PREVENTION:

PREVENTION: If patient is diagnosed to have ca colon determine the local and distant extent of disease spread in order to provide a framework for discussing therapy and prognosis by examining the biopsy specimen, having abdominopelvic ultrasonography/ CT for disease extent and X Ray chest for secondaries:
American Joint Committee on Cancer (AJCC) TNM Staging [56]
System for Colorectal Cancer
Primary Tumor (T)
Regional Lymph Nodes (N)
Distant Metastasis (M)
Stage Grouping
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma : intraepithelial or invasion of lamina propria
T1 Tumor invades submucosa
T2 Tumor invades muscularis propria
T3 Tumor invades through the muscularis propria into the subserosa,
or into non-peritonealized pericolic or perirectal tissues
T4 Tumor directly invades other organs or structures, and/or perforates visceral peritoneum
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in 1 to 3 regional lymph nodes
N2 Metastasis in 4 or more regional lymph nodes
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis


STAGE GROUPING [56]
Stage T N M Dukes MAC
0 Tis N0 M0 - -
I T1 N0 M0 A A
T2 N0 M0 A B1
IIA T3 N0 M0 B B2
IIB T4 N0 M0 B B3
IIIA T1-T2 N1 M0 C C1
IIIB T3-T4 N1 M0 C C2/C3
IIIC Any T N2 M0 C C1/C2/C3
IV Any T Any N M1 - D

• If the cancer is localized to the mucosa and submucosa, patient is said to have Dukes' A or TNM stage I [35]
• If the cancer is extending into or through the muscle layer without lymph node involvement patient is said to be in Dukes' B or TNM stage II [35]
• If there is lymph node involvement patient is said to be in Dukes' C or TNM stage III [35]
• If patient has distant metastases patient is said to be in Dukes' D or TNM stage IV [35]

SCREENING

• If person is 50 - 80 years of age having no personal or family history of colorectal carcinoma (Not having the following: A first degree relative or two second degree relatives with colorectal cancer, or clustering of HNPCC related cancers in the family) or no family history of adenomatous polyps before age of 60 yrs and no history of inflammatory bowel disease, advise cancer surveillance by either flexible sigmoidoscopy every 5 years, annual fecal occult blood test (FOBT), combination of flexible sigmoidoscopy or colonoscopy every 5 years and annual FOBT or total colon evaluation [32, 48]
• If patient is African American 45 to 80 years old having no personal or family history of colorectal carcinoma or no family history of adenomatous polyps before age of 60 yrs, advise cancer survillance by either flexible sigmoidoscopy every 5 years, annual fecal occult blood test (FOBT), combination of flexible sigmoidoscopy or colonoscopy every 5 years and annual FOBT or total colon evaluation [32]
• If colonoscopy is done (which is preferable if available) and is negative having no mass or polyps, repeat colonoscopy after 10 years. [48]
• If colonoscopy shows polyps recommend colonoscopic removal and histopathology of the specimen
• If polyp is hyperplastic advise routine colonoscopy after every 10 years. [48]
• If patient has polyp (adenoma with villous component, or any adenomatous polyp greater than 10 mm) or prior colorectal cancer advise colonoscopic surveillance at a 3- to 5-year interval [32]
• If patient has an abnormal sigmoidoscopy with significant pathology (single adenoma >1.0 cm, adenomas with tubulovillous or villous histology, or multiple adenomas) advise colonoscopy [37]
• If patient has an abnormal sigmoidoscopy with adenomas 0.6 to 1.0 cm, and for those with multiple adenomas advise colonoscopy
• For those with single tubular adenomas <0.6 cm, we advise discussing the marginal benefit of further investigation and seeking the patient's preference whether to proceed with colonoscopy.
• If fecal occult blood is advised to the patient, ask the patient to take the diet having no red meat or turnip/horseradishes (to prevent false-positive peroxidase reactions); no gastric irritant drugs (to prevent false-positive reactions from gastritis); no vitamin C (to prevent a false-negative chemical reaction); and high-fiber foods (to increase stool transit time) [36].
• If any sample of FOBT is positive proceed as follows [48]
Any positive test requires evaluation
3 successive stool specimens should be examined
Repeat test after prescribed diet
Sample not digital rectal examination
Guaiac-based nonrehydrated test should be performed
Immunochemical techniques are under investigation
Test should be coordinated by health care provider
Annual FOBT need not be performed if screening colonoscopy or doublecontrast enema is used as a screening measure in an average-risk patient

.
• If FOBT positive and colonoscopy negative, proceed with additional workup
• If patient has long standing inflammatory bowel disease involving the colon advise colonoscopic surveillance at a 1 to 2-year interval starting at 8 - 10 years from disease onset [32, 48]
• When clinically quiescent, 4 quadrant biopsies every 10 cm with > 30 total samples using large cup forceps (preferred). Additional extensive sampling of strictures and masses is also advised.
• Endoscopic polypectomy when appropriate with biopsies of surrounding mucosa for the assessment of dysplasia [48]
• The finding of definite dysplasia (of any grade) should be confirmed by an expert pathologist and is an indication for colectomy [38]
• Patients whose biopsies are indefinite for low grade dysplasia after review by an expert pathologist should undergo repeat surveillance colonoscopy at a shorter interval.

