Colorectal Cancer and Other Cancers of the Lower GI Tract

Colorectal cancer (aka cancer of the colon and rectum) is the second-leading cause of cancer-related deaths in the United States and affects both men and women equally. Everybody is at risk to develop colorectal cancer, typically with about 4 5% likelihood over a lifetime. However, some diet and lifestyle choices decrease the risk of developing colorectal cancer, such as eating plenty of vegetables, fruits, and whole grains, engaging in regular physical activity and avoiding tobacco or alcohol use. 

• Certain genetic factors and underlying colon diseases increase the cancer risk substantially. These include hereditary (genetic) syndromes such as – among others – (1) familial adenomatous polyposis (FAP), an inherited condition that predisposes people to growths in the colon or rectum, and (2) Lynch syndrome, as well as inflammatory bowel disease (aka ulcerative colitis or Crohn’s disease).
• Colorectal cancer may develop silently and not cause any symptoms until it has already reached a substantial size. Symptoms ultimately may include blood in the stool, change in bowel habits, abdominal pain and difficulty in passing stool.
• Colorectal cancer usually develops from a precursor – aka polyp, a mushroom- or cauliflower-like growths on the lining of the colon and rectum.
• Timely testing may dramatically reduce the cancer risk and allow doctors to identify cancer at earlier stages. Colorectal cancer screening starts at age 45 for individuals at average risk, and even earlier for patients with symptoms or factors that put them at high risk.
• The gold standard for screening is a colonoscopy, which allows physicians not only to find but also to remove polyps before they become cancerous. 
• Other screening tools include CT colonography, a three-dimensional X-ray imaging also referred to as the virtual colonoscopy, and stool tests such as Cologuard. It is important to note, though, that they are not as sensitive and specific as the colonoscopy and lack the ability to remove polyps.
• The cost of colorectal cancer screening, including colonoscopies, are covered by Medicare and most commercial health plans.

The specialists in City of Hope’s Division of Colorectal Surgery are experts in the diagnosis, treatment, and prevention of colorectal cancer.

Learn more about how we treat colorectal cancer

Approximately half of colorectal cancer patients will develop liver metastases, and and up to one-third of all colorectal cancer patients have liver metastases when they are diagnosed. Most hospitals offer a staged set of surgical procedures to treat the complications of colorectal cancer and liver metastases. This means that patients often have to undergo colectomy surgery separately from liver resection. At City of Hope, we have extensive experience in performing combined, synchronous colorectal cancer and liver resection, which improves patients’ quality of life during treatment.

Learn about our synchronous colectomy and liver resection

A polyp is an abnormal mushroom- or cauliflower-like growth rising from the otherwise flat lining of the colon. While all people are at risk for polyps of the colon, polyps are found in 35-45% of patients over a lifetime. The number, size and frequency vary from one person to another. All polyps start off benign, but some may progress and turn into cancer.

Colon cancer screening is recommended to start at age 45. How often an individual should receive further colonoscopies depends on the results of the test. The removal of polyps dramatically reduces the risk of developing colon cancer. Most polyps can be removed using a tool called an endoscope, which enters through the anus and thus does not require an incision. However, if a polyp goes undetected for too long and becomes very large, surgery may be required.

The colorectal surgeons at City of Hope  specialize in colonoscopies for both identifying and removing polyps and offer other techniques to remove larger polyps.

Rectal polyps appear in the lowermost portion of the large intestine. Because the rectum is so close to the anal opening, these polyps tend to cause symptoms more often than polyps of the colon. 

Fortunately, there are also more advanced tools and techniques available to address these precancerous growths. City of Hope offers the following procedures:

• Colonoscopy, in which a long tube with a camera, a light and instruments for removing polyps enter the body through the anus.
• Transanal excision, i.e. removal of the polyp under direct vision through the anus (similar to a hemorrhoid operation)
• Robotic or conventional transanal minimally invasive surgery (TAMIS) or transanal endoscopic microsurgery (TEMS) procedures that combine camera and instrument technology to reach and remove lesions that are further inside through the anus and without incision.

If a polyp is too large, it may be necessary to remove the section of the rectum while preserving the sphincter.

The colorectal surgeons at City of Hope are experts in all of the above techniques. They analyze the individual circumstances and tailor the treatment to provide the best approach for each patient while focusing on preserving function of the anal sphincter if possible to safeguard patients’ quality of life.
 

While most colorectal cancers seem to occur by chance, at least a third of cases are caused by genetic mutations that may be passed on from one generation to the next. About 5% of colon and rectal cancers are caused by known genetic conditions such as Lynch syndrome and familial adenomatous polyposis (FAP), both of which predispose people to develop growths in their colon and rectum at a high rate and a much younger age. There are also many other extremely rare genetic syndromes. 

It is especially important to recognize these syndromes because more than just one person in a family may be at high risk of developing colon and other cancers. The process involves a visit to our genetics team and a simple blood test. Carriers of hereditary cancer syndrome genes frequently require major surgery to treat or prevent cancer.

The colorectal surgeons at City of Hope are experts for patients and their families with such genetic syndromes. The surgeons are specialized in these complex decisions and operations which they frequently can carry out as minimally invasive surgeries (robotically or laparoscopically).

Lynch syndrome is one of the two most common genetic syndromes that greatly increase the risk for colorectal cancer and other malignancies at young age. Patients with Lynch syndrome tend to develop colon cancer much earlier in their lives, sometimes in their 30 or 40s, and they have a 50% chance to pass on the same defect to each of their children.

Once the care team diagnoses Lynch syndrome, City of Hope colorectal surgeons and gastroenterologists collaborate closely to develop an individualized treatment strategy that may involve surgery.

Familial adenomatous polyposis (FAP) is one of the two most common colon cancer syndromes. It is caused by a genetic mutation that leads to hundreds or even thousands of colon polyps. There is a 50% chance that a carrier of FAP will pass the syndrome on to each of their children. 

Unless the colon is removed in a timely fashion, almost all patients with FAP will develop colon cancer by the age of 40, although for some the onset is a bit later. Tumors in other organs may form as well. 

If FAP is known in a family or detected early, colorectal cancer can fortunately be prevented with a surgery called restorative proctocolectomy. In this procedure, a surgeon removes the colon and rectum and creates a “new rectum” with the small bowel. The surgery, aka as IPAA or “J-pouch” is extraordinarily successful and allows to nearly eliminate the cancer risk while preserving continence and safeguarding quality of life.

Such surgeries are complex and should only be done at centers with the required expertise. The colorectal surgeons at City of Hope specialize in restorative proctocolectomy and other surgeries for patients with FAP; frequently, they can carry out these surgeries as minimally invasive surgeries (robotically or laparoscopically).

MUTYH-associated polyposis (MAP), named for the gene that is mutated in the condition, is a rarer colon cancer syndrome that is similar to familial adenomatous polyposis. The main difference is that the hereditary pathway of MAP – in contrast to the autosomal dominant FAP - is autosomal recessive, i.e. if both parents carry the gene mutation, it is passed on to the next generation in only one-quarter of offsprings.