Abramson Cancer Center

Most risk factors for colon cancer, like age and family history, cannot be prevented. Patients who feel they are at risk for developing cancer may benefit from consulting with a Penn Medicine GI genetics risk assessment specialist.

Colon Cancer Risk Factors

Risk factors affect the chance of getting colon cancer. Having a risk factor, or even several, does not mean that someone will get cancer.

Here are some risk factors for colon cancer.

• Age. Most people diagnosed with colon cancer are age 50 or older.
• Family history. Having family members with colon or rectal cancer can increase someone’s risk of developing the disease. Having a sibling, parent or child with colon cancer, or a history or the disease, makes a person two to three times more likely to develop colon cancer.
• Hereditary conditions. Conditions such as familial adenomatous polypsis (FAP), Lynch syndrome, juvenile polyposis, MYH-associated polyposis, Peutz-Jeghers syndrome and Cowden syndrome may increase risk.
• Other health conditions. Having inflammatory bowel disease (ulcerative colitis or Crohn’s disease) may increase someone’s risk of developing colon cancer.
• Personal history. Someone who has had cancer of the colon, rectum, ovaries, endometrium is at an increased risk for developing colon cancer.
• History of polyps. Having polyps in the colon may increase risk.
• Being African American. African American men and women are diagnosed with and die from colorectal cancer at higher rates than men and women of any other ethnic group. The reason is not yet understood.
• Lifestyle factors. Studies show that people who eat a diet high in fat and red meat, but low in vegetables and fruits may be at an increased risk for colon cancer. Also, smoking, obesity and excessive alcohol intake may also put someone at a higher risk.
• Smoking. Smoking tobacco has been linked to an increased risk of colon cancer.

Colon Cancer Prevention

The best way to prevent colon cancer is to follow the colonoscopy guidelines. Removing polyps before they become cancerous can prevent the disease (see the detailed colonoscopy guideline for average- or high-risk population).

Most risk factors for colon cancer, like age and family history, cannot be avoided.
However, there are things people can do to minimize their risk of developing colon cancer.

• Quit smoking. Smoking or chewing tobacco can increase the risk of developing cancer. Patients can get help to stop smoking through Penn Medicine’s Lung Center or through a smoking cessation research program at the Abramson Cancer Center.
• Control weight. Maintaining a healthy weight by eating a low-fat diet, fruits and vegetables, and exercising can help prevent cancer.  

Colon Cancer Risk Assessment

People with a personal or familial history of colorectal cancer, or those with conditions that put them at risk may benefit from consulting with a genetic counselor to determine their risk of developing colon cancer.

Younger patients who develop colon cancer usually have a family member or close relative who has a history of colon or rectal cancer.

These programs offer knowledge about the presence of genetic risk factors for cancer and provide patients with important, sometimes life-saving options.

back to top

• Adenocarcinoma
• Carcinoid tumor

Adenocarcinoma

More than 95 percent of colon cancer is diagnosed as adenoncarcinoma. Adenocarcinomas are cancers that start in the glandular cells that make the mucus that lubricates the inside of the colon.

Carcinoid Tumor

Carcinoid tumors (may develop in other parts of digestive system) are tumors that start from specialized hormone-producing cells in the intestine. Carcinoid tumors are discussed in more depth under neuroendocrine tumors.

back to top

Symptoms of colon cancer can look like symptoms of other conditions. Patients who experience any of these symptoms should contact their healthcare provider.

• Bleeding from the rectum
• Blood (bright red or very dark) in the stool or toilet after a bowel movement
• A change, or narrowing of the stool
• Cramping or pain in the abdomen
• Feeling the need to have a bowel movement, but not having one
• Excessive fatigue
• Frequent gas, bloating or feeling of fullness
• Weight loss for no known reason
• Nausea and vomiting

back to top

Staging systems provide doctors with a common language for describing tumors. After cancer is first diagnosed, a series of tests are used to investigate the extent of the cancer and to see whether it has spread to other parts of the body from where it started. Staging is a way of recording the depth, aggressiveness and growth of a cancer, and determining the plan for treatment. By understanding the stage of their cancer, patients can make informed decisions about their treatment.

