors, which can cause other body tissues to be destroyed. Not all abnormal growths known as tumors are cancerous. A benign tumor is not cancerous. The cells in a benign tumor look like normal body cells. Although benign tumors can grow large enough to interfere with normal body functions, they do not spread to other parts of the body. Benign tumors that are removed rarely return. Cancerous or malignant tumors can invade surrounding tissue. Through a process known as metastasis, malignant cells travel to distant sites in the body, where the cells can multiply again and form tumors or metastases. Colorectal cancers arise in the lower portions of the digestive tract. Figure 1 shows the anatomy of the abdomen, including the colon and rectum. Also known as the large intestine or large bowel, the colon and the rectum absorb water and vitamins from digested food and compact the wastes into feces or stool that is eliminated from the body through the anus. The colon is about 3 inches in diameter and about 5 feet long. It is divided into four main sections that go up (the ascending colon), across (the transverse colon), down (the descending colon), and then curve into a S shaped segment (the sigmoid colon) before joining to the rectum. The rectum is about 6 inches long leading to the anus. The majority of colorectal cancers arise from the cells lining the inside wall of the colon and rectum. This lining is called the mucosa. From 90% to 95% of colorectal cancers are classified as adenocarcinomas. Determining the extent of a cancer is called staging. Usually, the stage of a cancer is based on factors such as the size of the tumor, and whether the cancer has spread into the lymph nodes and to more distant sites. In colorectal cancer, however, how deeply the tumor has invaded into the wall of the bowel plays a more important role in staging than does the size of the tumor. Myth Colon cancer affects only older people. Fact The median age at which colorectal cancer occurs is 62 years, but the risk of developing colon cancer starts rising at age 40. In addition, many younger people have colon cancer risk factors. There are also some cases of younger patients with no known risk factors who develop colon cancer before the age of 40. Before I was diagnosed with cancer, I used to make long-term plans for 5 years, even 10 years down the road, as if the future was guaranteed. I did not take the time to really enjoy what I had. Now I live one day at a time. I enjoy the simple things in life.

10 12 As with most cancers, the stage of colorectal cancer at the time of diagnosis is important in determining the prognosis or possible outcome for the patient, including whether the cancer is likely to return or recur and how it will affect survival. Other factors such as age, gender, whether a person has symptoms, and how long symptoms have lasted, have not been consistently linked to prognosis.

11 13 What Causes Colorectal Cancer? The exact causes of colorectal cancer are still largely unknown, but certain factors are known to increase the risk of developing this disease. Still other factors are suspected of increasing the risk of colorectal cancer, but the evidence is not as well established. KNOWN RISK FACTORS The following factors are known to increase the risk of developing colorectal cancer. History of Adenomatous Polyps: Colorectal cancers often arise out of a certain type of polyp, a growth found within the lining of the colon, known as an adenomatous polyp. Individuals with a history of adenomatous polyps develop colorectal cancer more often than those without these polyps. Figures 2A and 2B show how a normal colon might look on examination and how a colonic polyp might appear. Myth Colon cancer occurs primarily in people with a family history of cancer. Fact About 75% of all new cases of colon cancer occur in people with no known risk factors for the disease. A B FIGURE 2 The lining of the colon. A. Normal colon; B. Colonic polyp. Photos courtesy of Sidney J. Winawer, MD.

12 14 Myth All types of polyps found in the colon cause cancer. Fact Masses in the lining of the colon are known as polyps. Adenomatous polyps account for about 30% to 50% of all polyps in the colon. If these polyps are not removed, they can develop into cancer. Another 10% to 30% of polyps are known as hyperplastic polyps and mucosal tags. Having these polyps does not increase the risk of colon cancer. In general, the larger the size of the adenomatous polyp, the greater the probability that it harbors cancer cells. Adenomatous polyps that are larger than 2 cm in diameter (about three quarters of an inch) have up to a 40% chance of being cancerous. The likelihood of developing colorectal cancer also increases with the number of adenomatous polyps that are present. Certain people who have inherited a gene called adenomatous polyposis coli, or APC, usually develop numerous adenomatous polyps throughout their colon by the time they are in their late teens or early twenties. This condition is called familial adenomatous polyposis (FAP). Without medical care, almost all of these people will develop colorectal cancer at an age much younger than among the general population. Inflammatory Bowel Disease: Diseases that cause inflammation of the bowel such as ulcerative colitis and Crohn s disease increase the risk of colorectal cancer. The risk is greater for those with ulcerative colitis than for those with Crohn s disease, and it is directly related to how widespread and severe the disease is in a particular individual. Increasing the risk even more is how long an individual has had ulcerative colitis. Individuals who have had ulcerative colitis for 30 or more years have more than a 30% risk of developing colorectal cancer. Areas of the colon affected by colitis often give rise to dysplastic cells (abnormally developed), and from these arise cancer cells. Prior Personal History of Cancer: A person who has already been treated for colorectal cancer is at greater risk of developing another colorectal cancer. Women who have had breast, ovarian, or uterine cancer also have an increased chance of developing colorectal cancer. Family History of Cancer: The risk of colorectal cancer is also greater among people with a family history of cancer. Hereditary nonpolyposis colorectal cancer (HNPCC) is a group of diseases that tend to be more common in certain families. Members of these families have a higher risk of developing colorectal cancer. There are two types of HNPCC, designated as A and B. HNPCC type A is associated

