COLORECTAL CANCER FACTSHEET

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1 What does colorectal mean? Colorectal is a word which means 'the colon and rectum'. The colon and rectum are parts of the gut (gastrointestinal tract). The gut starts at the mouth and ends at the anus. When we eat or drink the food and liquid travel down the oesophagus (gullet) into the stomach. The stomach churns up the food and then passes it into the small intestine. The small intestine (sometimes called the small bowel) is several metres long and is where food is digested and absorbed. Undigested food, water and waste products are then passed into the large intestine (sometimes called the large bowel). The main part of the large intestine is called the colon which is about 150 cm long. This is split into four sections, the ascending, transverse, descending, and sigmoid colon. Some water and salts are absorbed into the body from the colon. The colon leads into the rectum (back passage) which is about 15 cm long. The rectum stores faeces (stools) before they are passed out from the anus. Source: Types of bowel cancer Adenocarcinomas More than 95% of colorectal cancers are adenocarcinomas. This means that the cancer started in the gland cells in the lining of the bowel wall. The gland cells normally produce mucus. This is a slimy substance that makes it easier for the stool to pass through the bowel. There are one or two particular types of adenocarcinoma of the colon and rectum. You may hear your doctor talking about a mucinous tumour or a signet-ring tumour. These terms refer to the look of the cells under the microscope. Mucinous tumours often have the cancer cells in pools of mucus. Signet-ring tumours have mucus inside the cells. The mucus pushes the nucleus (control centre) of the cell over to one side, making the tumour cell look the shape of a signet ring under the microscope. Only about 1-2% of all colorectal cancers are signet-ring type. They are treated the same way as other adenocarcinomas of the colon or rectum. Squamous cell cancers Squamous cells are the skin-like cells that make up the bowel lining together with the gland cells. Carcinoid tumours Carcinoid is an unusual type of slow growing tumour called a neuroendocrine tumour. These are cancers that grow in hormone producing tissues, usually in the digestive system. They are rare. Between 4 and 17% of carcinoid tumours begin in the rectum. Between 2 and 7% of carcinoid tumours begin in the large bowel. Carcinoid is a particular type of cancer and is treated differently to colorectal cancer. Sarcomas Sarcomas are cancers of the supporting cells of the body (bone, muscle etc), but are extremely uncommon within the bowel. Most sarcomas found in the colon or rectum are leiomyosarcomas. This means they are cancers that have started in the smooth muscle. Sarcomas are also treated differently to adenocarcinomas of the bowel or rectum. Lymphomas Lymphomas are cancers of the lymphatic system. Only about 1 in 100 cancers in the colon or rectum are lymphomas. They are treated very differently to other colorectal cancers. People with concerns about their own health should contact their GP or cancer team Source: WCISU

2 What causes colorectal cancer? A cancerous tumour starts from one abnormal cell. In the case of colorectal cancer, it is a cell in a polyp which is the most common site for a cancerous cell to develop. The exact reason why a cell becomes cancerous is unclear. It is thought that something damages or alters certain genes in the cell. This makes the cell abnormal and multiply 'out of control'. Risk factors Although colorectal cancer can develop for no apparent reason, there are certain 'risk factors' which increase the chance that colorectal cancer will develop. These include: Ageing. Colorectal cancer is more common in older people. Most cases are in people over the age of 50. If a close relative has had colorectal cancer (there is some genetic factor). This is really first degree relatives at an early age. If you have familial adenomatous polyposis or hereditary non-polyposis colorectal cancer. These are rare inherited disorders. If you have ulcerative colitis (a condition of the colon) for more than 8-10 years. Obesity. Lifestyle factors: little exercise, eating a lot of red meat, drinking a lot of alcohol, smoking. Source: WCISU What are the symptoms of colorectal cancer? When a colorectal cancer first develops and is small it usually causes no symptoms. As it grows, the symptoms that develop can vary, depending on the site of the tumour. The most common symptoms to first develop are: Bleeding from the tumour. You may see blood mixed up with your faeces (stools or motions). Sometimes the blood can make the faeces turn a very dark colour. The bleeding is not usually severe and in many cases the bleeding is not noticed as it is just a small 'trickle' which is mixed with the faeces. However, small amounts of bleeding that occur regularly can lead to anaemia which can make you tired and pale. Passing mucus with the faeces. A change from your usual 'bowel habit'. This means you may pass faeces more or less often than usual. Bouts of diarrhoea. A feeling of not fully emptying the rectum after passing faeces. Abdominal pains. As the tumour grows in the colon or rectum, symptoms may become worse and can include: The same symptoms as above, but more severe. You may feel generally unwell, tired, or lose weight. If the cancer becomes very large, it can cause a blockage (obstruction) of the colon. This causes severe abdominal pain and other symptoms such as vomiting. Sometimes the cancer makes a hole in the wall of the colon or rectum (perforation). If this occurs the faeces can leak into the abdomen. This causes severe pain. If the cancer spreads to other parts of the body, various other symptoms can develop. All the above symptoms can be due to other conditions, so tests are needed to confirm colorectal cancer. Source: Diagnosing bowel cancer This section tells you about the tests that are used to diagnose colorectal cancer, and the other tests you may have if colorectal cancer is diagnosed. Bowel cancer tests This part tells you about tests for bowel cancer (also called colon cancer or colorectal cancer). There is information on: Seeing your GP Tests at the hospital including sigmoidoscopy, barium enema and colonoscopy CEA blood test Other blood tests Further tests Source:

3 Diagnosing bowel cancer continued Seeing your GP Usually you begin by seeing your family doctor who will ask you about your general health and examine you and do some tests. Your GP may then refer you to hospital for any further tests or X-rays. At the hospital The bowel cancer specialist will ask about your medical history and your symptoms and will probably want to examine your back passage (rectum). The examination may be slightly uncomfortable, but should not be painful. You may have this done in the clinic with a sigmoidoscopy. You will have to arrange an appointment to have the rest of your bowel examined with a barium enema or colonoscopy. CEA blood test CEA stands for 'carcinoembryonic antigen'. It is a marker that shows up in some cancers, including colorectal cancers. A marker is a chemical produced by a cancer which can be picked up in the blood. It will go up when the disease is active and fall when treatment is working. It may go up if the cancer comes back. Some doctors are now taking a blood sample to get a baseline reading of CEA when patients are diagnosed. Other blood tests A full blood count includes a check for anaemia. Anaemia is commonly a feature of colorectal cancer. Blood tests are also done to check if your liver and kidneys are working normally. Further tests Your may have tests to check to see if the cancer has spread. These include a chest X-ray to rule out spread to the lungs. This is one of the areas where colorectal cancer can spread to. You may also have an ultrasound scan of your stomach (abdomen) to check that the cancer has not spread to the liver. Examining the bowel Your doctor may arrange for you to have one or more of these tests. They include: Sigmoidoscopy and proctoscopy Sigmoidoscopy (or proctoscopy) Colonoscopy Barium enema Virtual colonoscopy or CT colonography The doctor uses these tests to look inside the rectum (proctoscopy), or the rectum and lower part of the large bowel (sigmoidoscopy). While you lie on your side, the doctor puts a thin tube into your rectum and up into the large bowel. The bowel is inflated with air and there is a light inside the tube so the doctor can see if anything is wrong. The doctor can take a biopsy (sample of tissue) if necessary. The biopsies go to the lab, where a tissue specialist examines them under a microscope. You have this test in the outpatients department. Because this test is quite quick and usually painless, it isn't usual to need any anaesthetic, or anything to make you drowsy. You should be able to go home as soon as the test is over. You may notice a small amount of blood in your stool after the biopsy. Colonoscopy This test looks at the whole of the inside of the large bowel. It is done in outpatients and takes about an hour. For this test the bowel has to be empty. You will be given a list of things to do to help prepare the bowel for the test. These are likely to include: Stopping iron tablets Not eating solid food for 2 days before the test Drinking plenty of clear fluids Taking laxatives Source:

4 Diagnosing bowel cancer continued You will probably have medicine to make you drowsy just before the test. This is called a sedative. Colonoscopy is nearly always done with sedation and painkillers because it would be uncomfortable for you without. It may be possible to have a colonoscopy without a sedative, if you have particular reasons for wanting to. You would need to talk to your doctor beforehand about this. Your doctor will ask you to lie on your side. The doctor will pass a flexible tube into your rectum and up into your bowel. As the tube bends easily, it can pass around the curves in the bowel so your doctor can examine the whole length of it. The light inside the tube helps the doctor to see any problem areas or swelling. Photographs and biopsies of the lining of the bowel can be taken during the test. A colonoscopy can be uncomfortable but the sedative should help you to feel more relaxed. You should be able to go home a couple of hours after the test. You shouldn't drive for a few hours after the sedative. If you have had a sedative, you should have someone with you to take you home. Ideally they should stay overnight just to make sure everything is all right. Barium enema This is an X-ray of the large bowel. For this test you have to have an empty bowel. You will be: Given laxatives to take the day before Asked to drink lots of fluids the day before Asked not to eat solid food on the day before the test Asked not to eat and drink anything on the morning of the test Before the test, you may have a bowel washout, although this isn't done so often now as the laxatives they give you work very well. A bowel washout is a bit like having an enema. A tube is passed into your rectum and water is passed through the tube. The water then drains out of the tube again into a bowl or bucket. As the water drains out, it washes out the inside of the bowel. Barium is a white liquid which shows up on X-rays. A mixture of barium and water is passed into the rectum in the same way as the bowel washout. But you will be asked to try to hold the liquid in the rectum this time until all the X-rays have been taken. The barium passes through the bowel and shows up any lumps or swellings. The doctor can watch on an X-ray screen. The test can be uncomfortable and tiring. It is best to have someone to take you home afterwards. After the test: You may be constipated Your first couple of stools will be white You may want to ask the doctor for a mild laxative to take home with you after the test. Your stools will return to normal after the barium is out of your system. Virtual colonoscopy This is a new type of test. It is also called CT colonography. Instead of having the colonoscope put inside your bowel, you may be able to have a computer simulated examination. As it is a new type of test not all radiologists are trained and experienced in using it yet. The preparation is the same as for barium enema - laxatives and plenty of fluids to clear out your bowel. The test is done with a CT scanner. So you have this test in the CT scanning department. You can have it as an outpatient. Just before the test, the doctor will put a small tube into your back passage to pump air or carbon dioxide inside. This helps to open up the bowel, which gives a better result from the scan. You then have two CT scans done. One when you are lying on your back and one with you lying on your front. A computer matches up the two scans and makes a 'virtual' scan of the inside of your bowel. This will show up any growths on your bowel wall. You may still have to have a colonoscopy if a biopsy is needed. CT colonography is sometimes used instead of a barium enema to examine the bowel. Clinical trials are comparing it to standard tests to see if it is as good at helping to diagnose bowel cancer. Source:

5 Diagnosing bowel cancer continued Scans for bowel cancer This section has information about the scans you may have when you are having tests for bowel cancer. There is information on: Ultrasound of the stomach (abdomen) Ultrasound of the back passage CT scan MRI scan Ultrasound scan This test uses sound waves to build up a picture of the inside of your body. You will be asked to lie on your back. A gel is spread onto your abdomen. A small microphone will be passed over your abdomen. The microphone picks up echoes and sends the signals to a computer which converts them into a picture. The doctor may want to use this test to look at your liver. The liver is one of the areas colorectal cancer can spread to. Rectal ultrasound scan This is a type of ultrasound scan which is used to find out more about rectal cancer. It is usually used after the cancer has been diagnosed to find out more about: The size of the tumour Whether the tumour has spread This information helps your doctor decide how to treat your cancer. To do the scan, the ultrasound probe has to be placed inside the rectum. This can be uncomfortable, but the scan only takes a few minutes at most. CT scan (CAT scan) This is a type of X-ray that takes pictures from different angles. The pictures are fed into a computer and form a detailed picture of the inside of your body. The scan can show the area where the cancer is. The doctor can also use the scan to check whether the cancer has spread anywhere else. Before the scan you may be asked: Not to eat or drink for four hours To drink a special liquid a few hours before To drink more of the liquid in the X-ray department Just before the scan, the doctor may put more liquid into your rectum. This makes the scan picture clearer. MRI scan This scan uses magnetism to build up a picture. An MRI scan can give more detail than CT. MRI scans are increasingly used for rectal cancers for this reason. Your doctor may want you to have this test with an 'endo anal coil'. This is a small magnetic coil that goes inside your back passage during the scan. It is uncomfortable but gives a very accurate result. You may want to ask your doctor beforehand how long you will need to have the coil in, so that you know what to expect. Source:

