Fighting and

Killing
Colon Cancer Cells
Prepared by: Prof. Ped Salvador
March 11, 2009
 Good News:
Survivor Experience
Terry – Colon Cancer
• Hearing the words "you have cancer" is bad enough, but after the operation that
removed the tumor and part of my colon, I was informed that they also removed a small
tumor from my liver, which meant the cancer had metastasized. The oncologist did not
look too happy when he told me I was in stage 4. I must have been in total denial
because I really didn't believe this was happening to me. I had it all - a good marriage -
two great kids – a job I liked - good friends and about to become a grandmother. Maybe
life was a little too good. The chemotherapy that was selected for my cancer was infused
through a port-acath. I received about a teaspoon daily for 4 months.
• The side effects were minimal – no hair loss or nausea but other small inconveniences
which were bearable. You can imagine the anxiety I felt when I went for my first CT scan
but the news was good and it has been good for the past 14 years. I had one doctor tell
me he did not believe that I had this type of cancer and was still living until he saw the
reports. Why am I a survivor? I ask myself that question everyday when I thank God.
Maybe I needed to see my first granddaughter who was born later that year, or her sister
born 4 years later - or to see my two little grandsons, one of which was just born or
maybe I am still needed. I don't know the answer but if I did I would wish it for all the
cancer patients. It's been 14 years - I still think about it everyday and am so grateful to
the doctors who treated me and my family for their support. Courage and hope to all the
cancer patients. You are in my thoughts and prayers.

2
 Good News:
Survivor Experience
Scott Hamilton – A survivor!
• I remember I was tired. I thought I was just overworked, I mean I was on tour, skating,
traveling, doing a million things. But then I had trouble standing up straight. I have to
say I was in pain, but I still thought it
was from indigestion or something minor. I never imagined what was in store for me. I
went to a physician in Peoria, Illinois, and suddenly I was having all these tests, scary
tests. It all happened really fast, but one thing I
remember so clearly. I'll never forget when I first heard the words "You have cancer." At
first, I was petrified. I was in shock. I couldn't believe it. A lot of things go through your
mind, and sometimes all the thoughts aren't so good. But then, I made up my mind that
I would fight and that I could do it. That's when I first said, "The only disability in life is a
bad attitude." I really believe that. I had so much support from my friends and family
and the great folks at The Cleveland Clinic. There were some tough times, but the
chemotherapy wasn't as bad as I thought it was going to be. I was able to manage it
and make it and I know that other people can too.
I have learned a lot from my experience going through testicular cancer, but I guess
what I want to say is that the experience wasn't as bad as what I feared. The fear was
worse. If people can get information, they can overcome their fear and make it through.
I did it and you can too.

3
 Good News:
Survivor Experience
Greg - 6 Lessons I learned from my cancer
• Lesson #1: Many more people genuinely care about you than you can possibly
know - and they are ready to do everything in their power to help you through
your treatment.
• Lesson #2: God is NOT mean - sometimes bad things happen to good people.
• Lesson #3: All big words have simple explanations - you just have to keep
asking until you get it.
• Lesson #4: Not all doctors are very good; but some doctors are outstanding;
and personally dedicated to making you get well again. The same can be said
for Nurses, Radiation Techs, and Receptionists. Take the time to find the really
good ones.
• Lesson #5: It's OK to have a bad day. You're sick; you don't have to happy
about it.
• Lesson #6: You're a LOT tougher than you think you are - you CAN DO this.

4
 Good News:
Survivor Experience
Benjamin - Lung Cancer
I am 76 years old and I have one foot in the grave and the other is on a banana
peel, but life is a ball. In 1998 when I was a young man of 70, I was informed that
I had a growth in my left lung. After a few examinations and a needle biopsy, I
was informed it was a cancerous growth. After consultation with an Internist, a
Pulmonologist, a Cardiothoracic Sugeon and an Oncologist (here I would like to
wish that you all would have as wonderful a group of doctors and nurses as I
had), it was decided that chemotherapy and surgery would be our course of
action. This was accomplished. In January of 2002, it was discovered that I had a
tumor in the upper portion of my left lung. A biopsy indicated it was cancerous.
This time chemo and radiation was the prescribed treatment and it was
successful in eliminating the tumor. I mention this only to indicate I know of what
I speak. Do no let Cancer end your Life. Wade in with Faith, Humor, and Resolve
to survive and enjoy what ever length of time you have left on this green earth.
We will all die at some point, it is the living that we must face, conquer and
manage. Faith is a strong ally and is never to be overlooked. Humor is the
lubricant for an enjoyable Life, both for you and those around you. Resolve is the
determination to fight for every moment of enjoyment life has to offer. Let no
one "rain on your parade."

5
 What is cancer?

• Cancer is a group of more

than 100 different
diseases.
• They affect the body's
basic unit, the cell.
• Cancer occurs when
cells become abnormal
and divide without
control or order.

6
 Colon and Rectum
• Like all other organs of the
body, the colon and rectum
are made up of many types
of cells. Normally, cells
divide to produce more
cells only when the body
needs them. This orderly
process helps keep the
body healthy.

7
 What is cancer?

• If cells keep dividing when new cells are

not needed, a mass of tissue forms. This
mass of extra tissue, called a growth or
tumor, can be benign or malignant.

• Benign tumors are not cancer. They can

usually be removed and, in most cases,
they do not come back. Most important,
cells from benign tumors do not spread to
other parts of the body. Benign tumors are
rarely a threat to life.
8
 What is cancer?

• Malignant tumors are cancer. Cancer cells can invade and

damage tissues and organs near the tumor. Also, cancer cells
can break away from a malignant tumor and enter the
bloodstream or lymphatic system. This is how cancer spreads
from the original (primary) tumor to form new tumors in other
parts of the body. The spread of cancer is called metastasis.

• When cancer spreads to another part of the body, the new

tumor has the same kind of abnormal cells and the same
name as the primary tumor. For example, if colon cancer
spreads to the liver, the cancer cells in the liver are colon
cancer cells. The disease is metastatic colon cancer (it is not
liver cancer).

9
 What is cancer of the
colon ?
• The colon is the part of the digestive system where
the waste material is stored. The rectum is the end
of the colon adjacent to the anus.
• Together, they form a long, muscular tube called
the large intestine (also known as the large bowel).
• Tumors of the colon and rectum are growths arising
from the inner wall of the large intestine.
• Benign tumors of the large intestine are called
polyps. Malignant tumors of the large intestine are
called cancers.
• Benign polyps do not invade nearby tissue or
spread to other parts of the body.

10
 What is cancer of the
colon ?
• Benign polyps can be easily removed during colonoscopy
and are not life-threatening. If benign polyps are not
removed from the large intestine, they can become
malignant (cancerous) over time.
• Most of the cancers of the large intestine are believed to
have developed from polyps. Cancer of the colon and
rectum (also referred to as colorectal cancer) can invade
and damage adjacent tissues and organs.
• Cancer cells can also break away and spread to other parts
of the body (such as liver and lung) where new tumors form.
The spread of colon cancer to distant organs is called
metastasis of the colon cancer. Once metastasis has
occurred in colorectal cancer, a complete cure of the cancer
is unlikely.

11
 Colon Anatomy
• The colon is the
last portion of the
digestive system in
most vertebrates;
it extracts water
and salt from
solid wastes before
they are eliminated
from the body.

12
 Colon Sections
• The colon consists
of four sections:
the ascending
colon, the
transverse colon,
the descending
colon, and the
sigmoid colon.

13
 Colorectal Cancer
• Colorectal cancer, also called
colon cancer or large bowel
cancer, includes cancerous growths
in the colon, rectum and appendix.
• It is the third most common form of
cancer and the second leading cause
of cancer-related disease in the
Western world.

