Colorectal Cancer Prevention and Early Detection
Colorectal Cancer Prevention and Early Detection
Colorectal Cancer Prevention and Early Detection
Detection
What is colorectal cancer?
Cancer starts when cells in the body begin to grow out of control. Cells in nearly any part of the
body can become cancer, and can spread to other areas of the body. To learn more about how
cancers start and spread, see What Is Cancer?
Colorectal cancer is a term used to refer to cancer that develops in the colon or the rectum. These
cancers are sometimes called colon cancer or rectal cancer, depending on where they start. Colon
cancer and rectal cancer are often grouped together because they have many features in common.
certain types of polyps before they have the chance to turn into cancer. Screening can also help
find colorectal cancer early, when its small, hasnt spread, and is easier to treat.
When colorectal cancer is found at an early stage before it has spread, the 5-year relative survival
rate is about 90%. But only about 4 out of 10 colorectal cancers are found at this early stage.
When cancer has spread outside the colon or rectum, survival rates are lower.
Unfortunately, only a little more than half of people who should get tested for colorectal cancer
get the tests that they should. This may be due to things like lack of public and health care
provider awareness of screening options, costs, and health insurance coverage issues.
See Colorectal cancer screening tests for more on the tests used to screen for colorectal cancer.
The section American Cancer Society recommendations for colorectal cancer early detection
has our guidelines for using these tests to find colorectal cancer and polyps.
Physical inactivity
If youre not physically active, you have a greater chance of developing colorectal cancer. Being
more active might help lower your risk.
Smoking
People who have smoked for a long time are more likely than non-smokers to develop and die
from colorectal cancer. Smoking is a well-known cause of lung cancer, but its also linked to
other cancers, like colorectal cancer. If you smoke and would like to learn more about quitting,
see our Guide to Quitting Smoking.
Inherited syndromes
About 5% to 10% of people who develop colorectal cancer have inherited gene defects
(mutations) that can cause family cancer syndromes and lead to them getting the disease.
The most common inherited syndromes linked with colorectal cancers are familial adenomatous
polyposis (FAP) and Lynch syndrome (hereditary non-polyposis colorectal cancer or HNPCC),
but other rarer syndromes can also increase colorectal cancer risk.
Familial adenomatous polyposis (FAP): FAP is caused by changes (mutations) in the APC
gene that a person inherits from his or her parents. About 1% of all colorectal cancers are caused
by FAP.
In the most common type of FAP, hundreds or thousands of polyps develop in a persons colon
and rectum, usually starting in their teens or early adulthood. Cancer usually develops in 1 or
more of these polyps as early as age 20. By age 40, almost all people with FAP will have colon
cancer if their colon hasnt been removed to prevent it. People with FAP also have an increased
risk of cancers of the stomach, small intestines, and some other organs.
In attenuated FAP, which is a subtype of this disorder, patients have fewer polyps (less than
100) and colorectal cancer tends to occur at a later age.
Gardner syndrome is a type of FAP that also leads to benign (non-cancer) tumors of the
skin, soft tissue, and bones.
Lynch syndrome (hereditary non-polyposis colon cancer, or HNPCC): Lynch syndrome
accounts for about 2% to 4% of all colorectal cancers. In most cases, this disorder is caused by
an inherited defect in either the MLH1 or MSH2 gene, but changes in other genes can also cause
Lynch syndrome. These genes normally help repair DNA damage.
The cancers in this syndrome develop when people are relatively young. People with Lynch
syndrome can have polyps, but they tend to only have a few, not hundreds as in FAP. The
lifetime risk of colorectal cancer in people with this condition may be as high as 80%, but this
depends on which gene is affected.
Women with this condition also have a very high risk of cancer of the endometrium (lining of the
uterus). Other cancers linked to Lynch syndrome include cancer of the ovary, stomach, small
intestine, pancreas, kidney, brain, ureters (tubes that carry urine from the kidneys to the bladder),
and bile duct.
For more information on Lynch syndrome, see Genetic testing, screening, and prevention for
people with a strong family history of colorectal cancer.