• If patient has High-grade dysplasia/intraepithelial neoplasia or Multifocal low-grade dysplasia/intraepithelial neoplasia, prophylactic proctocolectomy with ileoanal pouch should be considered [48]

• If patient has a family history of colorectal cancer they can be familial adenomatous polyposis, attenuated familial adenomatous polposis or othe varients and heridiatry non polyposis colorectal carcinoma.
• If patient has a family history of colorectal cancer involving one first order relative diagnosed before age 60, two first order relatives diagnosed at any age or a single first order relative diagnosed after age 60 advise colonoscopic surveillance at a 1- to 5-year interval begin at age 40 or 10 years before the index carcinoma [48]
• Patients with only one first order relative with a history of colorectal cancer, could be followed using combined barium enema and flexible sigmoidoscopy at five-year intervals [39]
• If two related second degree relatives with colorectal cancer at any age, risk is equivalent to one affected first degree relative
• If person has one second degree relative or any third degree relative(s) with colorectal cancer screen as average risk. Individualized evaluation, including a careful family history, is encouraged
• If patient has first degree relative with adenoma(s), colonoscopy beginning at age 50 or at the age of diagnosis of the adenoma in the relative, whichever is earlier, repeat after 5 – 10 year (Consider the shorter interval when advanced or multiple adenomas are diagnosed prior to age 60 y) [48]
• Recommend repeating the flexible sigmoidoscopy or colonoscopy screening at five-year intervals in patients having adenomatous polyposis [39]
• If patient is a gene carrier or at risk for familial adenomatous polyposis (Includes the subcategories of familial adenomatous polyposis, Gardner syndrome, some Turcot syndrome families, and attenuated adenomatous polyposis coli) advise sigmoidoscopy annually, beginning at age 10 to 12 years or colonoscopy in case of AAPC starting at the age of 20 yrs and continued until age 35 to 40 if negative [39].
• If patient has > 100 polyps in colon or > 20 cumulative adenomas in colon, advise genetic testing for FAP [39]
• If person is a first degree relative of FAP or AFAP patient, advise genetic testing [39]
• If person has a family history of FAP, advise genetic studies in an affected family member. Others should be tested for the same gene [39]
• If no gene mutation is identified all members of family at high risk should undergo screening [39]
• If patient has FAP screening of the upper gastrointestinal tract with upper endoscopy for gastric and duodenal polyps has been recommended [40]
• Careful palpation of the thyroid is recommended annually for all patients with FAP, including asymptomatic gene carriers [41].
• If children are at risk for FAP, should undergo testing for serum alpha-fetoprotein and have abdominal palpation every six months until the age of six. Serum alpha-fetoprotein is elevated in approximately two-thirds of patients with a hepatoblastoma [42].
• Patients who have undergone colectomy remain at risk for the development of adenomas and adenocarcinoma in the ileum [42]
• Colectomy at the time of initial diagnosis is strongly recommended in patients with multiple large (>1 cm) adenomas or adenomas with villous histology and/or high grade dysplasia and is the safest approach of all those with profuse polyposis at initial diagnosis [43].
• Patients in the second decade of life with only sparse, small (<5 mm) adenomas can usually be followed endoscopically with surgery scheduled to accommodate school and work schedules [43].
• If patient is a gene carrier or at risk for hereditary non-polyposis colorectal cancer advise colonoscopy, every 1 to 2 years, beginning at age 20 to 25 years or 10 years younger than the earliest diagnosis in the family, whichever comes first. HNPCC more commonly involves proximal colon [44]
• If gene can be found in patient with HNPCC advise demonstration of a mutated gene can then be used to screen the remainder of the family, and identify those members who need intensive monitoring [45].
• If patient has HNPCC gene annual screening for endometrial and ovarian cancer beginning at age 25 to 35 years (pelvic examination and endometrial aspirate with or without transvaginal ultrasound) is also recommended. Discussion of prophylactic hysterectomy and salpingo-oopherectomy at around age 35 or at the end of childbearing [46].
• If patient has HNPCC gene advise annual urinalysis and cytologic examination beginning at age 25 [46]
• If patient has HNPCC gene annual skin surveillance is advised [46]
• If patient has HNPCC gene advice periodic upper endoscopy. It should be performed in all patients starting at age 30 [47]