Colorectal Cancer, Metastatic or Recurrent

Topic Overview

Is this topic for you?

This topic is about metastatic and recurrent colorectal cancer.

What is colorectal cancer?

Colorectal cancer happens when cells that are not normal grow in your colon or rectum. These cells grow together and form tumors. This cancer is also called colon cancer or rectal cancer.

Colon and rectal cancers often return months or years after treatment. This is called recurrent cancer. If the original cancer was removed before it was able to spread, the chances that it will return are lower.

Metastatic cancer is cancer that has spread to other parts of the body. When colon or rectal cancer spreads, it most often spreads to the liver. Sometimes it spreads to the lungs, bones, or brain.

What causes metastatic or recurrent colorectal cancer?

The exact cause is not known, but the cancer is more likely to come back or spread if it is in a later, more advanced stage when it is first discovered.

What are the symptoms?

Some people do not have any symptoms. When they do occur, the most common symptoms are:

  • Belly pain, especially gas pains, cramps, or a feeling of fullness.
  • Blood in your stool or very dark stools.
  • A change in your bowel habits, such as more frequent stools, thinner stools, or a feeling that your bowels are not emptying completely.
  • Loss of appetite.
  • Losing weight without trying.
  • Constant tiredness (fatigue).

If your cancer has spread, you may have other symptoms, depending on where the cancer is. If it has spread to:

  • The lymph nodesof your belly, it may cause bloating, a swollen belly, loss of appetite, or a feeling of fullness.
  • The liver, it may cause pain on the upper right side of your belly, bloating, loss of appetite, or a feeling of fullness.
  • The lungs, it may cause you to cough, spit up blood, or have a hard time breathing.
  • The bones, it may cause bone pain, especially in your back, hips, and pelvis.
  • The brain, it may cause problems with memory, concentration, balance, or movement.

How is metastatic or recurrent colorectal cancer diagnosed?

Colon or rectal cancer that has returned or spread is diagnosed using a physical exam and several tests, including blood tests, chest X-rays, bone scans, ultrasounds, and CT, PET, or MRI scans.

The diagnosis is usually confirmed with a biopsy. During this test, your doctor will take tissue samples from any areas that don't look normal. The tissue will be looked at under a microscope to see if it contains cancer.

If you have been treated for colon or rectal cancer in the past, it’s important to have regular checkups to find any new cancer as soon as possible.

How is it treated?

Colon and rectal cancers that have returned or spread may be cured in rare cases. Treatment may include surgery, radiation, and chemotherapy. When the cancer cannot be cured, treatment can help you feel better and live longer.

Learning that you have cancer can be upsetting. It may help to talk with your doctor or with other people who have had cancer. Your local American Cancer Society chapter can help you find a support group.

Frequently Asked Questions

Learning about metastatic and recurrent colorectal cancer:

Being diagnosed:

Getting treatment:

Ongoing concerns:

End-of-life issues:

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Cause

The exact cause of colorectal cancer is not known. Most cases begin as small growths, or polyps, inside the intestine.

If colorectal cancer is not detected and removed, it invades and destroys nearby tissues and may spread to other parts of the body.

Symptoms

Some people who have metastatic or recurrent colorectal cancer do not have any symptoms. When they do appear, the most common symptoms are:

  • A change in bowel habits, such as narrow stools or frequent diarrhea or constipation.
  • Blood in the stool, or stools that look like black tar.
  • Loss of appetite.
  • Pain in the belly.
  • Unexplained weight loss.
  • Constant fatigue.

If your cancer has spread, you may have other symptoms, depending on where the cancer is. If it has spread to:

  • The lymph nodes of your abdomen, it may cause bloating, a swollen belly, loss of appetite, or a feeling of fullness.
  • The liver, it may cause pain on the upper right side of your abdomen, bloating, loss of appetite, or a feeling of fullness.
  • The lungs, it may cause coughing, spitting up blood, or a hard time breathing.
  • The bones, it may cause bone pain, especially in the back, hips, and pelvis.
  • The brain, it may cause problems with memory, concentration, balance, or movement.

