Posted on March 8th, 2009 by
The Other Women’s Cancer
The Other Women’s Cancer
An update on screening, diagnosis, and treatment options for colorectal cancer
Medical Oncologist, Jay Monahan Center for Gastrointestinal Health
Medical Oncologist, Solid Tumor Service, NewYork-Presbyterian Hospital
Assistant Professor of Clinical Medicine, Weill Medical College of Cornell University,
Although many women believe colorectal cancer to be a disease that affects men only, each year it takes the lives of just as many women as men. In fact, colorectal cancer takes the lives of more women each year than does ovarian, uterine, or cervical cancer.1 The good news is, with utilization of recommended screening options (see Table 1),2 colorectal cancer can be prevented altogether; and for those who are diagnosed with this disease, there are more treatment options available than ever before.
Who Is at Risk of Colorectal Cancer?
Both men and women are at risk of developing colorectal cancer. In most cases colorectal cancer occurs in people age 50 or older, but younger individuals can also get this disease. In addition, there is some evidence to suggest that people of African-American or Ashkenazi Jewish descent are at increased risk of developing colorectal cancer.
Medical risk factors for colorectal cancer include:
Women who do not have any of these risk factors are considered at average risk for colorectal cancer and should begin screening at age 50. Women who do have one or more of these risk factors are considered at increased risk of the disease. Although these medical factors cannot be changed, women at increased risk can protect themselves by discussing their risk factors with their physician and undergoing earlier and more frequent screening as appropriate.
Lifestyle risk factors for colorectal cancer include obesity, physical inactivity, smoking, heavy alcohol consumption, a diet high in red or processed meats, and a diet inadequate in fruits and vegetables. Fortunately, these are risk factors that can be changed. Women who have any of these lifestyle risk factors can consult their physician or nutritionist about adjusting their lifestyle to reduce their colorectal cancer risk and optimize their overall health and well-being.3
The second step to reducing the risk of developing colorectal cancer and detecting any cancer early is to be vigilant about undergoing the recommended screening for this disease.
Colorectal cancer screening allows for both the prevention and the early detection of cancer. Early detection in turn allows for early treatment, when a cure is most likely. Indeed the five-year survival rate is 90 percent when this disease is detected in its early, localized stage.1 In addition, colorectal cancer is preventable when potentially precancerous colorectal polyps are detected and removed before they have the chance to develop into cancer.
It is hoped that with an increased awareness of the lifesaving benefit of colorectal cancer screening, more women will undergo this testing and colorectal cancer incidence and mortality rates will continue to decline.
For women and men at average risk for colorectal cancer, the American Cancer Society recommends one of the seven screening options, beginning at age 50 (see Table 1).2 In people who are at increased risk for colorectal cancer, screening may need to begin at a younger age and be performed at more-frequent intervals.
Early colorectal cancer causes no symptoms, which is why screening ideally begins when an individual feels well-before any symptoms of disease develop. As the cancer grows, however, symptoms may develop; these include rectal bleeding or blood in the stool, a change in bowel habits, abdominal pain, and unexplained fatigue.
In some cases people who experience the symptoms of colorectal cancer ignore them because they are scared or embarrassed. It’s important to understand that, first, these symptoms do not necessarily indicate colorectal cancer; they could be caused by another, less serious condition. Second, if the symptoms are due to colorectal cancer, this disease is treatable. And, third, no one should die of embarrassment. Anyone who experiences the symptoms of colorectal cancer should see a physician for prompt evaluation and diagnosis-the earlier the diagnosis, the greater the chance for cure.
If a diagnosis of colorectal cancer is made, staging of the disease is the next step in the treatment plan. The term staging refers to the local and distant extent of the disease and provides a framework for outlining treatment options and discussions regarding prognosis. An important step in this process is a review of the biopsy specimen by a pathologist. This should be done prior to making any decisions regarding the need for further studies or surgery. This is especially important for cancerous polyps, which may sometimes be fully removed with surgery. Other parts of the staging process include a physical examination by the physician; imaging studies, such as a CT scan, PET scan, or endoscopic ultrasound; and laboratory blood tests, including tumor markers.
