Conversely, in the over-50 crowd, the diagnosis rates of colorectal cancer have actually decreased, thanks in large part to more people getting the recommended screening tests to find the disease at its earliest stages—a huge factor in whether or not someone will survive a colorectal cancer diagnosis.

First, a recap: Colorectal cancer, like any cancer, begins from changes in one cell or a small group of cells in the body. "Cancer is an uncontrolled growth of a certain cell type and can be found in any tissue in your body," Richard Whelan, MD, chief of colon and rectal surgery at Northwell Health, tells Health.

Colon and rectal cancers are found in the digestive system. The colon is the main part of a person's large intestine and stretches nearly five feet long. The rectum is a section of tissue only a few inches long at the end of the large intestine.

What's different about colorectal cancers is that they grow out of polyps, which are small bundles of tissue that bulge out of the organ itself. "There's this normal progression from the normal, to the polyp, to a scary looking polyp or what we would call "high grade dysplasia" which is kind of pre-cancer, and then turning into a cancer," Dr. Rajput says.

Colorectal cancer is extremely preventable if the polyps are caught early. But if they aren't, they can puncture the intestine, causing bleeding or obstruction of the waste moving through the digestive tract, and travel from the colon or rectum to other parts of the body. Typically, colorectal cancer that spreads goes to the liver or the lungs, but once the cancer gets into the bloodstream or the lymphatic system (a network of tissues, vessels, and organs), it can spread anywhere. When it spreads, doctors classify it as metastatic colorectal cancer.

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How is colorectal cancer treated?

According to Dr. Rajput, there are three main ways colorectal cancer are treated: surgery, chemotherapy, and radiation. The National Institutes of Health classify seven different types of colorectal treatments overall, adding four more treatment options as offshoot treatments in addition to the main three: radiofrequency ablation, cryosurgery, targeted therapy, and immunotherapy—all offered depending on the stage of a patient's cancer.

Surgery

More often than not, colorectal cancer treatment will include surgery, Dr. Whelan says. "The vast majority of patients are treated by taking out a piece of the large bowel, and then the surgeon will try to put the two pieces back together," he says.

How invasive the surgery is depends on the stage the cancer is in. If colorectal cancer is caught in early stages, a surgeon may take out only a small amount of the colon through a process called local excision, according to the NIH. During a local incision, the surgeon will likely get to the colon through the rectum, putting a tube that includes a cutting tool up through the rectum so that they don't have to cut through the abdominal wall. After a local incision, doctors will follow the patient very carefully to ensure the cancer doesn't come back, Dr. Rajput says.

If the cancer isn't caught until later stages, the surgeon will perform what's called a partial colectomy, meaning that they'll cut out the cancerous portion of the colon as well as a small amount of healthy tissue around it. Usually, the doctor will also take out lymph nodes near the colon in order to test whether the cancer has metastasized.

In most cases, colon resections don't cause problems with the function of the bowel later. If they have to take out a section of the colon, surgeons will perform an anastomosis, meaning that they'll sew the two remaining, healthy parts of the colon together. The remainder of the colon then makes up for what was taken out, Dr. Rajput says. "So, most of the time you don't have to worry about getting a colostomy bag, although those are usually temporary, he says.

A colostomy bag is a bag placed around an opening surgeons make on the outside of the body (called a stoma) so that digestive waste can pass outside of the body if the two healthy sections of colon can't be sewn together. In emergency colon surgeries, a temporary bag may be used to allow the colon to heal. However, if the doctor needs to remove the entirety of the lower colon, the bag may be permanent.

Permanent colostomy bags are more common when the colorectal cancer is found in the rectum, Dr. Rajput says. "I often say that it's like real estate, it's 'location, location, location'," he says.

When patients have cancer very low in the rectum or cancer that involves the sphincter complex — which includes a ring of muscle that controls bowel movements — surgeons have to remove the sphincter in order to get control of the tumor. Without a sphincter, a person couldn't control when they poop and so surgeons will attach a permanent colostomy bag to collect waste.