13 15 with colon tumors only, and is more likely to involve the right side of the colon. HNPCC type B occurs in association with other cancers, such as those of the breast, stomach, kidney, ovaries, and uterus. OTHER POSSIBLE RISK FACTORS Environment: The risk of colorectal cancer is lower in Asia, Africa, and South America. Yet when individuals from these low-risk regions emigrate, they take on the colorectal cancer risk of their adopted country. This suggests that certain environmental factors play a role in the development of colorectal cancer. Diet: Diets high in fat and cholesterol have been linked to an increased risk of colorectal cancer. Tobacco Use: Recent studies suggest that longterm cigarette smoking is associated with increased rates of colorectal cancer. The risk appears to decrease after early cessation of smoking. POSSIBLE PROTECTANTS In the past, studies have indicated that diets high in fiber, vegetables, and calcium-rich foods may protect against colorectal cancer. Recent studies, however, have failed to prove that a high-fiber diet reduces the risk of the disease. Aspirin and NSAIDs: There is now evidence to support the chemoprotective effect of aspirin. Among individuals who had recently documented colorectal adenomas or a prior history of colorectal cancer, taking aspirin daily reduced the incidence of colorectal adenomas. Many studies also suggest that nonsteroid anti-inflammatory drugs (NSAIDs) such as sulindac can reduce the size and number of polyps in people with familial adenomatous polyposis (FAP). Other studies suggest a protective effect against polyps conferred by drugs known as COX-2 inhibitors. Celecoxib (Celebrex) is a COX-2 inhibitor that was approved by the FDA as the first drug treatment aimed at reducing the number of polyps in patients with FAP. The role of such drugs in the prevention of cancer is currently being investigated. Myth Polyps in people with a history of colon cancer progress to cancer faster than polyps in people without a history of colon cancer. Fact There is no evidence to suggest that polyps progress to cancer at a different rate in people with a history of colon cancer than in people with an average risk of developing colon cancer.

14 16 How Is Colorectal Cancer Detected and Diagnosed? Myth Rectal bleeding that resolves is not due to colorectal cancer. Fact Rectal bleeding can be caused by many factors, including cancer. Patients often make the mistake of attributing rectal bleeding only to hemorrhoids. When the bleeding stops, patients often do not seek proper medical care. Polyps and cancers bleed intermittently, so an episode of rectal bleeding may be the first sign of colorectal cancer. Therefore, rectal bleeding should always be properly evaluated to rule out colon cancer. Early detection of colorectal cancer and precancerous polyps is very important. The earlier the cancer or polyp is detected, the better the chance for cure. SYMPTOMS ASSOCIATED WITH COLORECTAL CANCER The symptoms of colorectal cancer depend upon the stage of the disease and the area of the colon that is involved. During the early stage of colorectal cancer, some people may not have symptoms. Others may complain of vague abdominal pain, bloating, gas, minor changes in bowel movement, and mild fatigue. Most of these symptoms are usually attributed to other conditions, such as ulcers, gallstones, hemorrhoids, or reactions to certain foods. Therefore, many people do not seek early medical care for colorectal cancer. Other symptoms depend on where in the colon or rectum the cancer is located. Colorectal cancer involving the right side of the colon can cause vague abdominal aching, weight loss, and a mass on the right side of the abdomen. Blood loss can cause anemia, a reduction in red blood cells that can cause weakness and fatigue. Colorectal cancer involving the left side of the colon can cause cramping, abdominal pain, nausea and vomiting, or alternating constipation and diarrhea. Periodic rectal bleeding can also occur. Persons whose cancer involves the rectum may experience a feeling of rectal fullness, rectal bleeding, painful spasms, change in bowel movements, and change in the diameter of stools.

15 17 PHYSICAL EXAMINATION Annual physical examinations are recommended for most individuals as part of their routine health maintenance. For most adults, especially those age 40 and older, a digital rectal examination (DRE) is often part of the examination. Rectal cancers low enough to be reached by the examining finger can usually be detected by digital rectal examination. Colon cancers, however, are too high up in the bowel to be felt during digital rectal examination and require additional tests to be detected. DIAGNOSTIC TESTS Fecal Occult Blood Test (FOBT): A guaiac test uses a card impregnated with a chemical that can detect the presence of small amounts of blood in the stool that cannot be seen with the naked eye. Although the presence of blood in the stool does not necessarily mean an individual has colorectal cancer, the guaiac test identifies individuals who should be further screened for the disease. The guaiac test is relatively inexpensive and painless, but it is not always accurate. Since bleeding does not always occur at the time of testing, some polyps and colorectal cancers are not detected by this test. In other cases, the test picks up blood in the stool from conditions other than colorectal cancer, resulting in additional testing for individuals who do not have this disease. Flexible Sigmoidoscopy and Colonoscopy: Both sigmoidoscopy and colonoscopy use a scope, a flexible instrument designed to directly observe the inside of the colon (Figures 3 and 4). At 60 cm (about 2 feet) in length, the sigmoidoscope can visualize much of the colon, but cannot examine the entire colon. The colonoscope can visualize the entire colon and can therefore detect cancers located in the upper colon. Figure 5 depicts the areas of the colon viewed on sigmoidoscopy and colonoscopy. During a colonoscopy, biopsies or snippets of colon tissue can be sampled. These specimens can then be looked at under the microscope for malig- Myth Because colon cancer is a common and serious disease, most people are already screened for the disease by their physicians. Fact Despite recommendations for screening of colon cancer, most Americans are currently not screened for colon cancer. In a recent survey of American men and women aged 50 years and older, 50% reported they had not had any colorectal cancer screening.

