General Information
Prognostic Factors
Risk Factors
Follow-up
Note: Separate PDQ summaries on Colorectal Cancer Screening; Colorectal Cancer Prevention; and Genetics of Colorectal Cancer are also available.
Information about colon cancer in children is available in the PDQ summary on Unusual Cancers of Childhood Treatment.
Note: Estimated new cases and deaths from colon cancer in the United States in 2008:[1]
- New cases: 108,070.
- Deaths (colon and rectal cancers combined): 49,960.
Note: Some citations in the text of this section are followed by a level of
evidence. The PDQ editorial boards use a formal ranking system to help the
reader judge the strength of evidence linked to the reported results of a
therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more
information.)
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.
Prognostic Factors
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.[2] Elevated pretreatment serum levels of carcinoembryonic antigen
(CEA) have a negative prognostic significance.[3] 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.[4-6] 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.[7-10]
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.[11-20]
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.[21] Treatment decisions depend on factors such as physician and patient preferences and the stage of the disease rather than the age of the patient.[22-24] 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.[25]
Risk Factors
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.[26,27] 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.[28][Level of evidence: 3iiiA] 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.[29,30] 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.[31] (Refer to the PDQ summaries on Colorectal Cancer Screening and Colorectal Cancer Prevention for more information.)
Follow-up
Following treatment of colon cancer, periodic evaluations may lead to the
earlier identification and management of recurrent disease.[32-35] 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.[36-40] 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:[41]
- A CEA level is not a valuable screening
test for colorectal cancer because of the large numbers of false-positive and
false-negative reports.
- Postoperative CEA testing should be restricted to
patients who would be candidates for resection of liver or lung metastases.
- Routine use of CEA levels alone for monitoring response to treatment should not be
recommended.
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.[38-40] New surveillance methods,
including CEA immunoscintigraphy [42] and positron emission tomography,[43] are
under clinical evaluation.
Gastrointestinal stromal tumors can occur in the colon. (Refer to the PDQ
summary on Adult Soft Tissue Sarcoma Treatment for more information.)
References
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