General Information
Prognostic factors
Risk factors
Follow-up
Note: Separate PDQ summaries on Screening for Colorectal Cancer, Prevention
of Colorectal Cancer, 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: 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 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 3
characteristics form the basis for all staging systems developed for this
disease. Bowel obstruction and bowel perforation are indicators of poor
prognosis.[1] Elevated pretreatment serum levels of carcinoembryonic antigen
(CEA) have a negative prognostic significance.[2]
Many other prognostic
markers have been evaluated retrospectively for patients with
colon cancer, although most, including allelic loss of chromosome 18q or
thymidylate synthase expression, have not been prospectively validated.[3-12]
Microsatellite instability, also associated with hereditary nonpolyposis colon
cancer (HNPCC), has been shown to be associated with improved survival independent of
tumor stage in a population-based series of 607 patients younger than 50 years with colorectal cancer.[13] Treatment decisions depend on factors such as physician and patient preferences and the stage of the disease rather than the age of the patient.[14-16] 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.[17]
Risk factorsBecause 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 starting at age 50 years, 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 ulcerative colitis.[18] 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.[19] [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.[20,21] 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.[22] (Refer to the PDQ summaries on Screening for
Colorectal Cancer and Prevention of Colorectal Cancer for more information.) Follow-upFollowing treatment of colon cancer, periodic evaluations may lead to the
earlier identification and management of recurrent disease.[23-26] 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.[27-31] 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:[32] - A CEA level is not a valuable screening
test for colorectal cancer due to 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, however, because the impact on patient survival is not
clear and the quality of data is poor.[29-31] New surveillance methods,
including CEA immunoscintigraphy [33] and positron emission tomography,[34] 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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- Jen J, Kim H, Piantadosi S, et al.: Allelic loss of chromosome 18q and prognosis in colorectal cancer. N Engl J Med 331 (4): 213-21, 1994.
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- Griffin MR, Bergstralh EJ, Coffey RJ, et al.: Predictors of survival after curative resection of carcinoma of the colon and rectum. Cancer 60 (9): 2318-24, 1987.
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- Watson P, Lin KM, Rodriguez-Bigas MA, et al.: Colorectal carcinoma survival among hereditary nonpolyposis colorectal carcinoma family members. Cancer 83 (2): 259-66, 1998.
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- Lonneux M, Reffad AM, Detry R, et al.: FDG-PET improves the staging and selection of patients with recurrent colorectal cancer. Eur J Nucl Med Mol Imaging 29 (7): 915-21, 2002.
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