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Chemoprevention

Chemoprevention ( Lee Sin Win)

Colorectal cancer (CRC) is one of the major cancer incidents and has a high mortality rate worldwide. It is also one of the most common and one of the most preventable cancers globally, with powerful but strongly missed potential for primary, secondary and tertiary prevention. According to Brenner & Chen (2018), CRC incidence has traditionally been the highest in the Western countries, but it is now increasing rapidly throughout the other parts of the world. CRC have few causing factors such as smoking, excessive alcohol consumption, physical inactivity and being overweight, with other common diseases

With the progress of scientific research over the past two decades, science have brought major advances in CRC screening and therapeutics. As a result, the incidence and mortality of CRC have started to decline and data shows that there is improvement in the increasing number of CRC survivors. Patients who have completed their therapy session show high interest in adopting dietary and lifestyle activities changes in an attempt to reduce the risk of recurrent cancer. According to Brenner & Chen (2018), this moment is known as the “teachable moment” for oncologists. It is a time when patients are receptive and willing to consider a different lifestyle approach to reduce the risk of cancer recurrence.

There are now statistics that show the importance in improving dietary and lifestyle behaviours for patients that were diagnosed with CRC. With the rising number of CRC survivors and advances in the understanding of several therapeutic agents, people are showing new interest in developing new strategies for CRC risk reduction among CRC patients. The United States National Cancer Institute (NCI)-supported cooperative group clinical trials system wishes to optimize the approach to reduce risk among CRC survivors over the next decade and beyond. NCI will start conducting trials that will involve a prolonged intervention period using oral medications to inhibit colorectal carcinogenesis.

Currently, a few medical components that are under review by the clinics as a tertiary prevention of CRC. These medical components such as 3-hydroxy-3-methylglutaryl-coenzyme A (HMG CoA) reductase inhibitors, NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) and low-dose aspirin.

STATIN

According to a study by Voorneveld et al. (2017) , it is reported that there is a decreased risk of death from any cause and from cancer in statin users belonging to a cohort of colon cancer patients. Statins act as lipid-lowering compounds through inhibition of 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR).It is a key enzyme of the mevalonate pathway involved in the cholesterol biosynthesis and in post-translational modification (isoprenylation) of small GTPase family members such as Ras and Rho. The statin effect is correlated with intact bone morphogenetic protein (BMP) signaling.The reported data based on Bifulco & Gazzerro, (2018) represent an expanded evidence-based analysis of statin antitumor activity. In the cohort analyzed by Voorneveld et al. (2017), statin users had more comorbidities and experienced tumors at an earlier stage than nonusers. In a recent analysis based on Bifulco & Gazzerro (2018) , a research was done to evaluate the relationship between lipid traits and colorectal cancer risk. A study by Rodriguez‐Broadbent et al. (2017) also yielded similar results that showed single nucleotide polymorphisms mimicking HMGCR inhibition were associated with 43% reduction in colorectal cancer occurrence. Intriguingly, recent data suggest that statins are able to prevent the progression from adenoma to adenocarcinoma rather than to directly inhibit cancer incidence. In the colon cancer cohort analyzed by Voorneveld et al. (2017), statin use after diagnosis significantly improved survival in colon cancer patients with intact BMP signaling and wild-type SMAD4.

ASPIRIN

Based on an observational study by Coyle et al.( 2016), there is evidence that the usage of low-dose aspirin which is categorized under chemoprevention is showing results that it can reduce CRC risk. According to Coyle et al. (2016), the first clinical evidence emerged in 1988 from a case-control study conducted in Melbourne, Australia, which showed that aspirin reduced the risk of developing CRC. This finding also shows that aspirin was associated with a lower risk of developing CRC (relative risk (RR) 0.73, 95 % confidence interval (CI), 0.67–0.79). Based on a research by (Li et al., 2015), aspirin goes along with enhanced survival after CRC diagnosis. Not only that, Sostres (2015) conducted a study that shows aspirin is one of the most likely key mechanisms that are related to cyclooxygenase (COX) inhibition but an additional role of non-COX mechanisms has also been postulated. Then, observations of enhanced survival of CRC patients treated with metformin should be followed up by randomised controlled trials (RCTs).According to Weberpals et al. (2016) , there are drugs that are commonly used for treatment of comorbidities among CRC patients such as beta-blockers, an apparent beneficial role for prognosis seems to have been spurious, and could have resulted from major flaws in pertinent pharmacoepidemiologic studies, such as immortal time bias.