Staging colon cancer attempts to discover the following:

• The depth of the tumor
• Whether the cancer has spread to nearby lymph nodes and tissues
• Whether the cancer has spread to other parts of the body

back to top

After being diagnosed with colon cancer, patients at the Abramson Cancer Center may be evaluated through the Gastrointestinal Cancer Evaluation Center (GICEC). The center provides patients with expert support and evaluation to discuss treatment options and individualized treatment plans.

Patients with pancreatic cancer are treated by a multidisciplinary team of cancer specialists who see more patients with gastrointestinal (GI) cancers in one year than many doctors see in their careers.

The physicians of Penn Medicine’s GI cancer program are nationally recognized for their expertise in the diagnosis and treatment of cancer.

Penn’s GI cancer treatment team includes:

• Nationally recognized medical experts with years of experience in diagnosing and treating GI cancer (including gastroenterologists, surgeons and medical oncologists).
• Nurses with advanced training and experience in caring for patients with GI cancer.
• Oncology Navigation Specialists to help patients navigate the health system.
• Registered dietitians to provide nutrition counseling.
• Cancer counselors to provide individual or family counseling for issues many cancer patients face.
• Rehabilitation therapists who specialize in the diagnosis and treatment of physical effects from cancer and its treatment.

Oncology Navigation Specialists

Every step of cancer treatment – from cancer diagnosis, to surgery and treatment to forming a survivorship plan – comes with different needs and issues that should be addressed.

Oncology Navigation Specialists at the Abramson Cancer Center are available to make a patient’s experience as seamless as possible. As experts in navigating complex health care situations, patient support specialists serve as a consistent point of contact and a reliable source for advice, support and direction for patients and families. They can help in a variety of ways including; provide emotional support, identify resources, and ensure access to information, support services, educational programs and community resources.

Learn more about Patient Navigation specialists at the Abramson Cancer Center.

back to top

Colon cancer is usually slow to develop, so the chances are good for catching it early through regular screenings.

Most colon cancer is found through a colonoscopy. A colonoscopy is a procedure done under sedation. The physician places a thin, tube-like instrument with a light and a lens for viewing inside the rectum and colon. The scope may also have a tool to remove polyps or tissue samples that are checked for cancer in a lab.

The American Cancer Society recommends a colonoscopy every 10 years beginning at age 50 for people at average risk. People at high risk for colon and rectal cancer should talk with their physicians regarding recommendations for screening.

back to top

If physicians suspect colon cancer, they might perform or order one or more of these tests to diagnosis and stage colon cancer.

• Medical history and physical exam. An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments is also taken.
• Digital rectal exam. The anus and rectum are examined by the physician or nurse who inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else unusual.
• Fecal occult blood test. This test examines stool samples for blood.
• Imaging tests. Pictures of the inside of the body can help find out whether a suspicious area might be cancerous, to learn how far cancer may have spread, and to help determine if treatment is working.
• Colonoscopy. Most rectal cancer is found through a colonoscopy. A colonoscopy is a procedure done under sedation.  The physician places a thin, tube-like instrument with a light and a lens for viewing inside the rectum and colon. The scope may also have a tool to remove polyps or tissue samples which are checked for cancer in a lab.
• Barium enema. An enema containing barium, a silver-white metallic compound, is put into the rectum. The barium coats the lower part of the digestive tract and X-rays are taken. Also called a lower GI series.
• Computed tomography (CT) scan. A CT scan creates a 3-D X-ray of the chest, abdomen and pelvis. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. A CT scan is used to see if the tumor has spread to the liver and to detect a carcinoid tumor in lymph nodes behind the abdomen. Sometimes, a contrast medium (dye) is used to provide better detail.
• Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body. Tumors absorb the radioactive substance, and a scanner detects this substance to produce images.
• Magnetic resonance imaging (MRI). Magnetic fields are used to create detailed images of the body. A contrast medium may be injected into a patient’s vein to create a clearer picture.
• Biopsy. When other tests find a change that is possibly cancer, a sample of the suspicious area or lymph node is removed and viewed under a microscope. A biopsy is the only way to tell if cancer is really present.
• Lab tests. A physician may order blood tests that measure the level of carcinoembryonic antigen (CEA) in the blood. CEA is released into the bloodstream by cancer and normal cells. When found in higher than normal amounts, it may be a sign of cancer. A complete blood count to assess the patient for anemia may also be ordered.
• Genetic testing. Molecular genotyping is used for people at high risk for hereditary syndromes and diseases.