16 18 Myth If an initial fecal occult blood test (FOBT) shows no blood, no further test is necessary. Fact Polyps, as well as cancers, may bleed intermittently. Therefore, an initial FOBT may be falsely negative. The sensitivity of FOBT increases with the number of samples per stool and the number of stools sampled. FIGURE 3 Flexible sigmoidoscope. Photograph courtesy of Olympus. FIGURE 4 Colonoscope. Photograph courtesy of Olympus. nant cells that would indicate the presence of cancer. Often, polyps can be totally removed during colonoscopy. To obtain the most accurate results, sigmoidoscopy or colonoscopy is performed after the patient has prepared for the procedure by following directions designed to remove all stool from the colon so the mucosa can be better seen. This usually involves limiting food intake on the day before the procedure and drinking a liquid that promotes

17 19 FIGURE 5 The Reach of Sigmoidoscopy and Colonoscopy The sigmoidoscope can visualize much of the colon, as indicated by the blue shading, but cannot visualize the entire colon, as can the colonoscope. Splenic Flexure Transverse Colon Ascending Colon Descending Colon Appendix Cecum Sigmoid Colon Rectum Anus

18 20 Myth Sigmoidoscopy visualizes the entire bowel. Fact The longest sigmoidoscope is about 60 cm (about 2 feet) and will not visualize the entire colon. To see the entire colon, a colonoscopy needs to be performed. Alternatively, a double contrast barium enema can also visualize the entire colon, but does not permit abnormal tissue to be removed for biopsy. emptying of the bowel. Both sigmoidoscopy and colonoscopy are performed as outpatient procedures and do not require hospitalization. Because these are invasive procedures, however, they do carry some small risk such as infection, perforation of the bowel, and bleeding. In experienced hands, these risks should be minimal. Double Contrast Barium Enema (DCBE): A double contrast barium enema provides a way to indirectly view the lining of the colon. Barium and air are used as a double contrast to detect abnormal areas that may indicate colorectal cancer. Unlike colonoscopy, DCBE does not allow tissue samples to be removed at the time of the test. Because the lower rectum may be poorly visualized by DCBE, the procedure may be combined with flexible sigmoidoscopy. Emerging Technologies in Screening for Colorectal Cancer: Several new diagnostic tests to screen for colorectal cancer are being investigated. These tests are expected to be less invasive, more accurate, and better tolerated, but the benefits of these emerging technologies need to be fully explored. CT virtual colonoscopy uses computer programming to combine CT scan to create 2- or 3-dimensional images of the interior of the colon. This allows viewing of the entire colon relatively quickly, and allows viewing of hidden surfaces of folds and bends from different angles. Immunohistochemical FOBT employs a complex reaction with antibodies that detect the human hemoglobin, a protein in the blood. This test is more specific than the guaiac test, causing less false-positive results. Lastly, stool screening using molecular markers examines the stool for the presence of DNA mutations that are known to occur in colorectal cancer as indicators of both pre-malignant polyps and colorectal cancer. This technology can potentially detect colorectal cancer with high specificity. However, which markers or combinations of markers are most appropriate for detection of cancer is still being defined.

19 21 RECOMMENDATIONS FOR SCREENING EXAMINATIONS Colorectal cancer screening can detect abnormalities in the colon before they develop into cancer and detect cancers at an early stage when the chance for cure is greatest. Screening recommendations vary according to an individual s risk. The guidelines listed here and in Table 1 were recently updated by the American Cancer Society (ACS) and include varying recommendations for people at average, increased, and high risk. Average Risk: Individuals at average risk do not have risk factors that would place them in the increased-risk or high-risk categories. Screening should begin by age 50. The ACS guidelines list five options for screening and appropriate follow-up evaluation. Increased Risk: Individuals at increased risk have approximately twice the average risk of developing colorectal cancer. This could be due to a diagnosis of adenomatous polyps, a personal history of colorectal cancer for which surgery with intent to cure (curative-intent resection) was performed, or a family history of colorectal cancer or colorectal adenomas. People with adenomatous polyps should have a colonoscopy to remove all polyps. The size, number, and type of polyps removed will determine when the colonoscopic exam should be repeated. If for some reason the colonoscopic exam is not performed, then double-contrast barium enema (DCBE) or flexible sigmoidoscopy followed by DCBE can be substituted. People who have had curative-intent resection of colorectal cancer should have a colonoscopy within 1 year of the surgery. If that exam is normal, it should be repeated in 3 years, and if normal at 3 years, the exam should be repeated in another 5 years. Increased risk due to a family history of colorectal cancer or colorectal adenomas refers only to those with an affected first-degree relative, such as a mother, father, sister, brother, or child. The risk is further increased if the first-degree relative had a colorectal cancer or adenomatous polyp diagnosed before age 60. In that case, or if there are multiple first-degree Myth People who have a firstdegree relative diagnosed with colon cancer should have their colon removed because they are at very high risk of developing colon cancer. Fact The risk for colon cancer in those with a positive family history is increased about twofold. But this is not sufficient reason to have the colon removed. In patients with the inherited colon cancer syndromes (e.g., familial adenomatous polyposis) total removal of the colon would be considered. People with a family history of colon cancer should, however, follow recommendations for starting colorectal cancer screening at a younger age than average risk individuals.