Chemotherapy

Sometimes, chemotherapy can be used on its own to treat colorectal cancer, but it's often used in combination with surgery, Dr. Whelan says. "The general trend is that if you've got metastatic disease that you cannot remove entirely, you rely on chemotherapy primarily before you do surgery," he says.

Chemotherapy uses drugs to stop cancer cells from growing, either by killing them or by stopping them from dividing, according to the NIH. Chemotherapy drugs can be taken by mouth or by an injection (known as systemic chemotherapy), or by an oncologist who will target the drugs directly to a specific area of the body (known as regional chemotherapy).

Often, doctors will suggest chemotherapy for patients who have cancer low in the rectum in an attempt to save the rectum and avoid a colostomy bag. "What we're finding with rectal preservation is that there's a subset of patients who have an excellent response with chemotherapy and radiation and we don't find any evidence of tumor when they come back," Dr. Rajput says. Then, the doctor will do something called "watchful waiting," essentially keeping a close eye on the cancer in case it comes back.

At times, chemotherapy will also be used after surgery as a way to ensure any leftover cancer cells are killed before they can spread. "It's a very small subset of these cells that can set up shop elsewhere, but that's what we're trying to kill," Dr. Rajput says.

RELATED: 12 Colorectal Cancer Risk Factors to Know About

Radiation therapy

The treatment options for rectal cancer are a little different than those offered for colon cancer, Dr. Rajput says, and that's mostly because rectal cancer treatment includes radiation therapy.

Radiation therapy uses high-energy x-rays or other radiation to kill cancer cells or stop them from growing, according to the NIH. Radiation therapy can be either internal or external. Interal radiation is given through a radioactive substance concealed inside needles, seeds, wires, or catheters that a doctor will place directly into or near the cancer. External radiation uses a machine to send x-rays or other radiation toward the cancerous area of the body.

Typically, external radiation is used as a palliative therapy once cancer has reached an incurable stage in order to help patients feel better. Internal, targeted radiation is used to kill the cancer from the inside and, as Dr. Rajput said, is often used in combination with chemotherapy.

Radiofrequency ablation

Radiofrequency ablation isn't used to treat the primary tumor, Dr. Rajput says. Instead, it can sometimes be used to treat colorectal metastases, which are tumors or abnormal cell growth in areas where the primary cancer has spread to.

During radiofrequency ablation, doctors will use a probe that has tiny electrodes that kill cancer cells through electrical energy and heat, according to the NIH. A radiologist will insert the probe directly through the skin or through an incision in the abdomen, using imaging technology to guide a thin needle into the cancer tissue.

Because it's so targeted, radiofrequency ablation is typically used to treat just one (usually particularly difficult) spot of cancer rather than the cancer as a whole, according to the Mayo Clinic.

Cryosurgery

Like with radiofrequency ablation, cryosurgery is a directed treatment used to destroy one tumor rather than treating the cancer overall. Cryosurgery uses a "cryoprobe" — a hollow instrument that circulates very cold gas such as liquid nitrogen or argon gas, according to the NIH. During the procedure, a doctor will use an ultrasound or MRI to guide the cryoprobe to the tumor. Once it touches the tumor, the cryoprobe forms a ball of ice that freezes the tissue, killing the cancer cells. After the cryosurgery, the frozen tissue will thaw and be absorbed by the body.

Cryosurgery is also used externally to treat tumors that have grown on the outside of the body, like those on the skin. For external cryotherapy, liquid nitrogen is applied directly to the tumor with a cotton swab or a spray, according to the NIH.

Targeted therapy

Targeted therapy falls under the broad category of chemotherapy, Dr. Rajput says. Medical oncologists will use targeted therapy to identify and attack specific cancer cells. "Targeted therapy uses newer drugs that target receptors or signaling pathways that are critical for tumor growth," Dr. Rajput says.

There are two types of targeted therapies used to treat colon cancer, according to the NIH. One, called monoclonal antibodies, are lab-made immune system proteins that can attach to cancer cells or cells that help cancer grow and then kill the cells, block their growth, or keep them from spreading.

