Rectal cancer is a disease in which cancer cells form in the tissues of the rectum; colorectal cancer occurs in the colon or rectum. Adenocarcinomas comprise the vast majority (98%) of colon and rectal cancers; more rare rectal cancers include lymphoma (1.3%), carcinoid (0.4%), and sarcoma (0.3%).
The incidence and epidemiology, etiology, pathogenesis, and screening recommendations are common to both colon cancer and rectal cancer. The image below depicts the staging and workup of rectal cancer.
Diagnostics. Staging and workup of rectal cancer patients.
Signs and symptoms
Bleeding is the most common symptom of rectal cancer, occurring in 60% of patients. However, many rectal cancers produce no symptoms and are discovered during digital or proctoscopic screening examinations.
Other signs and symptoms of rectal cancer may include the following:
Change in bowel habits (43%): Often in the form of diarrhea; the caliber of the stool may change; there may be a feeling of incomplete evacuation and tenesmus
Occult bleeding (26%): Detected via a fecal occult blood test (FOBT)
Abdominal pain (20%): May be colicky and accompanied by bloating
Back pain: Usually a late sign caused by a tumor invading or compressing nerve trunks
Urinary symptoms: May occur if a tumor invades or compresses the bladder or prostate
Pelvic pain (5%): Late symptom, usually indicating nerve trunk involvement
Emergencies such as peritonitis from perforation (3%) or jaundice, which may occur with liver metastases (< 1%)
See Clinical Presentation for more detail.
Perform physical examination with specific attention to the size and location of the rectal tumor in addition to possible metastatic lesions, including enlarged lymph nodes or hepatomegaly. In addition, evaluate the remainder of the colon.
Examination includes the use of the following:
Digital rectal examination (DRE): The average finger can reach approximately 8 cm above the dentate line; rectal tumors can be assessed for size, ulceration, and presence of any pararectal lymph nodes, as well as fixation to surrounding structures (eg, sphincters, prostate, vagina, coccyx and sacrum); sphincter function can be assessed
Rigid proctoscopy: This examination helps to identify the exact location of the tumor in relation to the sphincter mechanism
Routine laboratory studies in patients with suspected rectal cancer include the following:
Complete blood count
Liver and renal function tests
Carcinoembryonic antigen (CEA) test
Histologic examination of tissue specimens
Screening tests may include the following:
Stool DNA screening (SDNA)
Fecal immunochemical test (FIT)
Flexible sigmoidoscopy (FSIG)
Combined glucose-based FOBT and flexible sigmoidoscopy
Double-contrast barium enema (DCBE)
Computed tomography (CT) colonography
Fiberoptic flexible colonoscopy (FFC)
If metastatic (local or systemic) rectal cancer is suspected, the following radiologic studies may be obtained:
CT scanning of the chest, abdomen, and pelvis
Endorectal or pelvic magnetic resonance imaging (MRI)
Positron emission tomography (PET) scanning: Not routinely indicated
See Workup for more detail.
A multidisciplinary approach that includes colorectal surgery/surgical oncology, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer. Surgical technique, use of radiotherapy, and method of administering chemotherapy are important factors.
Strong considerations should be given to the intent of surgery, possible functional outcome, and preservation of anal continence and genitourinary functions. The first step involves achievement of cure, because the risk of pelvic recurrence is high in patients with rectal cancer, and locally recurrent rectal cancer has a poor prognosis.
Radical resection of the rectum is the mainstay of therapy. The timing of surgical resection is dependent on the size, location, extent, and grade of the rectal carcinoma. Operative management of rectal cancer may include the following:
Transanal excision: For early-stage cancers in a select group of patients
Transanal endoscopic microsurgery: Form of local excision that uses a special operating proctoscope that distends the rectum with insufflated carbon dioxide and allows the passage of dissecting instruments
Endocavity radiotherapy: Delivered under sedation via a special proctoscope in the operating room
Sphincter-sparing procedures: Low anterior resection, coloanal anastomosis, abdominal perineal resection
Adjuvant medical management
Adjuvant medical therapy may include the following:
Adjuvant radiation therapy
Intraoperative radiation therapy
Adjuvant chemoradiation therapy
The National Comprehensive Cancer Network guidelines recommend the use of as many chemotherapy drugs as possible to maximize the effect of adjuvant therapies for colon and rectal cancer.