20 22 Myth Colon cancer always causes symptoms that can be readily recognized by patients. Fact People with colon cancer may initially have no symptoms or have only vague symptoms that could be caused by a number of conditions. Such symptoms are often ignored. This can lead to delayed diagnosis and may affect chances for cure, since the best chance for cure in colon cancer is when the cancer is detected at an early stage. Current testing procedures are widely available and accurate, when used and interpreted properly. Myles Cunningham, MD past-president of the American Cancer Society relatives of any age with those diagnoses (but not due to a hereditary syndrome), individuals should have a colonoscopy repeated at intervals to be determined by the initial examination. If colonoscopy is not performed, then a DCBE or a flexible sigmoidoscopy followed by DCBE can be performed. High Risk: Individuals at high risk have more than twice the average risk of developing colorectal cancer due to inflammatory bowel disease or a hereditary syndrome. For people with inflammatory bowel disease affecting all or most of the colon, the risk of colorectal cancer is greatly increased 8 years after the onset of symptoms. Colonoscopy with biopsies to check for abnormal or dysplastic cells should be performed every 1 to 2 years after 8 years of symptoms. If dysplastic cells are persistently present, colectomy should be considered as a way to prevent colorectal cancer from developing. For individuals with leftsided colitis, these recommendations begin to apply 12 to 15 years after the onset of symptoms. Individuals with a family history of the genetic condition familial adenomatous polyposis (FAP) should have early surveillance with endoscopy, receive genetic counseling, and consider being tested to see if they carry the gene for FAP. If so, colectomy is indicated. Another hereditary syndrome, hereditary nonpolyposis colorectal cancer (HNPCC), can also cause colorectal cancer among family members. Individuals with a family history of HNPCC should receive genetic counseling to consider genetic testing. If the genetic testing is positive or not done, colonoscopy should be performed starting at age 21 and be repeated every 1 to 2 years until age 40 and then annually. Screening does not apply to individuals with symptoms of colorectal cancer. Once an individual has developed symptoms that may indicate colorectal cancer, appropriate diagnostic tests must be performed to confirm or rule out colorectal cancer.

21 23 TABLE 1 GUIDELINES ON SCREENING FOR COLORECTAL CANCER Average Risk: Those with no factors placing them at increased or very high risk. All procedures should begin at age 50. The options listed below are all acceptable choices for colorectal cancer screening in average-risk individuals. The ACS notes that flexible sigmoidoscopy together with fecal occult blood test (FOBT) is preferred compared with FOBT or flexible sigmoidoscopy alone. All positive tests should be followed up with colonoscopy. Procedure How Often (Beginning at age 50) Fecal occult blood test Every year plus flexible sigmoidoscopy Every 5 years Fecal occult blood test Every year Flexible sigmoidoscopy Every 5 years Double contrast barium enema Every 5 years Colonoscopy Every 10 years Increased Risk: People with approximately twice the average risk due to a diagnosis of adenomatous polyps, a personal history of curative-intent resection of colorectal cancer, or a family history of colorectal cancer. Procedure Risk Category When to Begin When to Repeat Colonoscopy People with a single, small 3-6 years after the If exam is normal, adenoma (< 1 cm) initial polyp repeat procedure as per is removed average-risk guidelines Colonoscopy People with large adenoma Within 3 years after If exam is normal, (> 1 cm), multiple adenomas, or removal of initial repeat in 3 years. If adenoma with high-grade dysplasia polyp or polyps still normal, follow or change in the villi (structures in screening guidelines for the lining of the colon) average-risk individuals Colonoscopy Personal history of Within 1 year of If exam is normal, curative-intent resection cancer resection repeat in 3 years. If still of colorectal cancer normal, repeat in 5 years Colonoscopy Colorectal cancer or Age 40, or 10 years Every 5-10 years adenomatous polyps in any before the youngest first-degree relative before age 60 case in the immediate or in two or more first-degree family experiencing relatives at any age (unless it is a colorectal cancer or hereditary syndrome) adenomatous polyps High Risk: People with much greater than twice the average risk due to inflammatory bowel disease or a hereditary syndrome. Procedure Risk Factor When to Begin Follow-up Colonoscopy, with Inflammatory bowel When cancer risk begins Repeat procedures biopsies for dysplasia disease to be significant 8 years every 1-2 years Chronic ulcerative after the onset of pancolitis colitis or years after the Crohn s disease onset of left-sided colitis Endoscopy, with Family history of Puberty If the genetic test is counseling to consider familial adenomatous positive, colectomy is genetic testing polyposis (FAP) indicated. Colonoscopy, with Family history of Age 21 If the genetic test is positive counseling to consider hereditary or genetic testing has not genetic testing nonpolyposis colon been performed, repeat cancer (HNPCC) colonoscopy every 1-2 years until age 40, and then every year Source: American Cancer Society, 2003

22 24 FIGURE 6 Areas of distribution of adenomatous polyps that may develop in the colon. Data from Winawer SJ, et al: Colorectal Cancer. In: Winawer SJ (Ed). Management of Gastrointestinal Diseases. Gower Medical, New York, Illustration by R. Futral. Transverse Colon 11% Ascending Colon 13% Descending Colon 18% Cecum 7% Rectosigmoid Colon 52%

23 25 FIGURE 7 Areas of distribution of malignancies that may develop in the colon. Data from Winawer SJ, et al: Colorectal Cancer. In: Winawer SJ (Ed). Management of Gastrointestinal Diseases. Gower Medical, New York, Illustration by R. Futral Transverse Colon 11% Ascending Colon 9% Descending Colon 6% Cecum 13% Rectosigmoid Colon 55%

24 26 When I was told my cancer had come back in my liver, I felt both angry and very scared. If it were not for my family, I would have totally broken down. Then I realized everything that was important to me was in that room, my husband, and my two sons. A sort of calm settled over me, and I knew that whatever happened, I would never be abandoned. Patients who had colorectal cancer surgery, but did not have a colonoscopy prior to their surgery should have this procedure performed within 1 year of their surgery. If this colonoscopy is normal, the next colonoscopy should be performed in 3 years. If that colonoscopy is normal, the procedure should then be repeated every 5 years. Figures 6 and 7 show the different anatomical areas of the colon and the distribution of polyps and cancers that develop in these areas. The numbers shown in each figure refer to the percentage of polyps and cancers that may develop in that particular anatomic section of the colon.