The other, called angiogenesis inhibitors, stops new blood vessels from growing in the tumor, which stops the tumor itself from growing.

Immunotherapy

Immunotherapy is also part of medical oncologists' toolbag in treating colorectal cancer, Dr. Rajput says. As it implies, immunotherapy uses the patient's immune system to fight cancer. Medical oncologists will use substances, such as certain proteins, made either in the body or in the lab to boost, direct, or restore the body's immune system in hopes that it will target the invading cancer cells, according to the NIH.

Though these treatment options can give anyone diagnosed with colorectal cancer a great fighting chance against the it, the best offense against the disease is still a good defense. That means scheduling and sticking to the recommended colorectal cancer screenings starting at age 45, like having a colonoscopy every 10 years, for those without an increased risk of the disease. Colorectal cancer is largely preventable, Dr. Rajput says, and while the screenings for the disease can seem off-putting at first, they can (and do) save lives.

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RELATED: 12 Colorectal Cancer Risk Factors to Know About

The Prep

The key to a successful colonoscopy is making sure your doctor can get a good look at every inch of your colon—and that means drinking a laxative solution and following certain dietary restrictions to get your insides squeaky-clean. The process has a bad rap, thanks in part to a foul-tasting liquid that is no longer used. The new drinks taste better, you don’t have to drink as much, and you typically can drink the laxative in two sessions.

The prep process may start five to seven days before the procedure, so be sure to read the instructions ahead of time, says Natalie Cosgrove, MD, an assistant professor of medicine at the Washington University School of Medicine in St. Louis. One of the most common mistakes patients make is waiting until the last minute to read the prep instructions—at which point they may realize they’ve done something wrong and need to reschedule the test, she says.

RELATED: When Should I Start Colorectal Cancer Screening?

Not every hospital or doctor recommends the exact same approach, so read your doctor’s guidelines at least 10 days before your procedure—and follow them carefully. She’ll most likely recommend that you stop taking over-the-counter fiber supplements and antidiarrheal medicines and supplements containing iron and vitamin E and stay away from high-fiber, slow-to-digest foods that might linger in the colon (like beans, seeds, multigrain bread, salad, vegetables, and fresh or dried fruit) several days to a week before the colonoscopy. She’ll also recommend that you arrange for a friend or family member to pick you up after the procedure since you’ll be having anesthesia or some type of sedation.

The day before the procedure, you can’t eat solid food or consume alcohol, but you should drink enough clear liquid—like water, apple or white grape juice, broth, and coffee or tea (without milk or creamer)—to stay hydrated. And you’ll probably start drinking the laxative at 6 p.m . It works by drawing water into your intestines, triggering numerous watery bowel movements. You’re going to go a lot, so don’t leave home. (The solution also contains electrolytes to prevent dehydration.) At some point, the stuff coming out is going to look clear, but don’t stop drinking until the solution is all finished. “Patients think they’re good to go when they’re having clear diarrhea, but there may [still] be fecal matter left in your colon. You have to drink all of it unless your doctor tells you it’s OK to stop,” says Dr. Cosgrove. You should refrain from eating or drinking anything two hours before the procedure.

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New Thinking on Screening

In response to the early-onset trend, the American Cancer Society revised its guidelines in 2018 to say that everyone should get screened for colon cancer, through either a colonoscopy or a stool-based test, at age 45—five years earlier than previously recommended.

Not all doctors or medical organizations agree with the change. “We end up doing a lot of screening and [proportionately] don’t find that many cancers,” says Dr. Kahi. (The American Gastroenterological Association recommends that average-risk people start screening at age 50.) So talk to your doctor about what’s best for you. She may want to begin screenings at 45 if you have any lifestyle-related risk factors associated with colon cancer—if you smoke or drink, for instance, or you’re inactive or you eat a low-fiber, high-fat diet. She’ll want to know if there is a family history of colon cancer or polyps. “If you have a first-degree relative who had colon cancer, start screening 10 years before the age that the relative was diagnosed or when you are 40, whichever is earlier,” says Jennifer Maratt, MD, a gastroenterologist and assistant professor of medicine at Indiana University School of Medicine in Indianapolis. Because African Americans are at an increased risk for early-onset colon cancer, the American College of Gastroenterology suggests they begin screening at age 45.