The staging of colorectal cancer is based on the depth of invasion of the cancerous tumor through the colon or rectal wall, and an integral component is the determination of whether cancer cells have spread to nearby lymph nodes or to distant organs. Stages I and II colorectal cancers are considered localized early-stage tumors that do not have lymph node involvement. Stage III colorectal cancer is locally advanced and has involvement of regional lymph nodes. Stage IV colorectal cancer indicates disease that has metastasized, or spread outside the colon to distant organs.4 Staging is critical in determining prognosis in colorectal cancer, as earlier-stage disease indicates longer survival and a better chance for cure.
Surgery is the only curative treatment for localized colorectal cancer. Surgery is often required for diagnosis and staging of the disease or for bleeding or obstruction associated with the tumor. Surgery entails removal of the cancerous tumor, as well as an adequate amount of normal tissue surrounding the tumor, and removal of regional lymph nodes.
When a disease recurrence develops after a potentially curative surgical procedure, it is believed to come from microscopic tumor cells that are present and undetectable at the time of surgery. The goal of adjuvant (postoperative) chemotherapy is to eradicate these microscopic tumor cells to decrease the likelihood of recurrence and to increase the cure rate. Data from multiple clinical trials over the past 50 years support the routine use of adjuvant systemic chemotherapy after surgical resection of colon cancer with lymph node involvement. Adjuvant chemotherapy is associated with an approximately 30 percent reduction in the risk of disease recurrence and a 22 to 32 percent reduction in mortality.5 The average length of adjuvant chemotherapy treatment is six months. The routine use of adjuvant chemotherapy for Stage II colon cancer is controversial and is considered only for patients with tumors with features that may increase the rate of recurrence.
Radiation therapy has emerged as a significant part of adjuvant treatment for rectal cancer, whereas adjuvant treatment of colon cancer that is removed by surgery includes chemotherapy alone. This is due to a higher rate of local recurrence in the pelvis in patients with rectal cancer. A series of clinical trials in the 1980s and 1990s determined that there is a survival advantage when postoperative radiation therapy is combined with chemotherapy following resection of Stage II and III rectal cancers.5,6,7,8,9,10
Chemotherapy and Targeted Therapies
Systemic chemotherapy and targeted antibody therapies represent newer treatment options for Stage IV colorectal cancer (disease that has spread to other sites in the body, also called metastatic disease). Approximately 30 to 40 percent of patients with colon or rectal cancer have metastatic disease at the time of diagnosis. Combining chemotherapy with targeted antibody therapy has been shown to improve survival in people with metastatic disease.11,12,13 The past decade in cancer therapy has led to the development of novel targeted therapies that enable people to live longer with metastatic disease. There is increased understanding of the biologic processes important for survival and growth of colorectal cancer cells, including the role of angiogenesis, which is the process by which a tumor makes blood vessels to support its own growth.13
Another important growth pathway in metastatic colorectal cancer is the epidermal growth factor receptor (EGFR) pathway. EGFR transmits signals through a set of proteins inside the cancer cell that instruct the cancer cell to reproduce and metastasize. Data suggest that blocking EGFR stops this growth signal. Antibodies have been developed that block the EGFR pathway (EGFR-blockers). These antibodies are used in combination with chemotherapy to slow the growth of tumors. In 2008 significant information about the use of EGFR-blockers was presented and published. This relates to another important gene inside the cancer cell called K-ras, which also controls cancer cell growth. Some tumors have mutations in the K-ras gene; this mutation leaves the K-ras protein always turned “on,” so signaling within the cancer cell continues regardless of whether the EGFR is blocked with an antibody. Mutations in the K-rasgene occur in approximately 40 percent of metastatic colorectal cancer patients. This finding is important because it affects what therapies can be used to fight the cancer.14,15
Advances in metastatic colorectal cancer will require identification of other targets and pathways that contribute to colorectal cancer progression and metastasis. Inhibitors of several key molecules and pathways are currently being studied. Three candidate proteins and pathways are active areas of research in colorectal cancer: insulin-like growth factor-I receptor (IGF-IR), Src, and toll-like receptor 9 (TLR9).
IGF-IR is a cellular protein, and activation of the IGF-IR pathway results in increased cellular proliferation, malignant transformation, resistance to apoptosis (programmed cell death), tissue invasion and metastasis, and angiogenesis.16 IGF-IR is overexpressed in colon cancer, but activation rather than overexpression may play a more important role. There is substantial overlap in signaling between the IGF-IR and EGFR pathways, raising the possibility that activation of the IGF-IR pathway may be one way in which cells can escape EGFR inhibition. The first IGF-IR inhibitors to enter Phase I clinical testing have been monoclonal antibodies: CP-751,871, AMG 479, and IMC-A12.
