Stages

If colorectal cancer is diagnosed, the doctor needs to know the stage, or extent, of the disease to plan the best treatment. Staging is a careful attempt to find out whether the cancer has spread, and if so, to what parts of the body.

The Spreading of Cancer
There are three ways that cancer spreads in the body:
  • Through tissue. Cancer invades the surrounding normal tissue. 
  • Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body. 
  • Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body. 
When cancer cells break away from the primary tumor and travel through the lymph or blood to other places in the body, another, or secondary tumor, may form. This process is called metastasis. The secondary, or metastatic, tumor is the same type of cancer as the primary tumor. For example, if colorectall cancer spreads to the lungs, the cancer cells in the bones are actually colorectal cancer cells. The disease is metastatic colorectal cancer, not lung cancer.

Stages of Colorectal Cancer
Staging of Colorectal Cancer depends on three factors:
  • T — for Tumor: How far the tumor extends from the inner lining of the colon through the layers of its walls. 
  • N — for Nodes: Whether cancer cells are found in the lymph nodes draining the colon near the site of the cancer and how many nodes are affected. Lymph nodes are small, bean-shaped structures found throughout the body that filter substances in a fluid called lymph and help fight infection and disease. 
  • M — for Metastasis: Whether cancer has spread beyond the colon and its adjacent tissues to distant organs like the lungs or liver. 
Stages of Colorectal Cancer 
Colorectal Cancer starts in the cells lining the inside of your colon or rectum. As it grows, the cancer begins to push through into deeper levels of the intestine and can release cancer cells into the lymph system and blood stream.

Colon and Rectal Cancers have similar but not identical definitions of staging, as follows:


Stage 0 (Carcinoma in Situ)
  • Colorectal: In stage 0, the cancer is found in the innermost lining of the colon or rectum only. 
Stage I
  • Colon: In stage I, the cancer has spread beyond the innermost tissue layer of the colon wall to the middle layers. Stage I colon cancer is sometimes called Dukes’ A Colon Cancer. 
  • Rectal: In stage I, cancer has spread beyond the innermost lining of the rectum to the second and third layers and involves the inside wall of the rectum, but it has not spread to the outer wall of the rectum or outside the rectum. Stage I rectal cancer is sometimes called Dukes’ A Rectal Cancer. 
Stage II Colon:
Stage II is divided into stage IIA and stage IIB.
  • Stage IIA: Cancer has spread beyond the middle tissue layers of the colon wall or has spread to nearby tissues around the colon or rectum. 
  • Stage IIB: Cancer has spread beyond the colon wall into adjacent organs and/or through the peritoneum. The peritoneum is a thin membrane that lines the inside of the abdomen. Stage II Colon Cancer is sometimes called Dukes’ B Colon Cancer. 
Stage II Rectal:
In Stage II, cancer has spread outside the rectum to nearby tissue, but it has not gone into the lymph nodes. Stage II rectal cancer is sometimes called Dukes’ B Rectal Cancer.

Stage III:
Colon Stage III colon cancer is divided into stage IIIA, stage IIIB and stage IIIC.
  • Stage IIIA - Cancer has spread from the innermost tissue layer of the colon wall to the middle layers and has spread to as many as 3 lymph nodes. 
  • Stage IIIB - Cancer has spread to as many as 3 nearby lymph nodes and has spread beyond the middle tissue layers of the colon wall or beyond the colon wall into adjacent fat or organs and/or through the peritoneum. 
  • Stage IIIC - Cancer has spread to 4 or more nearby lymph nodes and has spread to or beyond the middle tissue layers of the colon wall or to adjacent fat or organs and/or through the peritoneum. Stage III colon cancer is sometimes called Dukes’ C colon cancer. 
Rectal
In stage III, cancer has spread to nearby lymph nodes, but it has not spread to other parts of the body. Stage III rectal cancer is sometimes called Dukes’ C Rectal Cancer. S

Stage IV:
Colorectal
 In stage IV, cancer may have spread to nearby lymph nodes and has spread to other parts of the body, such as the liver or lungs. Stage IV Colorectal Cancer is sometimes called Dukes’ D Colorectal Cancer. It is also called advanced, or metastatic, cancer. Deciding on the best treatment for colorectal cancer depends on knowing the stage of the cancer. Factors that might affect your treatment decisions include: 

Following are standard treatments by stage: 
Stage 0 (in situ)
  • Surgery or a local excision (surgery that does not cut into the abdomen) or polypectomy (removal of polyps during a colonoscopy.) 
  • Transanal Resection (removal through the anus) for rectal tumors too large to be removed by local excision. 
  • Chemotherapy is not recommended for stage 0 cancer. 
  • Radiation may be used in some cases of very early rectal cancer. Both external beam radiation and internal radiation applied directly to cancerous tissues through the rectum may be used. 
Stage I
  • Surgery to remove the primary tumor and at least 12 regional lymph nodes if the tumor is in the colon, or 8 regional lymph nodes if the tumor is in the rectum. 
  • Chemotherapy is not recommended for stage I colon cancer. 
  • Internal radiation through the rectum may be used instead of surgery in selected cases. This is generally used only in very early stage disease. 
Stage II
  • Surgery to remove the primary tumor and at least 12 regional lymph nodes if the tumor is in the colon, or 8 regional lymph nodes if the tumor is in the rectum. Removal of all visible cancer in the area right around the primary tumor. 
  • Chemoradiation may be recommended. You may get it before or after surgery. 
Stage III
  • Surgery to remove the primary tumor and at least 12 regional lymph nodes if the tumor is in the colon, or 8 regional lymph nodes if the tumor is in the rectum. 
  • Removal of all visible local spread of cancer. 
  • Adjuvant therapy (to lower the risk of the cancer coming back) for colon cancer. 
  • Chemotherapy for Stage III colon cancer is 6 months of FOLFOX, 5-FU/leucovorin or Capecitabine. 
  • Adjuvant therapy for rectal cancer and chemoradiation. When given after surgery (“adjuvant” therapy), consists of chemotherapy for 2 months followed by infusional 5-FU or oral capecitabine during the radiation followed by chemotherapy for another 2 months. You may get some of this before surgery (“neoadjuvant” therapy) and the order of treatments may vary. 
Stage IV & Recurrent Disease (Metastatic Colorectal Cancer)
Treatment of metastatic colorectal cancer may be complex, and depends on many factors, including the location and size of the primary tumor and metastases. Oncologists generally agree that removal of the primary tumor and all metastatic disease is the only potentially curative treatment.

However, complete removal is not possible for everyone with stage IV colorectal cancer.

If the primary tumor and metastases can be completely removed by surgery, surgery followed by chemotherapy or chemotherapy followed by surgery may be the first steps in treatment. If the primary tumor can be removed but the metastases cannot be completely removed by surgery, chemotherapy should be given after removal of the primary tumor to shrink or control growth of the metastases for as long as possible.

In a minority of patients who experience an excellent response to chemotherapy and whose metastases are limited to a single organ, consideration should be given to surgical removal only if there is a good chance that all of the metastases could be safely removed.

When cancer is large enough to block the flow of stool (solid waste) through the colon or rectum but removal of the tumor is not possible, surgeons may create a diverting colostomy to let stool move around the tumor. Another technique is to insert a plastic or metal stent to keep the bowel open.

Patients with stage IV or Recurrent Colorectal Cancer generally receive a sequence of treatments. The treatments you and your doctors choose depend on many factors including your overall health and treatments you’ve had in the past.

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