NSAID

According to Rigas & Tsioulias (2015) , there are multiple epidemiologic studies, randomized clinical trials in patients and pooled analyses of patients who were administering non-steroidal anti-inflammatory drugs (NSAIDs) for the prevention of cardiovascular disease could show that conventional NSAIDs are able to prevent CRC to a certain extent. However, chronic medication with NSAIDs also bears various serious side effects that could harm the patients.Therefore , researchers are slowly researching newer and chemically modified NSAIDs so that the drugs could be more effective and safe in the future. In addition to that , recent work also indicates that targeting earlier stages of colorectal carcinogenesis with these new NSAIDs could be a promising approach for treating this malignant disease, since it may only require a relatively short use of these therapeutics.

Taking medication is not that easy isn’t? On paper, take the pills that were given by your oncologist, or doctor, by the time requested. Sometimes, concern seeps into our minds when taking medication, especially those that need to be taken in the long run. A lot of factors are considered, such as the opinion of others around us. One friend said that taking this medication isn’t good? Another mentioned about visiting this doctor again? What about side effects? (Kahwati et al., 2016)

The theory of planned behaviour is a theory that can be used to predict if the patient will perform a health related behaviour (Hasan et al., 2019). As explained by "The Theory of Planned Behavior" (2020) the theory of planned behaviour consists of 3 factors. It includes, attitude, subjective norm, and perceived behavioural control.

Attitude is the negative and positive feelings of the patient towards the behaviour, in this case, its taking medication to prevent CRC. Subjective norm is the view of the individual that has an influence on the patient (individual with authority, deemed to be more knowledgeable, trusted individuals) on the medication. Perceived behavioural control is the perceived difficulty of the patient towards the behavior. If the behaviour is too difficult to accomplish at first glance, it steers the patient away from completing the task.

Using this theory, it is possible to understand why the patient would refrain from taking the prescribed medication. Removing those barriers can increase adherence. For example, attitude towards the medication can be changed by introducing and explaining the benefits of the medication. Another tip can be to inform the individual in the patient’s life about the importance of the medication, so the patient would be more willing to take the medication. A study done by Granger et.al (2015) showed that adherence has gone up from 32% to 70%. In this study, patients were given intense education before the prescription of the medication in the hospital. The patients were informed about the goal of the medication, and response plans.

Another study done by Kopelowiz et. al. (2015) tested the possibilities of multi-family group intervention (MFG) paired with theory of planned behaviour. MFG intervention is an intervention method that involves the patient’s family, and is process oriented. MFG allows the family members to set the problem focus instead of the therapist. Then the problems are solved, giving the patient a ‘tailored’ solution for their problem. Culture specific concerns can be adapted and solved through MFG because the families are encouraged to point out all the problems and concerns they have. This fits the social norms aspect of the theory of planned behaviour.

The process of MFG as discussed by Kopelowiz et. al. (2015) first started with having the patient identify the problems they had with the medication. Then, the clinician or therapist addresses false beliefs or understanding of the medication by educating them with supporting research and journals. Then, other concerns such as weight gain (an example by Kopelowiz et. al., 2015), are dealt by having the group members voice out potential solutions.

The next step is to correct and change the social norms of the patient. The family members now voice out their concern and problems, the therapist addresses the problems, and correct misinformation. Any other additional problems are then solved by other group members. This corresponds to the social norm aspect of the theory of planned behaviour.

Lastly, perceived power of control was dealt with by correcting inaccurate beliefs and estimation of power (to perform the behaviour). The example that was used to study is the ability to purchase the medication. Suggestions such as ways to get more affordable and free medication is then explained.