And, at any age, if you have blood in your poop, ask your doctor for a test. “It used to be that we didn’t worry greatly about bright red blood in a young person because it is often associated with hemorrhoids. Given the increasing incidence of colon cancer in younger people, however, we’ve become more vigilant, offering a colonoscopy to anyone who experiences bleeding, regardless of the color of the blood,” says Dr. Kahi. Other possible colon cancer symptoms you should bring to your doctor’s attention: persistent abdominal discomfort or pain, or changes in the consistency of your stool. But everyone with a colon has a risk of developing colon cancer, says Dr. Kahi: “Everyone should be screened at 50 at the latest.”

RELATED: I Went to the Doctor With Stomach Pains—and Found Out I Had Stage 4 Colon Cancer

Your sedation options

When Stephanie Bell, of Lexington, Kentucky, had a colonoscopy at 52, she chose an option few people even know exists: no sedation at all. “My fiancé had recently undergone the procedure without sedation and said it didn’t hurt. I don’t like to get IVs, anesthesia upsets my stomach, and I didn’t want to be groggy afterward because I wanted to go to a party later that day. So I decided to try it too,” she says. “My doctor talked to me throughout the procedure and warned me when I might feel a little discomfort because the scope had to make a turn in my colon. I felt pressure, like a Pap smear, but it wasn’t painful. The embarrassment of having a tube inserted and seeing my colon on video was the worst part. But I would definitely do it again.”

Dr. Kahi says the majority of his patients who go sedation-free are enthusiastic about the approach. Because you don’t need an IV or medication, the procedure is less expensive than sedated colonoscopies. Another plus: You can drive yourself home afterward and do not have the same restrictions as someone who received sedation. But Dr. Kahi estimates that only a minority of patients choose it. “Most patients don’t want to be aware [of what’s happening] or feel any discomfort,” he says. If you’re one of them, here are the other two common approaches:

Moderate sedation (aka Conscious sedation or twilight sleep)

A doctor or nurse administers two medications, often midazolam, a benzodiazepine sedative that helps you relax, and fentanyl, an opioid to numb the pain. Because the drugs don’t knock you out, you might be aware of what’s happening during the procedure, but thanks to the amnesiac properties of midazolam, you’re unlikely to remember it afterward. It takes time for the drugs to clear from your system, so you’ll need to lie low for the rest of the day.

RELATED: This At-Home Stool Test Is Just as Effective as a Colonoscopy

Deep sedation (aka monitored anesthesia care)

An anesthesiologist administers a drug, usually propofol, and monitors you during the procedure, which makes it more expensive. The drug doesn’t numb pain, but you’re sedated enough that you should be completely unaware of what’s going on. (Deep sedation differs from general anesthesia, in which you’re intubated with a breathing tube and a machine breathes for you; this is very rarely needed for a colonoscopy.) It causes less residual grogginess than moderate sedation, though you still need a ride home.

Do-it-yourself testing

If you don’t have worrisome symptoms or lifestyle or genetic risk factors for colon cancer, there’s a simpler test that doesn’t involve days of prep or any downtime and is usually covered by health insurance. Known as Cologuard, all it requires is a small poop sample (you can get the testing kit from your doctor or online through a telemedicine provider), which you mail to a lab, so technicians can check for blood as well as changes in your cells’ DNA associated with colon cancer or precancer. If the test is positive, you’ll need a colonoscopy. If it doesn’t find anything, you can wait three years before repeating it. But be aware that the test isn’t as effective as a colonoscopy. A clinical study of nearly 10,000 people published in 2014 in The New England Journal of Medicine found that Cologuard detected 92 percent of the cancers that were found by colonoscopy and just 42 percent of suspicious polyps. So if you develop any symptoms—bleeding, stool changes, bloating, or unexplained weight loss—ask your doctor about having a colonoscopy, even if you’ve had a negative stool test, says Dr. Kahi.