25 27 How Is Colorectal Cancer Treated? Colorectal cancer can be managed in different ways, depending on the stage of disease. For localized disease, the primary treatment is surgery. Chemotherapy treatment with cancer-fighting drugs or radiation therapy may be recommended depending on certain factors. STAGING Staging of colorectal cancer is dependent on how deeply the cancer has invaded the lining of the bowel and whether the cancer has spread to the lymph nodes or more distant sites. Colorectal cancer is staged by either the TNM staging system or Modified Astler-Coller Dukes staging system. The TNM staging system classifies malignant tumors according to the characteristics of the primary tumor (T), involvement of lymph nodes (N), and presence or absence of metastases (M). Stages are denoted as 0, I, II, III, or IV. The Modified Astler-Coller Dukes staging system relies on similar criteria, but denotes stage as A, B, C, or D. A higher number or letter indicates a higher stage of cancer and a worse prognosis. Unlike staging systems for other common cancers, the staging systems for colorectal cancer do not take into account the size of the tumor (Table 2). The depth of penetration of the tumor through the bowel wall is an important indicator of prognosis. In general, the deeper the penetration, the worse the prognosis. Also, the involvement of local lymph nodes worsens prognosis. Figure 8 shows a cross-section of the bowel wall and different levels of invasion of colorectal cancer. Colorectal cancer that has been treated can come back at or close to the original site. If it does, Myth In colorectal cancer, the size of the tumor is the most important factor in predicting outcome for the patient. Fact Unlike other cancers, such as lung and breast cancers, the size of the primary tumor has little to do with prognosis (the predicted outcome) in colorectal cancer. What really matters is how deeply the tumor has invaded the wall of the bowel. A small tumor that has penetrated through the bowel wall is more serious than a larger tumor that has not penetrated the bowel wall.

26 28 Myth Patients with colon cancer should avoid surgery because cancer will spread rapidly when exposed to air. Fact Air has no effect on cancer. The spread of cancer depends on how aggressive the cancer cells are and whether, at the time of diagnosis and surgery, they have already spread to nearby structures or to blood and lymph vessels. A few cancer cells may have already spread to distant sites even when they cannot yet be detected by usual diagnostic methods, such as surgical exploration or CT scans. TABLE 2 STAGING SYSTEMS FOR COLORECTAL CANCER Modified Astler-Coller TNM Lymph Dukes Staging Primary Node Distant Staging System Tumor Metastasis Metastasis System 0 Tis N0 M0 I T1 N0 M0 A T2 N0 M0 B1 IIA T3 N0 M0 B2 IIB T4 N0 M0 B3 IIIA T1-2 N1 M0 C1 IIIB T1-2 N2 M0 C2, C3 IIIC Any T Any N M0 C1, C2, C3 IV Any T Any N M1 D Tis = carcinoma in situ; T1 = tumor invades submucosa; T2 = tumor invades muscularis; T3 = tumor invades through muscularis into adjacent tissue; T4 = tumor invades neighboring organs N0 = no regional lymph node metastasis; N1 = metastases in one to three lymph nodes; N2 = metastases in four or more lymph nodes M0 = no distant metastasis; M1 = distant metastasis it is referred to as a local recurrence. For colorectal cancer, local recurrence may occur at the site of anastomosis the area where two sections of the colon are joined back together after surgery to remove colorectal cancer. Local recurrences are more common in rectal cancers than in colon cancers. Colorectal cancer can also recur at a site distant to the original tumor. In that case, it is called a metastasis. The liver and lung are common metastatic sites of colorectal cancer. POLYP REMOVAL Polyps are frequently removed at the time of colonoscopy. The polyp tissue is then sent to the pathology laboratory to confirm that cancer is present and to what degree the cancer may have penetrated the bowel wall. Depending on the

27 29 FIGURE 8 Cross-section of bowel wall The depth of penetration of the tumor through the bowel wall is an important indicator of prognosis. The involvement of lymph nodes, indicated by the reddish hue around the lymph nodes in this figure, worsens the prognosis. TNM stage IV and modified Astler-Coller Dukes stage D denote distant metastases, for example, to the liver or lung. TNM I I II III III III IV Duke s A B1 B2/B3 C1 C2 C3 D Mucosa Submucosa Muscularis Lymph Nodes Neighboring Organ

28 30 Myth If surgery is performed to treat colorectal cancer, it automatically means wearing a (colostomy) bag for life. Fact Surgery, with or without chemotherapy, is the usual treatment for colorectal cancer. Most patients, however, will not need to have a permanent colostomy after surgery. Usually, the two ends of the colon can be surgically connected together (anastomosis). In cases of cancer located very low in the rectum involving the anal sphincters, a permanent colostomy may be required. I know that chemotherapy can have side effects, but I want my husband to have every chance he can to beat this cancer. pathology findings, subsequent surgery may be advisable. For patients with familial adenomatous polyps (FAP), surgery is frequently advised to reduce the risk of developing advanced cancers. The surgeon may remove the entire colon or the colon plus the rectum. As an adjunct to colonoscopy, polyp removal, and surgery, the drug celecoxib may be used to treat patients with FAP. This oral medication has been shown to decrease the number of polyps, but its role in reducing the chance of developing cancer has not been established. It is not known if its beneficial effects persist after stopping the medication. SURGERY The primary treatment for colorectal cancer is surgery, with resection or removal of the involved segment of colon and the draining lymph nodes. The feasibility and type of surgery for rectal cancer depend on a number of factors, including the size of the tumor, whether it is attached to the surrounding tissues, and whether the muscles of the anus the anal sphincters can be spared. Surgery for colorectal cancer does not necessarily mean the patient has to have a permanent colostomy a surgically created opening for the elimination of wastes and to wear a colostomy bag. More often than not, an anastomosis can be accomplished whereby the two ends of the remaining colon are surgically joined together so a colostomy bag is not needed permanently. Some patients may require a temporary colostomy while the site of surgery in the colon is healing. Permanent colostomies predominantly result from low lying rectal tumors when an anastomosis cannot be performed because there is not enough rectal tissue remaining to join the two ends together. Local recurrences also may be removed by additional surgery. The success of surgical removal of metastases from colorectal cancer depends on the site and number. Under ideal circumstances, resec-

