WHO IS AT RISK OF COLORECTAL CANCER?
• The lifetime risk of colorectal cancer (CRC) is approximately 1 in 15. The incidence in Australia is approximately 15,000 new cases per year. It is the 3RD MOST COMMON MALIGNANCY, 2nd most common cause of cancer deaths (after lung cancer).

WHAT ARE THE SIGNS AND SYMPTOMS OF COLORECTAL CANCER?
• Up to 60% of patients with CRC may be ASYMPTOMATIC.
• RIGHT SIDED CANCERS: Iron deficiency anaemia, appendicitis, right lower quadrant mass, per rectal bleeding.
• LEFT SIDED CANCERS: Altered bowel habit, colicky pain, blood in stool, left lower quadrant mass, per rectal bleeding.
• RECTAL CANCERS: Altered bowel habit (frequency, mucus), per rectal bleeding, tenesmus (stretching, spasmodic contractions with pain), perianal or sacral pain (Invasion of sphincters, sacrum/sacral nerves), mass or per rectal examination.

WHAT INVESTIGATIONS MAY BE PERFORMED?
• FBC - look for microcytic, hypochromic anaemia
• LFTs
• CEA (non-specific) not useful for screening, but for baseline and recurrence surveillance. Raised CEA prompts additional imaging (CEA = carcinoembryonic antigen)
• COLONOSCOPY 
• CT COLONOGRAPHY
• DOUBLE CONTRAST BARIUM ENEMA

STAGING INVESTIGATIONS
• If a diagnosis of bowel cancer is made, STAGING STUDIES should be performed - this includes a CT chest and abdomen to assess for metastatic lesion and extramural extension.
• PET may be used in the setting of RECURRENT COLORECTAL CANCER OR IF METASTATIC DISEASE SUSPECTED

CLASSIFICATION
• COLON CANCER TNM Classification
• Stage I (A/B1, T1/2 N0 M0)
• Stage II (B2, T3/4, N0, M0)
• Stage III (C, any T, POSITIVE NODES)
• Stage IV (D, distant metastasis)
• 5 year survival I 90%  II 75%  III 50%  IV 5%
• IIa T3 N0 M0 IIb T4 N0 M0  IIIa T1-2 N1 M0  IIIb T3-4 N1 M0  IIIc Any T, N2, M0
• T1, tumor invades submucosa
• T2, tumor extends into but not through muscularispropria (B1)
• T3, tumor invades through MP into pericolorectal tissue (B2)
• T4, tumor directly invades other organs or structures (T4b) and/or penetrates visceral peritoneum ((T4a)
• N0, no regional lymph node metastasis
• N1, metastasis to one to THREE regional lymph nodes
• N2, metastasis to FOUR OR MORE regional lymph nodes
• M0, no distant metastasis
• M1, distant metastasis

RECTAL CANCER TNM Classification
• Stage I (invadesubmucosa/muscularispropria T1/2 N0 M0) A B1
• Stage II (invades serosa/adjacent organs T3/4, N0, M0) B2
• Stage III (any T, positive nodes) C
• Stage IV (distant metastasis) D
• 5 year survival I 90%  II 75%  III 50%  IV 5%
• T1 Tumour invades submucosa
• T2 Tumour invades muscularispropria
• T3 Tumour invades non-peritonealized PERIRECTAL FAT TISSUE
• T4 Tumour invades into other organs or structures and/or perforates visceral peritoneum
• T4a Tumour perforates visceral peritoneum
• T4b Tumour directly invades other organs or structure

HOW DO WE MANAGE COLORECTAL CANCER?
• After a diagnosis of colorectal cancer is made and staging has been performed, the case is discussed at a Multi-Disciplinary Team (MDT) meeting.
• The MDT panel consists of surgeons, medical oncologists, radiation oncologists, nuclear imaging specialists, radiologists, nurses, allied health and genetic counsellors. 
• After discussion, the decision for the best treatment modality is made. If a recommendation for surgery is made, your surgeon will discuss the surgical options, approach and timing of surgery with you. If you need neoadjuvant therapy prior to surgery, a referral to a medical and radiation oncologist will be made.
• Decision making on post-operative adjuvant therapy including chemotherapy and radiotherapy will be determined after a review of the histopathology of the cancer at a subsequent MDT post surgery.

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