6 What are the treatment options for colorectal cancer? Treatment options that may be considered include surgery, chemotherapy and radiotherapy. The treatment advised for each case depends on various factors such as the stage of the cancer (how large the cancer is and whether it has spread), and your general health. You should have a full discussion with a specialist who knows your case. They will be able to give the pros and cons, likely success rate, possible side effects, and other details about the various possible treatment options for your type of cancer. You should also discuss with your specialist the aims of treatment. For example: Treatment may aim to cure the cancer. Some colorectal cancers can be cured, particularly if they are treated in the early stages of the disease. (Doctors tend to use the word 'remission' rather than the word 'cured'. Remission means there is no evidence of cancer following treatment. If you are 'in remission', you may be cured. However, in some cases a cancer returns months or years later. This is why some doctors are reluctant to use the word cured.) Treatment may aim to control the cancer. If a cure is not realistic, with treatment it is often possible to limit the growth or spread of the cancer so that it progresses less rapidly. This may keep you free of symptoms for some time. Treatment may aim to ease symptom. If a cure is not possible, treatments may be used to reduce the size of a cancer which may ease symptoms such as pain. If a cancer is advanced then you may require treatments such as nutritional supplements, painkillers, or other techniques to help keep you free of pain or other symptoms. Surgery It is often possible to surgically remove the primary tumour. Removing the tumour may be curative if the cancer is in an early stage. The common operation is to cut through the intestine above and below the tumour. The affected section is then removed and, if possible, the two cut ends of intestine are sewn together. Sometimes a temporary stoma is done to allow the joined ends to heal without faeces passing through. The stoma is often reversed in a second operation a few months later when the joined ends of the intestine are well healed. If the tumour is low down in the rectum, then the rectum and anus need to be removed. You would then need a permanent colostomy. A colostomy is where an opening (hole) is made through the wall of the abdomen. A section of colon is then cut and the edges are attached to the opening in the abdominal wall. This is called a stoma and it allows faeces to pass out from the colon into a disposable bag which is stuck over the stoma. Even if the cancer is advanced and a cure is not possible, surgery may still have a place to ease symptoms. For example, a stent can be inserted to ease a blocked colon. A stent is a thin metal tube which is placed through a narrowed or blocked section of colon. It can then be opened wide and remains in the colon to prevent a further blockage. Chemotherapy and radiotherapy One or other of these treatments may be advised depending on the site and stage of the cancer. Chemotherapy is a treatment of cancer by using anti-cancer drugs which kill cancer cells, or stops them from multiplying. Radiotherapy is a treatment which uses high energy beams of radiation which are focussed on cancerous tissue. This kills cancer cells, or stops cancer cells from multiplying. It is most commonly used for colorectal cancer when the tumour is in the rectum. When chemotherapy or radiotherapy are used in addition to surgery it is known as 'adjuvent chemotherapy' or 'adjuvent radiotherapy'. For example, following surgery you may be given a course of chemotherapy or radiotherapy. This aims to kill any cancer cells which may have spread away from the primary tumour site. Sometimes, adjuvant chemotherapy or radiotherapy is given before surgery to shrink a large tumour so that the operation to remove the tumour is easier for a surgeon to do, and is more likely to be successful. Source: WCISU

7 Staging of large bowel cancer The stage of a cancer describes its size and whether it has spread beyond its original area of the body. Knowing the extent of the cancer helps the doctors to decide on the most appropriate treatment. Often, the exact stage of a bowel cancer can only be known after it has been removed by surgery. Generally, cancer of the large bowel is divided into four stages: small and localised (stage A); spread into surrounding structures (stages B and C); or spread to other parts of the body (stage D). If the cancer has spread to distant parts of the body, this is known as secondary cancer (or metastatic cancer). Doctors often use a staging system created by a pathologist called Dukes to describe large bowel cancer. The Dukes staging system Dukes A The cancer is contained within the bowel wall. Dukes B The cancer has spread through the muscle of the bowel wall, but the lymph nodes are not affected. Dukes C The cancer has spread to one or more of the lymph nodes close to the bowel. Lymph nodes are usually the first place the cancer spreads to. Dukes D The cancer has spread to another part of the body such as the liver or the lungs (secondary cancer). TNM staging system The Dukes system is gradually being replaced by the TNM staging system. T describes the size of the tumour and if it has spread into the bowel wall. N describes whether the cancer has spread to the lymph nodes. M describes whether the cancer has spread to another part of the body, such as the liver or the lungs (secondary or metastatic cancer). Although this system is more complex, it can give more precise information about the tumour stage than the Dukes method. If the cancer comes back after initial treatment it is known as recurrent cancer. Source: What is the prognosis (outlook)? Without treatment, a colorectal cancer is likely to get larger, and spread to other parts of the body. However, in many cases it grows slowly and may remain confined to the lining of the colon or rectum for some months before growing through the wall of the colon or rectum, or spreading. You have a good chance of a cure if you are diagnosed and treated when the cancer is in an early stage. If the cancer is diagnosed when it has grown through the wall of the colon or rectum, or spread to other parts of the body, there is less chance of a cure. However, treatment can often slow down the progression of the cancer. The treatment of cancer is a developing area of medicine. New treatments continue to be developed and the information on outlook above is very general. The specialist who knows your case can give more accurate information about your particular outlook, and how well your type and stage of cancer is likely to respond to treatment. Source: Prevention To reduce the risk of developing colorectal cancer, you should eat a healthy, balanced diet including plenty of fresh fruit and vegetables. It is recommended that you cut down the amount of red meat you eat to around one or two portions a week. Red meat is any meat that is red before you cook it, such as beef, pork and lamb. You should also eat lots of fibre in your diet. The type of fibre found in foods such as wholemeal bread and rice, and whole grain cereals will make it easier for you to digest food, and lower your risk of developing colorectal cancer. It is also important to take regular exercise, maintain a healthy weight and avoid alcohol and smoking. Source:

8 * Please note the following information is for Colon cancer in Wales only * Summary Cancer of the colon was the 3rd most common cancer in both males and females in Wales during , with an average of 1258 new registrations per annum. The cumulative incidence rates (0-74 yrs) of colon cancer are 2.7% in males and 1.9% in females. Males Females Average registrations per annum ( ) Relative Frequency 8.2% 8.1% Rank 3rd 3rd Mean age at diagnosis (years) Cumulative Rate (0-64 years) 1.0% 0.8% Cumulative Rate (0-74 years) 2.7% 1.9% Percentage Annual Change in EASR (incidence) -0.2% -1.0* Percentage Annual Change in EASR (mortality) -2.3%** -3.2%** Percentage Death Certificate Only 5.0% 7.1% Average deaths per annum ( ) Mortality:Incidence Ratio ( ) 52.7% 54.5% * Significant at 5% level ** Significant at 1% level Number of incident cases and age-specific rates, Number of cases pecific rate per 100,000 population Age Sp Under Age Group Male Cases Female Cases Male ASR Female ASR Prevalence Statistics (at 31st December 2006) in Wales Males Number Rate per 100,000 % prev in pop % in each time interval Up to 1 year >1 to 5 years >5 to 10 years >10 to 20 years Total up to 20 years Females Number Rate per 100,000 % prev in pop % in each time interval Up to 1 year >1 to 5 years >5 to 10 years >10 to 20 years Total up to 20 years

9 Trends in Incidence Males Total Crude Rate EASR WASR Females Total Crude Rate EASR WASR

10 * Please note the following information is for Rectal cancer in Wales only * Summary In total there were about 720 new registrations of rectal cancer per annum in the period For males this cancer site is ranked 5 th and 6 th for females, representing 5.6% of cancers in males and 3.6% of cancers in females. Males Females Average registrations per annum ( ) Relative Frequency 5.6% 3.6% Rank 5th 6th Mean age at diagnosis (years) Cumulative Rate (0-64 years) 0.8% 0.4% Cumulative Rate (0-74 years) 2.0% 0.9% Percentage Annual Change in EASR (incidence) -0.7%* -0.6%* Percentage Annual Change in EASR (mortality) -1.6%** -2.1%** Percentage Death Certificate Only 2.7% 4.4% Average deaths per annum ( ) Mortality:Incidence Ratio ( ) 41.7% 41.3% * Significant at 5% level ** Significant at 1% level Number of incident cases and age-specific rates, Number of cases pecific rate per 100,000 population Age Sp 0 Under Age Group Male Cases Female Cases Male ASR Female ASR Prevalence Statistics (at 31st December 2006) in Wales Males Number Rate per 100,000 % prev in pop % in each time interval Up to 1 year >1 to 5 years >5 to 10 years >10 to 20 years Total up to 20 years Females Number Rate per 100,000 % prev in pop % in each time interval Up to 1 year >1 to 5 years >5 to 10 years >10 to 20 years Total up to 20 years

11 Trends in Incidence Males Total Crude Rate EASR WASR Females Total Crude Rate EASR WASR