Another model to consider is the transtheoretical model. The transtheoretical model describes the process of behaviour change in 5 stages. The behavioural change does not occur in a linear method, but in a spiral, where it is possible to move to previous stages via relapse. Intervention can be used to help the patient transition through the stages. The stages are explained below, and interventions will be discussed after. ("The Transtheoretical Model (Stages of Change)", 2020)

The first stage is precontemplation. Pre-contemplation is when the patient has no intention to change. This is likely before the advice of a doctor, or right after relapse (not adhering to the medication schedule after taking it for a long time). This stage can also be that not realizing that the patient is at high risk of CRC recurrence.

The next stage is contemplation. This stage occurs when the patient decides that there is a need to take the medication, and is considering to adhere to the medication schedule. The patient is thinking about the change, but not putting effort into changing yet. This should occur when the patient understands that they are at risk of CRC reoccurrence.

Next, preparation. Preparation is when the patient has the thought and intention to make change, in this case, it's to adhere to the medical advice given by their doctor.

Action comes next. This stage is the patient performing the behaviour. The patient is now taking medication as scheduled, in the correct dosage.

The last stage is maintenance. This stage is to maintain the new behaviour, and build up resistance to change. The old behaviour is replaced with the new, and incorporated to the patient’s daily life. This stage would be that the patient is getting used to taking the medication, and have no problems with taking it daily.

Conclusion

In conclusion, statin, aspirin and NSAID are medications that can help prevent the recurrence of CRC. Patients might not be keen to start taking medication, and may have a variety of issues from financial capabilities to afford the medicine to personal beliefs. There are ways to overcome such issues, such as talking to a medical professional and weight out the pros and cons. Talking to a therapist, or participating in a support group can help as well. 

  Reference 

Bifulco, M., & Gazzerro, P. (2018). Colon Cancer Survival and Statins: What More Evidence Do We Need?. Gastroenterology, 154(5), 1545-1546. https://doi.org/10.1053/j.gastro.2017.06.071

Brenner, H., & Chen, C. (2018). The colorectal cancer epidemic: challenges and opportunities for primary, secondary and tertiary prevention. British Journal Of Cancer, 119(7), 785-792. https://doi.org/10.1038/s41416-018-0264-x

Coyle, C., Cafferty, F., & Langley, R. (2016). Aspirin and Colorectal Cancer Prevention and Treatment: Is It for Everyone?. Current Colorectal Cancer Reports, 12(1), 27-34. https://doi.org/10.1007/s11888-016-0306-9

Granger, B., Ekman, I., Hernandez, A., Sawyer, T., Bowers, M., & DeWald, T. et al. (2015). Results of the Chronic Heart Failure Intervention to Improve MEdication Adherence study: A randomized intervention in high-risk patients. American Heart Journal, 169(4), 539-548. https://doi.org/10.1016/j.ahj.2015.01.006

Hasan, S., Muzumdar, J., Nayak, R., & Wu, W. (2019). Using the Theory of Planned Behavior to Understand Factors Influencing South Asian Consumers’ Intention to Seek Pharmacist-Provided Medication Therapy Management Services. Pharmacy, 7(3), 88. https://doi.org/10.3390/pharmacy7030088

Kahwati, L., Viswanathan, M., Golin, C., Kane, H., Lewis, M., & Jacobs, S. (2016). Identifying configurations of behavior change techniques in effective medication adherence interventions: a qualitative comparative analysis. Systematic Reviews, 5(1). https://doi.org/10.1186/s13643-016-0255-z

Kini, V., & Ho, P. (2018). Interventions to Improve Medication Adherence. JAMA, 320(23), 2461. https://doi.org/10.1001/jama.2018.19271

Kopelowicz, A., Zarate, R., Wallace, C., Liberman, R., Lopez, S., & Mintz, J. (2015). Using the theory of planned behavior to improve treatment adherence in Mexican Americans with schizophrenia. Journal Of Consulting And Clinical Psychology, 83(5), 985-993. https://doi.org/10.1037/a0039346

