Colorectal Cancer

Overview

What is Colon and Rectal Cancer?

Cancer occurs when the body’s cells fail to grow, divide and reproduce in a healthy, orderly way, producing too much tissue and forming an abnormal growth or polyp. These polyps can be benign (not cancerous) or malignant (cancerous) and can spread to other parts of the body.

Cancer that begins in the colon (the first four and a half feet of the large intestine) is called colon cancer, while cancer that arises in the rectum (the last six to nine inches of the digestive tract) is known as rectal cancer. Cancers affecting either of these organs also are referred to as colorectal cancer. Colorectal cancers generally arise over time from adenomatous (precancerous) polyps.

Colorectal cancer is the third-leading cause of cancer and the second most common cause of cancer deaths in the United States for both men and women.

How is Colorectal Cancer Diagnosed?

Colorectal cancer typically is detected by a colonoscopy, which may be done as a screening examination or done to evaluate symptoms. Most people with colorectal cancer have no symptoms. Changes in normal bowel habits, unexplained anemia (low blood count), weight loss, blood in the stool (not visible or obvious), or abdominal pain are all possible cancer symptoms.

A biopsy of abnormal appearing tissue is used to diagnose cancer. A biopsy is a diagnostic test in which a small sample of tissue is removed and examined under a microscope.

A Multidisciplinary Approach

Cleveland Clinic is committed to a multidisciplinary approach to colorectal cancer care, providing the most advanced care through patient education, screening, polyp and cancer detection and treatment.

Our team approach brings together experts in colorectal surgery, gastroenterology, medical oncology, radiation oncology and genetic counseling. The team works with patients and their families to develop treatment plans tailored to their individual needs. This approach offers patients the greatest chance of cure and the best possible quality of life. Our experts also continually seek to improve colorectal cancer care through weekly tumor board meetings where they review colorectal cancer cases for multidisciplinary clinical management decisions, including discussing new treatments or experimental therapies. For select patients, personalized medical approaches based on genetic testing are also available.

Young-Onset Colorectal Cancer

Up to 12% of colorectal cancers occur in individuals under the age of 50. According to the National Cancer Institute, since 1994, cases of young-onset colorectal cancer have increased by 51%. While a cancer diagnosis at any age calls for expert treatment, young patients with colorectal cancer often have diagnostic and treatment considerations that are specific to their early age of onset.

Our providers with renowned expertise in surgery, oncology, radiation therapy, genetics, gastroenterology, fertility, psychology, and lifestyle medicine come together to design a personalized care plan with a focus on curing cancer and maximizing survival, while also assuring optimal quality-of-life for patients whose cancer diagnosis can interrupt their most productive years.

Stages & Treatments

Doctors use staging to classify the location and extent of the disease. Your physician will discuss all treatment options with you, including possible surgery, chemotherapy and radiation therapy, to determine the best treatment for you. As with other cancers, treatment is individualized based on several factors.

The stages and treatments for both colon and rectal cancer are very similar (see box at right for unique aspects of rectal cancer).

STAGE I

Stage I colon cancer tumors are confined to the lining or the muscular wall of the colon but have not penetrated the outer wall of the colon. The cancer has not spread anywhere else.

Treatment

Standard surgery may include removal of the cancerous portion and a healthy piece of the colon on either side, as well as the lymph nodes in that area of the abdomen. The two ends of the colon can be reattached to maintain normal bowel function. Additional treatments, such as chemotherapy, usually are not needed.

STAGE II

Stage II colon cancer extends through the muscular wall of the colon, but there is no cancer in the lymph nodes or anywhere else in the body.

Treatment

Standard surgery may include removal of the cancerous portion and a healthy piece of the colon on either side, as well as the lymph nodes in that area of the abdomen. The two ends of the colon can be reattached to maintain normal bowel function. Your doctor may recommend chemotherapy if you have Stage II cancer with certain features that suggest a high risk of recurrence.

