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Chapter 68

Colorectal Cancer

Julio Garcia-Aguilar

Key Points

1 Incidence and overall mortality for colorectal cancer (CRC) are decreasing, most likely due to

increased screening. Risk-factor modification and improved therapy also likely contribute to this

trend.

2 Our greater understanding of the molecular biology of CRC may provide a means of identifying

disease biomarkers and developing more targeted therapies.

3 Advances in imaging techniques have improved risk stratification via more accurate baseline tumor

staging and treatment selection.

4 Improved risk stratification and neoadjuvant therapy have enabled physicians to eliminate some

therapeutic components in some patients’ treatment regimens.

5 Use of laparoscopic and robotic surgical techniques in combination with enhanced recovery

programs has accelerated patient recovery, reduced length of hospital stay, and reduced

postoperative complications.

6 While long-term survival for patients with stage IV disease remains low, median survival for these

patients has improved significantly in recent years, probably due to more effective chemotherapy

and more aggressive surgery.

7 Multidisciplinary treatment involving surgical oncologists, medical oncologists, radiation

oncologists, as well as liver surgeons, gastroenterologists, and stoma therapists improves outcomes

and quality of life in patients with CRC.

Colorectal cancer kills tens of thousands of people every year in the United States. If diagnosed at an

early stage, however, it is one of the most curable malignancies. Identification of populations at risk

and screening of asymptomatic patients are therefore crucial imperatives. This chapter provides a

comprehensive overview of the disease, including epidemiology, risk factors, molecular characteristics,

progression, staging, screening, diagnosis, and treatment.

EPIDEMIOLOGY

1 Colorectal cancer (CRC) is the third most common malignancy and the second most common cause of

cancer death in the United States. It is estimated that in 2015, a total of 132,700 people were diagnosed

with CRC in the United States, and 49,700 died from the disease.1 Approximately 1 in 20 Americans will

be diagnosed with CRC in their lifetime. Death from CRC could be reduced significantly by applying

current knowledge about screening, early diagnosis, and treatment standards. The incidence and

mortality rates for CRC have been decreasing for the last three decades, but the decreases have

accelerated since 2001 (Fig. 68-1). Between 2007 and 2011, the incidence of CRC decreased at a rate of

3.6% for both genders, and mortality at a rate of 2.6% in males and 3% in females. The declines in

incidence and mortality have been attributed to the detection and removal of precancerous polyps as a

result of CRC screening programs, changing patterns in CRC risk factors, and improvements in

treatment.

The incidence and mortality rates for CRC increase with age. The median age at colon cancer

diagnosis is 69 years in men and 74 years in women; for rectal cancer, 63 in men and 65 in women.

More than 90% of CRCs are diagnosed in patients 50 years or older. Both the incidence and mortality

for CRC are 30% to 40% higher in men than in women. The reasons for these differences are not

completely understood but probably reflect an interaction between risk factors and hormonal

differences. There are also gender differences in the distribution of CRC, with a higher proportion of

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