This article originally appeared in the September 2020 issue of Health Magazine. Click here to subscribe today!

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Boseman was only 43 when he died, and his death brings an important issue to light: that rates of colon (colorectal) cancer are higher among younger Black men. Rates of colon cancer are 30% higher in men than in women of all races. And Black people have the highest rates of colon cancer of any racial or ethnic group in the US, according to the American Cancer Society (ACS).

During a four-year span from 2012-2016, colorectal cancer incidence rates in Black people were about 20% higher than those in non-Hispanic whites (NHWs) and 50% higher than those in Asian/Pacific Islanders (APIs). Mortality is higher too. Colon cancer death rates in Black people are almost 40% higher than the rates for NHWs and double the rates for APIs. 

RELATED: 12 Colorectal Cancer Risk Factors to Know About

While the overall numbers for colon cancer are going down, the instances of it in men under 50 are actually going up. In 2017, a large study of invasive colorectal cancers, funded by the ACS and published in the Journal of the National Cancer Institute, found that people born around 1990 have double the risk of developing colon cancer and quadruple the risk of developing rectal cancer compared with those born around 1950. This prompted the ACS to lower its recommended screening age for colorectal cancers from 50 to 45. 

Why are colon cancer rates disproportionately high in younger Black people?

Experts don’t really understand why colorectal cases in younger people are rising, Mark Pochapin, MD, director of gastroenterology at NYU Langone Health and president of the American College of Gastroenterology, tells Health. “The rates are going up by 2% per year, though the rates of occurrence are still nowhere near as high for people who are over the age of 65.” Some believe it might have to do with a change in the microbiome, which is the bacteria in the gut, from either using antibiotics or other environmental factors experts aren’t aware of, he adds.

The higher incidence in Black people is also difficult to explain. “This in part may be due to socioeconomics and access to health care, but there may be other factors that we just do not understand,” he says. 

Stacey Cohen, MD, a physician at Seattle Cancer Care Alliance and an associate professor in the division of medical oncology at University of Washington School of Medicine, believes that the high incidence and mortality rates in Black patients are due in part to the systemic racism that prevents earlier recognition of a medical condition.

“Colorectal cancer is thought of as a disease for older individuals, and so the diagnosis may be missed for months or years in a younger person,” adds Dr. Cohen. “Cancer is also difficult to detect at an early stage if a provider is not specifically evaluating for it.” 

RELATED: The Colorectal Cancer Symptoms You Need to Know, Even if You're Young

What are the warning signs of colon cancer? 

In the very early stages, colon cancer typically doesn’t present any symptoms, because the tumor is small and causes no discomfort. “It can bleed as it grows, so people may see blood in their stool,” says Dr. Pochapin. “Additionally, the tumor can start to obstruct the opening of the colon, which can cause narrowing of the stool, making it look pencil-thin, or even cause difficulty passing it. Further, cancer can cause the development of pain and unexplained weight loss. There may also be unexplained anemia on a blood test that is caused by the chronic loss of blood.” 

People with inflammatory bowel disease (IBD) are at higher risk for developing colon cancer, says Dr. Cohen. “There are some hereditary conditions that increase an individual’s risk, and a family history of colorectal cancer or precancerous polyps also increases an individual’s likelihood of developing cancer themselves," she adds.

Lifestyle factors that may increase the risk of colorectal cancers include a diet high in red meat and alcohol consumption, and low in fiber. 

RELATED: What Is a Colonoscopy? From Prep to Recovery, Everything You Need to Know About the Procedure

What colorectal screening tests are available? 

Multiple screening tests are available for colorectal cancer. “The two most common are colonoscopy and something called ‘fecal immunochemical testing’ (FIT),” says Dr. Pochapin. 

A colonoscopy is a test done after a bowel prep, where you take a laxative to clean out the colon the night before. The next day, at a doctor’s office, procedure area, or hospital, a scope or instrument is inserted into the rectum while the patient is under sedation. 

