Colorectal cancer (CRC) is a malignant growth of the lower intestine – this is the organ responsible for the removal of water and the formation of solid stool from food waste. The colon is approximately 90 cm. (3 ft.) long and ends at the rectum and anus. In cancer of the colon, cells from the inner lining divide in a rapid and uncontrolled fashion, resulting in a growth that invades local tissues and may spread to other parts of the body.
Colorectal cancer (CRC) is a malignant growth of the lower intestine – this is the organ responsible for the removal of water and the formation of solid stool from food waste. The colon is approximately 90 cm. (3 ft.) long and ends at the rectum and anus. In cancer of the colon, cells from the inner lining divide in a rapid and uncontrolled fashion, resulting in a growth that invades local tissues and may spread to other parts of the body.
Unless diagnosed and treated in a timely manner, CRC is fatal. Every year, approximately 23,000 Canadians will be diagnosed with CRC and 9000 will die from this disease. It is the third most common form of cancer behind prostate and breast cancer, as well as the second most common cause of cancer death.
Most cases of CRC develop from pre-existing polyps, which are collections of cells limited to the lining of the bowel, often assuming the shape of a mushroom suspended from the wall. As many as 30% of people have polyps. Luckily, only a small number of these evolve into cancer. The evolution of cancer, including the formation of polyps and the transition to cancer, is a process that can take several years. Polyps and early-stage cancer do not cause symptoms. During this pre-symptomatic period, these early cancers and precancerous growths can be identified and removed, resulting in the prevention and/or cure of colon cancer.
Risk Factors for Colon Cancer
Age is an important risk factor - over 90% of CRC cases occur in individuals over the age of 50.
While both sexes are affected, CRC affects males significantly more frequently than females.
People of African descent may be more susceptible to CRC.
A personal history of CRC increases the risk for a second cancer of the colon.
A family history of CRC, particularly affecting younger individuals, or multiple cases within a family.
Inherited cancer family syndromes, including familial adenomatous polyposis, Lynch syndrome and others.
People with inflammatory bowel disease (ulcerative colitis and Crohn’s disease) develop CRC much more frequently than the general population.
Certain lifestyle factors appear to modestly increase the risk for CRC. These include obesity, lack of physical activity and tobacco usage. There is some evidence that a diet high in animal fat and low in fruits and vegetables may increase risk.
Low dose aspirin MAY lower the risk of polyps and CRC.
Failure to participate in a screening programme as described below. Persons who do not undergo screening are much more likely to develop CRC than those who do, because removal of polyps identified during screening serves as an effective preventative measure.
Signs and Symptoms of Colon Cancer
Polyps and early-stage CRC do not produce symptoms, with the exception of visible blood in stool when situated close to the bottom of the colon. As cancers grow, they begin to affect the activity of the colon resulting in:
Blood in stool
Anemia (low red blood cell count) from progressive blood loss, manifesting as fatigue
Persistent change in bowel movements, with looser and more frequent stools (diarrhea) or less frequent stools (constipation)
A sensation of fullness in the rectum or the persistent feeling of having to move (or empty) one's bowels
Cramps, abdominal discomfort or bloating with cancers that partially block the bowel
Weight loss, decreased appetite, nausea and vomiting with more advanced cancers.
In most instances, the symptoms described above do not prove to be due to CRC. However, the onset of any of these should prompt a visit to your physician to carry out the appropriate examinations to identify or exclude colon cancer. If in doubt, go to your physician.
How is Colon Cancer Diagnosed?
If you have symptoms that are potentially indicative of CRC, see your family physician. They will carry out a physical examination, particularly looking for palpable masses in the abdomen suggesting cancer. They may also carry out a digital rectal examination to detect cancer of the rectum, particularly if there has been blood in stool.
Your family doctor may elect to arrange imaging studies such as abdominal ultrasound or computerized axial tomography (CAT scan), but the sensitivity of these tests for CRC (particularly in its early stages) is low. More importantly, your family doctor will refer you to a specialist who can carry out visualization of the colon, usually by colonoscopy.