The following agents may be used in the management of rectal cancer:
Antineoplastic agents (eg, fluorouracil, vincristine, leucovorin, irinotecan, oxaliplatin, cetuximab, bevacizumab, panitumumab)
Vaccines (eg, quadrivalent human papillomavirus [HPV] vaccine)
Good diet and exercise habits may improve survival rates for people who have colon cancer, according to results of an observational study published April 12 in JAMA Oncology.
Patients with stage III colon cancer and a lifestyle considered highly consistent with the American Cancer Society (ACS) guidelines on diet and exercise had a 42% lower relative risk for death compared with patients who did not, said Erin L. Van Blarigan, ScD, from the University of California, San Francisco, and colleagues.
In an accompanying editorial, Michael J Fisch, MD, MPH, and coauthors urged physicians to heed the lesson about the applicability of the ACS Nutrition and Physical Activity Guidelines for people already facing colon cancer.
"If you were skeptical about emphasizing nutrition and physical activity for colorectal cancer survivors based on the nature of the end points previously examined or the size of demonstrated effects, or the fact that most of the similar studies were conducted among patients with breast cancer, these data should soften those concerns," write Fisch, who works for Anthem's AIM Specialty Health, Chicago, Illinois, and coauthors.
The editorialists also say that the new study will allow physicians who previously gave vague advice about diet and exercise to be more precise, and recommend five to six servings of fruits and vegetables per day and 150 minutes of exercise per week.
The editorialists describe the findings as a "cancer control gem that came out of the ashes of" an earlier failed trial.
That trial was the Cancer and Leukemia Group B (CALGB) 89803 study, a chemotherapy trial among patients with colon cancer involving irinotecan and started about 20 years ago. However, a lifestyle survey was administered in the clinic during and after chemotherapy as part of this study. After exclusions, there were 992 patients eligible for analysis by Van Blarigan and colleagues for an observational study.
Over a 7-year median follow-up, there were 335 recurrences and 299 deaths, including 43 deaths without recurrence. Compared with patients with a poor ACS guidelines score (0 to 1; n = 262; 26%), patients with an excellent score (5 to 6; n = 91; 9%) had a 42% lower relative risk for death during the study period (hazard ratio [HR], 0.58; P = .01 for trend) and improved disease-free survival (HR, 0.69; P = .03 for trend).
High adherence to the ACS guidelines (score of 5 to 6) was also associated with a 9.0% absolute reduction in the risk for death at 5 years compared with a score of 0 to 4, reported the study authors.
The editorialists described that mortality difference as "striking."
There may be no harm in recommending that patients who have stage III colon cancer adopt the ACS lifestyle recommendations, while acknowledging that this may be difficult for them, Van Blarigan said in an JAMA podcast interview.
"There's no reason to put it off, but they may not feel up to it if they are currently undergoing treatment," she said.
There's a demand for this kind of detailed information about lifestyle recommendations for people who have been treated for colon cancer, said senior study author, Jeffrey A. Meyerhardt, MD, MPH, from the Dana-Farber Cancer Institute in Boston, Massachusetts, in the same podcast.
"That's a question that patients ask a lot about…'What should I eat? Should I exercise?'" he said.
More Study Details
To compare outcomes based on lifestyle choices, the study authors assigned an ACS guidelines score for each included patient based on a combination of factors: body mass index; physical activity; and intake of vegetables, fruits, whole grains, and red and processed meats. As noted above, scores ranged from 0 to 6, with higher numbers indicating healthier behaviors.