Li, P., Wu, H., Zhang, H., Shi, Y., Xu, J., & Ye, Y. et al. (2014). Aspirin use after diagnosis but not prediagnosis improves established colorectal cancer survival: a meta-analysis. Gut, 64(9), 1419-1425. https://doi.org/10.1136/gutjnl-2014-308260

Rigas, B., & Tsioulias, G. (2015). The Evolving Role of Nonsteroidal Anti-Inflammatory Drugs in Colon Cancer Prevention: A Cause for Optimism. Journal Of Pharmacology And Experimental Therapeutics, 353(1), 2-8. https://doi.org/10.1124/jpet.114.220806

Rodriguez‐Broadbent, H., Law, P., Sud, A., Palin, K., Tuupanen, S., & Gylfe, A. et al. (2017). Mendelian randomisation implicates hyperlipidaemia as a risk factor for colorectal cancer. International Journal Of Cancer, 140(12), 2701-2708. https://doi.org/10.1002/ijc.30709

Sostres, C. (2015). Aspirin, cyclooxygenase inhibition and colorectal cancer. World Journal Of Gastrointestinal Pharmacology And Therapeutics, 5(1), 40. https://doi.org/10.4292/wjgpt.v5.i1.40

The Theory of Planned Behavior. Sphweb.bumc.bu.edu. (2020). Retrieved 4 March 2020, from http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/BehavioralChangeTheories/BehavioralChangeTheories3.html.

The Transtheoretical Model (Stages of Change). Sphweb.bumc.bu.edu. (2020). Retrieved 13 February 2020, from http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/BehavioralChangeTheories/BehavioralChangeTheories6.html.

Voorneveld, P., Reimers, M., Bastiaannet, E., Jacobs, R., van Eijk, R., & Zanders, M. et al. (2017). Statin Use After Diagnosis of Colon Cancer and Patient Survival. Gastroenterology, 153(2), 470-479.e4. https://doi.org/10.1053/j.gastro.2017.05.011

Weberpals, J., Jansen, L., Carr, P., Hoffmeister, M., & Brenner, H. (2016). Beta blockers and cancer prognosis – The role of immortal time bias: A systematic review and meta-analysis. Cancer Treatment Reviews, 47, 1-11. https://doi.org/10.1016/j.ctrv.2016.04.004

[coloncanceriumw]

Physical Activities   (Arcchana)

According to a 2016 meta-analysis of 126 studies, people who participate and engage in physical activity daily have a 19% lower risk of getting colon cancer than those who are less active physically  (Liu, et al., 2015). Nowadays, it is known that colorectal cancer has become the world’s fourth most deadly cancer with almost 900 000 deaths annually. Risk factors such as obesity, lack of physical activity and smoking increase the chance of getting colorectal cancer. It is the second most prone cancer diagnosed in women and third in men. As for women, the occurrence and mortality are roughly 25% lower than in men (Dekker, Tanis, Vleugels, Kasi, & Wallace, 2019).          

 People are recommended to change their lifestyle habits to prevent any type of cancer in general. According to Oruç & Kaplan (2019) study,  The International Agency for Research on Cancer (IARC) has reported that 25% of all the cancer cases worldwide are caused by obesity and a non-active lifestyle (Oruc & Kaplan, (2019) as cited in Vainio, Kaaks, & Bianchini, 2002). According to Oruc & Kaplan (2019), physical activities have chances to prevent roughly 15% of colorectal cancers. It is also known to decrease the mortality rate and risk or recurrence before and after the colorectal cancer diagnosis. There is no exact type of exercise, time and intensity of it but it is strongly known that having an active lifestyle is a good way to prevent any type of cancer. Audit research, including 19 surveys, 26 meta-investigations and 541 unique examinations, assessing physical activity and growth possibilities, has demonstrated that physical activity is valuable in preventing 7 sorts of tumors  (colon, breast, endometrium, lung, throat, pancreas and meningioma). The impact of physical activity on malignant growth hazard is a lot more grounded in breast and colon cancer than in different kinds of cancers (Oruc & Kaplan, (2019). As primary prevention, the recommended activity from a public health perspective is to daily exercise for at least 30 minutes.              