29 31 FIGURE 9 Lymphatics of the Colon Colorectal cancer cells can travel to distant sites via lymph vessels throughout the lymphatics of the colon shown in this figure. Illustration by R. Futral. Liver Stomach Lymph Nodes

30 32 Myth When cancer spreads to the liver, it is uniformly fatal. Fact If there is only one or a few metastases to the liver and these are located in areas where they can be surgically removed, surgery can result in long-term survival in up to 25% of patients. This is another reason why close follow-up is recommended. Myth Patients go bald with chemotherapy. Fact Although certain chemotherapy agents cause hair loss, many agents are not associated with this side effect. Hair can regrow after stopping treatment. tion of single liver metastasis can result in cure rates of up to 25%. CHEMOTHERAPY The use of drugs for the purposes of eliminating cancer cells is called chemotherapy. Except for those with the earliest stages of colorectal cancer, most patients will need some form of chemotherapy after surgery. This is because cancer cells can remain in the body even after a tumor has been removed. If not eliminated, these remaining cancer cells can multiply, grow, and spread, either at the site where they were originally or other sites reached by traveling through blood and lymph vessels (Figure 9). Chemotherapy is usually given through the veins via direct needle injection or via small flexible tubes called catheters. These catheters are often placed into the large veins of the chest. Cared for properly, catheters can be left in place for as long as they are needed, so that a patient does not have to have a needle stick for a new IV every time chemotherapy is given. Rather, the needle is injected into the plastic catheter. Your physician has a choice of several drug regimens for colorectal cancer. The technique of giving drugs through the veins to kill cancer cells is called systemic chemotherapy. Most of these drug regimens do not require hospitalization and can be given on an outpatient basis. Adjuvant Chemotherapy: Chemotherapy can be given as an adjuvant treatment to remove any residual cancer cells after surgery. In this setting, patients receive chemotherapy shortly after the primary tumor has been resected by surgery. The chemotherapy is given to patients who are presumed to have remaining disease too small to be detected and are therefore at high risk of recurrence. The aim of adjuvant chemotherapy is to increase cure rates.

31 33 CHEMOTHERAPY DRUGS Fluorouracil (5-FU) has been the primary drug used for chemotherapy of colorectal cancer. This drug can be given into the vein either as a bolus (rapid injection) or as a prolonged infusion. Chemotherapy with 5-FU is given in combination with a drug called leucovorin (also known as calcium leucovorin or folinic acid), which enhances the activity of 5-FU on cancer cells. This combination has been used as adjuvant chemotherapy for colorectal cancer and as treatment for advanced or metastatic disease. Capecitabine (Xeloda) is a pill taken orally (twice daily) that is eventually converted in the body to 5-FU. It is FDA approved for patients with metastatic colorectal carcinoma when treatment with 5-FU therapy alone is preferred. There is no survival benefit to using capecitabine alone over 5-FU and leucovorin. Because it is an oral medication, however, it may be a more convenient form of therapy for some patients. Although similar to 5-FU in its action, the safety profile is different. It causes less reduction in the blood count, but more diarrhea and hand-foot syndrome. Hand-foot syndrome will usually manifest as redness, tingling, numbness, swelling, or pain in the palms of the hands or soles of the feet. Combinations of irinotecan (Camptosar) and 5-FU plus leucovorin have been approved by the FDA as the initial treatment of patients with advanced colorectal cancer. Irinotecan kills colorectal cancer cells in a different way than 5-FU. Studies to assess the value of combining irinotecan with 5-FU plus leucovorin have demonstrated improved survival for patients compared to those treated with 5-FU plus leucovorin alone. Irinotecan also is a treatment for advanced colorectal carcinoma in patients who have not responded or who no longer respond to 5-FU or 5-FU plus leucovorin. This drug is given intravenously. The most common side effects associated with irinotecan are diarrhea and a lowering of blood counts, including white and red blood cells and platelets. Myth In developing treatment strategies, the only concern is shrinking the tumor. Fact There are many factors that are considered in developing new treatments for any disease. In cancer, tumor response to treatment is certainly one of the main goals, but quality of life is also an important issue. Quality-oflife issues are evaluated through the combination of physical and subjective information provided by patients. The information is gathered through questionnaires that ask patients how well they are performing in certain areas, including physical, functional, psychologic, social, and sexual activities, and at work.

