Colorectal cancer, what to know

How do you recognize colorectal cancer and what are its first symptoms? Are there any risk factors? What are the treatment options, the best screening techniques and the prospects for patients?

What are the warning signs of colorectal cancer?

There are some symptoms that should not be underestimated, classically associated with colorectal cancer, due to its location at the gastrointestinal level:

  • involuntary weight loss;
  • anemia and proctorhagia or blood loss in stools, which can make the patient feel tired and exhausted.

Sometimes, however, the presentation can instead be more subtle, such as a change in toilet habits that leads to constipation or diarrhea.

In other cases, the symptoms may be so subtle that they are not recognized by the patient.

Anemia alone is an example of this: the patient realizes through blood tests that he has altered values, caused by spontaneous bleeding from the tumor.

The good news is that we now have a formidable tool for identifying these cancers well before symptoms appear for early intervention – early screening.

It is nice to think that in an ideal and not too future world, colorectal cancer will be largely curable thanks to early identification through prevention appointments.

Can colorectal cancer be asymptomatic?

Yes, in the initial stages of the disease, i.e. when the tumor has not yet advanced, the tumor can also be asymptomatic and often show no sign of its presence.

For this reason it is essential to specify that the symptoms, in themselves, are unreliable and it is essential to dwell on screening and prevention, even before these appear.

Unfortunately, when the tumor is not identified in time, it has the possibility of spreading and localizing in other areas of the body, through metastasis, giving rise to different symptoms.

How common is this type of cancer?

Colorectal cancer is one of the leading cancers in Western countries.

What are the risk factors for colorectal cancer?

Risk factors can be divided into ‘modifiable’ and ‘non-modifiable’.

Modifiable risk factors include cigarette smoking, excess alcohol consumption, sedentary lifestyle and inadequate diet, rich in red meat, carbohydrates and fats with little intake of noble foods such as fruit, vegetables and legumes.

It is on these habits that we can act, by stopping smoking, limiting alcohol, exercising and choosing a healthy diet.

How important is familiarity?

Among the risk factors previously mentioned as ‘non-modifiable’ it is good to remember familiarity, some genetic diseases (such as Lynch syndrome and familial adenomatous polyposis) and chronic inflammatory bowel diseases (Crohn’s and ulcerative colitis).

Although these conditions are defined as non-modifiable, relying on expert doctors allows us to intervene early through dedicated surveillance programs that have been shown to reduce the risk of colorectal cancer.

Early diagnosis: occult blood test or colonoscopy?

Early diagnosis is a fundamental tool at our disposal to reduce mortality from colorectal cancer, if not the most important.

It is thanks to screening that we can remove adenomas before they become cancer, reducing the number of patients, but also diagnose it before it becomes symptomatic and therefore in the earliest stages.

All this allows us to offer more therapeutic possibilities, increase survival and save lives.

For the general population, the screening service is active, which can take place in 2 equally effective ways: faecal occult blood test every 2 years, the most common method;

Although the occult blood method is valid and fundamental for the prevention of this type of pathology, it should also be noted that it is suitable for the general population, but for the categories of patients most at risk of colorectal cancer (family history, inflammatory diseases and hereditary syndromes), occult blood screening is insufficient.

In these cases it is recommended to enter surveillance programs through endoscopy, with variable frequency according to many factors decided by the specialist or general practitioner.

For this, it is good to rely on centers of reference and with great experience.

What are the treatment options for colorectal cancer?

Until a few decades ago, for colorectal cancer, there were few treatment options and even less cure options.

Today we are witnessing a real revolution in the treatment of this tumor with many patients who can be offered.

For tumors in the earliest stage (stage I-III), resective surgery is offered, generally by laparoscopic (more rarely laparotomic) route.

For colon cancers, surgery is followed by chemotherapy for high-risk stage II and stage III.

For locally advanced rectal tumors, chemo-radiotherapy is generally performed before surgery and then a chemotherapy defined as adjuvant, i.e. which ‘helps’ the surgery to eliminate the tumor.

Recently this sequence has been innovated by studies on ‘total neoadjuvant therapy’, an approach which consists of moving all chemo and radiotherapy before surgery to avoid having to do chemotherapy after surgery.

Finally, for more advanced stage tumors there are many so-called ‘immunotherapy’ drugs that rekindle our immune defenses to fight the tumor with clinical studies and surprising results. But not only. There is a wealth of drugs that demonstrates that the science of the last decade has given us a truly vast arsenal.

All therapies can be used in combination with traditional chemotherapies to further enhance our therapeutic options.

Finally, a little known, but really important peculiarity of colorectal cancer should be underlined.

The so-called ‘T1’ tumors, ie the earliest stage that exists, can be treated endoscopically and be removed without having to make incisions on the belly.

These are delicate operations that in expert hands can allow us to intervene radically on a tumor, passing through natural orifices.

The advantage of this approach is obviously to avoid major surgery with the risk of ostomy, with longer hospitalization times and with greater anesthetic risks.

What are the survival prospects for patients?

It is good to begin by emphasizing that 5-year survival has been increasing beyond the wildest expectations in recent years.

Progress and research have added many new tools to the oncologists’ arsenal, including immunotherapy (today a daily reality), target therapies, as well as some new administration protocols, such as the recently introduced ‘total neoadjuvant therapy’, for regarding rectal cancer.

Clearly one of the factors determining survival is precisely the stage of the disease at diagnosis, since in the earliest stages survival is around 90% for colon and rectal cancer.

When the disease extends to the lymph nodes, the median survival is 72-73%.

Unfortunately, the chances of cure are drastically reduced when the disease is metastatic, since in this case the 5-year survival is less than 20%.

Risk of metastasis: where can they spread?

Approximately 20-25% of colorectal cancers are metastatic at diagnosis and, unfortunately, it can happen that patients develop them even years later.

The site that is most affected by metastases is the liver, followed by the lungs, peritoneum, ovaries, adrenal glands, bones and central nervous system.

The main risk factors for their development are essentially histological.

Generally speaking, ‘high-risk’ stage II cancers and stage III cancers are those with the greatest risk of developing distant metastases.

Based on this consideration, these patients generally receive adjuvant chemotherapy, but many details are taken into consideration.

Many studies have tried to identify other (non-histological) risk factors related to the risk of developing metastases, but for now no clear suspects have emerged.

What is the message to give to patients and their families?

Colorectal cancer is a potentially fatal disease if it is left free to progress, but if we manage to catch it in its earliest stages, there is a concrete possibility of making it almost completely curable.

Screening is an incomparable ally, because it can prevent the diagnosis of cancer, it can diagnose cancer in its earliest stages and, therefore, avoid death.

We are certainly faced with a frightening disease, but if we manage to catch it in time, then we will have a better chance of a cure.

It is vital to participate in screening programs, only so many lives will be saved.

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