Turcot syndrome: This is a rare inherited condition in which people are at increased risk of
adenomatous polyps and colorectal cancer, as well as brain tumors. There are actually 2 types of
Turcot syndrome:
One is caused by gene changes similar to those seen in FAP, in which cases the brain tumors
are medulloblastomas.
The other is caused by gene changes similar to those seen in Lynch syndrome, in which cases
the brain tumors are glioblastomas.
Peutz-Jeghers syndrome: People with this rare inherited condition tend to have freckles around
the mouth (and sometimes on their hands and feet) and a special type of polyps (called
hamartomas) in their digestive tracts. These people are at a greatly increased risk for colorectal
cancer, as well as several other cancers, which usually appear at a younger than normal age. This
syndrome is caused by mutations in the STK1 gene.
MUTYH-associated polyposis: People with this syndrome develop colon polyps which will
become cancer if the colon is not removed. These people also have an increased risk of cancers
of the small intestine, skin, ovary, and bladder. This syndrome is caused by mutations in the
MUTYH gene.
People with these inherited syndromes often get cancer at a younger age than usual. These
syndromes are also linked to some other types of cancer. Identifying families with these
syndromes is important because it lets doctors recommend specific steps such as screening and
other preventive measures at an early age.
Information on risk assessment, and genetic counseling and testing for some of these syndromes
can be found in Genetic testing, screening, and prevention for people with a strong family
history of colorectal cancer.
Type 2 diabetes
People with type 2 (usually non-insulin dependent) diabetes have an increased risk of colorectal
cancer. Both type 2 diabetes and colorectal cancer share some of the same risk factors (such as
being overweight or obese). But even after taking these factors into account, people with type 2
diabetes still have an increased risk. They also tend to have a less favorable prognosis (outlook)
after diagnosis.
might be due to changes in levels of melatonin (a hormone that responds to changes in light) in
the body. More research is needed to confirm or refute this finding.
Not smoking
Long-term smoking is linked to an increased risk of colorectal cancer, as well as many other
cancers and health problems. If you smoke and would like help quitting, call the American
Cancer Society at 1-800-227-2345.
lowering the chances of getting some types of heart disease, might outweigh the risks in certain
groups of people, such as those at higher risk for heart disease.
The value of these drugs for people at increased colorectal cancer risk is being studied.
Celecoxib (Celebrex) has been approved by the US Food and Drug Administration (FDA) for
reducing polyps in people with familial adenomatous polyposis (FAP). This drug may cause less
bleeding in the stomach than other NSAIDs, but it may increase the risk of heart attacks and
strokes.
Aspirin and other NSAIDs can have serious side effects, so check with your doctor before
starting to take any of them on a regular basis.
you have testing and are found to have an abnormal gene, there might be steps you can take to
help lower your risk of colorectal cancer, such as getting screened at an early age or even having
surgery.
But before getting genetic testing, its important to know ahead of time what the results may or
may not tell you about your risk. Genetic testing is not perfect, and for some people the tests may
not provide clear answers. This is why meeting with a genetic counselor or cancer genetics
professional is important before deciding to be tested. To learn more about this, see Genetic
Testing: What You Need to Know.
Genetic tests can help show if members of certain families have inherited a high risk of
colorectal cancer due to inherited cancer syndromes such as Lynch syndrome (also known as
hereditary non-polyposis colorectal cancer, or HNPCC) or familial adenomatous polyposis
(FAP).
In families known to have one of these inherited syndromes, family members who decide not to
get tested are still usually advised to start being screened for colorectal cancer at an early age,
and to get screened more often. Family members who are tested and are found not to have the
mutated gene may be able to be screened at the same age and frequency as people at average
risk.
Amsterdam criteria
Doctors have found that many families with Lynch syndrome tend to have certain characteristics,
which are known as the Amsterdam criteria:
At least 3 relatives have colorectal cancer (or another cancer linked with Lynch syndrome).
One is a first-degree relative (parent, sibling, or child) of the other 2 relatives.
At least 2 successive generations are involved.
At least 1 relative had their cancer when they were younger than age 50.
If all of these apply to your family, then you might want to seek genetic counseling. But even if
your family history satisfies the Amsterdam criteria, it doesnt always mean you have Lynch
syndrome. Only about half of families who meet the Amsterdam criteria have Lynch syndrome.
