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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, depending on where the cancer is.

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 other organs in the body.

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.

What causes metastatic or recurrent colorectal cancer?

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

Sometimes cancer cells are too small to be found by tests. These cells may continue to grow and show up later as metastatic cancer, even years after being treated.

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 nodes of 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 spread or returned 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 spread or returned 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 that has spread or come back can be very hard. Some people find that it helps to talk about their feelings with their family and friends. You may also want to talk with your doctor or with other people who have had this kind of 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. Even after treatment that seems successful, colorectal cancer may spread or come back.

Sometimes cancer cells are too small to be found by tests. These cells may continue to grow and show up later as metastatic cancer, even years after being treated.

Symptoms

Some people who have metastatic or recurrent colorectal cancer do not have any symptoms for some time. When symptoms do appear, the most common ones 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 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 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.

  • Colon cancer often 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 other organs in the body.
  • Rectal cancer may spread directly to the lungs, bypassing the liver.

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 people with colorectal cancer that has spread to nearby organs or lymph nodes is 68%.1 This means that 68 out of 100 people are still alive 5 years or longer after their cancer was discovered. For people who have colorectal cancer that has spread farther away to other parts of their bodies, the rate is 11%. This means that 11 out of 100 people are still alive 5 years or longer after their cancer was discovered.

These numbers are taken from reports that were done at least 5 years ago, before newer treatments were available. So the actual chances of your survival are likely to be higher than these numbers.

What Increases Your Risk

Even after treatment that seems successful, 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 for some time. Colorectal cancer may be discovered before symptoms appear, either on X-rays or other 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 tiredness (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 cannot 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 spread or come back include:

What to think about

Colorectal cancer often comes back, even after treatment that seemed successful. 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.
  • Medicines. The use of medicines, either swallowed or injected with a needle, to treat cancer is called chemotherapy. Medicines 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.

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 serious illnesses. 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.

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 or terminal 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

There may come a time when treatments to cure your cancer are no longer working. Or you may decide that you want to spend the time you have left in other ways and only have medical care that keeps you comfortable. If so, talk to your doctor about hospice care.

Hospice care is palliative care for people who are at the end of life, with about 6 months or less to live. 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.

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.

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

But there are lifestyle changes that can help you after treatment. Research shows that these things may help:3

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

The frequency of your follow-up visits and how often you have more tests will depend on your general health and the type of colorectal cancer you had. 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 stress

Learning that you have colorectal cancer and being treated for it can be very stressful. There are steps you can take to reduce your stress. You may want to talk with family or friends. Some people find that spending time alone is what they need.

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.

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 medicines to control cancer's growth or relieve symptoms. The medicines may be given through a needle in your vein, as pills you can swallow, or as a shot (injection).

For colorectal cancer that has spread to the liver, researchers are studying hepatic intra-arterial chemotherapy. This delivers medicines directly to the liver.

Several medicines are used to treat metastatic or recurrent colorectal cancer. Other medicines are also available to treat side effects, such as nausea.

Medication Choices

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

Cancer medicines 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 combinations.

Cetuximab (Erbitux) and panitumumab (Vectibix) may be used for colorectal cancer that has spread and has not improved 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 medicines include:

  • Aprepitant (Emend), which is used in combination with other medicines to prevent nausea and vomiting.
  • 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

Medicines 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 medicines 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 may be used to remove cancer that is in the colon or rectum. Or surgery may be done to remove cancer that has spread to other organs in the body.

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 and also cuts out 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. If the cancer in your liver is too large to remove with surgery, you may be given chemotherapy to shrink the tumor. If the tumor becomes small enough, it can be removed with surgery.
  • Lung, adrenal, or ovarian resection, depending on where the cancer has spread and whether you are a good candidate for this surgery.

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 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 cancer that has spread to the liver

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

  • Radiofrequency ablation. A small wire that emits radio waves is inserted into the tumor. The radio waves destroy the cancer that has spread to the liver without harming healthy tissue.
  • Cryosurgery. This may be done in surgery for cancer that has spread to the liver. Liquid nitrogen is used to freeze and destroy cancer cells.
  • Embolization. Tumor embolization shrinks a cancer that has spread to the liver by cutting off its blood supply.
  • 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

People sometimes use complementary therapies along with medical treatment to help relieve symptoms and side effects of cancer treatments. Some of the complementary therapies that may be helpful include:

Mind-body treatments like those mentioned above may help you feel better. They can make it easier to cope with cancer treatments. They also may reduce chronic low back pain, joint pain, headaches, and pain from treatments.

Before you try a complementary therapy, talk to your doctor about the possible value and potential side effects. Let your doctor know if you are already using any such therapies. Complementary therapies are not meant to take the place of standard medical treatment. But they may improve your quality of life and help you deal with the stress and side effects of cancer treatment.

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 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.

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 Society of Colon and Rectal Surgeons
85 West Algonquin Road
Suite 550
Arlington Heights, IL  60005
Phone: (847) 290-9184
Fax: (847) 290-9203
Email: ascrs@fascrs.org
Web Address: www.fascrs.org
 

The American Society of Colon and Rectal Surgeons is the leading professional society representing more than 1,000 board-certified colon and rectal surgeons and other surgeons dedicated to treating people with diseases and disorders affecting the colon, rectum, and anus.

Cancer.Net
Phone: 1-888-651-3038
(571) 483-1300
Fax: (571) 366-9537
Email: contactus@cancer.net
Web Address: www.cancer.net
 

Cancer.Net is the information website 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)
6116 Executive Boulevard
Suite 300
Bethesda, MD  20892-8322
Phone: 1-800-4-CANCER (1-800-422-6237)
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 who have 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
Email: 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 (2009). Cancer Facts and Figures 2009. Atlanta: American Cancer Society. Available online: http://www.cancer.org/acs/groups/content/@nho/documents/document/500809webpdf.pdf.
  2. Lewis C (2007). Colorectal cancer screening, search date November 2006. Online version of BMJ Clinical Evidence: http://www.clinicalevidence.com.
  3. National Comprehensive Cancer Network (2010). Colon cancer. NCCN Clinical Practice Guidelines in Oncology, version 2. Available online: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#site.

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. (2008). Rectal cancer. In VT DeVita Jr et al., eds., DeVita, Hellman, and Rosenberg's Cancer: Principles and Practice of Oncology, 8th ed., vol. 1, pp. 1285–1301. Philadelphia: Lippincott Williams and Wilkins.

Credits

By Healthwise Staff
Primary Medical Reviewer Kathleen Romito, MD - Family Medicine
Specialist Medical Reviewer Arvydas D. Vanagunas, MD - Gastroenterology
Last Revised September 13, 2010

Last Revised: September 13, 2010

Author: Healthwise Staff

Medical Review: Kathleen Romito, MD - Family Medicine & Arvydas D. Vanagunas, MD - Gastroenterology

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