32 34 I was not frightened about surgery, but I dreaded starting chemotherapy. I thought I would be so sick, lose all my hair, and become so thin. I was pleasantly surprised when none of those things happened. Although chemo was not a piece of cake, and there were times when I did not feel so well, I still look normal. People in the street can t tell that I am sick or that I have cancer. Oxaliplatin (Eloxatin) is a drug approved by the FDA for the treatment of metastatic colorectal cancer. Oxaliplatin is combined with infusional 5-FU plus leucovorin. This combination may be used as the initial treatment of metastatic colorectal cancer or after disease progression following therapy with 5-FU, leucovorin, and irinotecan. The most common side effects associated with oxaliplatin are neuropathy, fatigue, neutropenia, nausea/vomiting, and diarrhea. Another way of administering chemotherapy drugs is through the arteries supplying the liver. This is called hepatic intra-arterial chemotherapy. The rationale for using this technique is based on the principle that higher concentrations of the drug can be delivered directly to the cancer cells in the liver than with systemic chemotherapy. In certain patients with metastatic liver disease, this can be a viable alternative, but it is costly, can be associated with complications such as ulcers, and has serious toxic effects on the liver. This therapy must be used selectively in appropriate patients, usually in those patients whose metastases are solely located in the liver. Should it become a possibility in your care, your physician will discuss the pros and cons with you. SIDE EFFECTS OF CHEMOTHERAPY Chemotherapy may cause a lowering of the neutrophils, specialized white cells that help to fight infections. This lowering of the neutrophils (neutropenia) may put a patient at greater risk of infection. The lowering of blood cells called platelets may cause bleeding and the lowering of red blood cells may cause anemia, which leads to fatigue. Mouth sores, or oral mucositis or stomatitis, may occur as a side effect of chemotherapy. Diarrhea may also occur. If you are receiving chemotherapy and develop mucositis or diarrhea, you should contact your doctor because the treatment may be stopped. Medication, such as loperamide, is commonly used to reduce diarrhea associated with irinotecan.

33 35 Skin changes may occur as side effects of chemotherapy. These include darkening of the skin and discoloration along the vein where the drug is infused. Patients may develop enhanced sensitivity to the sun, known as photosensitivity. Also, swelling and redness of fingers and toes, called hand-foot syndrome, may occur along with peeling of the skin. Loss of hair (alopecia) is observed with some chemotherapy agents. Hair may grow back after treatment is stopped. Some chemotherapy, like oxaliplatin, may cause nerve sensitivity called neuropathy. This may be manifested by tingling, numbness, or pain in the fingers and toes. These sensations may be worsened by exposure to cold, such as drinking or holding iced drinks. On rare occasions, patients may experience a form of neuropathy called pharyngolaryngeal dysesthesia, characterized by difficulty swallowing or breathing. BIOLOGICALLY TARGETED THERAPIES Cetuximab (Erbitux) is a monoclonal antibody that competes for binding to a protein called the epidermal growth factor receptor (EGFR). It is given intravenously either alone or with chemotherapy. It is approved by the FDA for patients with EGFRexpressing, metastatic colorectal cancer whose disease has progressed after receiving irinotecan-containing chemotherapy, or as a single agent for those who are intolerant to irinotecan. The most common side effect with cetuximab is a rash similar to acne. On rare occasions, patients may experience severe infusion reactions, characterized by difficulty in breathing, swelling, and very low blood pressure. Bevacizumab (Avastin) is a monoclonal antibody that blocks angiogenesis, which is necessary for tumor growth, by binding to and inhibiting the biologic activity of a protein called the vascular endothelial growth factor (VEGF). Bevacizumab is given intravenously, and is approved by the FDA in combination with 5-FU-based chemotherapy for initial treatment of patients with metastatic colorectal carcinoma. The use of bevacizumab alone has not yet been established. The most common adverse Myth When I participate in a clinical trial, I will be a guinea pig and will therefore experience more toxicity and receive inferior care. Fact Specific and stringent guidelines are in place to ensure the safety of patients in a clinical trial. Because clinical trials are scrutinized carefully for scientific merit, therapies deemed inferior do not make it to clinical trials. Patients in clinical trials are followed more often and carefully, so side effects are often caught and managed early. Patients participating in clinical trials are helping to advance the knowledge and development of new therapies in colorectal cancer.

34 36 events with bevacizumab are bleeding including fatal hemorrhage, elevated blood pressure, and spilling of protein into the urine. Bevacizumab can interfere with wound healing and has been associated with a few cases of bowel perforation and wound dehiscence, in which the layers of a surgical wound may separate or open. RADIATION THERAPY Radiation therapy is a treatment option more often used in rectal cancer than colon cancer. In rectal cancer, radiation to the pelvis can be used before surgery to shrink the tumor, after surgery to prevent local recurrence, or in the treatment of a local pelvic recurrence. Unlike systemic chemotherapy, radiation therapy cannot control the recurrence of cancer outside the area that was irradiated. Often radiation therapy is used in combination with chemotherapy, a technique called chemoradiation. Chemoradiation therapy commonly combining pelvic radiation therapy with 5-FU is a treatment option for patients with locally recurrent colorectal cancer. When colorectal cancer recurs at distant sites, especially when the cancer has spread or metastasized to many distant sites, radiation therapy is usually not a treatment option in hope of cure. However, under certain circumstances it may be used to relieve symptoms such as pain, especially bone pain. INVESTIGATIONAL THERAPIES Investigational therapies are protocols aimed at developing new drugs and other treatment strategies. When a new treatment strategy is at a point where it is ready to be tried in patients, it usually undergoes three phases before it can be accepted as a standard of treatment. These phases are designated as I, II, and III. Phase I studies often involve a new treatment being tried in humans for the first time. The aim is to find a dose and schedule for administering the treatment that is safe and acceptable to patients and not too toxic to normal cells. These trials also

35 37 define the toxic effects of treatment. Phase II studies are initiated after phase I studies are completed. The goal of phase II studies is to determine if the new treatment has any beneficial effect in a specific cancer. Once a new treatment strategy has been shown to have a beneficial effect, it goes into a phase III study. The aim of a phase III study is to compare a new treatment to a standard treatment. These types of studies may involve large numbers of patients and usually multiple institutions or Cooperative Groups (see Appendix 1). Your treatment team may suggest an investigational clinical trial as the best treatment option for you. Trial protocols are reviewed by a board of experts in the disease, called an Institutional Review Board, to make sure the proposed treatment is appropriate and that specific guidelines are followed. Your physician or others on the treatment team should discuss the treatment options available to you, the cost of treatment, the effectiveness of the new treatment as compared to standard therapy, and the side effects of the new agent or regimen. You will also be given an informed consent form to sign after the proposed treatment has been fully explained to you and your spouse or family.