14
 Colorectal Cancer
• Many colorectal cancers are thought to arise from
adenomatous polyps in the colon. These
mushroom-like growths are usually benign, but
some may develop into cancer over time.
• The majority of the time, the diagnosis of
localized colon cancer is through colonoscopy.
• Therapy is usually through surgery, which in
many cases is followed by chemotherapy.

15
16
 Causes
• In general, cancer occurs when healthy cells become altered.
Healthy cells grow and divide in an orderly way to keep your
body functioning normally.

• But sometimes this growth gets out of control — cells continue

dividing even when new cells aren't needed. In the colon and
rectum, this exaggerated growth may cause precancerous cells
to form in the lining of your intestine.
• Over a long period of time — spanning up to several years —
some of these areas of abnormal cells may become cancerous.

• In later stages of the disease, colon cancer may penetrate the

colon walls and spread (metastasize) to nearby lymph nodes or
other organs.

17
Precancerous growths in the
colon
• Precancerous cells can occur anywhere in your large
intestine, the muscular tube that forms the last part of
your gastrointestinal tract. The colon comprises the
upper 4 to 5 feet of your large intestine, and the rectum
makes up the lower 6 inches.

• Precancerous growths most commonly occur as clumps

of cells (polyps) that extend from the wall of the colon.
Polyps can appear mushroom-shaped. Precancerous
growths can also be flat or recessed into the wall of the
colon (nonpolypoid lesions). Nonpolypoid lesions are
more difficult to detect, but are less common.

18
Polyps

19
 Several types of colon
polyps
Among the most common are:
• Adenomas. These polyps have the potential to become
cancerous and are usually removed during screening
tests such as flexible sigmoidoscopy or colonoscopy.
• Hyperplastic polyps. These polyps are rarely, if ever, a
risk factor for colorectal cancer.
• Inflammatory polyps. These polyps may follow a bout
of ulcerative colitis. Some inflammatory polyps may
become cancerous, so having ulcerative colitis increases
your overall risk of colon cancer

20
Polyps

21
 Symptons
• Colon cancer can be present for several
years before symptoms develop.

• Colon cancer often causes no symptoms

until it has reached a relatively advanced
stage. Thus, many organizations
recommend periodic screening for the
disease with fecal occult blood testing and
colonoscopy

22
 Symptons
• Symptoms vary according to where in the large bowel the
tumor is located. The right colon is spacious, and cancers
of the right colon can grow to large sizes before they cause
any abdominal symptoms.
• Typically, right-sided cancers cause iron deficiency anemia
due to the slow loss of blood over a long period of time.
Iron deficiency anemia causes fatigue, weakness, and
shortness of breath. The left colon is narrower than the
right colon. Therefore, cancers of the left colon are more
likely to cause partial or complete bowel obstruction.
• Cancers causing partial bowel obstruction can cause
symptoms of constipation, narrowed stool, diarrhea,
abdominal pains, cramps, and bloating. Bright red blood in
the stool may also indicate a growth near the end of the
left colon or rectum.

23
Bowel Symptoms Details
Change in bowel habits
– change in frequency (constipation and/or diarrhea),
– change in the quality of stools
– change in consistency of stools
• Bloody stools or rectal bleeding
• Stools with mucus
• Tarry stools (melena) (more likely related to upper
gastrointestinal i.e. stomach or duodenal disease)
• Feeling of incomplete defecation (tenesmus) (usually
associated with rectal cancer)
• Reduction in diameter of feces
• Bowel obstruction (rare)

24
 Constitutional Symptoms
Details
• Especially in the cases of cancer in the
ascending colon, sometimes only the less
specific constitutional symptoms will be found:
• Anemia, with symptoms such as dizziness,
malaise and palpitations. Clinically there will
be pallor and a complete blood picture will
confirm the low hemoglobin level.
• Anorexia
• Asthenia, weakness
• Unexplained weight loss.

25
 Metastatic Symptoms
Details
• There may also be symptoms attributed to
distant metastasis:
• Shortness of breath as in lung metastasis
• Epigastric or right upper quadrant pain, as
in liver metastasis. Rarely there can be
jaundice if the outflow of bile is blocked.
Clinically there might be liver enlargement
.

26
 Tumor

• The term tumor is derived from the Latin term

tumor or "swelling". It originally meant an
abnormal swelling of the flesh. In contemporary
English, tumor is synonymous with solid
neoplasm (abnormal proliferation of cells), while
all other forms of swelling are called swelling.
• Furthermore, this usage is common in medical
literature where the nouns tumefaction and
tumescence derived from the adjective
tumefied. These nouns are also the current
medical terms for non-neoplastic swelling.

27
 Diagnosis

• Specific and correct diagnosis can only be

rendered by a biopsy or skin biopsy. The
biopsy is submitted to a laboratory and a
pathology report is generated.
• Clinical diagnosis is by clinical history,
visual diagnosis often with dermatoscopy,
and palpation. But clinical diagnosis can
only be confirmed by a biopsy.

28
 Cause
• A neoplasm is an abnormal proliferation of tissues, usually
caused by genetic mutations. Most neoplasms cause a
tumor, with a few exceptions like leukemia or
carcinoma in situ.
• Other causes of tumor development include exposure to
chemicals and toxins like benzene, excessive alcohol and
tobacco consumption, excessive exposure to sunlight and/or
radiation, or an inactive sedentary lifestyle and obesity.
• Certain viruses can also play a role in the development of
tumors, such as cervical cancer (human papillomavirus) and
hepatocellular carcinoma (hepatitis B virus).
•
Tumors may be benign, pre-malignant or malignant. The
nature of the tumor is determined by a pathologist after
examination of the tumor tissues from a biopsy or a
surgical excision specimen

29
 Infectiousness of tumor
cells
• Tumor cells are generally not infective to
individuals other than the host.
• The reason behind this is the presence of MHC
proteins which are host-specific and help the
immune system distinguish between the self and
non-self.
• These proteins are present on the surface of the
cells and produces vigorous immune response if a
foreign cell is found in the body.
• However, tumor can be transplanted in an
individual if its immune system is compromised.

30
 Treatment

• Treatment depends on the size and type of the tumor,

the initial location of the tumor, and the general health
of the person. The goals of treatment may be relief of
symptoms, improved comfort or functioning.
• Tumor treatment also varies based on whether it is in
benign or malignant condition. If the tumor is benign
(has no potential to spread) and is located in a area
where it will not cause any symptoms or disrupt the
proper functioning of the organ, most often no treatment
is needed.
• However, benign tumors may be removed for cosmetic
reasons. If a tumor is malignant, possible treatments
include surgery, chemotherapy, radiation, or a
combination of these procedures.

31
 Treatment
• If the cancer is confined to only one location, the
purpose of treatment is usually surgical removal of
the malignant tumor and treatment.
• In some circumstances, if the malignant tumor has
spread only to local lymph nodes, these may also be
removed.
• If all of the cancer cannot be removed with surgery,
the options for treatment include radiation and
chemotherapy, or combination of these methods.
• In contrast, lymphoma usually is not treated with
surgery and chemotherapy; and radiation therapy
may be the possible treatment [

32
 Pathology

• The pathology of the tumor is • Histopathologic image

usually reported from the
analysis of tissue taken from a of colonic carcinoid
biopsy or surgery. stained by
• A pathology report will usually hematoxylin and
contain a description of eosin.
cell type and grade.
• The most common colon
cancer cell type is
adenocarcinoma which
accounts for 95% of cases.
• Other, rarer types include
lymphoma and
squamous cell carcinoma.

