Most colorectal cancers are adenocarcinomas, occurring when an adenomatous lesion becomes malignant. These tumors grow extremely slowly, taking from 10 to 20 years to become malignant. In the United States, about 160,000 cases of colorectal cancer are diagnosed each year, with most cases occurring in people over 60 years of age. Possibly for dietary reasons, these rates are significantly lower in other countries such as Japan and among blacks of South Africa.

Dietary, environmental, and genetic theories have been postulated as causative factors. Etiology remains unknown.

• Familial adenomatous polyposis or Gardner's syndrome—all develop neoplasms with median age of 39; abnormal APC gene 
• Hereditary nonpolyposis colorectal cancer or Lynch syndrome I and II—5% of colon cancers; Amsterdam criteria: three plus relatives, one being a first-degree relative, present for two generations, one onset before age 50; abnormal APC, p53, DCC gene 
• Adenomatous polyps larger than 2 cm—40% malignancy rate 
• Colonic dysplasia 
• Increase each decade after age 40 
• Crohn's disease 
• Inflammatory bowel disease (ulcerative colitis, Crohn's colitis) 
• Turcot syndrome 
• Juvenile polyposis 
• Peutz-Jeghers syndrome 
• High-fat, low-fiber diet—conflicting studies, possibly dependent of the type of fat or fiber consumed (e.g., cellulose and bran reduce carcinogenesis more) 
• Current alcohol use, current or past smoking 
• Acromegaly 
• Radiation treatment for gynecologic cancers 

• Change in bowel habit with reduced caliber of stool 
• Gastrointestinal or rectal bleeding 
• Abdominal distension or pain 
• Nausea, vomiting 
• Anemia, loss of strength 

• Benign adenomatous polyp 
• Irritable bowel syndrome 
• Diverticulitis 
• Crohn's disease 
• Hemorrhoids 
• Ulcerative colitis 
• Tuberculosis 
• Amebiasis 
• Endometriosis 
• Pancreatitis 

A digital rectal examination may reveal neoplasms of the anus or distal rectum. The abdomen is often distended, sometimes a mass is palpable, and the patient may appear cachectic in advanced cases. Hepatomegaly can indicate metastasis to liver.

• Plasma carcinoembryonic antigen (CEA) 
• Complete blood count (CBC)—anemia, white blood cell count 
• Fecal occult bleeding test (FOBT) 
• Liver enzymes—elevation may indicate liver metastasis 

• Adenomatous tissue, typically a polypoid lesion, becomes malignant 
• Neoplasms—ulcerated, irregular lumenal aspect with elevated advancing edge 
• 75% in the descending colon, rectosigmoid, or rectum 
• Synchronous or metachronous lesions 

Staging—not well standardized; modifications of Duke's staging is as follows:

• Carcinoma in situ—high-grade dysplasia, intramucosal carcinoma 
• Stage A—penetrates to the submucosa 
• Stage B—penetrates to the muscularis propia 
• Stage C—regional lymph node involvement with any degree of penetration 
• Stage D—lesions accompanied by distant metastasis 

• Chest radiography—diagnoses metastasis to lungs
• Computerized tomography (CT)—diagnoses metastasis to lungs, liver, or other organs
• Air-contrast barium enema—"apple core" lesion of invasive tumor
• Transrectal ultrasound

• Check CEA level 
• Perform FOBT 
• Review CBC 
• Colonoscopy—most accurate and sensitive; use when there is no suspicion of perforation or obstruction; perforation or hemorrhaging occurs 0.1% to 0.3% 
• Flexible sigmoidoscopy—less sensitive; reveals strictures, distal obstruction, rectosigmoid neoplasms; screening significantly reduces mortality but a third to half of neoplasms are beyond its reach 
• Anoscopy—anal canal visualization 

Treatment is determined by location and spread. Surgery is the primary treatment modality, often used in combination with chemotherapy and radiation. It is important to treat concurrent anemia and to obtain baseline CEA level for later comparison.

Adjuvant:

• Fluorouracil (5-FU)—most widely used agent (e.g., 600 mg/m² infusion for weeks to months); serious side effects—nausea, vomiting, diarrhea, stomatitis, dermatitis, alopecia, leukopenia, neurological symptoms. 5-FU combined with: 
• Levamisole—significant improvement in recurrence interval and survival rate for stage C only 
• Methotrexate—significant improvement in response rate, modest for survival 
• Leucovorin—significant improvement in response rate and survival 
• Radiation therapy—no benefit outside the rectum; 4,500 to 5,000 cGy, divided doses/five weeks
• Aspirin, nonsteroidal anti-inflammatory drugs—reduce incidence
• Celecoxib (SC 58635)—a COX-2 inhibitor with dramatic results in rats; promising human pretrials
• Curcumin—inhibits lipoxygenase and cyclooxygenase pathways; phase I study

Treatment for metastasis:

• Hepatic resection (single mass/lobe), 25% to 35% disease-free five-year survival
• Pulmonary resection, if isolated and smaller than 3 cm; improved survival not definitive
• Irinotecan (CPT-11)—topoisomerase I inhibitor; 20% to 30% response rate; side effects—neutropenia, diarrhea
• Tomudex (ZD 1694)—inhibits thymidylate synthase; 26% response rate
• 5-FU—survival not improved
• Hepatic arterial infusion of 5-fluorodeoxyuridine (FUDR)— survival not prolonged

• Colonoscopy—endoscopic polypectomy and mucosal biopsy
• Resect—tumor, regional lymph nodes (surgeon's skill is prognostic factor; 2% to 4.4% mortality; laparoscopy increasingly used)

Nutritional therapy in colorectal cancer can perhaps minimize the progression of cancer, help prevent recurrence, and minimize side effects of conventional treatments. Homeopathy, in particular, can be a useful tool for nausea secondary to chemotherapy.