What Happens

Cancer is the growth of abnormal cells in the body. These extra cells grow together and form masses, lumps, or tumors. In colorectal cancer, these growths usually start as harmless (benign) polyps in the large intestine (colon or rectum). Colon polyps are common and most do not cause problems. But if polyps are not detected and removed, some of them can turn into cancer.

If the cancer is allowed to continue growing, it eventually will invade and destroy nearby tissues and then spread farther. Colorectal cancer spreads first to nearby lymph nodes. From there it may spread to other parts of the body, usually to the liver. It may also spread to the lungs, bones, or brain.

Metastatic or recurrent colorectal cancer occurs when cancer cells travel, through either the bloodstream or the lymph system, to other parts of the body and continue to grow in their new location. Recurrent colorectal cancer occurs when the cancer begins to grow again months or years after treatment.

How colorectal cancer will affect your life span depends on the stage of your cancer. A cancer's stage depends on how far it has spread.

The 5-year survival rate for cancer that has spread to other parts of the body is 10%.1 The 5-year survival rate is the percentage of people who are still alive 5 years or longer after their cancer was discovered. It is important to remember that this is only an average. Everyone is different, and these numbers do not necessarily show what will happen to you.

What Increases Your Risk

Even after successful treatment, colorectal cancer comes back (recurs) about half the time.2 But this depends on the stage of the cancer before treatment. For example, if colorectal cancer is removed while it is still contained within the colon and has not spread, your risk of developing metastatic or recurrent colorectal cancer is less.

When To Call a Doctor

Some people who have metastatic or recurrent colorectal cancer do not have any symptoms. Sometimes it is discovered before symptoms appear, either on a chest X-ray or as part of lab tests.

You may be seeing a doctor regularly to check for symptoms, but symptoms might start between visits. Be aware of what is normal for you, and tell your doctor about any changes right away. Be sure to let your doctor know if you feel even very small changes.

What symptoms you may have will depend on which part of your body is affected by the cancer. Call your doctor if you have any of these symptoms:

  • A change in bowel habits, such as bleeding from your rectum, bright red or dark blood in your stools, frequent diarrhea, constipation, a feeling that your bowel is not emptying completely, or stools that are narrow (may be no wider than a pencil)
  • Pain in your belly
  • Bloating or loss of appetite
  • Unexplained weight loss
  • Constant fatigue
  • Cough
  • Difficulty breathing or shortness of breath
  • Bone pain

Watchful Waiting

Watchful waiting is a period of time during which you and your doctor observe your symptoms or condition without giving treatment to cure your cancer. Watchful waiting may be an option if treatment may cause more harm than good and is unlikely to cure your cancer. Remember, though, that watchful waiting does not mean your doctor won't treat your symptoms, such as pain.

Who To See

If you have been treated for colorectal cancer, doctors who can evaluate any new symptoms include:

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Tests to help your doctor see if colorectal cancer has metastasized or recurred include:

  • An abdominal ultrasound to find the cause of pain or swelling in your abdomen.
  • A colonoscopy to see if cancer has returned to your intestine.
  • Blood tests to find out if cancer has returned (CEA) or to find the cause of symptoms such as weakness, fatigue, fever, bruising, or weight loss (complete blood count and blood profile).
  • A chest X-ray to find the cause of symptoms such as persistent coughing, coughing up blood, chest pain, or difficult breathing.
  • A CT scan, MRI, or PET scan to see if colorectal cancer has spread into the chest or organs in the abdomen or pelvis.
  • A brain CT scan or MRI to look into symptoms such as confusion, paralysis, numbness, vision problems, vertigo, or headaches.
  • A biopsy, such as a liver biopsy or a lung biopsy, to find out where the cancer cells have spread.
  • A bone scan to find out whether cancer cells have spread to the bones.