The role of physical activity can be related to the number of colorectal polyps. In an epidemiological examination, it was seen that the individuals who practiced for ≥ 1 h for each week had a lower prevalence of colon polyps and adenoma than the individuals who practiced for < 1 h[17]. In this study, exercise decreased the risk of polyp development throughout the entire colon, and exercise was reported to decrease the total number of intestinal polyps by 50% and the number of large polyps by 67%. Many studies have shown that increasing your level of intensity on physical activities decreases the risk of colon cancer. Physical activity decreases insulin resistance and the insulin levels affect the IGF pathway and indirectly decreases the risk of CRC, recurrence and mortality (Oruc & Kaplan, (2019).

 Physical activity is characterized as any bodily movement delivered by skeletal muscles that results in energy consumption. It includes walking, running, dancing, biking, swimming, performing household chores, exercising, and engaging in sports activities. Exercise is a subset of physical movement that is planned, organized, and repeated and has the target of improvement or support of physical wellness. Physical activity is accounted for to be related to numerous diseases, not simply malignant growth. Such a relationship was first depicted for coronary illness, trailed by diabetes, obesity, bone and joint disease, and other chronic disorders including depression. Past research recommended that physical activity is successful in bringing down mortality hazard, and over 1.3 million deaths could have stayed away from a 25% increase in physical activity. The main importance of physical activity for wellbeing is demonstrated in the 2008 Physical Activity Guidelines for Americans which express that week after week high-impact exercise of at any rate 150 to 300 min at moderate force, or 75 to 150 min at intense power, will create good health advantages. Be that as it may, improved well being status and longer future is known to result from even a limited quantity of activity, which may add to decreased clinical expenses and treatment necessities (Yamaga, Yamamoto, & Keiji, 2017). 

 According to the U.S. Department of Health and Human Services Physical Activity Guidelines for Americans, 2nd edition, released in 2018, recommends that for significant health benefits and to lower the risk of chronic diseases, including cancer, adults should engage in 150 to 300 minutes of medium-intensity aerobic activity, around 75 to 100 minutes of high-intensity aerobic activity or an equal amount of both combinations each week. It can be done in any duration of time. Besides that activities such as muscle-strengthening for at least 2 days a week, aerobic and balance training. 

 Many studies dating back over 90 years have investigated cancer prevention. Physical acitivity reduces the risk of developing cancer across a wide range of the population, irrespective of sex and type of physical acitivity. The 2006 American Cancer Society (ACS) cancer prevention guidelines recommend 30 min, or preferably 45 to 60 min, of moderate-intensity (or greater) physical activity at least 5 days a week, for the prevention of cancer. Preventive effects of physical activity are described extensively in the literature on breast and colorectal cancer. Current guidelines recommend 150 min of physical activity weekly in order to experience substantial health benefits. However, the incidence of cancer is significantly reduced even at half the recommended level, an average of 15 min physical activity per day . This shows that almost all loss of physical activity is highly deleterious and that moderate-intensity activity, even in small amounts, is beneficial. Even light-intensity physical activity can be important in preventing cancer , and this is possible because increases in light-intensity physical activity are related to relative reduction of cancer.  

A meta-analysis of relationships between SB and cancer suggested that SB was associated with overall cancer risk and with the risk of uterine cancer, colon cancer, breast cancer, and lung cancer, specifically [24]. A metabolic equivalent of a task also known as the MET is to describe the intensity of physical activity. One MET is the pace of vitality consumed by an individual sitting very still. Light-power exercises exhaust under 3 METs, moderate-force exercises consume 3 to 6 METs, and enthusiastic exercises use at least 6 METs. An individual can be genuinely dynamic but invest a significant measure of energy being sedentary. Sedentary meaning a person tending to spend much time being seated or inactive Physical Activity Guidelines Advisory Committee, 2018). Physical activities such as exercising have many benefits on the body especially for colorectal cancer. These include:

•    Decreasing the level of sex hormones such as estrogen and growth attributes that are known to be associated with cancer development (Winzer, Whiteman, Reeves, & Paratz, 2011).  