• Include cruciferous vegetables (broccoli, cabbage, brussel sprouts, cauliflower, onions, etc.) which enhance glutathione activity. 
• A high-fiber, low-protein diet is beneficial. Fiber (whole grains and legumes) facilitates the excretion of toxins. 
• Fats from vegetable and fish sources (nuts, seeds, cold-water fish) help reduce inflammation. 
• Bromelain (500 mg bid between meals) is a proteolytic enzyme that has anti-tumor and anti-inflammatory activity. Take with turmeric (Curcuma longa), 250 to 500 mg/day, to potentiate action. 
• Supplement dietary intake with omega-3 and omega-6 oils (fish oil, evening primrose oil), 3 to 6 g/day. 
• Lactobacillus acidophilus (1 capsule with meals) may help prevent colon cancer by normalizing bowel flora. 
• Coenzyme Q10 (200 mg/day) is an antioxidant which has cardioprotective properties. Use with chemotherapy. 

Nutrients that may be deficient in patients with colorectal cancer and which may provide protection against tumor development and progression include the following.

• Vitamin B₁₂ (1,200 mcg/day) to avoid an imbalance between B₁₂ and folate. 
• Folic acid (800 to 1,200 mcg/day) 
• Calcium (1,000 mg/day) 
• Vitamin E (800 IU/day) 
• Selenium (200 to 400 mcg/day) 
• Beta-carotene (50,000 IU/day) 
• Vitamin C (3 to 6 g/day) 

Include vitamin B₁₂ (1,200 mcg/day) to avoid an imbalance between B₁₂ and folate

Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or tinctures (alcohol extraction, unless otherwise noted). Dose for teas is 1 heaping tsp. herb/cup water steeped for 10 minutes (roots need 20 minutes).

Hoxsey-like formulas are traditionally used in cancers. These formulas contain tumor-suppressing, immune-stimulating, and anti-mutagenic constituents. Licorice root (Glycyrrhiza glabra), red clover (Trifolium pratense), burdock (Arctium lappa), queen of the meadow (Stillingia sylvatica), barberry (Berberis vulgaris), poke root (Phytolacca americana), prickly ash bark (Xanthoxylum americanum), and buckthorn bark (Rhamnus purshiana) with potassium iodide salts. This is best taken as a tea (2 to 3 cups/day) or tincture (30 to 60 drops bid).

Other herbs to consider for immune-stimulating properties are coneflower (Echinacea purpurea), astragalus (Astragalus membranaceus), tree of life (Thuja occidentalis), schizandra berry (Schizandra chinensis), and Siberian ginseng (Eleuthrococcus senticosus). Combine herbs in equal amounts and take 30 to 60 g bid to tid.

An experienced homeopath would consider an individual's constitutional type to prescribe a more specific remedy and potency. Some of the most common acute remedies are listed below. Acute dose is three to five pellets of 12X to 30C every one to four hours until symptoms resolve.

• Arsenicum for anxiety, deathly nausea, with restlessness and burning pains 
• Ipecac for incapacitating nausea unrelieved by vomiting 
• Nux vomica for cramping, sharp abdominal pains and collapse, especially with anger 

• Colonoscopy—months three to six postoperatively; every three years; then every two to three years 
• CEA level—two-month intervals (controversial) 
• CT scan—detects metastasis 

Colonoscopic examination—protects longer and correlates with lower mortality than FOBT or sigmoidoscopy. National Cancer Institute recommendations:

• Beginning at age 50—annual FOBT, sigmoidoscopy every three to five years
• High-risk patients—colonoscopy at age 25, repeated every one to two years

• May require proctectomy and/or colostomy. Patients may need training or psychological counseling to help them adapt to colostomy appliance. 
• Liver and lung metastasis 
• Obstruction of colon, especially by distal tumor 

Duke's staging with crude, followed by age-adjusted, five-year survival rates

• Stage A—81% to 84%, 99%
• Stage B—62% to 65%, 85%
• Stage C—36% to 40%, 67%
• Stage D—0% to 3%, 14%

• Complicated by late detection—similarity of symptoms, young age of most mothers
• 86%—rectal
• Relatively safe—testing CEA level, ultrasound (shows hepatic metastasis), sigmoidoscopy, CT (after first trimester)
• Colonoscopy—experimental
• Chemotherapy and radiation—contraindicated
• Surgical and laparoscopic resection—safer first trimester, still performed at considerable fetal risk
• Ideally defer treatment until fetus is viable
• Maintain folic acid and nutritional needs
• Prognosis—generally poor

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