• Risk factor
• Diagnosis & Confirmation test
• Case study
• Cancer that affect the colon or the rectum, the last
20-25 centimeters of the colon.
• Normal cells in the lining of the colon or rectum
begin to change, grow without control, and no
• Usually begins as a noncancerous polyp that can,
over time, become a cancerous tumor.
Figure 1: Anatomical position of colon and rectum
• Colorectal cancer is the fourth leading cause of cancer
death worldwide (WHO, 2012).
• In Malaysia, colorectal cancer now is the most common
cancer in males and the third most common in females.
• One in 33 Malaysians are at risk of developing colorectal
cancer (World Health Organisation's Globocan, 2008)
• Majority of patients are above 40 years old.
• A cross sectional study was conducted from August 2009
till April 2010 involving average risk individuals from 44
primary care clinics in West Malaysia (Yusoff et al., 2012).
• The barrier questions domains:
1. patient factors
2. test factors
3. health care provider factors
• Descriptive analysis shows of 1905
respondents, only 13 (0.7%) had done screening
due to health problems and believed to have signs
Stages of Colorectal cancer
• Stage 0: Cancer found only in the innermost lining of the colon
• Stage I: Cancer involves more of the inner wall of the colon or
• Stage II: Cancer spread outside to nearby tissue except lymph
• Stage III: Cancer spread to lymph nodes but not to other parts
of the body
• Stage IV: Cancer spread to other parts of the body (tends to
spread to liver and/or lungs)
Figure 2: Stages of Colorectal Cancer (www.fmh.org/, 2012)
• Age (>40 years old)
• Family history
• Personal history
• Diet (high fat and low fibre)
• Body weight and physical activity
• Inflammatory Bowel Disease
Figure 3 : Colon polyp
Signs & Symptoms
• A change in bowel habits
• Diarrhoea, constipation or feeling that the bowel does
not empty completely
• Blood (either bright red or very dark) in the stool
• Stools that are narrower than usual
• General abdominal discomfort
• Constant tiredness
Diagnosis and Confirmation Tests
1. Physical exam and history
To check general signs of health
2. Digital rectal exam
inserts a lubricated gloved finger
into the rectum to feel for lumps
or anything else that seems
Figure 4: Digital Rectal Exam
3. Fecal occult blood test (FOBT)
Detects small amounts of blood in the feces which
would not normally see or be aware of.
The rectum and lower colon are examined using a
lighted instrument called a sigmoidoscope
Figure 5: Fecal occult blood test (FOBT) Figure 6: Sigmoidoscopy
The rectum and entire colon are examined
using a lighted instrument called a colonoscope
Figure 7: Colonoscopy
Figure 8: Colon viewed under colonoscope
6. Double contrast barium enema (DCBE)
A series of x-rays of the entire colon and rectum are
taken after the patient is given an enema with a
barium solution and air is introduced into the colon
The barium and air help to outline the colon and
rectum on the x-rays
Figure 9: Double contrast barium enema (DCBE)
7. Computed Tomography (CT Scan)
Combines special x-ray equipment with
sophisticated computers to produce multiple images
or pictures of the inside of the body
A CT scan may be used if colorectal cancer has
metastasized to other organs
Figure 10: CT scan of hepatic metastatic colorectal cancer.
8. Positron emission tomography (PET)
Help to determine whether an abnormal area seen
on another imaging test is a tumor or not.
For patients who have already been diagnosed with
cancer, this test help the doctor to see if the cancer
has spread to lymph nodes or other parts of the
Figure 11: Colorectal cancer showing
metastatic disease to the liver on PET imaging
• Local excision
• Removing cancer without cutting through abdominal
• put a tube through the rectum into the colon
• Part of the colon containing the cancer and nearby healthy
tissue are removed, and then the cut ends of the colon are
Figure 12 : Anastomasis
• Part of the colon containing the cancer and nearby healthy
tissue is removed, a stoma is created, and a colostomy bag
is attached to the stoma.
Figure 13 : Colostomy
• Use drugs to stop the growth of cancer cells
• killing the cells
• stopping them from dividing.
2 types :
i. Systemic chemotherapy
• Taken orally or intravenously
ii. Regional chemotherapy
• placed directly into the spinal column, an organ,
or a body cavity
• Use high-energy x-rays to kill cancer cells or keep them
• local therapy - affects the cancer cells only in the
2 types :
• External radiation therapy
• uses a machine outside the body to send radiation
toward the cancer.