33
 Pathology
• Cancers on the right side (ascending
colon and cecum) tend to be exophytic,
that is, the tumor grows outwards from
one location in the bowel wall.
• This very rarely causes obstruction of
feces, and presents with symptoms
such as anemia.
• Left-sided tumors tend to be
circumferential, and can obstruct the
bowel much like a napkin ring.
34
 Histopathology:
• Adenocarcinoma is a malignant epithelial
tumor, originating from glandular
epithelium of the colorectal mucosa.
• It invades the wall, infiltrating the
muscularis mucosae, the submucosa and
thence the muscularis propria.
• Tumor cells describe irregular tubular
structures, harboring pluristratification,
multiple lumens, reduced stroma ("back to
back" aspect).

35
 Histopathology:
• Sometimes, tumor cells are discohesive and secrete
mucus, which invades the interstitium producing large
pools of mucus/colloid (optically "empty" spaces) -
mucinous (colloid) adenocarcinoma, poorly differentiated.
• If the mucus remains inside the tumor cell, it pushes the
nucleus at the periphery - "signet-ring cell."
• Depending on glandular architecture, cellular
pleomorphism, and mucosecretion of the predominant
pattern, adenocarcinoma may present three degrees of
differentiation: well, moderately, and poorly differentiated.

36
Tumor Growth

37
Colorectal Cancer

38
 Colon polyps and colon
cancer
• Doctors believe that most colon cancers develop in
colon polyps. Therefore, removing benign colon polyps can
prevent colorectal cancer.
• Colon polyps develop when chromosome damage occurs in
cells of the inner lining of the colon. Chromosomes contain
genetic information inherited from each parent.
• Normally, healthy chromosomes control the growth of cells
in an orderly manner. When chromosomes are damaged,
cell growth becomes uncontrolled, resulting in masses of
extra tissue (polyps). Colon polyps are initially benign.
• Over years, benign colon polyps can acquire additional
chromosome damage to become cancerous.

39
 Risk Factor: Growing
Polyps
• Adenomatous polyps, are a
risk factor for colon cancer.
The removal of colon polyps
at the time of colonoscopy
reduces the subsequent risk
of colon cancer.
• This polyps carries a near
100% risk of developing
colorectal cancer by the age
of 40 if untreated.

40
 Risk Factor: Diet
• Studies show that a diet high in red meat and
low in fresh fruit, vegetables, poultry and fish
increases the risk of colorectal cancer. In June
2005, a study by the
European Prospective Investigation into Cancer and
an
suggested that diets high in red and
processed meat, as well as those low in fiber,
are associated with an increased risk of
colorectal cancer.
• Individuals who frequently ate fish showed a
decreased risk.
41
 Diet and colon cancer

• Diets high in fat are believed to predispose

humans to colorectal cancer. In countries with
high colorectal cancer rates, the fat intake by
the population is much higher than in countries
with low cancer rates.
• It is believed that the breakdown products of
fat metabolism lead to the formation of cancer-
causing chemicals (carcinogens).
• Diets high in vegetables and high-fiber foods
such as whole-grain breads and cereals may
rid the bowel of these carcinogens and help
reduce the risk of cancer.

42
 Risk Factor: Ulcerative
colitis and colon cancer
• Chronic ulcerative colitis causes inflammation of the inner
lining of the colon. Colon cancer is a recognized complication
of chronic ulcerative colitis. The risk for cancer begins to rise
after eight to 10 years of colitis. The risk of developing colon
cancer in a patient with ulcerative colitis also is related to the
location and the extent of his or her disease.
• Current estimates of the cumulative incidence of colon
cancer associated with ulcerative colitis are 2.5% at 10
years, 7.6% at 30 years, and 10.8% at 50 years. Patients at
higher risk of cancer are those with a family history of colon
cancer, a long duration of colitis, extensive colon
involvement, and those with primary sclerosing cholangitis
(PSC).

43
 Ulcerative colitis and colon
cancer
• Since the cancers associated with ulcerative colitis
have a more favorable outcome when caught at an
earlier stage, yearly examinations of the colon often
are recommended after eight years of known
extensive disease.
• During these examinations, samples of tissue
(biopsies) can be taken to search for precancerous
changes in the lining cells of the colon. When
precancerous changes are found, removal of the
colon may be necessary to prevent colon cancer.

44
 Risk Factor: Genetics and
colon cancer
• A person's genetic background is an important factor in
colon cancer risk. Among first-degree relatives of colon
cancer patients, the lifetime risk of developing colon
cancer is 18% (a threefold increase over the general
population in the United States).
• Even though family history of colon cancer is an important
risk factor, majority (80%) of colon cancers occur
sporadically in patients with no family history of colon
cancer. Approximately 20% of cancers are associated with
a family history of colon cancer.
• And 5 % of colon cancers are due to hereditary colon
cancer syndromes. Hereditary colon cancer syndromes are
disorders where affected family members have inherited
cancer-causing genetic defects from one or both of the
parents.

45
 Genetics and colon
cancer
• Chromosomes contain genetic information, and
chromosome damages cause genetic defects that lead to
the formation of colon polyps and later colon cancer.
• In sporadic polyps and cancers (polyps and cancers that
develop in the absence of family history), the chromosome
damages are acquired (develop in a cell during adult life).
• The damaged chromosomes can only be found in the polyps
and the cancers that develop from that cell. But in
hereditary colon cancer syndromes, the chromosome
defects are inherited at birth and are present in every cell
in the body.
• Patients who have inherited the hereditary colon cancer
syndrome genes are at risk of developing large number of
colon polyps, usually at young ages, and are at very high
risk of developing colon cancer early in life, and also are at
risk of developing cancers in other organs.

46
 Genetics and colon
cancer
• FAP (familial adenomatous polyposis) is a hereditary
colon cancer syndrome where the affected family members
will develop countless numbers (hundreds, sometimes
thousands) of colon polyps starting during the teens.
• Unless the condition is detected and treated (treatment
involves removal of the colon) early, a person affected by
familial polyposis syndrome is almost sure to develop colon
cancer from these polyps.
• Cancers usually develop in the 40s. These patients are also at
risk of developing other cancers such as cancers in the
thyroid gland, stomach, and the ampulla (the part where the
bile ducts drain into the duodenum just beyond the stomach).

47
 Genetics and colon
cancer
• AFAP (attenuated familial adenomatous polyposis) is a milder
version of FAP. Affected members develop less than 100 colon polyps.
Nevertheless, they are still at very high risk of developing colon
cancers at young ages. They are also at risk of having gastric polyps
and duodenal polyps.

• HNPCC (hereditary nonpolyposis colon cancer) is a hereditary

colon cancer syndrome where affected family members can develop
colon polyps and cancers, usually in the right colon, in their 30s to 40s.
Certain HNPCC patients are also at risk of developing uterine cancer,
stomach cancer, ovarian cancer, and cancers of the ureters (the tubes
that connect the kidneys to the bladder), and the biliary tract (the
ducts that drain bile from the liver to the intestines).

• MYH polyposis syndrome is a recently discovered hereditary colon

cancer syndrome. Affected members typically develop 10-100 polyps
occurring at around 40 years of age, and are at high risk of developing
colon cancer.