Src is a nonreceptor protein that is found on the intracellular portion of the cell membrane and was the first oncogene (a potentially cancer-inducing gene) discovered.17 Src promotes angiogenesis, the formation of new blood vessels to tumors, and is overexpressed in more than 80 percent of human colorectal cancers. Its activity increases with cancer progression, with higher levels found in metastases than in primary tumors. Src inhibitors are currently in clinical development; they are unlikely to cause shrinkage of solid tumors and are more likely to influence tumor progression, invasion, and metastasis.
TLR9 has a role in immune regulation in the gastrointestinal tract. It may also have a role in modulating cell signaling, including signaling through the EGFR pathway. Clinical evaluation of TLR9 agonists in cancer patients is under way.
People with colorectal cancer should always ask their physician if there is a clinical trial indicated for their type and stage of cancer. The recent advancements in the treatment of colorectal cancer emanate from results of large clinical trials investigating whether new drugs in combination with chemotherapy and radiation therapy improve survival. Members of the cancer healthcare team can help people with a colorectal cancer diagnosis decide whether to enroll in a clinical trial and to choose a trial that is right for them.
When an individual is facing a diagnosis of colorectal cancer, the whole family is in need of information and support to cope with this difficult event. People with colorectal cancer and their family members should feel comfortable asking their health professionals, including their physicians and nurses, for educational and support resources. Treatment centers often have nurses or social workers available to provide counseling and referrals to support groups and other resources.
Drawing on local and national education, support, and advocacy groups is also important. Some organizations-like the Colon Cancer Alliance (http://www.ccalliance.org)-provide a colorectal cancer survivor buddy program. Cancer Care (http://www.cancercare.org) offers professional counseling services in person, by phone, and online. Organizations such as the American Cancer Society (http://www.cancer.org), CancerConsultants.com (http://www.cancerconsultants.com), and the Jay Monahan Center for Gastrointestinal Health (http://www.monahancenter.org) are reliable sources of comprehensive, up-to-date information about colorectal cancer prevention, treatment, support, and clinical trials.
Finally, women often act as the caregivers in the family, putting others’ needs before their own. When a woman is diagnosed with colorectal cancer, it is important that she reach out to her family and friends to let them know how they can help. These loved ones want to help but often do not know how. Help with simple things-someone to drive to chemotherapy appointments, a neighbor to take out the trash each week, a different family member to bring dinner every day, or a friend to take the children out periodically-can be of tremendous support and can also alleviate the helplessness felt by family and friends.
For women who have been diagnosed with colorectal cancer, recent advances in treatment mean more hope for survival than ever before. Women need to be aware of the symptoms of colorectal cancer and should see a gastroenterologist for evaluation and diagnosis if they experience these symptoms. Remember that colorectal cancer often causes no symptoms at all. For this reason women need to speak with their primary care doctor or OB-GYN about undergoing regular screening for colorectal cancer, along with their routine screening for breast and cervical cancers. Colorectal cancer screening can result in the early detection or even prevention of colorectal cancer-and, ultimately, lives saved.
Table 1. Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008
Four Voices, Four Stories of Survival
I first saw blood in my stool as a freshman in college. Not knowing otherwise, I figured that, because it was such a tiny amount, it was normal-probably just a small tear as the stool passed through. It was the first time it had ever happened, and it recurred so rarely over the next few years I didn’t think anything of it. During my senior year of college, I started to lose my hair and just feel tired and worn down. I have always suffered from fatigue, and the loss of my locks was attributed to the stress of my final theses and graduation.
When school ended and the problem didn’t resolve itself, I went to see the doctor. I was diagnosed with an underactive thyroid and given some meds to fix the problem. But my hair kept falling out, I was still tired, and now I was suffering from mild constipation. The bleeding gradually got worse, and when I mentioned it to doctors I was told it was just hemorrhoids. I knew hemorrhoids were common in my family, so I had no reason to question this. Finally, during my second year in graduate school, the constipation, stomach cramps, and bleeding got so bad that I knew something was wrong and I needed to see a specialist.