back to top

Staging is a way of describing cancer: where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's chance of recovery.

The colon is made up of four layers:

• The innermost layer, called the mucosa.
• The next innermost layer, called the submucosa.
• The muscle layer.
• The outer layer called the serosa.

Knowing these layers can help patients understand how colon cancer is staged.

• Stage 0. Abnormal cells are found only in the mucosa, also called carcinoma in situ.
• Stage I. Cancer has formed in the mucosa and has spread to submucosa. Cancer may have spread to the muscle layer.
• Stage II. One of the following:

• IIA. Cancer has spread through the muscle layer of the colon to the serosa.
• IIB. Cancer has spread through the serosa of the colon wall, but not to nearby organs.
• IIC. Cancer has spread through the serosa of the colon wall to nearby organs.

• Stage III. One of the following:
  • IIIA. Stage IIIA is subdivided into two more divisions.
    • Cancer may have spread through the mucosa of the colon wall to submucosa, and may have spread to the muscle layer. Cancer has spread to at least one, but no more than three nearby lymph nodes or cancer cells are found in tissues near lymph nodes.
    • Cancer has spread through the mucosa to the submucosa. Cancer has spread to at least four, but no more than six nearby lymph nodes.
  • IIIB. Cancer has spread:
    • Through the muscle layer to the serosa or has spread through the serosa but not to nearby organs. Cancer has spread to at least one, but no more than three nearby lymph nodes or cancer cells have formed in tissue near the lymph nodes.
    • To the muscle layer of to the serosa. Cancer has spread to at least four, but no more than six lymph nodes.
    • Through the mucosa to the submucosa and may have spread to the muscle layer. Cancer has spread to seven or more lymph nodes.
  • IIIC. Cancer has spread:
    • Through the serosa but not to nearby organs. Cancer has spread to at least four, but no more than six nearby lymph nodes.
    • Through the muscle layer to the serosa or has spread through the serosa but not to nearby organs. Cancer has spread to seven or more nearby lymph nodes.
    • Through the serosa and to nearby organs. Cancer has spread to one ore more nearby lymph nodes or cancer cells have formed in tissues near lymph nodes.
• Stage IV. Divided into IVA and IVB.
  • IVA. Cancer may have spread through the colon wall and to nearby organs or lymph nodes. Cancer has spread to one organ that is not near the colon, or to a distant lymph node.
  • IVB. Cancer may have spread through the colon wall and to nearby organs or lymph nodes. Cancer has spread to more than one organ that is not near the colon or into the lining of the abdominal wall.

back to top

Surgery is the most common treatment for all stages of colon cancer. After the cancer is removed, the surgeon may sew together healthy tissue to reattach organs, or make an opening in the abdomen where stool can pass into a collection bag. 

Segmented Colon Resection

If the cancer has spread into the wall of the colon, the section of the colon with the cancer and nearby healthy tissue is removed. This is called a colectomy. The surgeon may sew together the healthy parts of the colon. Lymph nodes near the colon are usually removed and checked under a microscope for signs of cancer.

Local Excision

Typically used for early stage colon cancers, where the cancer has not spread into the wall of the colon. The cancer and some surrounding healthy tissue are removed.