STAGE III (AJCC)

Stage III colon cancer has spread outside the colon to one or more lymph nodes near the bowel. Stage III is further divided into the following classifications:

AJCC Stage IIIA — tumors that have not penetrated the muscular layer of the colon wall and have spread to 1-3 lymph nodes or to a tumor deposit neat the colon; or tumors that are confined to the inner lining of the colon but have spread to 4 to 6 lymph nodes

AJCC Stage IIIB — tumors that have not penetrated the muscular layer of the colon and have spread to 7 or more lymph nodes; tumors that have grown into or through the muscle layer of the colon and have spread to 4 to 6 lymph nodes; tumors that have grown through the muscle layer of the colon or through the outer layer of the colon without growing into another structure and have spread to 1-3 lymph nodes or a tumor deposit near the colon

AJCC Stage IIIC — tumors that have grown through the outer layer of the colon without growing into another structure and have spread to 4-6 lymph nodes; tumors that have grown through the muscle layer of the colon or through the outer layer without growing into other structures and have spread to 7 or more lymph nodes; tumors that have grown through the colon and into another structure and have also spread to lymph nodes

Treatment

Standard surgery may include removal of the cancer and a healthy portion of the colon on either side, as well as all involved lymph nodes, if possible. In most cases, the two ends of the colon can be reattached to maintain normal bowel function. The addition of chemotherapy can enhance survival when added to surgery.

STAGE IV

Stage IV colon cancer has spread outside the colon to other parts of the body, usually to the liver or lungs. The tumor can be any size, and it may or may not include affected lymph nodes.

Treatment

Treatment for Stage IV colon cancer varies depending upon the individual situation. In many cases, the primary colon tumor can be removed surgically to prevent blockage and restore or maintain bowel function. In some cases, surgery may be done to remove cancer that has spread to the liver or lung, but these procedures cannot be done in all cases. Doctors prescribe chemotherapy to patients with this stage of colon cancer to control their symptoms. In select cases, liver-directed therapy is used to control liver metastases.

Surgical Treatment

Removal (resection) of a portion or all of the colon and/or rectum is the main treatment for colon and rectal cancer.

Most of the surgical procedures for colon and rectal cancer are focused on preserving the function of the anal muscles (sphincter) and avoiding a stoma (bag). When the colon and/or rectum are removed, there must be another way for solid waste to exit the body. The surgeon will create a pouch as an alternate way for you to store and pass stool. Most patients at Cleveland Clinic receive a colonic J-pouch, formed out of the individual’s own proximal (ascending and transverse) colon.

Cleveland Clinic’s Department of Colorectal Surgery has vast surgical experience in sphincter-sparing rectal cancer surgery with excellent outcomes.

What should a colon and/or rectal cancer patient know about surgery?

The best indicator of surgical outcomes is the experience of the surgeon, not the particular technique used. Cleveland Clinic surgeons have a large experience with all methods of colorectal surgery, and many new approaches have been developed here. Today, we are offering more and more procedures minimally invasively (laparoscopically) or robotically, which means less pain and quicker recoveries for our patients. Patients should learn their surgeon’s level of experience when examining treatment options.

The Digestive Disease Institute’s Department of Colorectal Surgery is globally recognized as a leader in colorectal surgery and surgical innovation, attracting patients from around the world. Our team has one of the highest volumes of colorectal surgery in the nation and cure and our cure and survival rates are above the national average.

Colon Resection

Removal of a segment of the colon, also called a colectomy, is often done as a minimally invasive procedure, called laparoscopy, because of its benefits and comparable outcomes to open surgical procedures. Laparoscopy has evolved from requiring three or four incisions to a single-incision surgery. Depending on the location of the tumor, the segmental colectomy (removal of a portion of the colon) could be referred to as a right or left colectomy.

Total Colectomy

A total colectomy is the removal of the entire colon where the small bowel is reattached to the top of the rectum. This procedure is only used on occasions where patients have synchronous tumors (more than one cancer in the colon or rectum at the same time), or a strong family history of colorectal cancer, or a genetic condition that predisposes patients to developing colorectal cancer.

Transanal Resection

This advanced technique, in which a rectal tumor is removed by operating through the anus, can save a patient from needing a stoma (bag). This is offered for selected patients with early-stage rectal cancer.

Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

This multidisciplinary approach is used to treat hard-to-treat colorectal cancers that have spread to the lining of the abdominal cavity. HIPEC circulates a heated chemotherapy solution through the abdominal cavity for up to two hours to try and kill any cancer cells that may remain following surgery to remove all visible tumors (cytoreductive surgery). This new treatment option may significantly improve survival rates for patients with Stage IV colorectal cancer.

Robotic Colectomy (colon removal)

Cleveland Clinic colorectal surgeons also have added robotic colectomy to their range of minimally invasive surgical (MIS) treatment options for colorectal cancer. Robotically assisted surgery uses robotic equipment to imitate surgical movements. MIS procedures allow surgeons to operate through small ports rather than large incisions, resulting in shorter recovery times, fewer complications and reduced hospital stays. Surgical robotics combines minimally invasive techniques with highly advanced clinical technology.

How does the new technology assist the surgeon?

The 3-D vision system magnifies the surgical field up to 15 times and improves the surgeon’s ability to perform precise dissection of tissue, thereby reducing blood loss. Robot arms remain steady at all times and robot wrists make it easier for surgeons to manipulate tissue and work from all kinds of angles and positions they would have difficulty reaching otherwise.

After Surgery

Following surgery, patients typically stay two to five days in the hospital. During this time, the staff checks patients daily and provides detailed post-operative instructions at discharge. Patients are able to continue follow-up either at Cleveland Clinic or with their local physicians.

Medical Treatment

Medical treatment involves traditional anti-cancer drugs, including:

Chemotherapy – Chemotherapy regimens are complicated, but can preserve quality of life and extend life even in Stage IV disease. Commonly used chemotherapy regimens include FOLFOX, FOLFIRI and an oral agent called capecitabine (Xeloda®).

Chemotherapy is usually given intravenously, but one commonly used drug is available as tablets. Treatments vary in length, doses and the way the medications are given.

Side effects of chemotherapy for colon cancer are common but usually not serious. Most patients get nausea and inflammation of the lining of the mouth. Diarrhea and a feeling of pins and needles in the arms and legs may occur. There is not usually hair loss, and side effects go away after treatment.

Targeted therapy – This new generation of cancer drugs is specifically designed to affect particular targets on the surface of tumor cells or nearby blood vessels. These include antibodies such as bevacizumab (Avastin®), cetuximab (Erbitux®) or panitumumab (Vectibix®) or small molecule oral kinase inhibitors such as regorafenib (Stivarga®). These medications are generally added to enhance the effects of chemotherapy, but they may sometimes be used alone.

Personalized medicine approaches – Recent data shows that a “one-sizefits-all” approach does not work. Instead, personalizing medical care based an individual patient’s tumor characteristics is the best approach and is becoming more common. This is done through performing a genetic analysis of a tumor specimen to find out which medications are more likely to work. In clinical trials, Cleveland Clinic also is adopting a whole-genomic- based approach to help identify targets and drugs that may affect them.

Radiation Therapy

Radiation therapy is used in select cases to help control colon cancer. For example, colon cancer that has spread to the liver can be treated with radiation in some cases. Radiation can be delivered through machines that deliver high-energy X-ray and cause damage to the cancer cells leading to tumor shrinkage or control. The radiation may be delivered by special equipment that delivers radiation from outside the body (external beam radiation). New radiation techniques such as stereotactic body radiation (also called radiosurgery) are used to deliver large radiation doses to the tumor while sparing the normal liver from injury. In addition, radiation may also be delivered to some sites through an implant placed in the body (brachytherapy) or through small embolic beads (selective internal radiation therapy) that are delivered through the blood supply.

Stereotactic Body Radiation Therapy (SBRT)

Cleveland Clinic radiation oncologists have used stereotactic body radiation treatments (also known as radiosurgery) for treating metastases to the liver and lung. This treatment allows the radiation to be delivered in a small number of fractions or treatments that are concentrated to a well defined precise area. This technique allows better sparing of the normal structures, such as the liver and lung.

Liver Resection for Metastatic Colorectal Cancer

Long term survival is possible even when the colorectal tumor has spread to the liver (liver metastases). The combination of chemotherapy and advanced liver surgery, when possible and indicated, is very safe, usually very well tolerated by patients and represents the best treatment for colorectal liver metastasis. The liver is able to rapidly regenerate in case of need. This allows surgeons to remove a large amount of liver when needed.

