History
All patients should undergo a complete history (including a family history) and assessment of risk factors for the development of rectal cancer. Many rectal cancers produce no symptoms and are discovered during digital or proctoscopic screening examinations.
Bleeding is the most common symptom of rectal cancer, occurring in 60% of patients. Bleeding often is attributed to other causes (eg, hemorrhoids), especially if the patient has a history of other rectal problems. Profuse bleeding and anemia are rare. Bleeding may be accompanied by the passage of mucus, which warrants further investigation.
Change in bowel habits is present in 43% of patients; change is not evident in some cases because the capacity of a rectal reservoir can mask the presence of small lesions. When change does occur it is often in the form of diarrhea, particularly if the tumor has a large villous component. These patients may have hypokalemia, as shown in laboratory studies. Some patients experience a change in the caliber of the stool. Large tumors can cause obstructive symptoms. Tumors located low in the rectum can cause a feeling of incomplete evacuation and tenesmus.
Occult bleeding is detected via a fecal occult blood test (FOBT) in 26% of all cases. Abdominal pain is present in 20% of the cases. Partial large-bowel obstruction may cause colicky abdominal pain and bloating. Back pain is usually a late sign caused by a tumor invading or compressing nerve trunks. Urinary symptoms may also occur if the tumor is invading or compressing the bladder or prostate.
Malaise is a nonspecific symptom and present in 9% of rectal cancer cases. Bowel obstruction due to a high-grade rectal lesion is rare, occurring in 9% of all cases. Pelvic pain is a late symptom, usually indicating nerve trunk involvement, and is present in 5% of all cases. Other manifestations include emergencies such as peritonitis from perforation (3%) or jaundice, which may occur with liver metastases (< 1%).
The rising rates of colon and rectal cancer in persons younger than 50 years has prompted research in this population. A matched case-control study of 5075 incident colorectal cancers in patients younger than 50 years identified abdominal pain, rectal bleeding, diarrhea, and iron deficiency anemia within three months to two years before diagnosis as red-flag clinical manifestations in this age group. The presence of any one of those clinical manifestations was associated with 1.94-fold higher risk; any two, with 3.59-fold higher risk, and three or more, with 6.52-fold higher risk. The risk associations were stronger in younger patients and with rectal versus colon cancer. [22]
Physical
Physical examination is performed with specific attention to size and location of rectal cancer in addition to possible metastatic lesions, including enlarged lymph nodes or hepatomegaly. The remainder of the colon is also evaluated.
Digital rectal examination (DRE) provides an opportunity to readily detect abnormal lesions. 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. Fixation of the tumor to surrounding structures (eg, sphincters, prostate, vagina, coccyx and sacrum) also can be assessed. DRE also permits a cursory evaluation of the patient's sphincter function. This information is necessary when determining whether a patient is a candidate for a sphincter-sparing procedure. Rigid proctoscopy is also performed to identify the exact location of the tumor in relation to the sphincter mechanism.
Causes
The etiology of colorectal cancer is unknown, but colorectal cancer appears to be multifactorial in origin and includes environmental factors and a genetic component. Diet may have an etiologic role, especially diet with high fat content.
A cohort study by Tabung et al that followed 121,050 adults for 26 years found that in both men and women, intake of proinflammatory diets (replete in red, processed, and organ meat, for example) was associated with a significantly higher risk of developing colorectal cancer. Risk was especially high in overweight and obese men and, paradoxically, in lean women. Risk was also increased in men and women who do not drink alcohol. [23, 24]
Approximately 75% of colorectal cancers are sporadic and develop in people with no specific risk factors. The remaining 25% of cases occur in people with significant risk factors—most commonly, a family history or personal history of colorectal cancer or polyps, which are present in 15-20% of all cases. Other significant risk factors are certain genetic predispositions, such as hereditary nonpolyposis colorectal cancer (HNPCC; 4-7% of all cases) and familial adenomatous polyposis (FAP, 1%); and inflammatory bowel disease (IBD; 1% of all cases).
Environmental Factors
Diet
A high-fat, low-fiber diet is implicated in the development of colorectal cancer. Specifically, people who ingest a diet high in saturated animal fats and highly saturated vegetable oils (eg, corn, safflower) have a higher incidence of colorectal cancer. The mechanism by which these substances are related to the development of colorectal cancer is unknown.