“This travels through the colon looking for polyps," explains Dr. Pochapin, which are precancerous growths. “During the procedure we remove any that are found, so it is both diagnostic and also therapeutic—by removing the polyps we prevent the cancer. Of course colonoscopy also looks for early cancer, but the main purpose is prevention.”

FIT testing, on the other hand, is done at home, using a stick or small paintbrush to put a stool sample on a little card. This is sent to the lab to look for microscopic amounts of blood. 

“The concept here is that with early cancer, you will find trace amounts of blood in the sample,” says Dr. Pochapin. “If a FIT test is positive, the patient must get a colonoscopy relatively soon to make sure there isn’t a cancer causing the positive test. FIT testing looks for an early cancer, since it isn’t very good at finding polyps, and that’s why it’s more of a cancer detection test than a cancer prevention test, like colonoscopy.” 

RELATED: What Are Health Disparities? Why It's Important to Fight for Health Equity—Especially Right Now

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The patient, a 59-year-old man with metastatic colon cancer, presented to the clinic following 10 weeks of experiencing painless, nonpruritic (not itchy) skin lesions that had formed around a large abdominal scar from a previous procedure to remove part of the man's colon three years earlier. The same incision had been used to perform a liver resection and a cholecystectomy (removal of the gall bladder), following the initial procedure.

RELATED: This Man Died After Developing Huge Lesions on His Skin From Rectal Cancer

The occurrence of cancer spreading from a person’s internal organs to their skin—known as cutaneous metastasis—is rare, but it happens in 4–6% of colorectal cancer cases, according to Eric Johnson, MD, a colorectal surgeon at Cleveland Clinic. “It’s something you don’t see very often, [but] it can happen,” Dr. Johnson tells Health. More data, from a 2017 case report published in the Annals of Surgical Treatment and Research, puts the occurrence rate of cutaneous metastases resulting from colorectal adenocarcinoma at more like 3% of colorectal cancer cases.

Overall, the spread of cancer—referred to as metastasis—can happen through a series of steps, according to the National Cancer Institute (NCI). Initially, cancerous cells can grow into or invade nearby normal tissue. From there, those cells can move through the walls of nearby lymph nodes or blood vessels, where they can begin traveling through the lymphatic system and blood stream to other parts of the body. At any point in that process, those cancerous cells can stop at another location in the body, where they can form a tiny tumor and cause new blood cells to grow to create a blood supply for that new tumor.

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But Dr. Johnson says the man in the NEJM case report experienced a different type of metastasis—specifically through tumor cells' contact with the man's outside skin. “If you operate on a colon cancer patient, you’re extracting the tumor. You can shed tumor cells that can implant [in the skin]," says Dr. Johnson. This is why, according to the NEJM case report, "the most common site of cutaneous metastases in colon adenocarcinoma is the abdominal skin, sometimes in or around surgical scars, as was seen in this case." The 2017 case study also explains that cutaneous metastases in colon cancer "generally occur within the first two years after resection of the primary colorectal tumor."

To prevent this spread, surgeons often use devices called wound protectors, which are put in place around wound openings during surgery to keep cancer from spreading from an organ to an incision. “They’re basically a thin, vinyl sleeve that is sterile,” Dr. Johnson explains. While most surgeons use these wound protectors, they aren’t used in every operation, says Dr. Johnson. He goes on to say that this could have been the reason the patient featured in the NEJM report developed the lesions on his stomach, which had spread from his colon cancer, but without a full patient history, nothing can be said for sure.

Unfortunately, the man featured in the NEJM case report received hospice care following his diagnosis but passed away five months presenting to the dermatology clinic.

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The patient had a type of rectal cancer called mucinous adenocarcinoma, which is when a tumor is comprised in part by mucin, a compound found in mucus. His cancer was originally treated with a surgery called a laparoscopic abdominoperineal resection. This procedure is used to treat cancers in the anus and rectum that are close to the sphincter muscles, and it involves removing the anus, rectum, and part of the large intestine through multiple small incisions.

Two chemotherapy drugs—capecitabine and oxaliplatin—were recommended after surgery for this patient, according to the case report, but he decided against taking these medications, which can be expensive.