Early detection and treatment is key.
A common theme of colorectal cancer awareness in March is that this form of cancer is generally preventable. But when it occurs, the treatment approach follows a similar pattern: if the cancer is diagnosed earlier it is easier to treat and patients have better outcomes.
What are the common treatments to expect with colon cancer?
Colorectal cancer is a cancer that occurs in the colon and rectum in the last 5-10 feet of your intestine. Colon cancer generally begins as a small abnormal growth along the surface called a polyp. Polyps are abnormal growths of tissue in the colon and rectum. While polyps themselves are harmless (benign), they can progress to cancer, with adenocarcinoma being the most common. There are two primary treatment types: Local and systemic.
- Local treatment includes surgery, endoscopic excision, and radiation.
- Systemic treatment includes primarily chemotherapy, but also hormone, immune, and targeted therapy.
How is the specific treatment determined?
Treatment is determined based on the stage of the cancer. The stage is determined by how far the cancer has spread from its starting location in the mucosa of the colon or rectum. Stage is determined by three factors:
- tumor size (T)
- spread to lymph nodes (N), and
- spread to other body locations, also known as metastasis (M).
Together the "TNM" values are used to determine the stage of the cancer. Cancer stage ranges from one to four, designated by Roman numerals I-IV. Stage I occurs when the cancer is confined to the colon or rectum and Stage IV occurs when the cancer has spread to other locations in the body. This spread is known as metastasis.
Treatment is based on the stage of cancer.
- Earlier stages: surgical removal is the primary treatment when cancer has not spread to nearby lymph nodes.
- Later states: systemic chemotherapy, which affects the whole body, is used once the cancer has spread to the lymph nodes or beyond. In addition, surgery may be performed before or after chemotherapy to remove diseased tissue and reconnect the remaining portions of the colon when possible.
- Radiation is also used, but more commonly in rectal cancer or in metastatic disease, when cancer has spread.
TNM staging is determined by the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC).
What testing is used to determine the stage of cancer?
Colonoscopy is used to determine whether you have colorectal cancer. Tissue collected during the procedure must be analyzed by a pathologist, which can take several days to a week. Sometimes, surgical resection can also determine your diagnosis if you are having complications from advanced cancer like bowel obstruction or bleeding.
After colonoscopy, bloodwork – including specific tumor marks – and a staging CT scan or whole body PET/CT scan are typically used in addition to routine x-rays to finalize the stage of cancer. It can take weeks to finalize all the information. In the United States, the National Comprehensive Cancer Network updates testing and treatment guidelines based on the latest data.
What is chemotherapy?
Chemotherapy is a type of systemic treatment that is toxic to human cells but more toxic to cancer cells. It affects the whole body, but especially fast-growing cancer cells. Chemotherapy is administered through a subcutaneous port – a tube that reduces the need for repeated needle sticks over the course of treatment – that is placed during an outpatient procedure. Chemotherapy is used once the cancer has spread to at least the lymph nodes, which collect the body’s lymphatic fluids “downstream” from the primary site of the cancer. Systemic chemotherapy is also used for advanced cancer that has spread to other areas of the body, known as metastatic disease. There are other systemic treatments like immune, hormone, and targeted therapy. Chemotherapy is the most common, especially in colorectal cancer where it works well and is well tolerated.
What are the surgical treatment options?
Surgical intervention can occur before or after chemotherapy or radiation (especially in rectal cancer) depending on the stage of cancer. When possible, a minimally invasive approach (laparoscopic or robotic) is typically preferred. During surgery, the primary tumor is removed, along with its lymph nodes, and the remaining colon is reconnected (anastomosis). Tissue collected during the surgery is then sent to pathology where the extent of local invasion and spread to lymph nodes can be accurately determined.
