Colorectal cancer is the most frequent in the gastrointestinal tract and is one of the main causes of death from cancer. In Italy, 51,300 new cases were estimated in 2018. In the Italian population it is the third most frequent in man, preceded from lung and prostate cancers, while in women it ranks second, after breast (breast) cancer.
Colon cancer is localized in the part of intestine also defined large intestine, while rectal cancer develops in the last intestinal tract (Video).
About 80% of colorectal cancers develop from pre-existing formations, the so-called polyps, small growths, initially benign, which can become malignant within 7-15 years. As a form of prevention it is advisable to undergo control programs (screening) that make it possible to identify and eliminate polyps before they acquire dangerous characteristics.
The disease mainly affects the population from 60 years of age and is very rare before the age of 40.
The checks to identify benign intestinal polyps and colorectal tumors in the initial stages are part of the prevention programs offered free of charge by the National Health Service (read the Hoax).Symptoms
The main disorders (symptoms) caused by colorectal cancers are:
- presence of blood in the stool
- impaired bowel motility, constipation or diarrhea
- weight loss with no apparent cause
- pain localized in the abdomen or anus
- abdominal bloating
- anal itching
Such disorders (symptoms) do not always indicate the presence of colorectal cancer as they can be associated with many other intestinal diseases:
- blood in the stool, it could also be caused by hemorrhoids or inflammation of various origins
- abdominal pain, could be caused by the type of food ingested
- motility (peristalsis) of the intestine, it may have been changed after taking laxatives
If, within a few weeks, intestinal disorders do not improve, it is necessary to consult a specialist who will prescribe the most suitable clinical investigations to find out the cause.
Since colorectal cancer, in its initial state, does not cause disorders (symptoms), people who have one or more risk factors must undergo periodic check-ups.
The exact causes of colorectal cancer are not known, but there are numerous factors that can increase the risk of developing it:
- age,the disease mainly affects people over sixty "years of age
- diet, a diet rich in animal fats, red meats, sausages and low in fiber is associated with an increase in colorectal cancers; on the contrary, diets rich in fiber with consumption of fruit and vegetables seem to have a protective role for this type of tumor
- obesity, smoking, sedentary lifestyle and heavy alcohol consumption they increase the risk of colorectal cancer
- ulcerative colitis or Crohn's disease
- genetic factors, it is possible to inherit the risk of getting colorectal cancer if some diseases that predispose to the formation of intestinal tumors have occurred in the family of origin, such as, for example:
- familial adenomatous polyposis (FAP), a disease characterized by the presence of hundreds or thousands of adenomatous polyps that can transform (evolve) into malignant forms
- Lynch syndrome, an inherited form of colon cancer
Thanks to information campaigns to promote controls (screening) in the population, it is possible to ascertain (diagnose) colorectal cancer in the initial (early) stages, when it does not yet cause disturbances (symptoms) and is more treatable.
There are several forms of classification (staging) of the severity of the tumor. The most used refers to the TNM system which indicates with the letter T the size of the tumor; with the letter N the number of lymph nodes involved and with the letter M the spread, or not, of the tumor to other parts of the body (metastasis).
The assessment (diagnosis) of colorectal cancer is based both on a medical examination (clinical examination) and on laboratory and instrumental analyzes such as, for example, colonoscopy or CT scan.
The clinical examination consists of palpation of the belly (abdomen) to look for any tumors in the intestine and exploration of the rectum to check for the presence of a tumor in this area of the body.
Instrumental investigations include:
- rectosigmoidoscopy, an endoscopic examination which consists in "introducing through the anus a thin flexible probe, equipped with a camera, which allows you to view the" last part of the intestine (the sigma and the rectum)
- colonoscopy, specific investigation to ascertain this type of tumors through the "exploration of the internal walls (mucous membranes) of the large intestine and rectum.
It is an invasive procedure, performed on an outpatient basis by the doctor in collaboration with the nurse and, in the case of sedation, with the anesthetist. It consists in the introduction into the rectum, and its progression through the whole colon, of a thin flexible tube (colonoscope) of variable length containing a small camera and one or more channels through which to introduce, or aspirate, gases, liquids and surgical instruments ( biopsy forceps, needles) to remove any polyps and / or to take small amounts of tissue (biopsy) to be analyzed under a microscope.
The duration of the examination is linked to the specific situation of the person who undergoes it. In cases where no particular problems are highlighted, the colonoscopy can be performed in about 15/20 minutes. If, on the other hand, there is the need to remove some intestinal polyps, or to carry out biopsies, the examination can last up to 30/60 minutes.
At the end of the investigation it is possible to go home. If sedation has been performed, usually, it is necessary to remain under control for about two hours and it is advisable to be accompanied home by a family member, or by a trusted person, because for about 12 hours it is not recommended to drive the car
- virtual colonoscopy, radiological examination performed through a simple CT scan. It is a less invasive method than traditional colonoscopy as it does not require the use of any endoscopic probe and, therefore, does not cause particular discomfort
In addition to the tests for the evaluation of the functionality of the different organs, carried out on the sampling of a small amount of blood from a vein in the arm, by means of simple laboratory analyzes it is possible to evaluate:
the CEA, L"carcino-embryo antigen (CEA), a tumor marker (tumor marker), generally increased in the presence of the tumor and valid for following the course of the disease and evaluating the effectiveness of treatments. The value of the CEA, in fact, decreases if the therapies have had the desired effects
If the results of the investigations highlight the presence of a tumor (positivity), other tests are performed to evaluate its extension and aggressiveness:
- CT scan to the abdomen and chest to check if the tumor has spread to other parts of the intestine or to the lungs. In some cases the examination may involve the administration of a contrast medium, a liquid containing iodine, which makes the images clearer. In this case it is necessary to have fasted for at least 6 hours and to undergo some blood tests to evaluate the function of the kidneys and liver.