What to think about

Colorectal cancer often comes back, even after successful treatment. If you had colorectal cancer in the past, pay close attention to your body and see your doctor regularly. Tell your doctor about any changes, such as decreased appetite, bloating, or an increase in the size of your belly.

Your cancer may return even if you do everything you can to prevent it. If this happens, focus on what you and your doctor can do to treat your symptoms to help you feel better and live longer.

Treatment Overview

Your treatment for metastatic or recurrent colorectal cancer will depend on specific information about the cancer, your preferences, and your health.

Some cases of metastatic or recurrent colorectal cancer can still be cured. When it cannot be cured, treatment can help you feel better and live longer.

Your treatment may include:

  • Surgery. If your cancer has come back in your intestine, surgery may be used to remove it. If it has spread to other parts of the body, it can sometimes be treated surgically. Cancer that has spread to the liver is sometimes successfully removed with surgery. For more information, see the Surgery section of this topic.
  • Drugs. The use of drugs, either swallowed or injected with a needle, to treat cancer is called chemotherapy. Drugs can help you live longer by killing cancer cells that have spread to other parts of your body. They also can relieve pain caused by the cancer. For more information, see the Medications section of this topic.
  • Radiation therapy. X-rays can be used to shrink colorectal tumors that may be causing blockages. They can also reduce bleeding or pain. For more information, see the Other Treatment section of this topic.
  • Clinical trials. Clinical trials are studies of new or different ways to treat cancer.
  • Home treatment.There are things you can do at home to manage the side effects caused by cancer and its treatments. For more information, see the Home Treatment section of this topic.

Dealing with your emotions

If you have been told you have metastatic or recurrent colorectal cancer, you may have many different feelings. Most people feel some denial, anger, and grief. There is no "normal" or "right" way to react. But there are things you can do to help manage your emotional reaction.

You may find that talking with family and friends helps. Some people find that spending time alone is what they need. You may also contact your local chapter of the American Cancer Society to find a support group. Talking with other people who have had similar experiences can be very helpful.

If your reaction is interfering with your ability to make decisions, it is important to talk with your doctor. Your cancer treatment center may offer counseling services.

Palliative care

As your cancer gets worse, you may want to think about palliative care. Palliative care is a kind of care for people who have illnesses that do not go away and often get worse over time. It is different than care to cure your illness, called curative treatment. Palliative care focuses on improving your quality of life—not just in your body, but also in your mind and spirit. Some people combine palliative care with curative care.

Palliative care may help you manage symptoms or side effects from treatment. It could also help you cope with your feelings about living with a long-term illness, make future plans around your medical care, or help your family better understand your illness and how to support you.

If you are interested in palliative care, talk to your doctor. He or she may be able to manage your care or refer you to a doctor who specializes in this type of care.

For more information, see the topic Palliative Care.

End-of-life issues

The 5-year survival rate for colorectal cancer that has spread to other parts of the body is 10%.1 This means that 5 years after their cancer was discovered, 1 out of 10 people are still living. It is important to remember that this is only an average. Everyone is different, and these numbers do not necessarily show what will happen to you.

You may wish to discuss health care and other legal issues that arise near the end of life with your family and your doctor. You may find it helpful and comforting to state your health care choices in writing (with an advance directive or living will) while you are still able to make and communicate these decisions. Think about your treatment options and which kind of treatment will be best for you. You may wish to choose a health care agent in case you become unable to speak for yourself.

A time may come when your goals or the goals of your loved ones may change from treating your illness to maintaining your comfort and dignity. You may choose hospice care. Hospice caregivers are concerned with enhancing the quality of your remaining life by keeping you as alert and comfortable as possible in a familiar environment with family and friends. Hospice programs offer services in your own home or in a hospice center, nursing home, or hospital.

Learning all you can about end-of-life issues may help you feel better. For more information, see one of the following topics:

Care at the End of Life
Choosing a Health Care Agent
Writing an Advance Directive
Hospice Care

Prevention

There is no sure way to prevent colorectal cancer from returning or showing up in other parts of your body. After you have had it, your risk of having it again increases. When it comes back, it is called metastatic or recurrent colorectal cancer. It often comes back after surgery, especially if it was not discovered when it was in an early stage.2 This does not mean it will come back in your case. Everyone is different.