The researchers also examined the connections between these factors and death after colon cancer on their own.
They reported that patients with a body mass index (BMI) of 25.0 to 29.9 had lower risk for death than patients with a BMI of 30 or higher. Compared with patients who abstain from alcohol, heavy drinkers had a non–statistically significant increased risk for death, while patients consuming low to moderate amounts of alcohol had a non–statistically significant decreased risk for death, the authors said.
Consuming five or more servings of vegetables and fruits per day appeared to be helpful, but the findings on red and processed meat ran contrary to what might be expected, the authors said. Low intake of red and processed meat after colon cancer was associated with an increased risk for death.
"Higher protein intake may be beneficial for cancer survivors," Van Blarigan and study colleagues write. "Thus, it is possible that red meat is inversely associated with colon cancer mortality, despite being positively associated with colon cancer incidence."
The authors noted the limitations of their study. They couldn't conclude, for example, that the associations are independent of a patient's prediagnosis lifestyle or that changing behaviors after cancer diagnosis can achieve these results. They also pointed out that the study population was predominantly white and may not be representative of all patients with colon cancer.
The National Cancer Institute funded this study. The study authors and editorialists have disclosed no relevant financial relationships.
JAMA Oncol. Published online April 12, 2018. Abstract
Just like everyone else on the planet, you have hemorrhoids.
Yep: You were born with them, and you’ll croak with them, but hopefully they won’t cause you too much trouble along the way.
That’s because hemorrhoids are actually a normal part of your anatomy.
“Hemorrhoids are nothing more than veins that are inside and outside your anal canal,” says Mitchell Bernstein, M.D., Director in the Division of Colon & Rectal Surgery at NYU Langone Health. “It’s when they become symptomatic that you have a problem.”
There are two types of hemorrhoids: internal and external hemorrhoids. With internal hemorrhoids, the most common issues are irritation that causes bleeding, and prolapse, which means they “drop” out of the rectum. For the latter, many patients simply tuck them back in manually and it’s fine, says Dr. Bernstein.
The external hemorrhoids—which develop under the skin around the anus—are the ones that grab all the attention, because when something goes awry there, they tend to become swollen and very painful. That’s when simply sitting down can start to hurt like hell.
If anything’s irritating your hemorrhoids or causing them to flare up, it can certainly be unpleasant. So that’s why playing the preventive game for hemorrhoids is extra-important. Here, 5 things that might be causing your hemorrhoids to become symptomatic.
Why you get hemorrhoids: You’re sitting on the toilet too long
Look, we get it. Maybe toilet time is the only chance you get to scroll through social media or watch old Jackass clips on YouTube. You might think being on the toilet is the same as simply sitting in a chair. But that’s absolutely not true, says Dr. Bernstein.
“Hemorrhoids tend to become symptomatic whenever you have increased, downward pressure,” he says, noting that being on the toilet not only separates your butt cheeks, but the shape of the bowl and the way you sit causes a very slight suction effect. Basically, gravity is not your friend here.
“The longer you sit, the more your blood pools down in those veins, and the gravity creates more pressure,” says Dr. Bernstein. That creates inflammation that makes hemorrhoids flare. “Go in, do your business, and get out.”
In fact, you should never sit on the toilet longer than 15 minutes, as we reported.
Why you get hemorrhoids: You wait too long to poop
Part of the major function of the colon is to remove water from fecal matter, according to Heather Bartlett, M.D. a family practice physician in Columbus, Ohio. If you abide by your body’s signals to evacuate, your water-to-poop ratio is usually fine, unless you’re dehydrated to some degree.
But if you tough it out, the colon will continue its water removal mechanism, making the stool firmer.
“With less water content, it’s like trying to get a brick to go through a Play-Doh maker,” she says. “That causes tears and fissures, and makes the veins more easily exposed. When you add straining in there, then you’ll become symptomatic.”