Colonoscopy involves the passage of a long, flexible instrument (colonoscope) via the anus through the length of the colon. The tip of the colonoscope has a light which illuminates the interior, as well as a video chip which transmits an image to a monitor for the doctor to view. There is also a channel through the colonoscope that enables the passing of instruments, most notably a forceps which can take tissue samples from suspicious masses and a snare (or wire loop) which can grasp polyps and remove them from the lining of the bowel. Colonoscopy will identify roughly 98% of cancers. A normal colonoscopy very strongly excludes the presence of cancer and provides strong reassurance that CRC will not be a possibility for several years down the road, since the evolution of CRC from normal tissue is a very slow process.
The investigations below are available for people unable or unwilling to undergo colonoscopy. These examinations are somewhat less accurate than a colonoscopy in detecting growths and have no capability of removing polyps or confirming cancer by tissue sampling. Therefore, if a suspicious abnormality is identified, colonoscopy may still be recommended prior to more invasive surgical exploration:
Flexible sigmoidoscopy (FS), using a shorter viewing instrument which can visualize up to 60 cm. of the lower colon, performed with a simple preparation and without sedation. This option is not nearly as comprehensive, but might be utilized where colonoscopy is not readily available.
Barium enema in which the colon is filled with a radio-opaque material and X-rays are taken. A cleansing routine similar to colonoscopy is necessary.
CT colonography, also called virtual colonoscopy, in which computerized tomographic images are taken after the colon is filled with air from below. The procedure requires a cleansing preparation similar to colonoscopy but does not need sedation.
Magnetic resonance (MR), a relatively new way of imaging the colon using an MRI scanner.
Screening for Colon Cancer
If you have no symptoms and are not at increased risk, you should still consider getting a screening examination. Because screening is so proficient at identifying CRC and precancerous polyps, it is among the most effective preventive medical interventions. While there is controversy about which screening strategy is best, there is consensus that persons who engage in CRC screening have a longer life expectancy than those who do not, as a result of early diagnosis and treatment of CRC and removal of polyps before they turn malignant.
Current guidelines recommend commencing screening at age 50 and continuing to age 75. Whether to continue screening thereafter depends on one’s state of health and life expectancy.
There are two pre-eminent approaches to screening:
FIT (fecal immunochemical test) is directed towards detecting blood in stool and is based on the observation that most cancers and some advanced polyps shed small amounts of blood – not enough to be seen with the naked eye. A small sample of stool is smeared on a slide, which is submitted to a laboratory to analyze for the presence of blood. FIT testing is not appropriate for persons who have visible blood in stool and should not be carried out in the presence of blood thinners or non-steroidal anti-inflammatory drugs such as aspirin. The approximately 5% of persons with a positive FIT test are referred for colonoscopy to determine whether the blood loss is emanating from a tumour of the colon. If the colonoscopy is normal, no further screening is necessary for 10 years. Those with a negative FIT test should have it repeated at two-year intervals. The advantages of FIT are low cost, the relatively high participation rate, and its absolute safety and lack of invasiveness. The disadvantages are its failure to detect all cancers, its limited ability to detect and remove pre-cancerous polyps, and its dependence on repeated testing to achieve maximal benefit. Many provincial bodies advocate FIT as the preferred approach to screening.
Colonoscopy is the direct examination of the colon using a flexible videoendoscope. Colonoscopy detects the vast majority of cancers, most of which are curable by resection, either through the colonoscope for cancer confined to a polyp or by open surgical resection for more invasive tumours. If colonoscopy is normal, no further screening is required for 10 years. However, if polyps or cancer are identified, careful follow-up by colonoscopy is indicated, as a history of polyps enhances the risk for future CRC. The timing of follow-up is dependent on the characteristics of the tumour. The doctor performing the colonoscopy will advise you on the appropriate interval. The advantages of colonoscopy include its high detection rate for cancer and its potential to prevent cancer by removal of polyps. In addition, the benefit is long-lasting – the procedure need be carried out relatively infrequently. The disadvantages are the cost, the complex preparation, the need to take time from work, and the potential for complications.