Liver resection (removal of the tumor along with part of the healthy liver) can be achieved either using minimally invasive surgical techniques (laparoscopy) are through an incision (open liver resection). The technique used depends on location, number and size of liver metastasis.

Liver-Directed Therapy

For patients whose colon cancer has spread to the liver (stage IV), liver-directed therapies may be offered if it is not possible to remove the cancer surgically. These therapies, which may be used alone or with biologic agents, include:

Ablation – These approaches use extreme temperatures to destroy tumor cells. These treatments reduce the amount of liver tumor and can extend a patient’s life and ease symptoms.

Types of ablation include:

• Radiofrequency ablation – uses a needle-like probe to deliver heat to the tumor
• Microwave ablation – uses microwave to deliver heat to the tumor
• Irreversible electroporation – uses electrical fields to cause cancer cells to die while protecting non-cellular structures such as blood vessels and bile ducts

Radioembolization

This procedure uses radioactive (Y90) resin (SIR-Spheres®) or glass-based (TheraSphere®) particles that are delivered by catheter and provide a continuing radiation dose for approximately three and a half weeks to targeted tissues. While typically given as a third-line palliative treatment following first and second-line chemotherapy, Cleveland Clinic is participating in a study to see if it has any value earlier in treatment, in conjunction with second-line chemotherapy.

Follow-up Care

Follow-up care for colon cancer (after treatment is complete) is important. The disease sometimes returns — even when the cancer seems to have been completely removed or destroyed — because undetected cancer cells remain in the body after treatment. Regularly scheduled checkups help ensure that any changes in health are noted. Checkups may involve a physical exam including a digital rectal exam, lab tests, colonoscopy, X-rays, CT scans and other tests. You should call your doctor if any health problems appear between scheduled checkups.

Genetic Counseling

Hereditary cancer syndromes account for approximately 5 to 10 percent of colorectal cancer cases.

What about my family’s risk? Should I be concerned?

If your doctor suspects that the cause of your cancer is inherited or due to a specific genetic cause, he or she may recommend you see a genetic counselor for an evaluation. Genetic counselors can guide you through your diagnosis, provide education to help you better understand your condition, and identify risk to you and your family members. During a counseling session, they will:

• Obtain an extensive personal and family medical history
• Explain the natural history and inheritance of a hereditary colon cancer syndrome
• Discuss the testing process and options
• Evaluate the risks to other family members

Genetic counseling services are available at the Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia within Cleveland Clinic’s Digestive Disease Institute and the Genomic Medicine Institute.

Patient Services

Making Your Care Easier

Support Services

The life-changing events that occur when you or a loved one is diagnosed with cancer are challenging. Cleveland Clinic Cancer Center offers many services and programs to help you navigate those changes while promoting your well-being. Services include the 4th Angel Mentoring Program, educational resources, psycho-social programs, support groups, financial services, free wigs and a variety of wellness programs.

Survivorship clinic for colorectal cancer

Our clinic follows patients for long-term side effects, monitors them for recurrence of the cancer and can help arrange screening for family members.

Medical Concierge

If you are traveling from out of state and need any assistance, call the complimentary Medical Concierge at 800.223.2273, ext. 55580, or email medicalconcierge@ccf.org.

MyChart

This secure online tool connects patients to their own health information from the privacy of their home any time, day or night. Some features include renewing prescriptions, reviewing test results and viewing medications, all online. For the convenience of physicians and patients across the country, MyChart now offers a secure connection to Google™ Health. Google Health users can securely share personal health information with Cleveland Clinic, and record and share the details of their Cleveland Clinic treatment with the physicians and healthcare providers of their choice.

Virtual Second Opinion

If you cannot travel to Cleveland Clinic, help is available. You can connect with Cleveland Clinic specialists from any location in the world via a phone, tablet, or computer, eliminating the burden of travel time and other obstacles. If you’re facing a significant medical condition or treatment such as surgery, this program provides virtual access to a Cleveland Clinic physician who will review the diagnosis and treatment plan. Following a comprehensive evaluation of medical records and labs, you’ll receive an educational second opinion from an expert in their medical condition covering diagnosis, treatment options or alternatives as well as recommendations regarding future therapeutic considerations. You’ll also have the unique opportunity to speak with the physician expert directly to address questions or concerns.