48
 What tests can be done to
detect colon cancer?
• When colon cancer is suspected, either a lower
GI series (barium enema x-ray) or colonoscopy
is performed to confirm the diagnosis and to
localize the tumor.
• A barium enema involves taking x-rays of the
colon and the rectum after the patient is given
an enema with a white, chalky liquid
containing barium. The barium outlines the
large intestines on the x-rays. Tumors and
other abnormalities appear as dark shadows
on the x-rays.
49
 What tests can be done to
detect colon cancer?
• Colonoscopy is a procedure whereby a doctor inserts a
long, flexible viewing tube into the rectum for the
purpose of inspecting the inside of the entire colon.
• Colonoscopy is generally considered more accurate than
barium enema x-rays, especially in detecting small
polyps. If colon polyps are found, they are usually
removed through the colonoscope and sent to the
pathologist.
• The pathologist examines the polyps under the
microscope to check for cancer. While the majority of the
polyps removed through the colonoscopes are benign,
many are precancerous. Removal of precancerous
polyps prevents the future development of colon cancer
from these polyps. For more information, please read the
Colonoscopy article.

50
 What tests can be done to
detect colon cancer?
• If cancerous growths are found during colonoscopy, small
tissue samples (biopsies) can be obtained and examined
under the microscope to confirm the diagnosis.
• If colon cancer is confirmed by a biopsy, staging
examinations are performed to determine whether the
cancer has already spread to other organs. Since colorectal
cancer tends to spread to the lungs and the liver, staging
tests usually include chest x-rays, ultrasonography, or a
CAT scan of the lungs, liver, and abdomen.
• Sometimes, the doctor may obtain a blood test for
CEA (carcinoembyonic antigen). CEA is a substance
produced by some cancer cells. It is sometimes found in
high levels in patients with colorectal cancer, especially
when the disease has spread.

51
 Colonoscopy
• A lighted probe called a
colonoscope is inserted into
the rectum and the entire
colon to look for polyps and
other abnormalities that may
be caused by cancer. A
colonoscopy has the
advantage that if polyps are
found during the procedure
they can be immediately
removed. Tissue can also be
taken for biopsy.

52
Grown Polyps

53
Full Grown Tumor

54
 Staging

• Colon cancer staging is an estimate of the

amount of penetration of a particular
cancer.
• It is performed for diagnostic and research
purposes, and to determine the best
method of treatment.
• The systems for staging colorectal cancers
largely depend on the extent of local
invasion, the degree of lymph node
involvement and whether there is distant
metastasis.
55
Tumor Stages

56
 Staging
• Definitive staging can only be done after
surgery has been performed and pathology
reports reviewed.
• An exception to this principle would be after a
colonoscopic polypectomy of a malignant
pedunculated polyp with minimal invasion.
• Preoperative staging of rectal cancers may be
done with endoscopic ultrasound.
• Adjuncts to staging of metastasis include
Abdominal Ultrasound, CT, PET Scanning, and
other imaging studies.

57
 Dukes' system
• Dukes' classification, first proposed by Dr
Cuthbert E. Dukes in 1932, identifies the
stages as:
• A - Tumor confined to the intestinal wall
• B - Tumor invading through the intestinal wall
• C - With lymph node(s) involvement
• D - With distant metastasis

58
 TNM system
• The most common current staging system is the TNM (for
tumors/nodes/metastases) system, though many doctors still use the
older Dukes system. The TNM system assigns a number:
• T - The degree of invasion of the intestinal wall
– T0 - no evidence of tumor
– Tis- cancer in situ (tumor present, but no invasion)
– T1 - invasion through submucosa into lamina propria (basement membrane
invaded)
– T2 - invasion into the muscularis propria (i.e. proper muscle of the bowel wall)
– T3 - invasion through the subserosa
– T4 - invasion of surrounding structures (e.g. bladder) or with tumor cells on the
free external surface of the bowel
• N - the degree of lymphatic node involvement
– N0 - no lymph nodes involved
– N1 - one to three nodes involved
– N2 - four or more nodes involved
• M - the degree of metastasis
– M0 - no metastasis
– M1 - metastasis present

59
 Pathogenesis

• Colorectal cancer is a disease originating from the

epithelial cells lining the gastrointestinal tract.
Hereditary or somatic mutations in specific DNA
sequences, among which are included DNA replication
or DNA repair genes, and also the APC, K-Ras, NOD2
and p53 genes, lead to unrestricted cell division.
• The exact reason why (and whether) a diet high in
fiber might prevent colorectal cancer remains
uncertain.
• Chronic inflammation, as in
inflammatory bowel disease, may predispose patients
to malignancy.

60
 What are the treatments
and survival for colon
cancer?
• The treatment depends on the staging of the
cancer. When colorectal cancer is caught at early
stages (with little spread) it can be curable.
However when it is detected at later stages (when
distant metastases are present) it is more difficult
to cure.
• Surgery remains the primary treatment while
chemotherapy and/or radiotherapy may be
recommended depending on the individual
patient's staging and other medical factors.

61
 What are the treatments
and survival for colon
cancer?
• Surgery is the most common treatment for
colorectal cancer. During surgery, the tumor, a
small margin of the surrounding healthy bowel,
and adjacent lymph nodes are removed.
• The surgeon then reconnects the healthy sections
of the bowel. In patients with rectal cancer, the
rectum is permanently removed.
• The surgeon then creates an opening (colostomy)
on the abdomen wall through which solid waste in
the colon is excreted. Specially trained nurses
(enterostomal therapists) can help patients adjust
to colostomies, and most patients with
colostomies return to a normal lifestyle

62
 Treatment: Surgery
• Surgeries can be categorized into curative, palliative,
bypass, fecal diversion, or open-and-close.
• Curative Surgical treatment can be offered if the tumor
is localized.
• Very early cancer that develops within a polyp can often
be cured by removing the polyp (i.e., polypectomy) at
the time of colonoscopy.
• In colon cancer, a more advanced tumor typically
requires surgical removal of the section of colon
containing the tumor with sufficient margins, and radical
en-bloc resection of mesentery and lymph nodes to
reduce local recurrence (i.e., colectomy). If possible, the
remaining parts of colon are anastomosed together to
create a functioning colon. In cases when anastomosis
is not possible, a stoma (artificial orifice) is created.

63
 Curative and Non Curative
Surgery
• Curative surgery on rectal cancer includes
total mesorectal excision (lower anterior resection) or
abdominoperineal excision.
• In case of multiple metastases, palliative (non curative)
resection of the primary tumor is still offered in order to
reduce further morbidity caused by tumor bleeding,
invasion, and its catabolic effect. Surgical removal of
isolated liver metastases is, however, common and may be
curative in selected patients; improved chemotherapy has
increased the number of patients who are offered surgical
removal of isolated liver metastases.
• If the tumor invaded into adjacent vital structures which
makes excision technically difficult, the surgeons may
prefer to bypass the tumor (ileotransverse bypass) or to
do a proximal fecal diversion through a stoma.

64
 Colon Prognosis
• The long-term prognosis after surgery depends on
whether the cancer has spread to other organs
(metastasis).
• The risk of metastasis is proportional to the depth of
penetration of the cancer into the bowel wall. In
patients with early colon cancer which is limited to the
superficial layer of the bowel wall, surgery is often the
only treatment needed.
• These patients can experience long-term survival in
excess of 80%.
• In patients with advanced colon cancer, wherein the
tumor has penetrated beyond the bowel wall and there
is evidence of metastasis to distant organs, curing will
be more than difficult.

65
 Treatment: Chemotherapy

• Chemotherapy is used to reduce the likelihood

of metastasis developing, shrink tumor size, or
slow tumor growth.
• Chemotherapy is often applied after surgery
(adjuvant), before surgery (neo-adjuvant), or
as the primary therapy if surgery is not
indicated (palliative).
• The treatments listed here have been shown
in clinical trials to improve survival and/or
reduce mortality rate and have been approved
for use by the
US Food and Drug Administration.
66
 Chemotherapy
• In some patients, there is no evidence of distant
metastasis at the time of surgery, but the cancer has
penetrated deeply into the colon wall or reached adjacent
lymph nodes. These patients are at risk of tumor
recurrence either locally or in distant organs.
• Chemotherapy in these patients may delay tumor
recurrence and improve survival.
• Chemotherapy is the use of medications to kill cancer cells.
It is a systemic therapy, meaning that the medication
travels throughout the body to destroy cancer cells. After
colon cancer surgery, some patients may harbor
microscopic metastasis (small foci of cancer cells that will
hardly be detected).