These options should first be discussed with a family physician. Personal comfort level, as well as age, state of health and family history should be taken into consideration.
Staging and Treatment of Colon Cancer
CRC is classified according to how far it has spread into and beyond the wall of the bowel. In the earliest stage, cancer has not penetrated through the wall and is curable by resection with no further therapy. If CRC has grown beyond the confines of the bowel into adjacent tissues, or if cancer has spread to local lymph nodes, it is likely that, following surgery to remove the primary tumour, further treatment in the form of radiation or chemotherapy (anti-cancer drugs) will be recommended. In the most advanced stage, cancer has spread via the blood stream to remote sites. In this circumstance, chemotherapy may be recommended to delay the progression of cancer, but definitive cure is unlikely.
For cancers arising in the rectum, radiation therapy is often recommended prior to surgery. Evidence suggests that this approach can shrink the tumour preoperatively and increase the likelihood of successful removal.
What to Know about Colonoscopy
Colonoscopy involves the passage of a long, flexible instrument, via the anus, approximately 90 cm (3 ft) through the length of the colon. The instrument has a source of light that illuminates the inside of the bowel, and a mechanism to distend the bowel with air for better visualization. There is a channel for the passage of accessories that can remove polyps, take tissue samples (biopsies) from suspicious areas and cauterize bleeding points. The examination is carried out in a specialized room designed to maximize safety and comfort. Most procedures are carried out sedated – this means you will receive an injection immediately beforehand that will make you sleepy and diminish any sensation of pain or recollection of the examination. Colonoscopy time averages 20-30 minutes.
An effective colonoscopy depends on good visibility. For this reason, the examination requires meticulous preparation. For the 24 to 48 hours prior to your examination, you will be instructed to engage in measures that include a liquid diet and a combination of laxatives. It is crucial that you adhere carefully to the instructions to optimize the examination.
Screening colonoscopy aims to identify cancer and to remove precancerous polyps. Polyps with a stem or stalk (pedunculated) can be removed during colonoscopy with electrocautery applied to a wire loop.
Suspicious lesions without a stalk can be biopsied. If biopsies reveal cancer, removal requires formal surgery.
While colonoscopy is generally considered a safe procedure, there are potential complications. Those directly related to the colonoscope itself include bleeding, usually from the site from which polyps have been taken. Such bleeding often stops on its own or with the application of cauterizing material through the colonoscope. Very rarely, bleeding is delayed and may start up after discharge from the procedure area. In that instance, a return to the endoscopy unit could be necessary. Another risk is perforation, or a hole in the bowel resulting from distension or the application of cautery used in the removal of polyps. Perforation is reported to occur approximately one in every 2000 colonoscopies and is usually manifested by severe pain immediately following the procedure. Rarely, the symptoms of perforation, as for bleeding, may be delayed. Should you experience substantial bleeding or progressive and severe pain after discharge from colonoscopy, you should contact the unit or go to an emergency department immediately.
If polyps are removed during colonoscopy, they are retrieved and sent for microscopic (pathology) examination. The results of this examination determine when one’s next colonoscopy should take place. Some polyps, termed hyperplastic, have no firm relationship to cancer and do not require early re-examination. Other polyps are termed adenomatous and will trigger a recommendation for a follow-up colonoscopy between one and five years later. The overall effectiveness of a screening regimen with colonoscopy is highly dependent on timely follow-up. If the interval advised is too short, the benefit of screening will be compromised by the expense and the hazards of too many exams. If the interval is too long, the risk of developing an incurable cancer during follow-up becomes significant. Therefore, should you have polyps removed during your colonoscopy, be sure that the pathology report is a part of your records, and available when consideration of a repeat colonoscopy arises down the road.