Saturated fats from dairy products do not have the same carcinogenic effect, nor do oils containing oleic acid (eg, olive, coconut, fish oils). Omega-3 monounsaturated fatty acids and omega-6 monounsaturated fatty acids also appear to be less carcinogenic than unsaturated or polyunsaturated fats. In fact, epidemiologic data suggest that high fish consumption may provide a protective effect against development of colorectal cancer. Long-term diets high in red meat or processed meats appear to increase the risk of distal colon and rectal cancers. [25, 26]
The ingestion of a high-fiber diet may be protective against colorectal cancer. Fiber causes the formation of a soft, bulky stool that dilutes carcinogens; it also decreases colonic transit time, allowing less time for harmful substances to contact the mucosa. The decreased incidence of colorectal cancer in Africans is attributed to their high-fiber, low–animal-fat diet. This favorable statistic is reversed when African people adopt a western diet. Findings of a meta-analysis of 22 studies with a total of 2,876,136 subjects suggest that dietary fiber intake could be a protective factor against rectal cancer with a clinically relevant reduction in rectal cancer risk. [25]
Increased dietary intake of calcium appears to have a protective effect on colorectal mucosa by binding with bile acids and fatty acids. The resulting calcium salts may have antiproliferative effects, decreasing crypt cell production in the mucosa. A double-blind placebo-controlled study showed a statistically significant reduction in the incidence of metachronous colorectal adenomas. [27] Other dietary components, such as selenium, carotenoids, and vitamins A, C, and E, may have protective effects by scavenging free-oxygen radicals in the colon.
Alcohol
Alcohol intake of more than 30 g daily has been associated with increased risk of developing colorectal carcinoma, with risk of rectal cancer greater than that of colon cancer. Risk appears greater with beer than with wine. [28] Specifically, Kabat et al found that daily beer consumption of 32 ounces or more increases the risk of rectal cancer in men (odds ratio 3.5). [29]
Tobacco
Smoking, particularly when started at a young age, increases the risk of colorectal cancer. [30] Possible mechanisms for tumor development include the production of toxic polycyclic aromatic amines and the induction of angiogenic mechanisms due to tobacco smoke.
A study by Phipps et al found that smoking is also associated with increased mortality after colorectal cancer diagnosis, especially among patients with colorectal cancer with high microsatellite instability. [31]
Cholecystectomy
Following cholecystectomy, bile acids flow freely, increasing exposure to the degrading action of intestinal bacteria. This constant exposure increases the proportion of carcinogenic bile acid byproducts. A meta-analysis by Giovannucci et al revealed an increased risk of proximal colon carcinoma following cholecystectomy. Although a large number of studies suggest the increased risk of proximal colon cancer in patients following cholecystectomy, the data are not compelling enough to warrant enhanced screening in this patient population. [3]
Hereditary Factors
The relative risk of developing colorectal cancer is increased in the first-degree relatives of affected patients. For offspring, the relative risk is 2.42 (95% confidence interval [CI]: 2.20-2.65); when more than one family member is affected, the relative risk increases to 4.25 (95% CI; 3.01-6.08). If the first-degree family member is younger than 45 years at the time of diagnosis, the risk increase is even higher. [32]
Regarding the personal history of colorectal cancer or polyps: Of patients with colorectal cancer, 30% have synchronous lesions, usually adenomatous polyps. Approximately 40-50% of patients have polyps on a follow-up colonoscopy. Of all patients who have adenomatous polyps discovered via a colonoscopy, 29% of them have additional polyps discovered on a repeat colonoscopy one year later. Malignancy develops in 2-5% of patients. The risk of cancer in people who have had polyps removed is 2.7-7.7 times that of the general population. [33]
Genetic Disorders
Familial adenomatous polyposis (FAP)
FAP is an autosomal dominant inherited syndrome that results in the development of more than 100 adenomatous polyps and a variety of extra-intestinal manifestations. The defect is in the APC gene, which is located on chromosome 5 at locus q21. The disease process causes the formation of hundreds of intestinal polyps, osteomas of bone, desmoid tumors, and, occasionally, brain tumors. Individually, these polyps are no more likely to undergo malignant transformation than are polyps in the general population. The increased number of polyps, however, predisposes patients to a greater risk of cancer. If left untreated, colorectal cancer develops in nearly 100% of these patients by age 40. Whenever the hereditary link is documented, approximately 20% of FAP cases are found to be caused by spontaneous mutation.
