– Colorectal Cancer

CHARACTERISTICS:

Colorectal cancer is the third most common type of nonskin cancer and the second leading cause of cancer related mortality in the United States when considering tumors that affect both genders. The lifetime risk of developing colorectal cancer in this country is over four percent.

The overall incidence and mortality from colorectal cancer has decreased over the past two decades, due to screening, early detection and intervention, and improved treatments.

However, the colorectal cancer incidence and mortality in people under age 50 has significantly increased, although the great majority of colorectal cancers are diagnosed over age 50, and the incidence tends to increase with age.

RISK FACTORS:

A number of risk factors have been identified for colorectal cancer, including a personal or family history of adenomatous colorectal polyps or colorectal cancer, including hereditary colorectal cancer syndromes; a history of inflammatory bowel disease, which includes Crohn’s disease and ulcerative colitis; diets high in animal fats and low in fruits, vegetables, and fiber; physical inactivity; obesity; cigarette smoking; type 2 diabetes; and heavy alcohol use.

SUCCESSFUL ERADICATION OF COLORECTAL CANCER ENTAILS SURGICAL RESECTION, AND DEPENDING ON THE STAGE, POSSIBLY ALSO CHEMOTHERAPY. RADIATION THERAPY MAY ALSO BE PART OF THE TREATMENT REGIMEN, ESPECIALLY WITH RECTAL CANCER

Colorectal polyps are growths on the walls of the colon that are characterized based upon their microscopic features. Common types of polyps include hyperplasic polyps (completely benign growths) and adenomatous polyps (gland-like growths that develop on the membrane that lines the large intestine), which can be subdivided into tubular, villous, and tubulovillous.

The colorectal cancer risk is higher if polyps are larger than 1 cm, if villous features or at least moderate dysplasia is present, or if there are multiple polyps. For example, a tubular adenoma has less cancer risk than a tubulovillous adenoma, which has less cancer risk than a villous adenoma.

Let’s have a look at your challenging case.

DIAGNOSIS:

Most colorectal cancers are thought to arise from adenomatous polyps through a process that can take several years and which can be prevented with complete removal of the polyp during colonoscopy. Polyps can be pedunculated, meaning that they are on a stalk, or sessile, meaning that they are flat. In general, pedunculated polyps are more easily removed during colonoscopy than sessile polyps.

While hyperplastic polyps have traditionally been thought to have negligible cancer risk, certain types of hyperplastic polyps, called serrated adenomas (flat polyps growing on the wall of the intestine), which include sessile serrated adenomas and traditional serrated adenomas, are now thought to have malignant potential.

It is recommended that people at average risk for colorectal cancer begin screening at age fifty. Colonoscopy allows polyp removal and tissue biopsy and is the screening modality of choice. Other screening modalities include fecal occult blood testing, fecal DNA testing, flexible sigmoidoscopy, air contrast barium enema, and CT colonography, which is also known as virtual colonoscopy.

Colorectal cancer screening for those at increased risk may be recommended at younger ages than 50, depending on specific risk factors.

Most colorectal cancers are adenocarcinomas. The preferred staging system for colorectal cancer is the TNM system, where T represents tumor size, N represents regional lymph node involvement, and M represents distal metastatic disease.

TREATMENT:

Successful eradication of colorectal cancer entails surgical resection, and depending on the stage, possibly also chemotherapy. Radiation therapy may also be part of the treatment regimen, especially if the cancer involves the rectum.

In cases of rectal cancer, chemotherapy and possibly also radiation therapy may be given before surgery, which is referred to as neoadjuvant therapy. It can be challenging to assess cases of colorectal cancer in which neoadjuvant therapy has been administered, since the surgical pathology report reflects the results of presurgical treatment, and it is possible that the initial stage might have been higher before any treatment was administered.

Regular follow up after treatment for colorectal cancer is important, and can include periodic physical examinations, colonoscopy, imaging of the abdomen, pelvis, and chest, such as with CT scanning, and measurement of levels of a tumor marker in the blood cell called Carcineombryonic antigen, or CEA. Elevated or rising CEA levels after treatment can indicate persistent or recurrent disease.

CASE STUDIES:

APPLICANT 1 is a 70 year old applicant with a history of Grade I histology (cancer cells that resemble normal cells) localized adenocarcinoma of the colon that was treated with surgery ten years ago. There has been regular follow up with no evidence of recurrence. This would be Standard Plus.

APPLICANT 2 is a 65 year old applicant with a history of Grade IV histology (cancer cells appear bizarre, barely looking like normal cells) adenocarcinoma of the colon that invaded two local lymph nodes that was treated with surgery and chemotherapy. There has been regular follow up with no evidence of recurrence since the completion of treatment just over seven years ago. This would have a flat extra of $15 per $1000 rated off of Standard for three years.

APPLICANT 3 is a 50 year old applicant with a history of adenocarcinoma of the colon metastatic to the liver who has not seen a doctor since completion of surgery and chemotherapy two years ago. This is a decline.

Let’s have a look at your challenging case.

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