3 Colorectal Cancer

Addison Mohl

This image shows a diagram of the digestive system. It illustrates where the rectum and colon are located within the body. This is where colorectal cancer originates.

“Anatomy of lower digestive system, showing the colon, rectum, and other organs” by Terese Winslow, National Institutes of Health is in the Public Domain, CC0

Risk Factors

While the majority of cases occur in individuals who are at average risk, there are many risk factors correlated with developing colorectal cancer. Modifiable risk factors associated with colorectal cancer include obesity, physical inactivity, smoking, heavy alcohol use, and diets high in salt and red meat (Lewandowska et al., 2022). Maintaining a healthy lifestyle is vital in preventing this disease. Nonmodifiable factors associated with an increased risk for developing the cancer include age, a personal history of colorectal edemas or inflammatory bowel diseases, a family history of cancer or adenomas, and racial and ethnic backgrounds.

Signs and Symptoms

Colorectal cancer can present itself in the form of various symptoms. Common signs include changes in bowel habits, rectal bleeding, blood in the stool, cramps or abdominal pain, weakness or fatigue, unexplained weight loss, and anemia without cause (Kuipers et al., 2015). These symptoms are typically only experienced once the cancer has progressed to an advanced disease state, which is why screening and early detection are vital.

Screening

Colorectal cancer is considered to be the most preventable, yet least prevented form of cancer. It can be prevented through regular screening and early detection. The American Cancer Society (2020) recommends regular screening starting at age 45. Screening options include a colonoscopy completed every ten years, a flexible sigmoidoscopy or CT colonography completed every five years, a fecal immunochemical test completed every year, or a multi-target stool DNA test completed every three years. Primary care providers can order these procedures at annual wellness exams or refer patients to a specialist to complete them.

Stages of Cancer

According to the National Cancer Institute (2022), stage one colorectal cancer is characterized by a small tumor that has infiltrated the mucosa membrane. Stage two colorectal cancer is characterized by an increased tumor size that has reached the intestinal wall. Stage three colorectal cancer is present when a tumor has spread to surrounding lymph nodes. Stage four occurs when that tumor has spread to surrounding organs. The five-year survival rates for colorectal cancer are 90% in stages one and two, 72% in stage three, and 14% in stage four (Kuipers et al., 2015). This drastic decrease in survival rates between stages illuminates the importance of early detection to improve health outcomes.

This image portrays a cross section of the colon. This cross section illustrates how colorectal cancer progresses through stages.

“Stages of colorectal cancer” by National Cancer Institute is in the Public Domain, CC0

Treatment Methods 

According to the National Cancer Institute (2022), treatment methods for colorectal cancer currently include surgery, radiation therapy, chemotherapy, immunotherapy, and numerous other advanced treatment options. Stages one and two are typically treated through the use or surgery. Stage three is commonly treated through a combination of surgery and chemotherapy. Stage four is treated through multiple surgeries to remove tumors where the cancer has spread throughout the body along with radiation and chemotherapy.

Colorectal Cancer and Men

Colorectal cancer is currently the third most common cause of cancer among men. According to the American Cancer Society (2020) the lifetime risk for developing the disease for men is one in 23 compared to one in 25 for women. Each year over 44 million average risk patient aged 45 years and older remain overdue for regular colorectal cancer screening. According to the American Cancer Society, only 48% of adults aged 50-54 years of age reported recent screening for colorectal cancer (2020). Only 21% of adults aged 45-49 years reported recent screening. It is vital to raise awareness of this disease and to increase urgency to get screened to improve health outcomes in men.

Colorectal cancer disproportionately affects men across race and age groups. African Americans have the highest age-adjusted mortality rate and the poorest five-year survival rate when compared to other racial and ethnic groups in the United States when it comes to colorectal cancer (Rogers et al., 2015). These disparities may be attributed to the prevalence of late-stage diagnoses in African American males. In a clinical study there was a 28% difference observed in the incidence in the diagnosis of late-stage colorectal cancer between African Americans and non-Hispanic Whites (Jackson et al., 2016). The study revealed colorectal cancer as the second most common cancer identified in Hispanic males

While certain races experience higher incidence rates of colorectal cancer, they also may be subjected to disproportionate treatment after being diagnosed. A study by researchers at the Institute for Technology Assessment was conducted to shed light on the racial and ethnic disparities that exist regarding colorectal cancer treatment utilization. Their findings revealed that Black colorectal cancer patients were significantly less likely than White patients to receive treatment with surgery, radiation, or chemotherapy (Tramantano et al., 2020). The same trends were observed when comparing Hispanic and Asian patients with White patients. The study also found that Hispanic and Asian patients tend to have lower rates of treatment utilization and higher surgery costs. This may be attributed to a lack of insurance coverage among this population.