Hereditary nonpolyposis colorectal cancer
HNPCC, or Lynch syndrome, is an autosomal dominant inherited syndrome that occurs because of defective mismatch repair genes located on chromosomes 2, 3, and 7. Patients have the same number of polyps as the general population, but their polyps are more likely to become malignant. These patients also have a higher incidence of endometrial, gastric, thyroid, and brain cancers.
The revised Amsterdam criteria are used to select at-risk patients (all criteria must apply):
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Three or more relatives who are diagnosed with an HNPCC-associated cancer (colorectal, endometrium, small bowel, ureter, or renal pelvis)
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One affected person is a first-degree relative of the other two
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One or more cases of cancer are diagnosed before age 50 years
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At least two generations are affected
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FAP has been excluded
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Tumors have undergone a pathology review
The National Comprehensive Cancer Network (NCCN) guidelines discuss various strategies for identifying patients who should undergo testing for HNPCC. One approach is to test patients with any of the following [34] :
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Personal history of colorectal, endometrial, or other Lynch syndrome–associated cancer
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Suspicious family history
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≥5% risk of having a mismatch repair (MMR) gene pathogenic variant, based on predictive models (PREMM5,11 MMRpro, MMRpredict)
Another strategy is so-called universal screening, in which all individuals newly diagnosed with colorectal cancer have either microsatellite instability (MSI) or immunohistochemistry (IHC) testing for absence of 1 of the 4 DNA MMR proteins. An alternative is to test all patients with colorectal cancer diagnosed before age 70 years, and test those 70 years and older only if they meet the Bethesda criteria for colorectal cancer. The primary method for detecting HNPCC in tumor tissue from biopsied or surgically resected specimens is with either immunohistochemistry or microsatellite instability testing. The NCCN guidelines also indicate that genetic counseling is not necessary before “routine tumor testing” at a center. [34]
Inflammatory Bowel Disease
The malignant pathway in these patients does not involve any adenoma-carcinoma sequence. Cancer risk increases with duration of disease. After 10 years, the incidence of colorectal cancer in ulcerative colitis (UC) is approximately 1% per year. Patients should be evaluated for dysplastic changes via an annual colonoscopy. Dysplasia is a precursor of cancer and when present, the risk of cancer is 30%.
The incidence of colorectal cancer in patients with Crohn disease is 4-20 times greater than that of the general population. Cancer occurs in patients with disease of at least 10 years' duration. The average age at cancer diagnosis, 46-55 years, is younger than that of the general population. Cancers often develop in areas of strictures and in de-functionalized segments of intestine. In patients with perianal Crohn disease, malignancy is often present in fistulous tracts. Patients with Crohn colitis should undergo the same surveillance regimen as those with UC.
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Diagnostics. Staging and workup of rectal cancer patients.
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Staging and treatment. Rectal cancer treatment algorithm (surgery followed by adjuvant chemotherapy and radiotherapy). Initial stages are Endorectal ultrasound staging (uT).