67
 Chemotherapy
• Chemotherapy is given shortly after surgery to destroy
these microscopic cells.
• Chemotherapy given in this manner is called adjuvant
chemotherapy. Recent studies have shown increased
survival and delay of tumor recurrence in some patients
treated with adjuvant chemotherapy within five weeks of
surgery.
• Most drug regimens have included the use of 5-flourauracil
(5-FU).
• On the other hand, however, chemotherapy for shrinking
or controlling the growth of metastatic tumors has been
disappointing.
• Improvement in the overall survival for patients with
widespread metastasis has not been convincingly
demonstrated.

68
 Chemotherapy
• Chemotherapy is usually given in a doctor's office, in the
hospital as a outpatient, or at home.
• Chemotherapy is usually given in cycles of treatment
periods followed by recovery periods. Side effects of
chemotherapy vary from person to person, and also depend
on the agents given. Modern chemotherapy agents are
usually well tolerated, and side effects are manageable.
• In general, anti-cancer medications destroy cells that are
rapidly growing and dividing. Therefore, red blood cells,
platelets, and white blood cells are frequently affected by
chemotherapy.
• Common side effects include anemia, loss of energy, easy
bruising, and a low resistance to infections. Cells in the hair
roots and intestines also divide rapidly. Therefore,
chemotherapy can cause hair loss, mouth sores, nausea,
vomiting, and diarrhea.

69
 Chemotherapy Drugs
• Adjuvant (after surgery) chemotherapy. One regimen involves the combination of
infusional 5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX)
– 5-fluorouracil (5-FU) or Capecitabine (Xeloda®)
– Leucovorin (LV, Folinic Acid)
– Oxaliplatin (Eloxatin®)
• Chemotherapy for metastatic disease. Commonly used first line
chemotherapy regimens involve the combination of infusional 5-fluorouracil, leucovorin,
and oxaliplatin (FOLFOX) with bevacizumab or infusional 5-fluorouracil, leucovorin, and
irinotecan (FOLFIRI) with bevacizumab
– 5-fluorouracil (5-FU) or Capecitabine
– Leucovorin (LV, Folinic Acid)
– Irinotecan (Camptosar®)
– Oxaliplatin (Eloxatin®)
– Bevacizumab (Avastin®)
– Cetuximab (Erbitux®)
– Panitumumab (Vectibix)
• In clinical trials for treated/untreated metastatic disease. [2]
– Bortezomib (Velcade®)
– Oblimersen (Genasense®, G3139)
– Gefitinib and Erlotinib (Tarceva®)
– Topotecan (Hycamtin®)

70
 Chemotherapy using
Drug C225
• Miracle Drug
Thus it was with considerable delight that cancer researchers
at the meeting of the American Society of Clinical Oncology in New
Orleans learned last Monday of a patient who had done the
seemingly impossible. Shannon Kellum, a 30 year old accountant
from Fort Myers, Florida, learned in 1998 that she had terminal colon
cancer, and could not expect to live long. The cancer had already
spread to her liver, with tumors the size of grapefruits, far too large
to remove. Her life expectancy was nil.
Today she is tumor-free, and not at all dead .
The drug C225 was administered to Kellum once a week
intravenously, with chemotherapy to aid in knocking out any tumor
cells weakened but not killed by lack of EGF. Her liver tumors shrank
by 80% in four months. Four months later, the tumors were small
enough to be removed surgically. Today she is tumor-free. Only time
will tell if she is cured -- some cancer cells may remain that could
restart tumors. But there is no denying the fact that she is very much
alive and leading a normal life, a year after she should have died.
71
72
 Treatment: Radiation
therapy
• Radiotherapy is not used routinely in colon cancer, as it could lead to
radiation enteritis, and it is difficult to target specific portions of the
colon. It is more common for radiation to be used in rectal cancer,
since the rectum does not move as much as the colon and is thus
easier to target. Indications include:
• Colon cancer
– pain relief and palliation - targeted at metastatic tumor deposits if
they compress vital structures and/or cause pain
• Rectal cancer
– neoadjuvant - given before surgery in patients with tumors that
extend outside the rectum or have spread to regional lymph nodes,
in order to decrease the risk of recurrence following surgery or to
allow for less invasive surgical approaches (such as a low anterior
resection instead of an abdomino-perineal resection)
– adjuvant - where a tumor perforates the rectum or involves regional
lymph nodes (AJCC T3 or T4 tumors or Duke's B or C tumors)
– palliative - to decrease the tumor burden in order to relieve or
prevent symptoms

73
 Radiation Therapy
• Radiation therapy in colorectal cancer has been limited
to treating cancer of the rectum. There is a decreased
local recurrence of rectal cancer in patients receiving
radiation either prior to or after surgery.
• Without radiation, the risk of rectal cancer recurrence
is close to 50%. With radiation, the risk is lowered to
approximately 7%.
• Side effects of radiation treatment include fatigue,
temporary or permanent pelvic hair loss, and skin
irritation in the treated areas.
• Other treatments have included the use of localized
infusion of chemotherapeutic agents into the liver, the
most common site of metastasis.

74
 Radiation Therapy
• This involves the insertion of a pump into the blood
supply of the liver which can deliver high doses of
medicine directly to the liver tumor.
• Response rates for these treatments have been
reported to be as high as eighty percent. Side effects,
however, can be serious.
• Additional experimental agents considered for the
treatment of colon cancer include the use of cancer-
seeking antibodies bound to cancer-fighting drugs.
• Such combinations can specifically seek and destroy
tumor tissues in the body.

75
 Radiation Therapy
• Other treatments attempt to boost the immune
system, the bodies' own defense system, in an effort to
more effectively attack and control colon cancer.
• In patients who are poor surgical risks, but who have
large tumors which are causing obstruction or
bleeding, laser treatment can be used to destroy
cancerous tissue and relieve associated symptoms.
• Still other experimental agents include the use of
photodynamic therapy. In this treatment, a light
sensitive agent is taken up by the tumor which can
then be activated to cause tumor destruction.

76
 Others Treatment
Immunotherapy
• Bacillus Calmette-Guérin (BCG) is being investigated as an
adjuvant mixed with autologous tumor cells in immunotherapy
for colorectal cancer.

Vaccine
• In November 2006, it was announced that a vaccine had been
developed and tested with very promising results.
• The new vaccine, called TroVax, works in a totally different
way to existing treatments by harnessing the patient's own
immune system to fight the disease.
• Experts say this suggests that gene therapy vaccines could
prove an effective treatment for a whole range of cancers.
Oxford BioMedica is a British spin-out from Oxford University
specializing in the development of .
• Phase III trials are underway for renal cancers and planned for
colon cancers.

77
 Treatment of colorectal
cancer metastasis to the
liver
• According to the American Cancer Society
statistics in 2006 greater than 20% of patients
present with metastatic (stage IV) colorectal
cancer at the time of diagnosis, and up to 25% of
this group will have isolated liver metastasis that
is potentially resectable.
• Lesions which undergo curative resection have
demonstrated 5-year survival outcomes now
exceeding 50%.