Why you get hemorrhoids: You’re pushing too hard
Speaking of straining, it’s another top contributor to hemorrhoids becoming a problem. That’s because it’s a source of downward pressure, says Dr. Bernstein.
Trying to push the poop out can overtax the veins enough that it could damage a vein’s surface and cause it to bleed, or may be enough to push an internal hemorrhoid out.
Why you get hemorrhoids: You don't get enough fiber and water
Anything that limits your time in the bathroom and makes your stools more pliable is a good thing, says Dr. Bernstein. Fiber has been touted endlessly as a make-you-go tool, and for good reason: Fiber adds bulk to your digestive system, shortening the time it takes for waste to travel through the colon.
Water, too, speeds the process by keeping your intestines smooth and flexible.
Ideally, your poop should be soft and easy to pass, Dr. Bernstein says. Check out the Bristol Stool Chart for some insight on how you rate.
Anything that involves having to push is usually an indication that you’re not as hydrated as you could be, adds Dr. Bartlett.
Why you get hemorrhoids: You squat too heavily, too quickly
This can be particularly true for those who don’t work their way up gradually, and aim to do all the squats, all in one day. Dr. Bernstein says leg presses can have the same effect, or even helping a friend move.
“It’s all about the sudden pressure as you’re pushing,” he says. “We often see people who’ve done a heavy workout come in with hemorrhoid issues.”
He advises warming up by doing lighter weight sets first, so you push less when you get to those heavier weights.
When to see a doctor for hemorrhoids
Symptomatic hemorrhoids are very common, but that doesn’t mean you shouldn’t keep an eye out for some signs that you might need to get checked out.
Dr. Bernstein says that any time you have rectal bleeding, make an appointment. It’s most likely that it’s hemorrhoids, but since that’s also a warning sign for colon or rectal cancer, it’s better to be safe (Here are 7 signs of colon cancer young guys should never ignore).
Also, if the pain becomes too intense or continues for more than a couple weeks, see your doctor for some relief. He or she can do therapies designed to cut off blood flow from the hemorrhoid, which cause it to shrink. In more advanced cases, you may need surgery to remove a hemorrhoid completely, or staple one that’s prolapsed back into place.
By EJ Mundell
Numerous studies have linked a high intake of red meat to colon cancer. In fact, guidelines from the American Institute for Cancer Research and World Cancer Research Fund International, released in September, recommended that people limit their intake of red meat to just over a pound per week to lower colon cancer risk.
In the new study, researchers tracked data on more than 32,000 women in the United Kingdom who were followed for an average of 17 years.
During that time, 335 cases of colon cancer were diagnosed, including 119 cases of distal colon cancer, which occurs in the descending section of the colon, where feces is stored.
Women who regularly ate red meat were more likely to develop distal colon cancer than those who did not eat red meat, according to the research team led by Diego Rada Fernandez de Jauregui, of the Nutrition Epidemiology Group at the University of Leeds.
Two experts in the United States noted that while the study had its flaws, the findings could give guidance to people concerned about cancer risk.
The research couldn't prove cause and effect, but "multiple studies have already highlighted that long-term consumption of red meat or processed meats are associated with an increased risk of colorectal cancer, particularly for left-sided or distal tumors, and this study does uphold this," said Dr. Elena Ivanina. She's a gastroenterologist at Lenox Hill Hospital in New York City.
Ivanina said that even though the study didn't control for certain factors -- the women's use of supplements or cancer-fighting aspirin, for example -- it "does positively reinforce the importance of a meat-free diet in preventing colorectal cancer."
And colon surgeon Dr. Nathaniel Holmes stressed that when it comes to preventing these cancers, "a low-fat, high-fiber diet is recommended."
Beyond that, "smoking, alcohol consumption and obesity are all associated with increased risk of colon and rectal cancer," said Holmes, who practices at Staten Island University Hospital in New York City.