Tables
Rectal Cancer Stages |
TNM Staging |
Duke Staging |
5-Year Survival |
|
Stage I |
T1-2 N0 M0 |
A |
>90% |
|
Stage II |
A |
T3 N0 M0 |
B |
60%-85% |
B |
T4 N0 M0 |
60%-85% |
||
Stage III |
A |
T1-2 N1 M0 |
C |
55%-60% |
B |
T3-4 N1 M0 |
35%-42% |
||
C |
T1-4 N2 M0 |
25%-27% |
||
Stage IV |
T1-4 N0-2 M1 |
5%-7% |
||
Resection Margins |
Proximal Resection Margin |
Distal Resection Margin |
Ideal Margins |
5 cm or more |
2 cm or more |
Minimally acceptable margins |
5 cm or more |
0.5-1 cm |
Regimen |
Frequency |
Schedule |
FOLFOX |
Every 2 weeks |
Oxaliplatin 85 mg/m2 day 1 Leucovorin 200 mg/m2 day 1 5-Fluorouracil (5-FU) 400 mg/m2 IV bolus day 1 and 2 5-FU 600 mg/m2 IV infusion day 1 and 2 (22 hours) |
FOLFOX 4 |
Every 2 weeks (Four cycles) |
Oxaliplatin 85 mg/m2 day 1 Leucovorin 200 mg/m2 day 1 5-FU 400 mg/m2 IV bolus day 1 and 2 5-FU 2400 mg/m2 IV infusion day 1 (46 hours) |
mFOLFOX 6 |
Every 2 weeks (Four cycles) |
Oxaliplatin 85 mg/m2 day 1 Leucovorin 400 mg/m2 day 1 5-FU 400 mg/m2 IV bolus day 1 and 2 5-FU 1200 mg/m2 IV infusion day 2 days |
CapeOx |
Every 3 weeks |
Oxaliplatin 130 mg/m2 day 1 Capecitabine 1000 mg/m2 PO BID for 14 days |
FOLFIRI |
Every 2 weeks |
Irinotecan 165 mg/m2 day 1 Leucovorin 200 mg/m2 day 1 5-FU 400 mg/m2 IV bolus day 1 and 2 5-FU 600 mg/m2 IV infusion day 1 and 2 (22 hours) |
FOLFOXIRI |
Every 2 weeks |
Irinotecan 180 mg/m2 day 1 Oxaliplatin 85 mg/m2 day 1 Leucovorin 200 mg/m2 day 1 5-FU 3200 mg/m2 IV infusion day 1 and 2 (48 hours) |
Bevacizumab |
Every 2 weeks with chemotherapy |
5-10 mg/kg IV |
Cetuximab |
With chemotherapy |
400 mg/m2 IV day 1, then 250 mg/m2 IV weekly |
Parameter |
Organization |
|||
ESMO (2013) [108] |
ASCO (2013) [107] |
NCCN (2019) [1] |
ASCRS (2015) [109] |
|
History and physical exam |
Every 3-6 mo for 3 y, then every 6 -12 mo at 4 and 5 y |
Every 3-6 mo for 3 y, then every 6 mo to 5 y |
Every 3-6 mo for 2 y, then every 6 mo to 5 y |
Every 3-6 mo for 2 y, then every 6 mo to 5 y |
CEA |
Every 3-6 mo for 3 y, then every 6 -12 mo at 4 and 5 y |
Every 3 mo for 3 y* |
Every 3-6 mo for 2 y, then every 6 mo to 5 y |
Every 3-6 mo for 2 y, then every 6 mo to 5 y |
Chest CT* |
Every 6-12 mo for first 3 y |
Every 1 y for 3 y |
Every 6-12 mo to 5 y |
Every 1 y for 5 y |
Colonoscopy** |
At y 1 after surgery, and every 3-5 y thereafter |
At 1 y, then every 5 y, dictated by the findings on the previous colonoscopy |
At 1 y, 3 y, and 5 y if negative |
At y 1 after surgery, and every 3-5 y dictated by the findings on the first postoperative examination. |
Abdominal CT* |
Every 6-12 mo for first 3 y |
Every 1 y for 3 y |
Every 6-12 mo to 5 y |
Every 1 y for 5 y |
ESMO = European Society of Medical Oncology; ASCO = American Society of Clinical Oncology; NCCN = National Comprehensive Cancer Network; American Society of Colon and Rectal Surgeons = ASCRS CEA = carcinoembryonic antigen; CT = computed tomography * For patients at high risk for recurrence (eg, lymphatic or venous invasion, or poorly differentiated tumors). **Colonoscopy should be performed 3-6 mo postoperatively if preoperative colonoscopy was not done, due to an obstructing lesion; otherwise, colonoscopy in 1 y; if abnormal, repeat in 1 year; if no advanced adenoma (ie, villous polyp, polyp >1 cm, or high-grade dysplasia), repeat in 3 y, then every 5 y. |
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