• Averting high blood levels of insulin which too has been associated with yo cancer development (Winzer, Whiteman, Reeves, & Paratz, 2011).  

• Reducing inflammation 

• Adjusting the metabolism of bile acids, decreasing the exposure of the gastrointestinal tract to these suspected carcinogens.  

 • Reduces the time for food to travel through the digestive system which leads to decreasing gastrointestinal tract exposure to possible carcinogens. 

Concerning primary prevention, compelling evidence indicates that PA can inhibit CRC growth, either in leisure or during work. In a meta-analysis, involving 52 observative and retrospective trials, Wolin et al. found that recreational PA could substantially reduce colon cancer incidence by a total of 24%. Moreover, in an earlier epidemiological review of 150,000 participants with a 6-year follow-up, it was observed that 4–6 hours of exercise a week could theoretically decrease the risk of colon and rectal cancer by 13% and 30% respectively. Thus, with increased cumulative hours of physical activities, the risk of colon cancer decreased dramatically, although this result was not shown in rectal cancer. The purpose of this review, however, is to focus on the effect of PA after diagnosis of CRC (tertiary prevention) and its impact on quality of life (QOL) and prognosis. The prognosis of the disease will thereby be defined as overall and disease-free survival (as cited in Schoenberg, 2016)

CRC diagnosis and treatment, in most cases include operation, chemotherapy, and in some cases radiation, inevitably adds to the patient's growing inactivity. The side effects include anemia, leukopenia, fatigue, diarrhea and vomiting, among others, as well as cardiomyopathy depending on the medications used. That obviously impairs the patients 'functioning PA. In addition, patients also suffer from cancer-related fatigue that leads to weariness, exhaustion and sometimes depression. During treatment, as both physical and mental symptoms can impair the ability to continue with and retain adequate PA. Recently evolving clinical studies have shown that physically active survivors of the CRC often decrease their chance of cancer recurrence and increased mortality. Meanwhile this idea has been backed by seven prospective reports (Schoenberg, 2016). 

  What to consider before preparing a fitness programme?

• Start slowly. Even if you can only do an activity for a few minutes a day will be of assistance. How much will a basic task like walking be increased gradually, and how long does it take? When you need to calm down and relax your muscles say you. 

 • Seek brief workout cycles and regular rest breaks. For starters, walk briskly for a few minutes, slow down, and walk briskly again until you've done brisk exercise for 30 minutes. You can break the task into three 10 minute sessions if you need to. You are going to also get the advantage of the exercise.

 • Aim to incorporate aerobic exercise using large classes of muscles including the legs, abdominal (belly), arms, and back. Power, endurance and physical fitness are also essential aspects of a workable workout program. 

 • Aim to do other workouts that can help you maintain lean muscle mass and bone strength, such as resistance training or light weights. 

 • You may want to do movements that can make the joints more stable and maintain the range of motion within.

 • The warm-up exercises often continue for around 2 to 3 minutes. Examples of these movements include shoulder shrugs, overhead raising shoulders, toe-tapping, leg lifts and marching. Term your session of workouts on stretching or endurance. Keep a rest, and breathe for about 15 to 30 seconds. Note as you rest, to relax.  

• Pay care to your joints, and relax while you need to.

Source:

https://www.cancer.org/content/dam/cancer-org/cancer-control/en/booklets-flyers/life-style-changes-that-make-a-difference.pdf

 Self-determination theory is the most simple but efficient theory that can be used in this situation.  Deci and Ryan’s Theory of Motivation (1985), Self-determination theory is unique among human motivation theories to investigate the differential impact of qualitatively distinct incentive forms that can underlie behaviour. Originating from a humanistic viewpoint and therefore profoundly based on meeting desires, self-actualizing and understanding human capacity, self-determination theory is a systematic and emerging macro-theory of human personality and inspired behaviour.