Not wanting to go by myself, I waited until I went home for Thanksgiving break to see the gastroenterologist. During my consultation he told me that I likely suffered from irritable bowel syndrome, but because the bleeding was not consistent with this diagnosis, he wanted to take a look. He scheduled a sigmoidoscopy during his lunch the next day so that the issue could be resolved sooner rather than later. However, he sat there and told me: “I’m not even concerned about colon cancer. You are too young for that.” The next day I was lying down looking at the inside of my colon! The doctor took some biopsies and sent me home. Five days later, at the age of 22, I was diagnosed with rectal cancer.
When I found out about my diagnosis, I started crying. The first thing I asked my parents was if I was going to die. From the very beginning, they were extremely positive and assured me that we would get through this. I was told that colorectal cancer was a very curable disease and we would find the best doctors to care for me. Obviously, I was scared, but knew I had to do whatever the doctors told me to beat this disease. My family and I chose a team of doctors we were confident would provide me with the best care possible. At my age quality of life was as big an issue as saving my life; once the cancer was annihilated, I would have to live with the side effects of treatment for the rest of my life. As such I opted to forgo radiation, a common treatment for rectal cancer, and be treated with a much stronger chemotherapy regimen.
I went for treatment every week. Chemotherapy made me even more exhausted than usual; sometimes I couldn’t even get out of bed. I suffered from either severe diarrhea or constipation, which made going out very difficult. I had mouth sores, couldn’t eat or drink, and lost a great deal of weight. My skin hurt because it was dry and chapped and covered with a rash. I lost all my hair, including my eyebrows, and generally felt bad. I tried to take advantage of the times when I did feel better by getting out of the house or seeing some friends.
My experience with cancer has definitely had a significant impact on my life. After battling-and beating-cancer twice, I know I am strong enough to handle anything life throws my way. Each day really is a gift, and I have learned not to worry about and stress over the little things quite as much. I try to keep a positive attitude and remain hopeful about my future. In addition, while I continue to focus on staying healthy and enjoying life, I spread awareness about colorectal cancer whenever I can. But, most important, the message I want to send others is to be your own advocate: you know your body best, and if something isn’t right, find a doctor who will listen to you. And above all else, never lose hope. Colon cancer truly is preventable, treatable, and beatable!
On December 28, 2006, my life changed forever. It was the day I was diagnosed with Stage IV colorectal cancer that had metastasized in the liver. As I sat there alone in my doctor’s office, I could only cry and think about my daughter. I was a busy single mother of a 10-year-old, working a full-time job and struggling to manage life on my own. I couldn’t believe this was happening to me. I was totally devastated. I had no idea how to tell my family let alone my daughter. For two weeks I couldn’t eat, sleep, or think of anything except that I was going to die and leave my daughter alone. During that time I went through every emotion; after the initial shock, I became angry and then very depressed. I just wanted to stay in bed and cover my head, but I was afraid I would go to sleep and not wake up.
I managed to work up the courage to sit down with my daughter and talk to her about my cancer. Even a 10-year-old knows that cancer is a scary word and that cancer can kill. She was so afraid of losing me-as afraid as I was of leaving her. I made the determination that day to fight, and I made a promise to her that I would do everything in my power to be there for her.
I first went to see an oncologist, who hospitalized me to perform a battery of tests. His recommendation was to perform surgery on my colon. One possible outcome of the surgery would be that I would have a colostomy bag for the rest of my life. At 46 years old, that is a scary proposition, and the surgery alone would still not get rid of the cancer in my liver. I was devastated all over again. Thankfully, I spoke to a co-worker who had been diagnosed with cancer a few years earlier. She encouraged me, as did other friends, to get a second opinion. I discharged myself that day and went to see Allyson Ocean, MD, an oncologist at NewYork-Presbyterian/Weill Cornell Hospital. Dr. Ocean changed my whole outlook on this illness.
After Dr. Ocean reviewed my test results and performed her own tests, she discussed the possibilities with me. She did not feel that surgery should even be an option at that point. She recommended chemotherapy treatment. I had a port inserted in my upper chest to facilitate the delivery of the chemo drugs. Having the port installed was quick and painless. I had to wear a machine around my waist day and night for three days per week to administer the chemotherapy. It was scary at first, and I thought I would disconnect the machine in my sleep, but soon I became used to it. Yes, I had some side effects, but none of my hair fell out (and I was prepared to buy the wig if I needed to). My fingertips and toes were discolored, but it was such a small price to pay.