78
 Metastasis to the liver

• Resectability of a liver met is determined using preoperative

imaging studies (Ct or MRI), intraoperative ultrasound, and by
direct palpation and visualization during resection.
• Lesions confined to the right lobe are amenable to en bloc
removal with a right hepatectomy (liver resection) surgery.
Smaller lesions of the central or left liver lobe may sometimes be
resected in anatomic "segments", while large lesions of left
hepatic lobe are resected by a procedure called hepatic
trisegmentectomy.
• Treatment of lesions by smaller, non-anatomic "wedge"
resections is associated with higher recurrence rates. Some
lesions which are not initially amenable to surgical resection may
become candidates if they have significant responses to
preoperative chemotherapy or immunotherapy regimines.
Lesions which are not amenable to surgical resection for cure can
be treated with modalities including radio-frequency ablation
(RFA), cryoablation, and chemoembolization.

79
 Metastasis to the liver

• Patients with colon cancer and metastatic disease to the liver

may be treated in either a single surgery or in staged
surgeries (with the colon tumor traditionally removed first)
depending upon the fitness of the patient for prolonged
surgery, the difficulty expected with the procedure with either
the colon or liver resection, and the comfort of the surgery
performing potentially complex hepatic surgery.
• Poor pronostic factors of patients with liver metastasis include
• Synchronous (diagnosed simultaneously) liver and primary
colorectal tumors
• A short time between detecting the primary cancer and
subsequent development of liver mets
• Multiple metastatic lesions
• High blood levels of the tumor marker, carcino -embryonic
antigen (CEA), in the patient prior to resection
• Larger size metastatic lesions

80
 What is the follow-up care
for colon cancer?
• Follow-up exams are important after treatment for colon cancer.
The cancer can recur near the original site or in a distant organ
such as the liver or lung. Follow-up exams include a physical
examination by the doctor, blood tests of liver enzymes, chest x-
rays, CAT scans of the abdomen and pelvis, colonoscopies, and
blood CEA levels.
• Abnormal liver enzymes may indicate growth of liver metastasis.
CEA levels may be elevated before surgery and become normal
shortly after the cancer is removed. Slowly rising CEA level may
indicate cancer recurrence. A CAT scan of the abdomen and pelvis
can show tumor recurrence in the liver, pelvis, or other areas.
Colonoscopy can show recurrence of polyps or cancer in the large
intestine.
• In addition to checking for cancer recurrence, patients who have
had colon cancer may have an increased risk of cancer of the
prostate, breast, and ovary. Therefore, follow-up examinations
should include these areas.

81
 Follow-up

• The aims of follow-up are to diagnose in the earliest possible stage any
metastasis or tumors that develop later but did not originate from the
original cancer (metachronous lesions).
• The U.S. National Comprehensive Cancer Network and
American Society of Clinical Oncology provide guidelines for the follow-up of
colon cancer. A medical history and physical examination are recommended
every 3 to 6 months for 2 years, then every 6 months for 5 years.
Carcinoembryonic antigen blood level measurements follow the same
timing, but are only advised for patients with T2 or greater lesions who are
candidates for intervention.
• A CT-scan of the chest, abdomen and pelvis can be considered annually for
the first 3 years for patients who are at high risk of recurrence (for example,
patients who had poorly differentiated tumors or venous or lymphatic
invasion) and are candidates for curative surgery (with the aim to cure).
• A colonoscopy can be done after 1 year, except if it could not be done
during the initial staging because of an obstructing mass, in which case it
should be performed after 3 to 6 months. If a villous polyp, polyp >1
centimeter or high grade dysplasia is found, it can be repeated after 3
years, then every 5 years. For other abnormalities, the colonoscopy can be
repeated after 1 year.

82
 How can colon cancer be
prevented?
• Unfortunately, colon cancers can be well advanced before they
are detected. The most effective prevention of colon cancer is
early detection and removal of precancerous colon polyps before
they turn cancerous.
• Even in cases where cancer has already developed, early
detection still significantly improves the chances of a cure by
surgically removing the cancer before the disease spreads to
other organs. Multiple world health organizations have suggested
general screening guidelines.
• Digital rectal examination and stool occult blood testing
• It is recommended that all individuals over the age of 40 have
yearly digital examinations of the rectum and their stool tested
for hidden or "occult" blood. During digital examination of the
rectum, the doctor inserts a gloved finger into the rectum to feel
for abnormal growths. Stool samples can be obtained to test for
occult blood (see below). The prostate gland can be examined at
the same time.

83
 How can colon cancer be
prevented?

• Most colorectal cancers should be preventable, through increased

surveillance, improved lifestyle, and, probably, the use of dietary
chemopreventative agents.
Surveillance
• Most colorectal cancer arise from adenomatous polyps. These
lesions can be detected and removed during colonoscopy. Studies
show this procedure would decrease by > 80% the risk of cancer
death, provided it is started by the age of 50, and repeated every
5 or 10 years.
• As per current guidelines under
National Comprehensive Cancer Network, in average risk
individuals with negative family history of colon cancer and
personal history negative for adenomas or
Inflammatory Bowel diseases, flexible sigmoidoscopy every 5
years with fecal occult blood testing annually or double contrast
barium enema are other options acceptable for screening rather
than colonoscopy every 10 years (which is currently the Gold-
Standard of care).

84
 How can colon cancer be
prevented?
• An important screening test for colorectal cancers and polyps is
the stool occult blood test. Tumors of the colon and rectum tend
to bleed slowly into the stool.
• The small amount of blood mixed into the stool is usually not
visible to the naked eye. The commonly used stool occult blood
tests rely on chemical color conversions to detect microscopic
amounts of blood.
• These tests are both convenient and inexpensive. A small amount
of stool sample is smeared on a special card for occult blood
testing. Usually, three consecutive stool cards are collected.
• A person who tests positive for stool occult blood has a 30% to
45% chance of having a colon polyp and a 3% to 5% chance of
having a colon cancer.
• Colon cancers found under these circumstances tend to be early
and have a better long-term prognosis.

85
 How can colon cancer be
prevented?
• It is important to remember that having stool tested positive for occult
blood does not necessarily mean the person has colon cancer. Many
other conditions can cause occult blood in the stool.
• However, patients with a positive stool occult blood should undergo
further evaluations involving barium enema x-rays, colonoscopies, and
other tests to exclude colon cancer, and to explain the source of the
bleeding.
• It is also important to realize that stool which has tested negative for
occult blood does not mean the absence of colorectal cancer or polyps.
Even under ideal testing conditions, at least 20% of colon cancers can be
missed by stool occult blood screening.
• Many patients with colon polyps are tested negative for stool occult
blood. In patients suspected of having colon tumors, and in those with
high risk factors for developing colorectal polyps and cancer, flexible
sigmoidoscopies or screening colonoscopies are performed even if the
stool occult blood tests are negative.

86
 How can colon cancer be
prevented?
• Flexible sigmoidoscopy and colonoscopy
• Beginning at age 50, a flexible sigmoidoscopy screening tests is
recommended every three to five years. Flexible
sigmoidoscopy is an exam of the rectum and the lower colon
using a viewing tube (a short version of colonoscopy).
• Recent studies have shown that the use of screening flexible
sigmoidoscopy can reduce mortality from colon cancer. This is
a result of the detection of polyps or early cancers in people
with no symptoms. If a polyp or cancer is found, a complete
colonoscopy is recommended.
• The majority of colon polyps can be completely removed by
colonoscopy without open surgery. Recently doctors are
recommending screening colonoscopies instead of screening
flexible sigmoidoscopies for healthy individuals starting at ages
50-55.