Colorectal cancer is expected to be the third most commonly diagnosed cancer in Canada in 2021 (excluding non-melanoma skin cancers). It is the second leading cause of death from cancer in men and the third leading cause of death from cancer in women in Canada.
It is estimated that in 2021:
24,800 Canadians will be diagnosed with colorectal cancer. This represents 11% of all new cancer cases in 2021.
9,600 Canadians will die from colorectal cancer. This represents 12% of all cancer deaths in 2021.
13,700 men will be diagnosed with colorectal cancer and 5,300 will die from it.
11,100 women will be diagnosed with colorectal cancer and 4,300 will die from it.
On average, 68 Canadians will be diagnosed with colorectal cancer every day.
On average, 26 Canadians will die from colorectal cancer every day.
It is estimated that about 1 in 14 Canadian men will develop colorectal cancer during their lifetime and 1 in 34 will die from it.
It is estimated that about 1 in 18 Canadian women will develop colorectal cancer during their lifetime and 1 in 40 will die from it.
Am I going to die if I am diagnosed with colon cancer?
Survival is closely linked with the stage of the disease at the time of surgery. When cancers are still localized to the bowel, the 5-year survival rate is very good -- about 85-95%. Unfortunately, by the time colon cancer causes advanced symptoms, most cancers have spread beyond the bowel and the survival rate is less than 40%. Screening, therefore, is designed to detect and remove polyps early while they are can be completely removed.
How is colon cancer prevented?
It is now well established that effective colon cancer screening using stool tests, sigmoidoscopy and colonoscopy can prevent colon cancer. These screening methods lead to detection and removal of polyps and small cancers that can be easily removed. The use of screening is critical to the prevention of colon cancer.
Is it true that taking aspirin can reduce the risk of colon cancer?
No, a recommendation has not been made by the Canadian Association of Gastroenterology about taking ASA for cancer prevention for the following reasons:
The evidence of ASA reducing the risk of colon cancer is largely circumstantial. While interesting, there have been no actual trials designed to look at colon cancer reduction with ASA
There are hazards associated with taking ASA, including bleeding in the intestinal tract, which are typically at par with the reduction of risk of cancer.
People may think that if they are taking ASA as a preventative measure, they may not go for standard screening which should not be missed if you are over 50, have a family history of colon cancer or polyps, or suffer from inflammatory bowel disease. Colon cancer is over 90% preventable if detected early.
What is the difference between a colonoscopy and sigmoidoscopy?
The difference between colonoscopy and sigmoidoscopy is related to which parts of the colon each can examine. Sigmoidoscopy allows doctors to view only the lower part of the colon, while colonoscopy allows doctors to view both the upper and lower sections. Recent research suggests that colonoscopy is superior to flexible sigmoidoscopy as a colon cancer screening method.
Protecting Yourself from Colon Cancer
https://www.youtube.com/watch?v=9gIq7GuSrwA
Healthy Gut Summit 2016 presentation by Dr. David Armstrong on protecting yourself from Colon Cancer.
What is a Colonoscopy? And How to Prepare
The prospect of undergoing a colonoscopy can be intimidating, especially if you’ve never had the procedure. The following information will help you to understand the experience and ease any anxiety leading up to the examination.
What is a colonoscopy?
Colonoscopy is a visual inspection of the large intestine or colon, the lowest three feet of your bowel. The examination is carried out using a long, flexible tube about one-half inch in diameter. The tube (or colonoscope) has at its tip a light and a video camera which transmits an image of the interior to a monitor. The colonoscope is passed upwards from the anus to the top of the colon and often into the lowest part of the small intestine. The image generated through a colonoscope is magnified so that abnormalities as small as one millimeter can be identified. To facilitate ideal visualization of the entire lining of the intestine, the bowel is distended with air instilled through the colonoscope.