- nuclear magnetic resonance (NMR), an examination that uses magnetic fields to process detailed images not only of the skeleton and joints but also of the internal structures of the organism. It can be useful for establishing the extent of the tumor and obtaining important information for planning a subsequent surgery
Colorectal cancer therapy includes different types of interventions based on the stage and grade of the cancer.
The main cure is surgery. If the cancer is in an early (early) stage of its development, only the small part of the colon wall affected by the disease can be removed. local excision. If the tumor is more extensive, it is necessary to completely remove the affected part of the colon and, if possible, rejoin the two parts of the intestine located above and below the eliminated part to fully recover intestinal function. In some cases, this is not possible and it is necessary to create an opening in the abdominal wall, temporary or permanent, for the escape of stool (ostomy). In people with an ostomy, both physical and psychological rehabilitation plays a fundamental role in learning how to manage daily problems and to improve the quality of life, also understood as participation in social relationships.
Surgical therapy, more often than not, is accompanied by other types of treatments.
Chemotherapy is the administration of drugs to reach and kill cancer cells throughout the body through the bloodstream. It plays an important role in both the treatment of operable and inoperable disease. Chemotherapy drugs can be administered:
- before surgery to reduce the extension of the tumor (neoadjuvant therapy) thus facilitating subsequent surgery by the surgeon
- after surgery to prevent the recurrence of relapses (relapses)
- to slow the progression of the disease in cases of inoperable tumors
Radiation therapy consists in the use of controlled doses of high-energy radiation to destroy cancer cells and, at the same time, not cause damage to healthy tissues. It is used both before surgery to reduce the size of the tumor mass and to slow the progression of the disease in cases of inoperable tumors. It can be performed:
- from the outside, using a special machine that releases waves on the intestine to kill cancer cells
- from the inside, through a radioactive tube inserted into the anus and placed near the tumor (brachytherapy)
Important results in the treatment of colorectal cancers have been obtained with biological drugs. These medicines (for example, bevacizumab, cetuximab, panitumumab), used in combination with chemotherapy, are able to interact with some proteins found on the surface of cancer cells (for example VEGF, vascular endothelial growth factor and EGFR, the epidermal growth factor receptor) and to interfere with their function to slow down or block the growth of the tumor mass. Biological drugs, however, can only be used in people with certain genetic characteristics (presence of mutations in some specific genes) and in particular stages of the disease.Prevention
The colorectal cancer is a disease characterized by a high number of new cases and a "high mortality. Nevertheless, thanks to prevention and its detection in the initial stages of development (early diagnosis), before it causes disturbances (symptoms), today it is increasingly curable.
Controls (screening) to detect colorectal cancer are part of a prevention program organized and proposed by the National Health Service, every two years, to all people between 50 and 69 years of age. The most common test, which allows to identify any lesions in the initial stages, is the search for occult blood in the faeces. Thanks to prevention, in 5 years (2014-2019) the number of these tumors has significantly decreased with a reduction in internal mortality of 20%. In Italy, however, there are strong territorial differences both in the adhesion and in the coverage of the test, in particular the coverage is 92% North, 95% Center, 50% South, and membership 52% North, 35% Center, 24% South. Rectosigmoidoscopy is foreseen only in some Italian regions in the field of screening, to be performed once between 58 and 60 years of age. If the checks show the presence of blood in the stool, the person who has undergone the examination will be invited to perform further tests such as, for example, a colonoscopy.
To reduce the risk of developing colorectal cancer, there are many aspects to consider regarding lifestyle:
- movement, practicing physical activity every day has a highly protective function to avoid the development of this type of tumor
- diet, avoiding eating animal fats, red meats, cured meats and increasing the consumption of fruit, vegetables and fiber can reduce the risk of colorectal cancer
- body weight, the risk of developing colorectal cancer increases with obesity. Consequently, it is advisable to try to maintain a healthy weight
- alcohol, limit alcohol to one glass of wine per meal
- smoke, stop smoking
Colorectal cancer can affect the daily life of those affected in different ways depending on the stage of the cancer and the treatment given.
Currently, about 470 thousand people live in Italy after being diagnosed with colorectal cancer and survival records a significant and constant increase in both genders.
It is therefore advisable to be well informed about the disease and the treatments available.
The new drug-based therapies to be taken orally are certainly an important novelty because they are easier to take by patients who, having to go to the hospital less frequently, can maintain their daily habits. For a good result it is essential that the therapy is followed with great attention, keeping in mind the relevance of the drug you are taking. Oncologists believe that keeping a diary can be of great help to patients and doctors themselves.
In addition, maintaining a positive mental attitude can help the body better cope with the disease and subsequent therapies. The most difficult period is represented by the end of treatment in the hospital since leaving this structure can cause a sense of loneliness and uncertainty.
If this happens, it can be useful:
- sharing their problems, feelings and fears with friends and family to receive support and comfort
- participate in psychological support groups for colorectal cancer to get to know other people who live the same experience
- be informed about all aspects of the disease
Italian Association of Cancer Patients, Relatives and Friends (AIMaC). Colorectal Cancer Symptoms
Italian Association for Cancer Research (AIRC). Colorectal cancer
Italian Association of Medical Oncology (AIOM). AIOM guidelines 2019- Colon cancers