Resection of Limited Metastatic Disease

Surgical experts at Penn may perform surgical resection of metastatic disease in liver or lung, and try to cure some patients who may have limited (less) metastatic disease in liver or lung after they have responded to chemotherapy (with or without monoclonal antibodies).

back to top

Radiation therapy for colon cancer is rarely used. If it is, it is used only in selective instances.

Radiation oncologists at Penn Medicine are recognized for techniques that target radiation precisely to the disease site while sparing nearby tissue.

Proton therapy at Penn Medicine is now being used to treat upper gastrointestinal cancers and recurrent tumors in the digestive tract. Penn Medicine is one of the only facilities in the country treating gastrointestinal cancers in this way.

Radiation therapy uses high-energy radiation to kill cancer cells. A radiation therapy schedule usually consists of a specific number of treatments given over an extended period of time. In many cases, radiation therapy is capable of killing all of the cancer cells.

3-D Conformal Radiation Therapy

The imaging technology used by radiation oncologists at Penn Medicine helps shape the radiation treatment beam to the shape of the tumor. Conformal radiation therapy gives doctors more control when treating tumors.

Special computers use CT imaging scans to create 3-D maps of the location of the cancer in the body. The system permits the delivery of radiation from several directions, and the beams can then be shaped, or conformed, to match the shape of the cancer. Conformal radiation therapy limits radiation exposure to nearby healthy tissue as well as the tissue in the beam's path.

Intensity-Modulated Radiation Therapy

This advanced type of radiation therapy uses a computer-controlled device, called a linear accelerator, to deliver precise doses of radiation to tumors or specific areas within the tumors. Radiation therapy, including IMRT, stops cancer cells from dividing and growing, thus slowing or stopping tumor growth. In many cases, radiation therapy is capable of killing all of the cancer cells, including those that may have been missed during surgery.

Using 4-D computed tomography (CT) images along with computerized dose calculations, IMRT allows for the radiation dose to conform more precisely to the shape of the tumor by controlling, or modulating, the intensity of the radiation beam while tracking any movement of the tumor. The therapy allows higher radiation doses to be delivered to areas within the tumor while minimizing the dose to the surrounding area.

Volumetric-Modulated Arc Therapy (VMAT)

Volumetric modulated arc therapy (VMAT) is a type of specialized intensity modulated radiation therapy. VMAT delivers radiation by rotating the linear accelerator through one or more arcs while radiation is continuously delivered.

VMAT allows Penn radiation oncologists to treat complex cancers while minimizing exposure to surrounding healthy tissue. VMAT shortens radiation delivery time, and offers patient more comfort because it does not require patients to lie completely still for long periods of time.

Penn radiation oncologists use RapidArc™ radiotherapy technology to treat hard to reach tumors.

Proton Therapy

Penn Medicine is the only health care facility in the country that is using proton therapy to treat recurrent gastrointestinal tumors in clinical trials.

Penn Medicine's Roberts Proton Therapy Center is the largest and most advanced facility in the world for this precise form of cancer radiation. Patients have access to one of the most sophisticated weapons against cancer, seamlessly integrated with the full range of oncology services available at Penn Medicine. Proton therapy is external beam radiotherapy in which protons are directed at a tumor.

The radiation dose that is given through protons is very precise, and limits the exposure of normal tissues. This allows the radiation dose delivered to the tumor to be increased beyond conventional radiation. The result is a better chance for curing cancer with fewer harmful side effects.

Proton therapy, like all forms of radiation therapy, works by aiming the energized particles, in this case protons, onto the target tumor. The particles damage the DNA of cells, ultimately causing their death. Unlike X-rays, protons can be manipulated to release most of their energy only when they reach their target. With more energy reaching the cancerous cells, more damage is administered by each burst of radiation.

back to top

Penn Medicine specializes in a team approach to treatment with interdisciplinary care and innovative approaches that use chemotherapy to target tumors prior to and after surgery.

Chemotherapy

Chemotherapy uses drugs to kill cancer cells. It is delivered through the bloodstream, targeting cancer cells throughout the body. Chemotherapy is usually delivered intravenously through a catheter, or orally by pill.