Initial treatment for colorectal cancer is followed by regular doctor visits and screening to help catch the cancer if it returns.

As part of your follow-up visits, you may have:

Home Treatment

Home treatment may be all that is needed to help manage the side effects that often accompany metastatic or recurrent colon cancer or its treatment. Healthy habits such as eating a balanced diet and getting enough sleep and exercise may help control your symptoms. Be sure to follow any instructions your doctor has given you.

Managing your emotions

Learning that you have colorectal cancer and being treated for it can be very stressful.

If your emotions interfere with your ability to make decisions, it is important to talk to your doctor about them. Your cancer treatment center may offer counseling services, support groups, and classes such as yoga. You may be able to reduce your stress by expressing your feelings to others. Learning relaxation techniques may also help you reduce your stress. Some people find that spending time alone is what they need.

Your feelings about your body may change after treatment. Dealing with your body image may involve talking openly about your worries with your partner and discussing your feelings with a doctor.

Contact your local chapter of the American Cancer Society to find a support group. Talking with other people who have had similar experiences can be very helpful.

Medications

Chemotherapy is the use of drugs to control cancer's growth or relieve symptoms. Often the drugs are given through a needle in your vein, and your blood vessels carry the drugs through your body. Sometimes the drugs are available as pills you can swallow. Sometimes they are given through a shot, or injection. For colorectal cancer that has spread to the liver, researchers are studying hepatic intra-arterial chemotherapy. This delivers drugs directly to the liver.

Several drugs are used to treat metastatic or recurrent colorectal cancer. Drugs are also available to treat side effects such as nausea.

Medication Choices

The most commonly used drugs for the treatment of colorectal cancer are:

Cancer drugs are often used in combination. For example, a treatment called FOLFOX4 uses oxaliplatin, leucovorin, and fluorouracil, while the treatment called FOLFIRI uses folic acid, fluorouracil, and irinotecan. There are several of these specific drug combinations.

Cetuximab (Erbitux) and panitumumab (Vectibix) may be used for colorectal cancer that has spread and has not gotten better during or after treatment with other drugs. These kinds of medicines, called monoclonal antibodies, may not work for some people. So before you have this treatment, your tumor tissue will be checked for certain gene changes (mutations).

Your doctor may prescribe medicines to control nausea and vomiting. These drugs include:

  • Aprepitant (Emend), which is used in combination with ondansetron and dexamethasone as part of a 3-day program.
  • Metoclopramide (Reglan).
  • Phenothiazines, such as promethazine and prochlorperazine.
  • Serotonin antagonists, such as ondansetron (Zofran), granisetron (Kytril), or dolasetron (Anzemet). These medicines prevent nausea and vomiting caused by chemotherapy more effectively when they are combined with corticosteroids, such as dexamethasone.

Clinical trials that test new drugs are ongoing. Talk with your doctor about participating in a clinical trial.

What To Think About

Drugs may not cure metastatic or recurrent colorectal cancer, but they can help you feel better and live longer by slowing the cancer's growth.

Talk to your doctor about drugs to help you manage pain and other symptoms that may accompany cancer. For more information, see the topic Cancer Pain.

Surgery

Surgery to remove cancer may be used to treat metastatic or recurrent colorectal cancer. The type of surgery chosen depends upon the stage of the cancer.

Surgery Choices

Surgical options include:

  • Bowel resection. This operation involves cutting into the abdomen to reach the area of the colon or rectum that is affected by the cancer. The surgeon cuts out the cancer as well as the parts of the colon or rectum that are next to it. Then the two healthy ends of the colon or rectum are sewn back together.
  • Liver resection. In this operation the surgeon cuts out cancer that has spread to the liver, as well as parts of the liver that are next to the cancer. Up to half of your liver can be removed as long as the rest is healthy. Two other methods to destroy cancer cells in the liver include radio waves (radiofrequency ablation) and heat (microwave coagulation).
  • Cryosurgery . Also called cryotherapy, this type of surgery uses liquid nitrogen to freeze and destroy colorectal cancer that has spread to the liver. It is used when the tumors in the liver are still fairly small.