Abnormalities can be sampled using a biopsy instrument through a channel in the colonoscope. In addition, polyps, many of which are precancerous, can be removed from the lining of the bowel using a wire loop that is passed over the head of the polyp, which is then removed by electrocautery (a procedure that uses heat from an electric current to destroy abnormal tissue). Any tissue removed is retrieved and sent to the laboratory for microscopic or bacteriologic analysis.
Who should get a colonoscopy?
There are two broad categories of indications for colonoscopy. The first is the evaluation of symptoms such as rectal bleeding, a change in bowel habit, or blood tests suggesting bleeding from the intestine. Potential findings in such cases include inflammation, tumours or abnormal blood vessels.
The second indication is colorectal cancer screening, which is the examination of asymptomatic persons for colon cancer or precancerous lesions called polyps. Colon cancer develops within pre-existing polyps and the clearance of polyps from the colon very much reduces the risk for future cancer. Having a colonoscopy, therefore, has the potential to prevent as well as to identify cancer, usually at an early and curable stage. There is general agreement that the frequency of colon cancer and the high cure rate of cancers identified on routine colonoscopy justify screening examinations.
How do I prepare for a colonoscopy?
Preparation for a colonoscopy involves cleansing of the bowel with a carefully defined laxative preparation. Since the most important determinant of a successful colonoscopy is the effectiveness of the preparation, ensuring that you closely adhere to the instructions you receive is crucial.
A typical “prep” includes a clear liquid diet for 24 to 48 hours prior to the examination and the administration of laxatives. These usually include some tablets and a substantial volume, usually 2 to 4 litres, of a salty solution. Mixing the solution with ginger ale or a lemony soda can render the solution more palatable. Liquids that are red or blue should be avoided, as the resulting discolouration of the stool may be misinterpreted as blood. Sometime after the initiation of this process, you will develop mild bowel cramping and increasingly liquid stools. Eventually, with a successful prep, the stools will consist of virtually clear liquid.
If your procedure is scheduled for the morning, the preparation is carried out the preceding day and evening. For afternoon examinations, a portion of the prep can be administered in the evening and the remainder in the morning. In all instances, the prep should be fully consumed no less than 4 hours prior to the procedure.
It is important to inquire about which of your medications should be withheld before the procedure. In particular, in most instances, blood thinners need be withdrawn to limit the likelihood of bleeding when samples are taken. Medications which lower blood pressure including water pills might be withheld to avoid a dangerous fall in blood pressure resulting from fluid losses during preparation. A careful review of all your medications should be undertaken to minimize potential ill effects.
It is impossible to over-emphasize the importance of the prep. Be sure to understand the instructions and clarify any uncertainties with your doctor.
You will be asked to have someone available to accompany you home after the examination. You are forbidden to drive for 24 hours and cannot use public transportation.
What happens on the day of a colonoscopy?
Your colonoscopy may be carried out in a hospital or at an out-of-hospital clinic. The quality and safety of the procedure is the same regardless of the setting. Once you have registered, you will change into a hospital gown and an intravenous needle will be inserted. In the procedure room, you will be asked to lie on your left side. Supplemental oxygen will be administered through nasal prongs and you will be attached to equipment to monitor your heart rate, blood pressure and blood oxygen level. Once you are comfortable, your physician or an anaesthesiologist-assistant will administer sedative medication through the intravenous line. It is likely that you will fall asleep and have no recollection of the examination. While you are asleep, the colonoscopist will insert the colonoscope and proceed with the examination. An average examination takes 20 to 30 minutes. When it is completed, you will be transferred to a recovery area, where you will regain consciousness and be observed for up to an hour prior to discharge. During this period, you may have some mild cramping and will expel the residual gas from the procedure. Once you are sufficiently alert, you will be discharged in the care of your accompanying person.
Prior to discharge, your colonoscopist will review with you the findings at the examination and may provide you with a brief written summary. A full note will be sent later to the referring physician. This should include the results of any laboratory examination of samples taken at the procedure as well as further recommendations for follow up.