36 38 Follow-Up Care for Colorectal Cancer Patients Myth When stomas are irritated, they cause severe pain. Fact Stomas are rich in blood vessels but do not have nerves. Therefore, they do not transmit sensations such as pain. Follow-up care is essential for all patients with cancer. Good follow-up care includes examinations that look for recurrence of cancer, as well as psychological and social support to help with the longterm effects of a diagnosis of cancer and cancer treatment. One of the greatest fears of individuals with cancer is that the cancer will come back. Oftentimes, any change in the body and symptoms of illness are attributed to cancer recurrence. This may cause great distress. Although symptoms are important indicators of a possible recurrence of cancer, and must not be ignored, other physical illness can also produce similar symptoms. Good follow-up care helps to find out the real cause of these symptoms, and if there are recurrences, to detect them early. Among people who develop recurrent colorectal cancer, 50% do so within 1 year, and 80% within 3 years of their initial surgery. Therefore, follow-up within the first few years is critical. PHYSICAL EXAMINATIONS An individual who has been treated for colorectal cancer should have a full physical examination by a physician annually, and a more focused physical examination whenever returning for a follow-up appointment. A more thorough exam may be warranted in certain situations, such as when there are new symptoms or abnormal findings. An abnormal finding on a physical exam, like an enlarged lymph node (called lymphadenopathy) or yellowing of the whites of the eyes (called scleral

37 39 icterus), may alert the physician to the possibility of a recurrence. Another sign of possible recurrence of colorectal cancer is called ascites the accumulation of fluid in the abdomen. In the presence of any of these signs, further work-up may be necessary to confirm or rule out a recurrence. LABORATORY TESTS Laboratory tests often require the patient to give blood samples. Most of these tests are performed at regular intervals to check for any abnormality or suspicious trend. At first, the tests may be performed frequently, but if the results are repeatedly normal, they may be spaced out to every 3, 6, or even 12 months. Because colorectal cancer often metastasizes to the liver, a set of lab tests called liver function tests are analyzed and closely watched. These tests are frequently performed in conjunction with other routine blood tests, such as blood counts and chemistries. Certain tumors, including colorectal cancer, produce a substance that can be detected in the blood and is called a tumor marker. In colorectal cancer, the specific tumor marker produced is called carcinoembryonic antigen or CEA. Rising levels of CEA may indicate the development of metastasis and warrant further investigation. COLONOSCOPY Apart from their risk of recurrence, patients with a history of colorectal cancer are at increased risk of developing a second colorectal cancer. Such second tumors occur in about 3% of patients. The aim of colonoscopy for those who have already been treated for colorectal cancer is twofold. The first purpose is to detect local recurrence. The second is to detect polyps or new tumors. Patients who had colorectal cancer surgery, but did not have a colonoscopy prior to their surgery should have one within 1 year of their surgery. If this is normal, then the next colonoscopy should be Myth Even when colorectal cancer has been cured, bowel habits never return to normal, and food intolerance is common. Fact Patients may initially have treatment-related side effects such as diarrhea, nausea, or vomiting, but these symptoms usually improve after completion of therapy. Once the cancer has been cured, people often lead normal lives, including those who have had colostomies. At first, when I had my colostomy, I felt very awkward and I was over cautious. When I realized that the colostomy did not really deter me from doing the things I like to do, I gradually felt more comfortable. Now, I am back to doing everything I was doing before my colostomy, and no one can even tell I have one.

38 40 Myth Patients with a colostomy will never be able to engage in sports activities such as swimming. Fact Proper care of a colostomy may take some getting used to, but patients often adapt well and are able to go back to their usual activities after recovering from treatment. Contact sports would require that the stoma be protected. Sports such as swimming and golf can be enjoyed as usual. performed in 3 years. If that is normal, colonoscopies should continue to be performed every 5 years. CT SCANS, MRI, AND OTHER SCANS Special x-rays like computed tomography (CT) scans or magnetic resonance imaging (MRI) can be used to measure response to treatment as well as detect recurrence or metastatic disease. Like some other laboratory tests, CT scans or MRIs are initially performed frequently and then less often as time passes. Symptoms, physical findings, or lab tests that indicate cancer may have recurred may prompt a physician to order a CT scan or MRI scan. Specialized scans called radioimmunoscintigraphy also may be performed to detect metastatic disease. This is particularly important in patients with rising CEA levels, but with no apparent disease detected by more conventional tests. COLOSTOMY CARE A colostomy is a surgically created opening into the colon through the abdomen to permit the elimination of stool. The majority of patients with colon cancer can be treated without requiring a permanent colostomy. A temporary colostomy may be needed in some patients while the surgical site in the colon is healing. Depending upon where a colostomy is located in the colon, the frequency and consistency of the stool will vary. A B C FIGURE 10 The ConvaTec pouching system collects the discharge from the stoma. A. The open end of a colostomy is called a stoma, and the surrounding skin is the peristomal skin. The peristomal area should be cleansed with soap and water before the pouchng system is attached. B. The pouching bag is secured to the skin surrounding the stoma. C. The adhesive skin barrier is pressed gently against the skin.