The other half do not, and although their colorectal cancer rate is about twice as high as normal,
its not as high as that of people with Lynch syndrome. On the other hand, many families with
Lynch syndrome do not meet the Amsterdam criteria.
In families known to carry a Lynch syndrome gene mutation, doctors recommend that family
members who have tested positive for the mutation and those who have not been tested should
start colonoscopy screening during their early 20s to remove any polyps and find any cancers at
the earliest possible stage. (See the section American Cancer Society recommendations for
colorectal cancer early detection.) People known to carry one of the gene mutations may also be
offered the option of removal of most of the colon.
Rectal bleeding
Blood in the stool, which may make it look dark
Cramping or abdominal (belly) pain
Weakness and fatigue
Unintended weight loss
Colorectal cancers can often bleed into the digestive tract. While sometimes you can see blood in
the stool or it looks darker, often the stool looks normal. But over time, the blood loss can build
up and can lead to low red blood cell counts (anemia). Sometimes the first sign of colorectal
cancer is a blood test showing a low red blood cell count.
Most of these problems are more often caused by conditions other than colorectal cancer, such as
infection, hemorrhoids, or irritable bowel syndrome. Still, if you have any of these problems, its
important to see a doctor right away so the cause can be found and treated, if needed.
Using the sigmoidoscope, your doctor can look at the inside of the rectum and part of the colon
to detect (and possibly remove) any abnormality. The sigmoidoscope is only 60 centimeters
(about 2 feet) long, so the doctor is able to see the entire rectum but less than half of the colon
with this procedure.
Before the test: Be sure your doctor knows about any medicines you are taking. You might need
to change how you take them before the test. Your colon and rectum must be empty and clean so
your doctor can see the lining of the sigmoid colon and rectum. You will get specific instructions
to follow to clean them out. You may be asked to follow a special diet (such as drinking only
clear liquids) for a day before the test. You may also be asked to use enemas or to use strong
laxatives to clean out your colon before the test. Be sure to tell your doctor about any medicines
you are taking, as you might need to change how you take them before the test.
During the test: A sigmoidoscopy usually takes about 10 to 20 minutes. Most people dont need
to be sedated for this test, but this might be an option you can discuss with your doctor. Sedation
may make the test less uncomfortable, but youll need some time to recover from it and youll
need someone with you to take you home after the test.
Youll probably be asked to lie on a table on your left side with your knees pulled up near your
chest. Before the test, your doctor may put a gloved, lubricated finger into your rectum to
examine it. For the test itself, the sigmoidoscope is first lubricated to make it easier to insert into
the rectum. The scope may feel cold as its put in. Air will be pumped into the colon through the
sigmoidoscope so the doctor can see the walls of the colon better.
During the procedure, you might feel pressure and slight cramping in your lower belly. To ease
discomfort and the urge to have a bowel movement, it helps to breathe deeply and slowly
through your mouth. Youll feel better after the test once the air leaves your colon.
If a small polyp is found during the test, the doctor may remove it with a small instrument passed
through the scope. The polyp will be sent to a lab to be looked at. If a pre-cancerous polyp (an
adenoma) or colorectal cancer is found, youll need to have a colonoscopy later to look for
polyps or cancer in the rest of the colon.
Possible complications and side effects: This test may be uncomfortable because of the air put
into the colon, but it should not be painful. Be sure to let your doctor know if you feel pain
during the procedure. You might see a small amount of blood in your first bowel movement after
the test. More serious bleeding and puncture of the colon are possible complications, but they are
very uncommon.
Colonoscopy
For this test, the doctor looks at the entire length of the colon and rectum with a colonoscope, a
thin, flexible, lighted tube with a small video camera on the end. Its basically a longer version of
a sigmoidoscope. Its put in through the anus and into the rectum and colon. Special instruments
can be passed through the colonoscope to biopsy (sample) or remove any suspicious-looking
areas such as polyps, if needed.
Colonoscopy may be done in a hospital outpatient department, in a clinic, or in a doctors office.
Before the test: Be sure your doctor knows about any medicines you are taking. You might need
to change how you take them before the test. The colon and rectum must be empty and clean so
your doctor can see their inner linings during the test. This can be done many ways, but the most
common involves drinking large amounts of a liquid laxative the evening before and the morning
of the procedure. This leads to spending a lot of time in the bathroom.