Biologic (Targeted) Therapy
Biologic therapy, also called targeted therapy, uses the patients' own immune system to target cancer cells. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body's natural defenses against cancer, and are delivered orally by pill or intravenously, such as EGFR-inhibitor therapy.  This type of cancer treatment is also called immunotherapy.

Liver-Directed Therapies

Colon cancer can spread to other organs, most often the liver. Cancer treatments are available to treat colon cancer that has spread to the liver.

Chemoembolization of the Hepatic Artery
Injecting an anticancer drug into the hepatic artery, which supplies blood to the liver, blocks blood flow to the liver and disrupts the blood supply to the tumor. This starves the tumor of blood and other nutrients.

Radiofrequency Ablation

A special probe is inserted into the colon, and uses tiny electrodes to kill cancer cells. This can be done through the skin, or through an incision in the abdomen. This is done under local or general anesthesia.

back to top

Today, more and more people are surviving cancer. Clinical trials benefit patients with access to breakthrough therapies and treatments. These new advances in cancer treatment are occurring every day at Penn Medicine, giving patients hope that even greater discoveries lie ahead. Through clinical trials:

• Diagnosing cancer has become more precise.
• Radiation and surgical techniques have advanced.
• Medications are more successful.
• Combinations of medical, surgical and radiation therapy are improving treatment effectiveness and enhancing outcomes.
• Strategies to address the late effects of cancer and its treatment are improving quality of life.

Penn Medicine is the only health care facility in the country that is using proton therapy to treat recurrent gastrointestinal tumors in clinical trials. Also, radiation oncologists at Penn Medicine will soon use proton therapy to treat gastrointestinal cancers in the upper digestive tract.

back to top

In addition to standard treatments and clinical trials, patients at Penn Medicine may wish to add additional therapies and treatments such as massage therapy, acupuncture and art therapy. These therapies do not have curative intent, and are designed to complement standard treatments – not take their place.

Integrative Medicine and Wellness Programs

At Penn Medicine, integrative medicine and wellness services can supplement traditional cancer treatments such as chemotherapy, surgery and radiation therapy. While conventional medicine plays a critical role in eradicating cancer, integrative medicine and wellness programs offer patients and their families ways to enhance the quality of their lives, minimize or reduce the side effects of cancer and cancer treatment, and promote healing and recovery.

Cancer specialists at Penn Medicine are knowledgeable and supportive of complementary cancer treatments. The cancer team works with patients and families to integrate these supportive programs into the overall care plan, while ensuring the safety and health of patients.

The Abramson Cancer Center’s range of integrative supportive services is designed to help patients cope with the cancer experience and improve their overall sense of well-being. Services include:

• Acupuncture
• Diet and nutrition
• Mindfulness-based stress reduction therapy
• Reiki therapy
• Yoga
• Exercise and rehabilitation

The Joan Karnell Cancer Center at Pennsylvania Hospital offers a variety of supportive care programs for patients and families, from diagnosis through survivorship. These programs are available at no cost to the patients treated at Pennsylvania Hospital, and some are open to patients treated elsewhere. These services include social work counseling, nutrition counseling, psychological counseling and spiritual counseling.

The Cancer Appetite and Rehabilitation Clinic focuses on patients with loss of appetite and weight.

The Supportive Care Clinic helps to manage cancer related symptoms. Integrative support programs include:

• Music therapy
• Art therapy
• Shiatsu massage
• Mindfulness meditation

Support groups and educational programs are available at Pennsylvania Hospital throughout the year.

Palliative Care

Palliative care provides medical and non-medical interventions to ease the symptoms of cancer and its treatment. Palliative care includes physical, emotional and spiritual care that can enhance the quality of life for cancer patients.

Palliative care can be used to complement traditional cancer therapies, or can be used to improve quality of life when curative therapies are no longer an option.

