Colorectal adenocarcinoma: risks, prevention and diagnosis
BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i3590 (Published 14 July 2016) Cite this as: BMJ 2016;354:i3590Linked Practice
Management of colorectal cancer
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Many thanks for this comprehensive and useful paper. However, we are told that 'No patients were involved in the creation of this article.' If they had been, perhaps it would have been even better. I suggest it is time that the BMJ insisted on patients always being consulted in this kind of situation: patient and public involvement (PPI) is now required as a condition of funding by many sponsors of medical research, to its great benefit.
My own father suffered from cancer of the colon, which was not actually diagnosed till the day he died, although he had repeatedly consulted his GP about chronic constipation, and was only prescribed laxatives. He was taken very ill suddenly, but by the time he arrived at the nearest hospital his blood pressure was so low that the surgeon declined to operate, since 'he would have died on the table'. I watched him die from general peritonitis: his sole concern was to know that we (my mother and brother and myself) were 'all right'. Since then I have wanted to make sure that people around me knew the risk factors: my grandfather and an aunt also died of bowel cancer, so family history was obviously important.
However, the current literature is really not clear, and this article too is not altogether helpful when it comes to describing symptoms. Table 3 (Pre-diagnostic features of colorectal cancer) is the only place where 'Constipation' is actually spelt out. Table 4 (Urgent referral criteria for suspected colorectal cancer for an appointment within two weeks) explains 'altered bowel habit' as 'Change in bowel habit to looser stools or increased frequency of defecation, or both': it does not specify constipation.
My father died in 1961, but it seems that things have not improved a great deal since then with regard to alerting the public and even GPs to possible symptoms of bowel cancer, if constipation is still not specifically mentioned. Cancer Research UK publishes a leaflet for lay people on 'Spotting the signs of cancer', and only includes 'A change to more frequent bowel motions for three weeks or more', not chronic constipation, as something to worry about. It seems to me that current guidance should be clearer about the symptoms of bowel cancer, and your paper could also have been clearer. 'Change of bowel habit' is too vague for the average layman: it should be spelt out.
Heather Goodare
retired counsellor
hm.goodare@virgin.net
Competing interests: No competing interests
Useful review of this important area, it is a shame that an image illustrating better colonoscopy technique could not have found to compliment the paper. The endoscopist appears to have the screen behind him and on the opposite side to the patient. Colonoscopy is indeed the best technique for investigating colonic symptoms, but results are much better if the room and equipment are set up optimally.
Competing interests: No competing interests
Overlooking Oncological Terrain-Dependent, Inherited Real Risk of Colorectal Cancer, all researches on this adenocarcinoma, e.g., risks, prevention and diagnosis, are fundamentally biased (1-3). As a consequence, primary prevention, realized on individuals rationally enrolled, is not possible if physicians ignore such a Inherited Real Risk, bedside diagnosed from birth with a stethoscope, and removed promptly by inexpensive Restructuring Mitochondrial Quantum Therapy (4, 5).
For instance, any statement that advancing age increases colorectal cancer is wrong, as demonstrates the absence of cancer in the majority of old people . As a matter of fact, not all individuals are created equal, so that the time has come, where we physicians have to adopt the paradigms of Single Patient Based Medicine (2). I fear that overlooking Oncological Terrain-Dependent heritable risk of Colorectal Cancer, conditio sine qua non of colorectal cancer, such a malignancy will continue to be the third cause of death among cancers in men. Finally, based on a long clinical experience, we prefer the efficient primary prevention to screening.
References.
1. Stagnaro-Neri M., Stagnaro S. Introduzione alla Semeiotica Biofisica. Il Terreno Oncologico. Travel Factory, Roma, 2004. www.travelfactory.it
2. Stagnaro S., Stagnaro-Neri M., Le Costituzioni Semeiotico- Biofisiche.Strumento clinico fondamentale per la prevenzione primaria e la definizione della Single Patient Based Medicine. Ed. Travel Factory, Roma, 2004. http://www.travelfactory.it/
3. Stagnaro Sergio. Reale Rischio Semeiotico Biofisico. I Dispositivi Endoarteriolari di Blocco neoformati, patologici, tipo I, sottotipo a) oncologico, e b) aspecifico. Ediz. Travel Factory, www.travelfactory.it, Roma, 2009.
