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Estimated new cases and deaths from colon cancer in the United States in 2007:
Cancer of the colon is a highly treatable and often curable disease when localized to the bowel. Surgery is the primary form of treatment and results in cure in approximately 50% of the patients. Recurrence following surgery is a major problem and is often the ultimate cause of death.
The prognosis of patients with colon cancer is clearly related to the degree of penetration of the tumor through the bowel wall, the presence or absence of nodal involvement, and the presence or absence of distant metastases. These three characteristics form the basis for all staging systems developed for this disease. Bowel obstruction and bowel perforation are indicators of poor prognosis. Elevated pretreatment serum levels of carcinoembryonic antigen (CEA) have a negative prognostic significance. The American Joint Committee on Cancer and a National Cancer Institute-sponsored panel recommended that at least 12 lymph nodes be examined in patients with colon and rectal cancer to confirm the absence of nodal involvement by tumor. This recommendation takes into consideration that the number of lymph nodes examined is a reflection of the aggressiveness of lymphovascular mesenteric dissection at the time of surgical resection and the pathologic identification of nodes in the specimen. Retrospective studies demonstrated that the number of lymph nodes examined in colon and rectal surgery may be associated with patient outcome.
Many other prognostic markers have been evaluated retrospectively for patients with colon cancer, though most, including allelic loss of chromosome 18q or thymidylate synthase expression, have not been prospectively validated. Microsatellite instability, also associated with hereditary nonpolyposis colon cancer (HNPCC), has been associated with improved survival independent of tumor stage in a population-based series of 607 patients younger than 50 years with colorectal cancer. Treatment decisions depend on factors such as physician and patient preferences and the stage of the disease rather than the age of the patient. Racial differences in overall survival after adjuvant therapy have been observed, without differences in disease-free survival, suggesting that comorbid conditions play a role in survival outcome in different patient populations.
Because of the frequency of the disease, ability to identify high-risk groups, demonstrated slow growth of primary lesions, better survival of patients with early-stage lesions, and relative simplicity and accuracy of screening tests, screening for colon cancer should be a part of routine care for all adults aged 50 years or older, especially for those with first-degree relatives with colorectal cancer. Groups that have a high incidence of colorectal cancer include those with hereditary conditions, such as familial polyposis, HNPCC or Lynch syndrome variants I and II, and those with a personal history of ulcerative colitis or Crohn colitis.Together, they account for 10% to 15% of colorectal cancers. Patients with HNPCC reportedly have better prognoses in stage-stratified survival analysis than patients with sporadic colorectal cancer, but the retrospective nature of the studies and possibility of selection factors make this observation difficult to interpret. More common conditions with an increased risk include a personal history of colorectal cancer or adenomas; first-degree family history of colorectal cancer or adenomas; and a personal history of ovarian, endometrial, or breast cancer. These high-risk groups account for only 23% of all colorectal cancers. Limiting screening or early cancer detection to only these high-risk groups would miss the majority of colorectal cancers.
Following treatment of colon cancer, periodic evaluations may lead to the earlier identification and management of recurrent disease. The impact of such monitoring on overall mortality of patients with recurrent colon cancer, however, is limited by the relatively small proportion of patients in whom localized, potentially curable metastases are found. To date, no large-scale randomized trials have documented the efficacy of a standard, postoperative monitoring program. CEA is a serum glycoprotein frequently used in the management of patients with colon cancer. A review of the use of this tumor marker suggests the following:
The optimal regimen and frequency of follow-up examinations are not well defined because the impact on patient survival is not clear, and the quality of data is poor. New surveillance methods, including CEA immunoscintigraphy and positron emission tomography, are under clinical evaluation.
Gastrointestinal stromal tumors can occur in the colon.
PreventionNonsteroidal Anti-Inflammatory DrugsPostmenopausal Hormone UsePolyp RemovalDiet ModificiationUse of Nonsteroidal Anti-Inflammatory Drugs Benefits
There is inadequate evidence that the use of nonsteroidal anti-inflammatory drugs (NSAIDs) reduces the risk of colorectal cancer. Based on solid evidence, NSAIDs reduce the risk of adenomas, but the extent to which this translates into a reduction of colorectal cancer is uncertain.
Description of the Evidence
Based on solid evidence, harms of NSAID use include upper gastrointestinal bleeding and serious cardiovascular events such as myocardial infarction, heart failure, and hemorrhagic stroke.
Based on solid evidence, postmenopausal estrogen plus progesterone hormone use decreases the incidence of colorectal cancer, but this benefit is not applicable to estrogen alone use.
Based on solid evidence, harms of postmenopausal combined estrogen plus progestin hormone use include increased risk of breast cancer, coronary heart disease, and thromboembolic events.
Based on fair evidence, removal of adenomatous polyps reduces the risk of colorectal cancer.
Based on solid evidence, harms of polyp removal include infrequent perforation of the colon during the procedure as well as bleeding and infection following the procedure.
A Diet Low in Fat and High in Fiber, Fruits, and Vegetables
There is inadequate evidence to suggest that a diet low in fat and high in fiber, fruits, and vegetables decreases the risk of colorectal cancer. However, these studies were powered to detect differences in adenoma incidence and not cancer incidence.
There are no known harms from dietary modification, including reduction of fatty acids and increase in the intake of fiber, fruits, and vegetables.
Source: National Cancer Institute