When the cancer has advanced to cause complications like bowel obstruction, perforation, or bleeding, sometimes more urgent surgery is performed, typically open surgery with a large incision. In these cases, it is not always possible to reconnect the separated sections of colon, so many times an ostomy is formed. An ostomy is when a piece of intestine is sutured to the skin so that stool exits the skin instead of through your rectum and is collected in an external bag. Many times, the ostomy is reversable. Ostomies are also used in low rectal cancer, where a temporary kind of ostomy called a loop ileostomy is used to divert stool, allowing the reconnected sections of the rectum to heal. These are almost always reversed.
A key point here is that when cancer is diagnosed early, the surgical treatments are less invasive and better tolerated.
What physicians are involved in treatment?
Cancer treatment takes a multi-disciplinary approach involving many physicians, advanced practitioners, nurses, and coordinators across specialties. There are regular meetings called tumor boards, where the treatment of specific patients are discussed. The following summarizes the physicians involved.
- Gastroenterologist or general surgeon performs colonoscopy for diagnosis.
- General surgeon, surgical oncologist or colorectal surgeon performs resection (surgical removal) of the tumor.
- Oncologist, a medical doctor specializing in cancer treatment, prescribes a chemotherapy regime and directs any additional care or follow up.
- Radiation oncologist performs radiation when indicated.
- Radiologist interprets the various imaging tests, like CT scans and x-rays.
What can I do to ensure the best outcome?
Key recommendations include:
- Schedule a routine screening test (usually colonoscopy) for colorectal cancer starting at age 45 for individuals at average risk, and younger for high-risk individuals.
- Engage in physical activity (like daily walking for at least 30 minutes).
- Eat a whole food, healthy diet high in vegetables, certain fruits, and fiber.
- If diagnosed, follow the recommended treatment guidelines by your oncologist or surgeon.
What is my next step?
If you have symptoms that might indicate colorectal cancer, talk to your Primary Care Physician (PCP) as soon as possible. He or she can assess your symptoms and then refer you to a gastroenterologist or general surgeon, as appropriate. If you don't have a PCP, you can use our "Find a Doctor" website feature or call us at (706) 389-3892 to find one. Symptoms may include:
- A long-lasting change in your bowel habits such as diarrhea, constipation, or a change in the consistency of your stool
- Blood in your stool
- Persistent abdominal cramps, gas, or pain
- A feeling that your bowel doesn’t empty completely
- Weakness or fatigue
If you do not have symptoms and are 45-50 years of age, talk to your PCP at your next wellness visit about when you should have your first screening exam. Again, if you need to find a PCP, visit our "Find a Doctor" feature or give us a call.
The general surgeons at Athens General and Colorectal Surgery, part of St. Mary's Medical Group, are highly skilled and experienced in performing colonoscopies and surgeries to treat colorectal cancer.
About Aaron Carr, M.D.
Dr. Carr specializes in general, foregut and bariatric surgery. At UC Davis in Sacramento, he has practiced within the Division of Foregut and Endometabolic Surgery and has been a Co-instructor of Record for Surgical Education in the School of Medicine.
He earned his bachelor’s degree in physics, Magna Cum Laude, from the University of Alabama in Birmingham, where he was also a NASA Space Center Grant Scholar. He went on to receive his medical degree from the University of South Alabama College of Medicine in Mobile, and to complete his residency in categorical general surgery at Atlanta Medical Center, where he served as chief resident in 2012.
He is certified by the American Board of Surgery and holds specialty certifications in fundamentals of laparoscopic and endoscopic surgery. He is a member of the Society of American Gastrointestinal and Endoscopic Surgeons, the American Society for Metabolic and Bariatric Surgery, and the American College of Surgeons.
Dr. Carr has been active in a wide variety of research projects on topics such as diabetes in bariatric surgery patients, single-incision and multi-incision robotic gallbladder removal surgery and alleviating chronic pain in thoracic surgery patients. His current research interests include comorbidities and outcomes in bariatric surgery and robotic and endoscopic surgical innovation.