4. Sergio Stagnaro and Simone Caramel. BRCA-1 and BRCA-2 mutation bedside detection and breast cancer clinical primary prevention. Front. Genet. | doi: 10.3389/fgene.2013.00039. http://www.frontiersin.org/Cancer_Genetics/10.3389/fgene.2013.00039/full [MEDLINE]
5. Caramel S., Marchionni M., Stagnaro S. Morinda citrifolia Plays a Central Role in the Primary Prevention of Mitochondrial-dependent Degenerative Disorders. Asian Pac J Cancer Prev. 2015;16(4):1675. http://www.ncbi.nlm.nih.gov/pubmed/25743850[MEDLINE]
Competing interests: No competing interests
Re: Colorectal adenocarcinoma: risks, prevention and diagnosis
COLORECTAL CARCINOMA IN CHILDREN
Primary GI cancers constitute approximately 2% of pediatric neoplasms, and, of these, colorectal carcinoma ( mostly seen above 10 years of age) is the second most common next to primary liver tumors.1 2 Thus colon cancer is extremely rare in children presenting with or without past history or family history of gastrointestinal problems. Hence unexplained persistent constipation and abdominal distension or bleeding per rectum (mostly due to hemorrhage and necrosis) should make one suspect this disease because delay in diagnosis worsens the situation.3 Further, it is relatively more frequent in the west than in Asia, except Japan, and this is another reason for the delay in diagnosis. Lastly, tumors of the large colon may need to become huge before symptoms appear like thinning of the stools, thus delaying the diagnosis even up to the advanced stage.3 Adult colorectal cancers are moderately differentiated or well differentiated adenocarcinomas.4 In contrast the majority of colorectal cancers in children are poorly differentiated mucinous adenocarcinoma, and many are of the signet-ring cell type.1
Changes are constipation or diarrhea, thinning or thickening of stools, tarry stools, rectal bleeding, weight loss. Tumors involving the cecum and descending colon may become bulky before symptoms appear. Tumors of the sigmoid colon and rectum may have hematochezia, and anemia.5 The diagnosis of CRC in young patients is often delayed because it is seldom suspected. Acute bowel symptoms necessitate immediate abdominal exploration, at which time perforation of the large bowel with multiple metastatic deposits may be observed. Intestinal obstruction by tumor occurs more frequently in adolescents than in adults with this cancer.1 Symptoms like abdominal mass with ascites or a mass seen in the lower anus (confirmed by PR examination), weight loss with pallor make it somewhat easier to suspect this unsuspecting disease . . Intestinal obstruction by tumor occurs more frequently in adolescents than in adults with this cancer.1
Abdominal X-rays or better still an abdominal ultrasound and barium enema for mucosal pattern confirm a stenotic segment with or without any obvious shouldering. CT for an abdominal mass and lymph node involvement is another important diagnostic modality. Adenocarcinoma is diagnosed by straightaway excision and biopsy or biopsy alone during colonoscopy or laparotomy,showing atypia, etc. Sometimes the endoscope fails to pass. Blood picture often shows normocytic and normochromic anemia. CRC risk increases in Peutz-Jeghers syndrome, familial juvenile polyposis, hereditary mixed polyposis syndrome, hereditary non-polyposis colon cancer, and familial adenomatous polyposis. All may have similar presentations.6 The differential diagnosis includes malignant carcinoid tumor, leiomyosarcoma, etc. Complete surgical resection is the rule, like in adults, or else cure is not possible. Adjuvant multi-agent fluorouracil based chemotherapy with folinic acid rescue factor is the mainstay but there is little role for radiation. 7 The outcome is poor in most CRCs.
1. Rao, B.N., Pratt, C.B., Fleming, I.D., Dilawari, R.A., Green, A.A., and Austin, B.A. Colon carcinoma in children and adolescents. A review of 30 cases. Cancer. 1985; 55: 1322–1326 Pratt, C.B., Rivera, G., Shanks, E. et al. Colorectal carcinoma in adolescents implications regarding etiology. Cancer. 1977; 40: 2464–2472. Casuitik, A.F. Der congenitalen neoplasm. Arch Gynaekol. 1980; 16: 135–137
2. Karnak, I., Ciftci, A.O., Senocak, M.E., and Büyükpamukçu, N. Colorectal carcinoma in children. J Pediatr Surg. 1999; 34: 1499–1504
3. Skibber, J.M., Minsky, B.D., and Hoff, P.M. Cancer of the colon. in: V.T. DeVita, S. Hellman, S.A. Rosenberg (Eds.) Cancer: principles and practice of oncology. Lippincott Wilkins & Williams,Philadelphia; 2001: 1216–1271
4. Fleming M, Ravula S, Tatishchev SF, Wang HL. Colorectal carcinoma: Pathologic aspects. Journal of Gastrointestinal Oncology. 2012 Jun 19;3(3):153-73.
5. Al-Tonbary Y., Darwish A., El-Hussein A., Fouda A. Adenocarcinoma of the colon in children: Case series and mini-review of the literature
Hematology/ Oncology and Stem Cell Therapy,; (2013) 6 (1) 29-33.
6. Mishra N, Hall J. Identification of patients at risk for hereditary colorectal cancer. Clinics in colon and rectal surgery. 2012 Jun;25(02):067-82.
7. Pappo, A.S. and Furman, W.L. Management of infrequent cancers of childhood: colorectal carcinoma. in: P.A. Pizzo, D.G. Poplack (Eds.) Principles and practice of pediatric oncology. 5th ed. Lippincott Williams & Wilkins, ; 2006: 1174
Competing interests: No competing interests