Palliative care is an approach to patient care that can be integrated with curative therapies at any point from diagnosis to survivorship or end of life care.

Palliative care services include palliative chemotherapy, radiation therapy and surgery as well as psychological counseling, art therapy and support groups for patients and families. The goals of palliative care are to enhance the quality of life for cancer patients and their families, and provide emotional and spiritual support to enhance personal growth.

Palliative care services are offered at Pennsylvania Hospital, and at the Hospital of the University of Pennsylvania.  

Penn Home Care and Hospice Services

Penn Home Care and Hospice Services offer a full range of home health care needs by partnering three top-level home health care services under one roof:

• Penn Wissahickon Hospice
• Penn Care at Home
• Penn Home Infusion Therapy

Penn Home Care and Hospice Services offer an array of specialized therapies and medications for patients with cancer and cancer-related conditions.

Oncology Navigation Specialists

Every step of cancer treatment – from cancer diagnosis, to surgery and treatment to forming a survivorship plan – comes with different needs and issues that should be addressed.

Oncology Navigation Specialists at the Abramson Cancer Center are available to make a patient’s experience as seamless as possible. As experts in navigating complex health care situations, patient support specialists serve as a consistent point of contact and a reliable source for advice, support and direction for patients and families. They can help in a variety of ways including; provide emotional support, identify resources, and ensure access to information, support services, educational programs and community resources.

Learn more about Patient Navigation specialists at the Abramson Cancer Center.

back to top

At the end of treatment, colon cancer patients should schedule a survivorship visit with their oncologist and nurse practitioner. At this time, patients are provided with a summary of the treatment received as well as a plan for follow-up care.

Penn cancer providers work one-on-one with patients to develop survivorship care plans. Since every cancer is unique, the plans are tailored to the patients. 

The survivorship care plan includes information on:

• Potential long-term or late side effects of cancer treatment, the symptoms and treatment.
• Recommendations for cancer screening for disease recurrence or a new cancer.
• Psychosocial effects, including relationships and sexuality.
• Planning follow-up visits.

A survivorship care plan encourages patients to review the information with their health care team and become active participants in their follow-up care.

Penn also offers colon cancer patients a number of support programs and groups to enhance their survivorship care plans.

Oncology Navigation Specialists

Every step of cancer treatment – from cancer diagnosis, to surgery and treatment to forming a survivorship plan – comes with different needs and issues that should be addressed.

Oncology Navigation Specialists at the Abramson Cancer Center are available to make a patient’s experience as seamless as possible. As experts in navigating complex health care situations, patient support specialists serve as a consistent point of contact and a reliable source for advice, support and direction for patients and families. They can help in a variety of ways including; provide emotional support, identify resources, and ensure access to information, support services, educational programs and community resources.

Learn more about patient navigation specialists at the Abramson Cancer Center.

back to top

Penn Medicine’s Living Well After Cancer™ Program is a nationally recognized program that focuses on issues facing cancer survivors. In 2007, the Abramson Cancer Center was designated a LIVESTRONG ™ Survivorship Center of Excellence Network.  The Abramson Cancer Center is only one of eight LIVESTRONG centers in the United States, and is the only LIVESTRONG Survivorship Center of Excellence in the Philadelphia region. The program focuses on survivorship, a distinct phase of care.

Prescription for Living: The Cancer Survivorship Program at the Joan Karnell Cancer Center at Pennsylvania Hospital, provides patients with a summary of important information about specific cancer diagnoses and treatments, as well as follow-up information and steps to take towards recovery, supportive care and education to help patients adjust to their lives as cancer survivors.

back to top

Penn offers cancer patients support programs and groups to enhance their survivorship care plans.

The Abramson Cancer Center and Joan Karnell Cancer Center at Pennsylvania Hospital have materials and host a wide range of activities that provide education and support to address key areas of concern including survivorship for cancer patients and their loved ones.

Focus On: Gastrointestinal Cancers is a day-long conference that addresses issues for patients with colon cancer, as well as their loved ones.

back to top