What are the risks of colonoscopy?
Colonoscopy is generally considered a safe procedure, but it is invasive and has the potential for complications. Substantial sedation is administered during colonoscopy. In spite of careful monitoring, there is a tiny risk that you will be over-sedated requiring assisted breathing or even short-term mechanical ventilation. As well, as with any medication, allergic reactions to the sedatives can occur.
Complications directly related to colonoscopy include bleeding and perforation. Bleeding can occur following the removal of tissue by biopsy or by excision of polyps. Such bleeding can be trivial or, in rare cases, substantial. It usually occurs during or shortly after the procedure, but occasionally can be delayed for up to a week. The likelihood of bleeding following polypectomy, which occurs in less than 1% of procedures, is closely related to the size of polyps removed. Your discharge instructions will include the advice to go to a hospital if substantial bleeding is noted after discharge. When bleeding does occur, it is often self-limited even when precipitous. Where bleeding does not stop spontaneously, it may be necessary to re-insert the colonoscope, identify the site of bleeding and cauterize the bleeding vessel. Very rarely is surgery required to stop post-colonoscopy bleeding.
Perforation resulting from colonoscopy is uncommon, occurring in less than one in a thousand examinations. It represents a hole in the intestine with the potential for leakage of bowel contents into the abdomen and subsequent infection. Perforation can result from mechanical puncturing of the bowel wall by the colonoscope or its accessories, by overdistension of the bowel wall by insufflated air or by burning through the wall with cautery used to remove polyps. Perforation is manifest by pain, usually during or shortly after the procedure, but occasionally delayed for several days if the hole is very small. Unattended perforation will result in fever indicating intra-abdominal infection.
If perforation is suspected, it can be confirmed with simple x-rays of the abdomen or, if uncertain, by CT scanning. These tests generally require a hospital setting and the support of a surgeon. Management of confirmed perforation includes the administration of antibiotics and surgical exploration of the abdomen to repair the disruption of the bowel wall. Death resulting from colonoscopy or its complications is extremely rare.
After the procedure
You will be discharged in the care of an accompanying adult. You should not drive a car or operate dangerous machinery for 24 hours after the examination. The use of public transportation is not advisable. Following the procedure, you can resume your usual diet, but may prefer to begin with relatively light foods. Mild cramping and flatulence are common after colonoscopy, but severe and persistent pain or fever raise the suspicion of perforation and should prompt a visit to the nearest emergency department. Similarly, while minor, self-limited bleeding is not worrisome, substantial or persistent bleeding should be assessed at a hospital.
Most medications can be resumed shortly after the procedure. If uncertain, ask your physician.
Make sure you understand the findings of the examination and the recommendations for follow-up. Since you may still be under the influence of sedatives, it is preferable for your accompanying person to be present when your colonoscopist visits after the procedure and that you receive a written summary of the results.
Guideline for Colorectal Screening
Canadians with family history of colorectal cancer need to be screened earlier, more often. The Canadian Association of Gastroenterology (CAG) has released a guideline for colorectal screening.
There is evidence that people with first degree relatives (parents, brothers, sisters or children) with colorectal cancer are at an increased risk.
Checking for evidence of a disease in a group of people who do not show any symptoms is done through a screening program. In Canada, each province has a program to screen a portion of the population for Colorectal Cancer. Screening helps to identify cancer, often before any symptoms develop in an individual. An individual’s prognosis, or chances of successful treatment, are much better when colorectal cancer is found and treated early. In general, individuals who are between 50 and 74 years of age, or who have a higher risk for colorectal cancer, participate in a screening program.
To read more about your provincial colorectal cancer screening program, click here.
Too many people skip potentially life-saving procedures because of misunderstandings and misconceptions about the bowel prep. However, most people who have had colonoscopies, will tell you it isn't nearly as bad as you think and that the benefits far outweigh the risks. Robbie, Anne and Laurie, who range in age from 11 to 80 years, openly share their experiences with you in this video.