After a year on this chemotherapy, I was doing great: the cancer cells in my liver were stable and inactive. Because I was doing so well, Dr. Ocean recommended another type of medication. I now take chemotherapy in pill form, along with a once-per-week half-hour treatment through my port. I get it done on my lunch hour. As a matter of fact, I have worked full-time throughout my illness, taking only a few days here and there to rest.
For others facing this journey, I would say, first, get a second opinion. I am so grateful for the care I have received. Dr. Ocean’s medical team (doctors, nurses, and administrative staff) make me feel that my good health is a group effort and that is their focus. I also have great faith in God that I will be healed: faith is the substance of things hoped for. I pray that God will allow me to see my daughter grow into a woman who can take care of herself. Seeing me as a strong woman ready to fight this illness will hopefully help her be ready to take on whatever life brings her way; and hopefully I will help others going through the same thing. Don’t be afraid to lean on family and friends and to seek counseling and cancer support groups. Talking to survivors can give you the strength to make it, too.
It has been almost two years since my diagnosis, and I am thriving, not just surviving. If you are facing cancer, just know that it is a battle and only by fighting, being strong, and positive can we emerge victorious.
‘Cil M. Shaw-Brewer
July 10, 2002, will be indelibly etched into my mind. I had severe pain in my right side and was taken to the hospital. I remember going into the operating room, believing I was going to have my appendix removed. After spending nine days in the hospital, I was told I had colon cancer and had a third of my colon removed. I would need further treatment.
Total shock, anxiety, and fear overwhelmed me. My main concern was for my two children, ages six and eight at the time. I was only 42 years old, with no family history of this hideous disease and no symptoms. All our plans assumed that my husband, who is 20 years older than me, would die first. We had to seriously consider whom we would select as guardians for our children, as well as financial issues. All of this just compounded the matter and added more stress to our lives.
We prayed a lot and got strength and energy from God’s promise that He would never forsake us. We immediately sought help through prayer and got on several family and friends’ prayer lists. Our prayer was for my health, for us as a family, and for the doctors, nurses, and staff whom we would soon encounter.
We were blessed with an amazing oncologist, the late Scott Wadler, MD, who seemed to understand my fears and anxieties. We heard he was a fantastic doctor, but we never expected him to be the voice of reason. He always knew exactly what to say to relieve me of my fear. He taught me how to play the cards I was dealt.
After six months of chemotherapy, eating healthier, exercising, paying attention to my body, and growing in my faith, I am here six years later with a much stronger and healthier body than ever before. We owe it all to God and the doctors, nurses, and staff. We thank them all from the bottom of our hearts.
On the day before Thanksgiving 2007, at the age of 52, I got the dreaded news: I had colon cancer. One of the first things I asked was if I would need chemo or radiation. I was originally told I would need only surgery. After my surgery I found out that the cancer had spread to my lymph nodes and I would need chemo. The whole idea scared me more than the surgery.
I remember the day I met Dr. Allyson J. Ocean and the whole staff at Cornell Medical. They were all very compassionate and understanding, and they made ongoing attempts to put me as well as my husband at ease, although that was not an easy thing to do at that point. Dr. Ocean explained everything and told me about the side effects that were possible. Unfortunately, I had them all and more. There were good days and there were bad days. Some days I really had to push myself just to leave the house and get through my day.
It was when I found out I needed chemo that everything became a reality and depression kicked in. Cancer is something you hear about all the time, but you never think it’s going to happen to you. I didn’t want to take anything for depression (I am not a pill person), so I found that keeping a journal and talking to people about it helped. Sometimes I still can’t believe it happened to me-I had always been healthy and never had any symptoms. I was very lucky that it was found through a routine colonoscopy, and I had a wonderful doctor, Lawrence Herbert, MD. Now I tell everyone how important it is to be checked and not to put it off.
Even though I’m now finished with chemo, there are still some side effects, and I cannot wait to finally feel like my old self again. But I made it and I’m alive. Recently, I read somewhere, Today is a gift…that’s why it’s called the present. That couldn’t be more true; life is definitely a present!
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