Your doctor will give you specific instructions. Its important to read these carefully a few days
ahead of time, since you may need to follow a special diet for at least a day before the test and to
shop for supplies and laxatives. If youre not sure about any of the instructions, call the doctors
office and go over them with the nurse.
You will probably also be told not to eat or drink anything after midnight the night before your
test. If you normally take prescription medicines in the mornings, talk with your doctor or nurse
about how to manage them for the day.
Because a sedative is used during the test, youll need to arrange for someone you know to take
you home from the test (not just a cab or Uber).
During the test: The test itself usually takes about 30 minutes, but it may take longer if a polyp
is found and removed. Before it starts, youll be given a sedating medicine (into a vein) to make
you feel relaxed and sleepy during the procedure. For most people, this medicine makes them
unaware of whats going on and unable to remember the procedure afterward. Youll wake up
after the test is over, but might not be fully awake until later in the day.
During the test, youll be asked to lie on your side with your knees pulled up. A drape will cover
you. Your blood pressure, heart rate, and breathing rate will be monitored during and after the
test.
Your doctor might insert a gloved finger into the rectum to examine it before putting in the
colonoscope. The colonoscope is lubricated so it can be inserted easily into the rectum. Once in
the rectum, the colonoscope is passed all the way to the beginning of the colon, called the cecum.
If youre awake, you may feel an urge to have a bowel movement when the colonoscope is
inserted or pushed further up the colon. The doctor also puts air into the colon through the
colonoscope to make it easier to see the lining of the colon and use the instruments to perform
the test. To ease any discomfort, it may help to breathe deeply and slowly through your mouth.
The doctor will look at the inner walls of the colon as he or she slowly removes the colonoscope.
If a small polyp is found, it may be removed. This is because some small polyps may become
cancer over time. Removing the polyp is usually done by passing a wire loop through the
colonoscope to cut the polyp from the wall of the colon with an electric current. The polyp is
then sent to a lab to be checked to see if it has any areas that have changed into cancer.
If your doctor sees a larger polyp or tumor or anything else abnormal, a biopsy may be done. A
small piece of tissue is taken out through the colonoscope. The tissue is checked in the lab to see
if its cancer, a benign (non-cancerous) growth, or a result of inflammation.
Possible side effects and complications: The bowel preparation before the test is unpleasant.
The test itself might be uncomfortable, but the sedative usually helps with this, and most people
feel normal once the effects of the sedative wear off. Because air is pumped into the colon during
the test, people sometimes feel bloated, have gas pains, or have cramping for a while after the
test until the air passes out.
Some people may have low blood pressure or changes in heart rhythm due to the sedation during
the test, but these are rarely serious.
If a polyp is removed or a biopsy is done during the colonoscopy, you might notice some blood
in your stool for a day or 2 after the test. Serious bleeding is uncommon, but in rare cases,
bleeding might need to be treated or can even be life-threatening.
Colonoscopy is a safe procedure, but in rare cases the colonoscope can puncture the wall of the
colon or rectum. This is called a perforation. Symptoms can include severe abdominal (belly)
pain, nausea, and vomiting. This can be a major (or even life-threatening) complication, because
it can lead to a serious abdominal (belly) infection. The hole may need to be repaired with
surgery. Ask your doctor about the risk of this complication.
You can read more about colonoscopy and sigmoidoscopy in Frequently Asked Questions About
Colonoscopy and Sigmoidoscopy.
During the test: The test takes about 30 to 45 minutes, and sedation isnt needed. You lie on a
table on your side in an x-ray room. A small, flexible tube is put into your rectum, and barium
sulfate is pumped in to partially fill and open up the colon and rectum. You are then turned on
the x-ray table so the barium moves throughout the colon and rectum. Then air is pumped into
the colon and rectum through the same tube to expand them. This might cause some cramping
and discomfort, and you may feel the urge to have a bowel movement.
X-ray pictures of the lining of your colon and rectum are then taken to look for polyps or
cancers. You may be asked to change positions to help move the barium and so that different
views of the colon and rectum can be seen on the x-rays.