• Internal radiation therapy
• uses a radioactive substance sealed in needles or
catheters that are placed directly into or near the
• 6 out of every 10 deaths could be prevented if all
men and women aged 50 years or older were
• Remove precancerous polyps before they turn into
2. Reduce risk of developing colorectal cancer
• increasing physical activity
• eating fruits and vegetables
• limiting alcohol consumption
• avoiding tobacco
HISTORY OF PRESENT ILLNESS:
• 70 year old white male
• post resection of a stage III adenocarcinoma of the
sigmoid colon (approx. 10 days)
• 2 weeks prior to surgery he had significant coronary
artery disease and had underwent a CABG
• highly aggressive T3, N2 adenocarcinoma of the colon,
stage III with angiolymphatic invasion.
• 6 of 11 lymph nodes were positive .
• He underwent adjuvant 5FU leucovorin chemotherapy
• Recently he experience some vague abdominal pain.
• Mother died of cancer of unknown etiology
• A son who died of lymphoma at age 46.
• A flexible sigmoidoscopy : negative.
• Ultrasound of the liver showed calcifications
• CT scan : negative.
• PET scan : negative.
• No areas of increased FDG uptake to suggest recurrent or
• Sensitivity of this study is decreased due to the patient's
hyperglycemia. (Blood glucose level was 175mg/dl)
ASSESSMENT AND PLAN:
• A 70 year old white male with a history of Stage III colon
cancer, now with a rising CEA level, negative CT scan and
negative PET scan.
• Recheck his CEA in two months. If it continues to rise,
should move forward with a PET-CT scan follow-up.
FOLLOW-UP PET-CT SCAN:
• Recurrence : Focal area of intense FDG uptake
corresponding to mildly enlarged left paraaortic lymph
• Hepatic metastasis : Additional area of intense FDG
uptake identified within the right lobe of the liver.
• Early diagnosis of colorectal cancer is key to its cure.
• If found early, the disease is considered curable.
• If the tumor spreads to lymph nodes, a patient's chance
of living at least five years drops to 40 - 60%.
• If the cancer has already spread to distant organs, the
long-term survival may be lower.
• Early and accurate detection is highly importance to
improve patient outcomes.
• Anonymous. (2005). Understanding Colorectal Cancer. [Online]. Available
from http://www.webmd.com/colorectal cancer/guide/understanding-
colorectal-cancer-symptoms [Accessed: 18th January 2013].
• Anonymous. (2012). Colon Cancer. [Online]. Available from
ml [Accessed: 18th January 2013].
• Anonymous. (2011). Colorectal Screening. National Cancer Institute.
[Online]. Available from
screening [Accessed: 18th January 2013].
• Anonymous. 2012. Introduction to Colorectal Cancer. National Cancer
Institute [online] Available at:
http://training.seer.cancer.gov/colorectal/intro/ [Assessed 29 January 2013].
• Anonymous. 2012. Colorectal cancer [ppt] Available at:
30 January 2012].
• A. G. Norsidawati. 2009. Colorectal Cancer. COEd Sevices, Universiti Putra
Malaysia. Available from : http://www.care.upm.edu.my/download/colon-
ca.pdf [Accessed on 20th January 2013].
• Centre for Disease Control and Prevention, CDC. 2012. Colorectal Cancer
Prevention. Available from :
[Accessed on 21st January 2013].
• Colorectal Association of Canada. 2012. PET & Colorectal Cancer. Available
from : http://www.colorectal-cancer.ca/en/screening/pet-cancer/#D1
[Assessed on 1st February 2013]
• M. Varma et al., 2012. Division of General Study, University of San Francisco.
Available from : http://colorectal.surgery.ucsf.edu/conditions--
procedures/colon-cancer.aspx [Accessed on 21st January 2013].
• Blodgett. T. Colorectal Case Study#1. Available from : http://www.ri-
[Assessed on 1st February 2013].
• Pillay. S. 2012. Colorectal Cancer on Rise. Available from :
1.150298 [Assessed on 1st February 2013]
• Yusoff, H., Daud, N., Noor, N. and Rahim, A. 2012. Participation and Barriers
to Colorectal Cancer Screening in Malaysia. Research Article; Vol.13, p:3983-
3987 [online] Available at:
• World Health Organization. 2012. Fact sheet No. 297. [online] Available at:
http://www.who.int/mediacentre/factsheets/fs297/en/ [Assessed 28