If cancer that has returned to your intestine is large, more of your colon or rectum may have to be removed. The ends of your colon or rectum are rejoined during surgery. If they can't be rejoined, you may need a colostomy. Most people do not need a permanent colostomy.

For more information, see:

Click here to view an Actionset. Bowel disease: Caring for your ostomy.

When cancer has spread to other parts of the body, the kind of surgery you will need depends on where the cancer is and how big the tumor is. Sometimes surgery is used not to cure your cancer but to make your life more comfortable. If a tumor is blocking your colon, for example, the surgeon may remove it to allow your intestine to work normally. If advanced cancer is blocking your rectum, your doctor may place an expandable tube, called a stent, in the rectum to unblock it.

What To Think About

Surgery may be used to remove metastatic or recurrent colorectal cancer that is confined to the colon or that has spread to the liver, lungs, or bones. Surgery does not usually cure metastatic or recurrent colorectal cancer, but it may relieve pain and discomfort, slow the spread of the disease, and help you live longer.

Other Treatment

Radiation treatment

Radiation therapy uses X-rays to destroy colorectal cancer cells. It is often combined with surgery or chemotherapy. Radiation therapy may also be used to reduce the cancer's size when it is blocking the colon or rectum or to relieve pain from cancer that has spread to other organs.

Radiation treatments are not likely to cure metastatic or recurrent colorectal cancer, but they may ease pain and discomfort, slow the spread of the disease, and help you live longer.

Treatment for liver cancer

Sometimes colorectal cancer that has spread to the liver can be removed by surgery. But usually other treatments are necessary, such as:

  • Radiofrequency ablation. A small wire that emits radio waves is inserted into the tumor. The radio waves destroy the liver tumor without harming healthy tissue.
  • Cryosurgery. This is often done in surgery for liver cancer but sometimes can be done through the skin (percutaneous). When cryosurgery is done through the skin, the doctor uses ultrasound or magnetic resonance imaging (MRI) to guide probes that deliver liquid nitrogen directly to the tumor in the liver. The liquid nitrogen freezes and destroys cancer cells.
  • Embolization. Tumor embolization shrinks a liver tumor by cutting off its blood supply. Guided by ultrasound or MRI, the doctor puts a thin, flexible tube, called a catheter, into an artery near your groin or in your arm. The catheter is guided into the liver artery (the hepatic artery) that supplies blood to the tumor. A mixture of chemicals and small particles (like grains of sand) are sent through the catheter into the hepatic artery. This mixture blocks the artery and stops blood from getting to the liver tumor.
  • Interstitial radiation therapy. In this type of internal radiation therapy, radioactive material sealed in needles, wires, seeds, or catheters is placed directly into the tumor or body tissue.
  • Intra-arterial hepatic chemotherapy. The surgeon implants a small pump in the belly that delivers chemotherapy right into the tumor. The pump can be left in place as long as needed.

Complementary therapies

In addition to conventional medical treatment, complementary therapies may improve the quality of your life by helping you manage the stress and side effects of cancer treatment. But these complementary therapies should not replace standard therapy.

Before you try any of these therapies, discuss their possible benefits and side effects with your doctor. Let him or her know if you are already using any such therapies. For more information, see the topic Complementary Medicine.

What to think about

Clinical trials are studies designed to find better ways to treat people and are based on the most up-to-date information. There are a number of clinical trials involving the treatment for metastatic or advanced colorectal cancer. If you match the guidelines, you may be able to enroll in one. If you are interested, ask your doctor whether there are trials in which you can participate. The National Cancer Institute or your local chapter of the American Cancer Society can also help you find clinical trials.