If polyps or other suspicious areas are seen on this test, youll probably need a colonoscopy to
remove them or to explore them fully.
Possible side effects and complications: You may have bloating or cramping after the test, and
will probably feel the need to empty your bowels soon after the test is done. The barium can
cause constipation for a few days, and your stool may look grey or white until all the barium is
out. Theres a very small risk that inflating the colon with air could injure or puncture it, but this
risk is thought to be much less than with colonoscopy. Like other x-ray tests, this test also
exposes you to a small amount of radiation.
lot of time in the bathroom. The morning of the test, sometimes more laxatives or enemas may
be needed to make sure the bowels are empty.
During the test: This test is done in a special room with a CT scanner. It takes about 10 minutes.
You may be asked to drink a contrast solution before the test to help tag any stool left in the
colon or rectum, which helps the doctor when looking at the test images. Youll be asked to lie
on a thin table thats part of the CT scanner, and will have a small, flexible tube put into your
rectum. Air is pumped through the tube into the colon and rectum to expand them to provide
better images. The table then slides into the CT scanner, and youll be asked to hold your breath
while the scan is done. Youll likely have 2 scans: one while youre lying on your back and one
while youre on your stomach. Each scan usually takes only about 10 to 15 seconds.
Possible side effects and complications: There are usually few side effects after this test. You
may feel bloated or have cramps because of the air in the colon and rectum, but this should go
away once the air passes from the body. Theres a very small risk that inflating the colon with air
could injure or puncture it, but this risk is thought to be much less than with colonoscopy. Like
other types of CT scans, this test also exposes you to a small amount of radiation.
This test is done with a kit that you can use in the privacy of your own home that allows you to
check more than one stool sample. A FOBT done during a digital rectal exam in the doctors
office (which only checks one stool sample) is not sufficient for screening. Also, unlike some
other tests (like colonoscopy), this test must be done every year.
People having this test will get a kit with instructions from their doctors office or clinic. The kit
will explain how to take stool samples at home (usually samples from 3 consecutive bowel
movements are smeared onto small squares of paper). The kit is then returned to the doctors
office or medical lab (usually within 2 weeks) for testing.
Before the test: Some foods or drugs can affect the results, so you may be instructed to avoid
the following before this test:
Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil), naproxen
(Aleve), or aspirin (more than 1 adult aspirin per day), for 7 days before testing. (They can
cause bleeding, which can lead to a false-positive result.) Acetaminophen (Tylenol) can be
taken as needed. Note: People should try to avoid taking NSAIDs for minor aches. But if you
take these medicines daily for heart problems or other conditions, dont stop them for this test
without talking to your doctor first.
Vitamin C in excess of 250 mg daily from either supplements or citrus fruits and juices for 3
days before testing. (This can affect the chemicals in the test and make the result negative,
even if blood is present.)
Red meats (beef, lamb, or liver) for 3 days before testing. (Components of blood in the meat
may cause a positive test result.)
Some people who are given the test never do it or dont return it because they worry that
something they ate may affect the test. For this reason, many doctors tell their patients its not
critical that they follow the diet restrictions. The most important thing is to get the test done.
Collecting the samples: Have all of your supplies ready and in one place. Supplies typically
include a test kit, test cards, either a brush or wooden applicator, and a mailing envelope. The kit
will give you detailed instructions on how to collect the stool samples. Be sure to follow the
instructions that come with your kit, as different kits might have different instructions. If
you have any questions about how to use your kit, contact your doctors office or clinic. Once
you have collected the samples, return them as instructed in the kit.
If this test finds blood, a colonoscopy will be needed to look for the source. Its not enough to
simply repeat the gFOBT or follow up with other types of tests.
FOBT. This test reacts to part of the human hemoglobin protein, which is found in red blood
cells.
Early versions of this test were not as good at finding colorectal cancers. Highly sensitive
versions, which the American Cancer Society recommends for screening, have been around for
at least 10 years.
The FIT is done much like the gFOBT, in that small amounts of stool are collected on cards (or
in tubes). Some people may find this test easier because there are no drug or dietary restrictions
(vitamins and foods do not affect the FIT), and collecting the sample may be easier. This test is
also less likely to react to bleeding from other parts of digestive tract, such as the stomach.