87
 How can colon cancer be
prevented?
• Patients with a high risk of developing colorectal cancer may
undergo colonoscopies starting at earlier ages than 50. For
example, patients with family history of colon cancer are
recommended to start screening colonoscopies at an age 10 years
before the earliest colon caner diagnosed in a first-degree relative,
or five years earlier than the earliest precancerous colon polyp
discovered in a first-degree relative.
• Patients with hereditary colon cancer syndromes such as FAP, AFAP,
HNPCC, and MYH are recommended to begin colonoscopies early.
The recommendations differ depending on the genetic defect, for
example in FAP; colonoscopies may begin during teenage years to
look for the development of colon polyps.
• Patients with a prior history of polyps or colon cancer may also
undergo colonoscopies to exclude recurrence. Patients with a long
history (greater than 10 years) of chronic ulcerative colitis have an
increased risk of colon cancer, and should have regular
colonoscopies to look for precancerous changes in the colon lining.

88
 How can colon cancer be
prevented?
• Genetic counseling and testing
• Blood tests are now available to test for FAP, AFAP, MYH, and HNPCC
hereditary colon cancer syndromes. Families with multiple members
having colon cancers, members with multiple colon polyps, members
having cancers at young ages, and having other cancers such as
cancers of the ureters, uterus, duodenum, etc., should be referred for
genetic counseling followed possibly by genetic testing.
• Genetic testing without prior counseling is discouraged because of
the extensive family education that is involved and the complicated
nature of interpreting the test results.
• The advantages of genetic counseling followed by genetic testing
include: (1) identifying family members at high risk of developing
colon cancer to begin colonoscopies early; (2) identifying high risk
members so that screening may begin to prevent other cancers such
as ultrasound tests for uterine cancer, urine examinations for ureter
cancer, and upper endoscopies for stomach and duodenal cancers;
and (3) alleviating concern for members who test negative for the
hereditary genetic defects.

89
 How can colon cancer be
prevented?
Lifestyle
• The comparison of colorectal cancer incidence in
various countries strongly suggests that
sedentarity, overeating (i.e., high caloric intake),
and perhaps a diet high in meat (red or
processed) could increase the risk of colorectal
cancer.
• In contrast, physical exercise, and eating plenty
of fruits and vegetables would decrease cancer
risk, probably because they contain protective
phytochemicals.
• Accordingly, lifestyle changes could decrease the
risk of colorectal cancer as much as 60-80%.

90
 How can colon cancer be
prevented?
Chemoprevention
• More than 200 agents, including the above cited phytochemicals, and
other food components like calcium or folic acid (a B vitamin), and
NSAIDs like aspirin, are able to decrease carcinogenesis in preclinical
models: Some studies show full inhibition of carcinogen-induced tumors
in the colon of rats.
• Other studies show strong inhibition of spontaneous intestinal polyps in
mutated mice (Min mice). Chemoprevention clinical trials in human
volunteers have shown smaller prevention, but few intervention studies
have been completed today.
• Calcium, aspirin and celecoxib supplements, given for 3 to 5 years
after the removal of a polyp, decreased the recurrence of polyps in
volunteers (by 15-40%).The "chemoprevention database" shows the
results of all published scientific studies of chemopreventive agents, in
people and in animals.

91
 How can colon cancer be
prevented?
Aspirin chemoprophylaxis
• Aspirin should not be taken routinely to prevent colorectal
cancer, even in people with a family history of the disease,
because the risk of bleeding and kidney failure from high dose
aspirin (300mg or more) outweigh the possible benefits.
• A clinical practice guideline by the
U.S. Preventive Services Task Force (USPSTF) recommended
against taking aspirin (grade D recommendation).The Task Force
acknowledged that aspirin may reduce the incidence of colorectal
cancer, but "concluded that harms outweigh the benefits of
aspirin and NSAID use for the prevention of colorectal cancer". A
subsequent meta-analysis concluded "300 mg or more of aspirin
a day for about 5 years is effective in primary prevention of
colorectal cancer in randomised controlled trials, with a latency
of about 10 years". However, long-term doses over 81 mg per
day may increase bleeding events.

92
 How can colon cancer be
prevented?
Calcium
• A meta-analysis by the Cochrane Collaboration of
randomized controlled trials published through 2002 concluded
"Although the evidence from two RCTs suggests that calcium
supplementation might contribute to a moderate degree to the
prevention of colorectal adenomatous polyps, this does not
constitute sufficient evidence to recommend the general use of
calcium supplements to prevent colorectal cancer.".
• Subsequently, one randomized controlled trial by the
Women's Health Initiative (WHI) reported negative results.
• A second randomized controlled trial reported reduction in all
cancers, but had insufficient colorectal cancers for analysis.

93
 What does the future hold
for patients with colorectal
cancer?
• Colon cancer remains a major cause of death and disease, especially in
the western world. A clear understanding of the causes and course of the
disease is emerging. This has allowed for recommendations regarding
screening for and prevention of this disease.
• The removal of colon polyps helps prevent colon cancer. Early detection
of colon cancer can improve the chances of a cure and overall survival.
Treatment remains unsatisfactory for advanced disease, but research in
this area remains strong and newer treatments continue to emerge.
• New and exciting preventive measures have recently focused on the
possible beneficial effects of aspirin or other anti-inflammatory agents. In
trials, the use of these agents has markedly limited colon cancer
formation in several experimental models.
• Other agents being evaluated to prevent colon cancer include calcium,
selenium, and vitamins A, C, and E. More studies are needed before
these agents can be recommended for widespread use by the public to
prevent colon cancer.

94
 DIETARY
MANAGEMENT

95
 Objectives
• Recognize the special nutritional
needs of cancer survivors during
active cancer treatment
• Advise cancer survivors about
nutrition and physical activity during
the recovery phase and beyond
• Resolve controversial nutritional
issues facing cancer survivors

96
 Challenges of Cancer
Survivors
• Highly motivated to seek information
about diet and lifestyle changes.
• Often receive conflicting dietary advice.
• Claims abound on the use of dietary
alternatives.
• Currently there are many gaps and
inconsistencies in the scientific evidence.

97
 NUTRITIONAL DEFICIENCIES
There are several factors that may contribute to the type and
degree of nutrient deficiencies:

• The primary organ where the malignancy

occurs.
• The severity of the cancer at the time of
diagnosis.
• The symptoms experienced by the person
with cancer.
• The type and frequency of the cancer
treatment being used and the side effects
associated with that treatment (surgery,
radiation, or chemotherapy).
• The effect of the malignancy or disease on
food and nutrient ingestion, tolerance, and
utilization. 98
Body Weight Changes
• Intentional weight loss during cancer treatment is
not recommended
• Some cancer survivors may gain weight during
and after treatments
• During treatment, a healthy eating plan that
meets but does not exceed caloric needs (along
with physical activity) is advisable
• Healthy weight loss is best initiated after the
recovery phase
• Obesity is associated with increased risk and
poorer prognosis of breast and colon cancers

99
The Phases of Cancer Survival
• Phase 1: Active Treatment

• Phase 2: Recovery from Treatment

• Phase 3: Preventing Cancer Recurrence,

Second Primary Cancers.

• Phase 4: Living with Advanced Cancer –

Dietary management
100
 Phase 1: Nutritional
Issues During Active
Treatment
• Energy balance is the most important goal

•ENERGY INTAKE
•ENERGY EXPENDITURE
•NUTRITIONAL SUPPLEMENTS

101
 ENERGY INTAKE
– The need for caloric intake is usually
increased during cancer treatments
– Nausea, vomiting, taste changes, loss of
appetite, bowel changes all interfere with
the usual eating patterns.
– Food choices at this time should be easy
to chew, swallow, digest and absorb and
should also be appealing.
– Adjust usual food choices and usual food
patterns.