Other Places To Get Help

Organizations

American College of Gastroenterology
P.O. Box 342260
Bethesda, MD  20827-2260
Phone: (301) 263-9000
Web Address: www.acg.gi.org
 

The American College of Gastroenterology is an organization of digestive disease specialists. The Web site contains information about common gastrointestinal problems.


American Cancer Society (ACS)
Phone: 1-800-ACS-2345 (1-800-227-2345)
TDD: 1-866-228-4327 toll-free
Web Address: www.cancer.org
 

The American Cancer Society (ACS) conducts educational programs and offers many services to people with cancer and to their families. Staff at the toll-free numbers have information about services and activities in local areas and can provide referrals to local ACS divisions.


Cancer.Net
Phone: 1-888-651-3036
(571) 483-1300
Fax: (571) 366-9530
E-mail: foundation@asco.org
Web Address: www.cancer.net
 

Cancer.Net is the information Web site of the American Society of Clinical Oncology (ASCO) for people living with cancer and for those who care for them. ASCO is the world's leading professional organization representing physicians of all oncology subspecialties. Cancer.Net provides current oncologist-approved information on living with cancer.


National Cancer Institute (NCI)
NCI Publications Office
6116 Executive Boulevard
Suite 3036A
Bethesda, MD  20892-8322
Phone: 1-800-4-CANCER (1-800-422-6237) 9:00 a.m. to 4:30 p.m. EST, Monday through Friday
TDD: 1-800-332-8615
E-mail: cancergovstaff@mail.nih.gov
Web Address: www.cancer.gov (or https://cissecure.nci.nih.gov/livehelp/welcome.asp# for live help online)
 

The National Cancer Institute (NCI) is a U.S. government agency that provides up-to-date information about the prevention, detection, and treatment of cancer. NCI also offers supportive care to people with cancer and to their families. NCI information is also available to doctors, nurses, and other health professionals. NCI provides the latest information about clinical trials. The Cancer Information Service, a service of NCI, has trained staff members available to answer questions and send free publications. Spanish-speaking staff members are also available.


National Institutes of Health: Health Information
9000 Rockville Pike
Bethesda, MD  20892
Phone: (301) 496-4000
TDD: (301) 402-9612
E-mail: NIHinfo@od.nih.gov
Web Address: http://health.nih.gov
 

The U.S. National Institutes of Health (NIH) conducts and supports medical research to improve people's health and save lives. NIH provides access to health and wellness information, free newsletters, current research, health databases, fact sheets, and many other resources.


Related Information

References

Citations

  1. American Cancer Society (2005). Colorectal Cancer Facts and Figures: Special Edition 2005, pp. 1–20. Available online: http://www.cancer.org/docroot/STT/content/STT_1x_Colorectal_Cancer_Facts_and_Figures_-_Special_Edition_2005.asp.
  2. Lewis C (2007). Colorectal cancer screening, search date November 2006. Online version of BMJ Clinical Evidence. Also available online: http://www.clinicalevidence.com.

Other Works Consulted

  • Levin B (2006). Colorectal cancer. In DC Dale, DD Federman, eds., ACP Medicine, section 12, chap. 5. New York: WebMD.
  • Libutti SK, et al. (2005). Cancer of the colon. In VT DeVita Jr et al., eds., Cancer: Principles and Practice of Oncology, 7th ed., pp. 1061–1109. Philadelphia: Lippincott Williams and Wilkins.
  • Libutti SK, et al. (2005). Cancer of the rectum. In VT DeVita Jr et al., eds., Cancer: Principles and Practice of Oncology, 7th ed., pp. 1110–1124. Philadelphia: Lippincott Williams and Wilkins.

Credits

Author Bets Davis, MFA
Editor Maria Essig
Editor Susan Van Houten, RN, BSN, MBA
Associate Editor Pat Truman, MATC
Primary Medical Reviewer Anne C. Poinier, MD - Internal Medicine
Specialist Medical Reviewer Arvydas D. Vanagunas, MD - Gastroenterology
Last Updated October 1, 2008

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