While the recommended screening age for colorectal cancer is 45, individuals in younger age populations suffer from the disease. Among patients under the age of 50 in the United States, there has been a 2.2% annual increase in the incidence rate of colorectal cancer (Done & Fang, 2021). It is estimated that more than 12% of individuals with colorectal cancer are diagnosed before reaching 50 years of age, and African American and Hispanic populations hold higher rates of 13.9% and 18.9%, respectively (Virostko et al., 2019). The greatest increase in incidence rates was observed among patients aged 20-34.

When compared to older men, younger men tend to be diagnosed with more aggressive forms of colorectal cancer. To this point, a retrospective study, using national cancer data, found that early onset colorectal cancer typically has more aggressive histology than traditional colorectal cancer (Virostko et al., 2019). This may be attributed to the absence of screening recommendations for individuals in younger populations. .  Younger men also may not report symptoms of colorectal cancer due to masculinity beliefs. It may be viewed as a sign of weakness to seek healthcare for symptoms they perceive to be mild. This could also increase their chances of receiving a late-stage diagnosis.

Of the many factors attributed to men’s increased risk for colorectal cancer, a key factor is delaying screening due to threats to their masculinity. While colonoscopies are an effective method of screening for colorectal cancer, they are invasive procedures. Colonoscopies are conducted through the use of a small camera attached to a flexible tube passed through the anus. Apprehension about receiving a colonoscopy is believed to be experienced by men because the rectum is often framed by hegemonic masculinity as a vulnerable and off limit zone (Rogers et al., 2015). Penetration even in a medical setting could be a threat to their traditional masculine identity.

Call to Action

Within the United States, there is currently a lack of urgency to complete recommended screening for colorectal cancer. In 2020 only 69.4% of adults aged 50-74 reported being up to date with recommended colorectal cancer screening (Richardson et al., 2022). Early detection and regular screening are vital in reducing mortality rates due to the drastic decrease in survival rates as colorectal cancer progresses.

An event that has been successful in raising awareness of this disease is Colorectal Cancer Awareness Month. Each March information surrounding colorectal cancer is shared through social media, brochures in healthcare provider offices, education events, fundraising, and volunteering in communities. These activities promote the importance of early screening and support patients undergoing treatment. A way in which men can be influenced to complete screening in this event could be combatting traditional masculinity beliefs. One traditional masculinity norm that may be translated into healthcare is self-reliance. Self-reliance may be associated with the avoidance of healthcare, and therefore the avoidance of screening recommendations. Educational events and information spread through social media must disseminate the importance of regular screening and combat the idea that receiving primary care services is not masculine.

Another movement that has been successful in motivating men to complete screening for colorectal cancer is the Real Men Wear Gowns campaign. This campaign consisted of a series of television commercials in which men were encouraged to participate in annual preventative care screenings. These videos combat the belief some men hold that preventative care screenings are unnecessary if they do not feel ill. They also help to further refute the view that it is not masculine to go to the doctor.

The Physician Payment Rule was recently finalized by the United States Department of Health and Human Services to improve access to cancer screening coverage. The Centers for Medicare and Medicaid Services (2022) announced this policy will now reduce the minimum age for colorectal cancer screening from 50 years to 45 years. This policy will also ensure Medicare patients full coverage for follow up colonoscopies after receiving a positive result from a non-invasive stool-based test. Barriers due to cost will be reduced to ensure wider access to colorectal cancer screening for men.

The risks to delaying screening need to be communicated with patients so they understand the importance of their decision. Colorectal cancer is the most preventable, yet least prevented form of cancer. With early detection and regular screening this narrative can be changed.