Deci and Ryan have developed the Self-Determination Theory (SDT) and have been used in several experiments to seek to understand what motivates individuals to engage in PA (Deci & Ryan, 1985, 2000 as cited in Ball et al., n.d.). According to Deci and Ryan, motivation emerges when basic psychological needs are met (Deci and Ryan, 1985, 2000, 2002 as cited in Ball et al., n.d.). The basic psychological needs include three constructs: autonomy (choice power), competence (mastering skills) and communication (creating or establishing meaningful connections) (Deci & Ryan, 1985, 2000, 2002). Studies have reported mixed findings about whether or not a person's degree of autonomy, competence and relatedness promotes engagement and involvement in physical activity.

The specific performance of the regulations ranges from feeling of low autonomy to feeling of high autonomy. From the least autonomous to the most autonomous: motivation, external control, introjection, recognition, integration and inner motivation. The theory notes that satisfying three psychological needs (autonomy, competence, relationship) would lead to a change from low to high autonomous control (Deci & Ryan, 2000 as cited in Lewis et al., 2020).  

First of all, self-determination theory distinguishes between intrinsic and extrinsic motivation types that control one's behaviour. Intrinsic motivation is characterized as behaviour due to its inherent satisfactions. As the intrinsically motivated person feels feelings of pleasure, the exercising of their skills, personal success, and anticipation, SDT distinguishes between intrinsic and extrinsic forms of motivation that control one's behaviour. Intrinsic motivation is characterized as performing an activity because of its inherent satisfactions. When the individual is intrinsically inspired, he feels feelings of happiness, skill exercise, personal achievement, and excitement. Extrinsic motivation refers to doing an action for functional purposes, as opposed to inherent motivation, or to achieve a purpose separable from the task per se. For example, when a person participates in an action to receive a monetary or social benefit or escape rejection, they are motivated in an extrinsic context (Teixeira, Carraça, Markland, Silva, & Ryan, 2012).

‌By putting together the strengths of both strategies, it might be best prepared to establish successful interventions that provide meaningful safety, safety and well-being outcomes not only among highly motivated patients willing to engage in clinical trials, but also among more general patient populations with whom clinicians communicate on a daily basis. It is only by promoting the creation of long-lasting realistic solutions that we can succeed in enhancing the duration and quality of life through lifestyle change. Collaborative efforts between complementary approaches will foster the development of a rigorous science of health behavior change that is equipped to tackle these issues in the real world of health care practice.

References 

 Ball, J., Bice, M., & Maljak, K. (n.d.). Exploring the Relationship Between Self-Determination Theory, Adults’ Barriers to Exercise, and Physical Activity. Retrieved September 19, 2019, from https://files.eric.ed.gov/fulltext/EJ1156136.pdf

Dekker, E., Tanis, P. J., Vleugels, J. L. A., Kasi, P. M., & Wallace, M. B. (2019). Colorectal cancer. The Lancet, 394(10207), 1467–1480. doi:10.1016/s0140-6736(19)32319-0 

 Lewis, L. S., Shaw, B., Banerjee, S., Dieguez, P., Hernon, J., Belshaw, N., & Saxton, J. M. (2020). The Role of Self-Determination in Changing Physical Activity Behavior in People DiagnosedzWith Bowel Polyps: A Pilot Randomized Controlled Trial. Journal of Aging and Physical Activity, 28(1), 42–52. https://doi.org/10.1123/japa.2018-0279

 Oruç, Z., & Kaplan, M. A. (2019). Effect of exercise on colorectal cancer prevention and treatment. World journal of gastrointestinal oncology, 11(5), 348.

 Teixeira, P. J., Carraça, E. V., Markland, D., Silva, M. N., & Ryan, R. M. (2012). Exercise, physical activity, and self-determination theory: a systematic review. International journal of behavioral nutrition and physical activity, 9(1), 78.

 Vainio, H., Kaaks, R., & Bianchini, F. (2002). Weight control and physical activity in cancer prevention: international evaluation of the evidence. European journal of cancer prevention: the official journal of the European Cancer Prevention Organisation (ECP), 11, S94-100.