102
 ENERGY EXPENDITURE
– cancer treatment can cause fatigue
– light regular physical activity during
treatment should be encouraged to
improve appetite, stimulate digestion,
prevent constipation.
– Helps to maintain energy level and muscle
mass and provide relaxation or stress
reduction

103
 NUTRITIONAL
SUPPLEMENTS
 Nutritional products such as Boost, Ensure
etc… can be helpful on a temporary basis to
assist with intake of calories and nutrients.
 Other supplements is quite controversial.
For example, it is counterproductive for
patients to take vitamin supplements that
contain high levels of folic acid or to eat
foods fortified with high amount of folic acid,
when on Methotrexate. (metho interferes
with folate metabolism).

104
 NUTRITIONAL
SUPPLEMENTS
 Antioxidants(Vitamins C, E and phytochemicals
or antioxidant minerals), may reduce the
effectiveness of RT or CX. May help protect
normal cells from treatment collateral damage
 No good answer or evidence at this time there
fore it would be prudent to advise patients not to
exceed the upper intake limits for vitamins and
to avoid other nutritional supplements that
contain antioxidant compounds.

105
 Phase 2: Nutritional
Issues After Treatment is
Completed
• Most important goal Rebuild muscle strength
and correct problems.

•Adequate food intake

•Physical activity
– Required to rebuild muscle strength.
– Consultation required for elder patients.

106
Benefits of Moderate Regular
Physical Activity for Cancer
Survivors
• reduce anxiety
• reduce depression
• improve mood
• boost self esteem
• reduce symptoms of fatigue,
• beneficial effects on heart
rate, lean body mass and
respiratory capacity

107
 Diet and Cancer
The American Cancer Society
recommends 4 rules of thumb for cancer
prevention
• Choose most of the foods you eat from
plant sources. 5 or more servings
• Limit intake of high fat foods,
particularly from animal sources.
• Be physically active.
• Limit alcohol intake.
108
 Dietary Components
Associated with Cancer
THE BAD GUYS!!!
Excesses of Certain substances such as:
• Fat- the end products of metabolism have
been found to be carcinogenic.
• Alcohol- has been connected with liver,
colorectal, and breast cancers.

109
 Dietary Components
Associated with Cancer
THE BAD GUYS!!!
• Pickled and Smoked Foods- related to
cancers of the esophagus and
stomach. that may increase the risk.
• Cooking methods have also been found
to have a role in cancer. Frying or
charcoal-broiling meats at very high
temperatures creates chemicals

110
Protective Dietary Components
THE HEROES
• Certain foods and nutrients have
been shown to protect against
certain types of cancers.
• Vitamin C - has been shown to
protect against cancer of stomach,
esophagus, and oral cavity.
• Antioxidants- these are certain
protective substances found in
fruits and vegetables.
111
Protective Dietary Components
THE HEROES
• Fruits and Veggies- contain vitamins,
fiber and phytochemicals.
• Vitamin E and selenium- both
antioxidants that protect cells against
breakdown.
• Calcium- Calcium reduces cell turnover
rates.
• Water- drinking more than 5 glasses a
day has been associated with a lower
risk of cancer.

112
 Diet and Cancer
• Fiber- Insoluble fiber is connected to
decreased risk of colon cancer.
• Beans, vegetables, whole grains and
fruit are good sources.
• Salt- some evidence links diets
containing large amounts of foods
preserved by pickling and salting to
increased cancers of the stomach,
nose and throat.

113
 Diet and the Cancer
Patient
• Nutrition is an important part
of treatment.
• Eating the right kinds of food
before, during and after
treatment can help the patient
feel better and stay stronger.
• Treatments can have an affect
on appetite.
114
Diet and the Cancer Patient
• People with cancer have unique
nutrition needs.
• Eating enough food is usually
not a problem. Treatment can
have an adverse effect on
appetite.
• Nutrition suggestions often
emphasize eating high calorie,
high protein foods.
115
Diet and the Cancer Patient
Side Effects
Treatments kill cancer cells but they also kill healthy
cells. This can cause side effects such as:
• Loss of appetite
• sore mouth or throat
• dry mouth
• dental and gum problems
• changes in taste or smell
• Nausea
• Diarrhea
• Constipation
• fatigue
• depression.
116
 Diet and the Cancer
Patient
• It is very important to have good
nutrition to minimize the side
effects of cancer, prevent or
reverse nutritional deficiencies,
and to maximize the quality of
life.
• The best method of calorie intake
is by mouth. Sometimes this is
not possible.
117
 Diet and the Cancer
Patient

Other options of intake are:

• Feeding Tube
• TPN or total parental nutrition-
this is nutrition directly through
a vein.

118
 FIVE FOR CANCER
Five things you should remember about
preventing cancer.

• Eat lots of fruits, vegetables, and whole

grains.
• Discover the pleasure of physical activity.
• Stay tobacco free
• Enjoy a low-fat diet
• Protect yourself from the sun between
10:00 am and 4:00 pm.

119
COMMON DIET THERAPIES

• FULL FLUID
DIET
• SOFT DIET

120
 FULL FLUID DIET
FOOD VEGETARIAN NON-VEGETARIAN
• Initial diet.
• Administered alongside
or immediately after Corn flour 50 mg 50 mg

therapy.
Dhal flour 30 mg ---
• Predominant diet for
oral, pharyngeal, Milk 1000 ml 800 ml

oesophagal and GI tract Meat --- 50mg

cancer.
• Administered at regular Egg --- One

intervals (Every 2 hours). Fruit juice 800ml 850ml

Butter 2 Tbsps 2 Tbsps

Sugar 100 mg 100 mg

The above table shows amount of food to be consumed per

day 121
 SOFT DIET
FOOD VEGETARIAN NON-VEGETARIAN
• Secondary diet.
• Administered following a Milled cereals 300 mg 300 mg
period of full fluid diet. Dhal 50 mg 30 mg
• Enriched with nutrients. Milk 1000 ml 600 ml
• Supplementation of
essential vitamins like Meat, fish, sausages--- 100 mg

folate and Vit C lost during

drug therapy. Egg --- 30 mg

• Meats can be avoided as far Tender vegetables 50 mg 50 mg

as possible as it results in
the formation of Potatoes 100 mg 100 mg

nitrosamines in stomach. Tender leafy 100 mg 100 mg

• This can be countered by vegetables

administration of Vit C Fruits (Apples & 100 mg 100 mg

Oranges)
Fats and Oils 30 mg 30 mg

Sugar 80 mg 80 mg

The above table shows amount of food to be consumed per

122
day
 Conclusion
• Cancer is a preventable
disease in most cases.
• Lead a healthy lifestyle.
• Be aware of your body.

123
 Summary
• Colorectal cancer is a malignant tumor arising from the inner wall of
the large intestine.
• Colorectal cancer is the third leading cause of cancer in males and
fourth in females in the U.S.
• Risk factors for colorectal cancer include heredity, colon polyps, and
long-standing ulcerative colitis.
• Most colorectal cancers develop from polyps. Removal of colon polyps
can prevent colorectal cancer.
• Colon polyps and early cancer can have no symptoms. Therefore
regular screening is important.
• Diagnosis of colorectal cancer can be made by barium enema or by
colonoscopy with biopsy confirmation of cancer tissue.
• Treatment of colorectal cancer depends on the location, size, and
extent of cancer spread, as well as the age and health of the patient.
• Surgery is the most common treatment for colorectal cancer.
• Effective Nutrition Management is a necessity to alleviate cancer cells.

124
 References
• Microsoft Encarta 2006
• Wikipedia 2009
• MedicineNet.com
• MayoClinic.com
• Chemocare.com
• Inquirer.net
• Scribd.com http://www.cancer.gov
• http://www.cancer.org
• http://muextension.missouri.edu

125
Do our Best and GOD will
do the Rest !!

126