Like the gFOBT, the FIT may not detect a tumor thats not bleeding, so multiple stool samples
should be tested. And if the results are positive for hidden blood, a colonoscopy will be needed
to investigate further. This test must be done every year.
Collecting the samples: Have all of your supplies ready and in one place. Supplies typically
include a test kit, test cards or tubes, long brushes or other collecting devices, waste bags, and a
mailing envelope. The kit will give you detailed instructions on how to collect the samples. Be
sure to follow the instructions that come with your kit, as different kits might have
different instructions. If you have any questions about how to use your kit, contact your
doctors office or clinic. Once you have collected the samples, return them as instructed in the
kit.
What are some of the pros and cons of these screening tests?
Test
Pros
Cons
Flexible sigmoidoscopy
Colonoscopy
Relatively safe
No sedation needed
CT colonography (virtual
colonoscopy)
No sedation needed
No bowel prep
Inexpensive
No bowel prep
Fairly inexpensive
Stool DNA test
No bowel prep
American Cancer Society Guidelines on Screening and Surveillance for the Early
Detection of Colorectal Adenomas and Cancer in People at Increased Risk or High Risk
INCREASED RISK People who have a history of polyps on prior colonoscopy
Risk category
When to test
Recommended
test(s)
Comment
Colonoscopy, or
other screening
options at same
intervals as for
those at average
risk
Colonoscopy
People with 1 or 2
5 to 10 years after
small (less than 1 cm) the polyps are
tubular adenomas with removed
low-grade dysplasia
People with 3 to 10
adenomas, or a large
(at least 1 cm)
adenoma, or any
adenomas with highgrade dysplasia or
villous features
When to test
Recommended
test(s)
Comment
Colonoscopy to
look at the entire
colon and remove
all polyps
Age to start
testing
Colorectal cancer or
adenomatous polyps in
any first-degree
relative before age 60,
or in 2 or more firstdegree relatives at any
age (if not a hereditary
syndrome).
Colorectal cancer or
Age 40
adenomatous polyps in
any first-degree
Recommended
test(s)
Same options as
for those at
Comment
Every 5 years.
relative aged 60 or
older, or in at least 2
second-degree relatives
at any age
average risk.
HIGH RISK
Risk category
Age to start
testing
Recommended
test(s)
Familial adenomatous
polyposis (FAP)
diagnosed by genetic
testing, or suspected
FAP without genetic
testing
Age 10 to 12
Yearly flexible
If genetic test is positive,
sigmoidoscopy to removal of colon (colectomy)
look for signs of should be considered.
FAP; counseling
to consider
genetic testing if it
hasnt been done
Lynch syndrome
(hereditary nonpolyposis colon
cancer or HNPCC), or
at increased risk of
Lynch syndrome based
on family history
without genetic testing
Age 20 to 25 years,
or 10 years before
the youngest case
in the immediate
family
Colonoscopy
every 1 to 2 years;
counseling to
consider genetic
testing if it hasnt
been done
Inflammatory bowel
disease:
Colonoscopy
every 1 to 2 years
with biopsies for
dysplasia
-Chronic ulcerative
colitis
-Crohns disease
Comment
The Bethesda criteria can be found in Genetic testing, screening, and prevention for people with a strong family
history of colorectal cancer.
Federal law
Coverage of colorectal cancer screening tests is required by the Affordable Care Act (ACA), but
the ACA doesnt apply to health plans that were in place before it was passed (called
grandfathered plans). You can find out your insurance plans grandfathered status by
contacting your health insurance company or your employers human resources department. If
your plan started on or after September 23, 2010, it must cover colonoscopies and other
colorectal cancer screening tests. If a plan started before September 23, 2010, it may still have
coverage requirements from state laws, which vary, and other federal laws.
Additional resources
More information from your American Cancer Society
We have a lot more information that you might find helpful. Explore www.cancer.org or call our
National Cancer Information Center toll-free number, 1-800-227-2345. Were here to help you
any time, day or night.
No matter who you are, we can help. Contact us anytime, day or night, for information and
support. Call us at 1-800-227-2345 or visit www.cancer.org.