The study was published April 2 in the International Journal of Cancer.
WebMD News from HealthDay
By Robert Preidt
THURSDAY, March 29, 2018 (HealthDay News) -- Despite recommendations, only about one in 10 U.S. baby boomers has been screened for hepatitis C virus (HCV), a new study reveals.
Hepatitis C is a contagious virus that causes nearly half of the cases of liver cancer in the United States. Health officials estimate that about one in 30 Americans born between 1945 and 1965 (the baby boom generation) has chronic HCV infection.
But most don't know it.
"Hepatitis C is an interesting virus because people who develop a chronic infection remain asymptomatic for decades and don't know they're infected," said study lead author Monica Kasting.
"Most of the baby boomers who screen positive for HCV infection were infected over 30 years ago, before the virus was identified," added Kasting, a postdoctoral fellow at Moffitt Cancer Center in Tampa, Fla.
The U.S. Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force recommend that baby boomers get a blood test to screen for HCV.
But when Kasting and colleagues analyzed federal government data, they found that HCV screening rates among baby boomers ranged from 11.9 percent in 2013 to 12.8 percent in 2015.
The study findings were published in the March 27 issue of Cancer Epidemiology, Biomarkers & Prevention.
Women were less likely to have been screened than men. The researchers also found that among baby boomers and Americans born between 1966 and 1985, HCV screening rates were lower among Hispanics and blacks.
"This is concerning because these groups have higher rates of HCV infection and higher rates of advanced liver disease," Kasting said in a journal news release.
"This may reflect a potential health disparity in access to screening, and therefore treatment, for a highly curable infection," she added.
The most important study finding is that the HCV screening rate isn't increasing in a meaningful way, said Anna Giuliano, who founded Moffitt's Center for Infection Research in Cancer. "Between 2013 and 2015, HCV screening only increased by 0.9 percent in the baby boomer population," she pointed out.
A lot of patients ask me the quickest way to lose weight before summer. Of course, diet and exercise are everything, but CoolSculpting is honestly amazing to freeze away your fat in no time.
We created a discount only for our patients, so I just wanted to share below from our in-office aesthetic division, Aesthetic Body Solutions.
If you're interested, I highly suggest you start with the free consultation.
- Dr. P
By Alan Mozes
WEDNESDAY, March 14, 2018 (HealthDay News) -- A large study has confirmed what many public health experts have long believed: Colonoscopy saves lives.
The study looked at roughly 25,000 patients in the Veterans Affairs (VA) health system, where colonoscopy is widely used. The VA views it as the main screening test for patients aged 50 and older who have average odds for developing colon or rectal cancer.
Those who died were significantly less likely to have had a colonoscopy, the study found.
A comparison of screening histories over about two decades found that "colonoscopy was associated with a 61 percent reduction in colorectal cancer mortality," said study author Dr. Charles Kahi.
Kahi is gastroenterology section chief with the Roudebush VA Medical Center in Indianapolis.
The U.S. Centers for Disease Control and Prevention recommends everyone between the ages of 50 and 75 get screened for colon cancer. Those at high risk -- including those with a family history of the disease -- should be tested even earlier, the CDC advises.
Screening can take several forms, including stool tests; a lower colon exam called flexible sigmoidoscopy; and even a "virtual" colonoscopy that relies on X-rays to scan the entire colon.
But many public health advocates favor a full colon exam, or colonoscopy. For the test, a patient is typically sedated and a doctor inserts a flexible, lighted tube to examine the entire colon. If found, growths called polyps can be removed during the procedure.
Between 11.5 million and 14 million Americans have a colonoscopy each year, according to the study team.
The new study focused on patients aged 50 and older who were treated at VA facilities between 1997 and 2010.
The investigators found that a colonoscopy reduced the risk of death from right-sided colorectal cancer by 46 percent and left-sided cancer by 72 percent, equaling a combined drop of 61 percent.