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How Patient Registries Help Improve Care for Future Patients

Approximately 5% of all colorectal cancer occurs within a hereditary syndrome. This is when there are multiple family members, often across generations, who have colorectal cancer or other associated cancers.

The Digestive Disease & Surgery Institute is home to The David G. Jagelman Inherited Colorectal Cancer Registries, within the Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia. The mission of the Weiss Center is to prevent deaths from cancer through patient care and screening, education, and research. Conditions that are managed in the Weiss Center include:

• Lynch syndrome, including Hereditary Non-polyposis Colorectal Cancer (HNPCC),
• Familial Adenomatous Polyposis (FAP),
• Peutz-Jegher’s Syndrome (PJS),
• PTEN-Hamartoma Syndrome,
• Juvenile Polyposis (JP), and
• Serrated Polyposis. 

The David G. Jagelman Registries are among the largest in the world. Its staff members work with thousands of diagnosed and at-risk individuals to support them in their experiences. If you are concerned that there is a strong family history of cancer in your family, contact your physician to be evaluated for a possible hereditary syndrome, or contact the Weiss Center directly at 216.444.6470.

Contact Us

Still have questions?

Call our CancerAnswer Line. We are here to help you get the cancer information you need. Please contact Cleveland Clinic Cancer Answer Line at 866.223.8100. Two oncology clinical nurse specialists and their staff provide information and answer questions about cancer. The Cancer Answer Line operates from 8:30 a.m. to 4:30 p.m., Monday – Friday.

Ready to schedule an appointment with a specialist?

Cleveland Clinic Cancer Center provides patients with convenient locations throughout Northern Ohio for screening and treatment of colon and rectal cancer. In addition to Cleveland Clinic’s main campus, patients can visit Cleveland Clinic regional hospitals and family health centers. Every member of our colorectal cancer treatment team is committed to providing you with outstanding, comprehensive, efficient and compassionate care. To find a cancer specialist near you, call 866.223.8100.

Cleveland Clinic Cancer Specialists are located in Cleveland, regionally throughout Northern Ohio and in Florida. View a complete list of cancer care locations.

Why Choose Us?

A New Home for Cancer Care

When you visit Taussig Cancer Center, Cleveland Clinic’s new $276 million, 377,000-square-foot home for cancer care, some of its features are immediately apparent: expansive, welcoming spaces, the abundance of natural light, and the combination of clinical care and support services. A deeper look reveals a facility designed expressly to improve patient outcomes through a collaborative, multidisciplinary approach to cancer care. The new cancer building on Cleveland Clinic’s main campus, with 126 exam rooms and 98 treatment rooms, incorporates all outpatient cancer services under one roof. The building creates a seamless, personalized experience for patients and provides easy access to a variety of support services intended to reduce cancer’s psychological stress.

Choosing Your Colon and Rectal Cancer Care

While you have many options for the treatment of your cancer, you should consider the experience of the program when selecting where to seek care. Cleveland Clinic colorectal surgeons, medical oncologists, radiation oncologists and other cancer specialists work together to explore the best medical and surgical options to ensure the most successful outcome for each patient.

Our program unites all of the specialists you need in one convenient spot, so you get the care you need right away — without waiting for separate appointments with multiple doctors in various locations.

National Accreditation Program for Rectal Cancer

Cleveland Clinic’s rectal cancer program has earned a three-year accreditation from the National Accreditation Program from Rectal Cancer (NAPRC), a program launched in 2017 and administered by the American College of Surgeons (ACS). To earn this voluntary accreditation, Cleveland Clinic’s rectal cancer program met 19 standards, including the presence of a rectal cancer multidisciplinary team that includes clinical representatives from surgery, pathology, radiology, radiation oncology, and medical oncology.

Resources

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• Visit our Center for Young-Onset Colorectal Cancer, specializing in treating this disease in patients under age 50.
• Visit our Endoluminal Surgery Center, dedicated to delivering the highest quality of care for patients with precancerous and early cancerous lesions of the gastrointestinal tract.
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