Yamaga, T., Yamamoto, S., & Keiji, M. (2017). The impact of physical activity on cancer prevention and survivorship. Physical Medicine and Rehabilitation Research, 2(2). doi: 10.15761/pmrr.1000138 (Yamaga, Yamamoto, & Keiji, 2017)

[coloncanceriumw]

Yearly Check-up (Fang Ling)

People nowadays are so busy with their life and this is also one of the reasons they don’t really have time to take care of their health, thus this has caused a lot of diseases, one of them is colon cancer. There are a lot of factors that will lead to colon cancer such as smoking, obesity, lack of physical exercise and unhealthy lifestyle will increase the risk of getting colon cancer. Other than these factors, ageing and dietary habits of the individual also play as the factors that will lead to colon cancer as well. Even though, nowadays the medical is very advanced compared to the previous, so good news is there are a number of treatment plans that we can choose such as endoscopic, radiotherapy, systemic therapy and surgery. Even though these new treatments can help to increase the lifespan of the patient, is there any way that we can prevent ourselves from getting colon cancer? The answer is yes (Dekker.E., Tanis.P.J., Vleugels.J.L.A., Kasi.P.M., & Wallace.B.M., 2019).

People always say that prevention is better than cure. Thus, it is better to take precautions before getting the disease. What are the ways that we can prevent ourselves from getting colon cancer? There are few ways that can help to prevent colon cancer such as go for yearly check-up, maintain healthy weight, stop smoking, be physically active and maintain a healthy lifestyle. One of the ways that people tend to ignore is to go for yearly check-up (Dekker.E., et al., 2019). This targeted health behaviour, which is yearly check-up can be explained by using the transtheoretical model. Transtheoretical models are also known as stages-of-change models. This model consists of 5 stages which include, pre-contemplation, contemplation, preparation, action and maintenance and it will relapse if we don’t continue the behaviours (Friman.M., Huck.J., & Olsson.L.E., 2017).

Most people don't have the awareness of how important yearly check-ups are to maintain a healthy body. Most of the people will be more concerned about their diet and also physical exercise. People always think that yearly check-ups are troublesome and sometimes they are too busy to go for a check-up. People nowadays are too busy with their work, even though their body is feeling uncomfortable, they still do not take action to solve it and they choose to ignore it. According to the transtheoretical model, this is in the stage one, which is the pre-contemplation, where people do not have any intention to do anything (Friman.M., Huck.J., & Olsson.L.E., 2017).

Actually one of the best ways to protect ourselves from colon cancer is go for a yearly check-up by getting a few screening tests for colon cancer. This is very helpful in preventing colon cancer especially for the people who are 45 years old and above. Most of the people are encouraged to start the yearly check-up when they reach the age of 45 because people within the age of 50 to 75 years old are the population that are most likely to get colon cancer. Other than that, getting screening tests of colon cancer is also recommended for those individuals that are from the family that had a history of colon cancer or polyps (Harvard Medical School, 2016). Many of the people will be wondering why it is important for us to go for yearly check-ups and get screened for colon cancer. According to Dekker.E., et al. (2019), the reason why we should go for yearly check-up and get screening for colon cancer is because screening test for colon cancer is much effective to notice the colon cancer in the earlier stage, which is the stage that be treat well and it also help to prevent the colon cancer from growing abnormally in other part of the body. By sharing the medical knowledge of colon cancer to the public, people will be more aware of the risk factors that will cause colon cancer and also the negative effects that colon cancer will bring to our life but they do not know how to prevent it. Thus, at this moment, people are in the second stage of transtheoretical models. In this stage, people started to aware on the issue of colon cancer, but they have no intention to change their behaviour to prevent themselves from getting colon cancer, due to lack of information on how to prevent (Friman.M., Huck.J., & Olsson.L.E., 2017).

According to Simon.S. (2020), there are several types of screening tests for colon cancer. Some of the tests are easy and some are more complicated to carry out. For the easy tests the individual is required to be carried more often, whereas the complicated tests don’t have to be carried out often. If the individual isn’t sure which test is most suitable for them, they can consult your doctor or specialist first before going for the screening tests. There are also differences in the price and the doctor will suggest the clients to go for the tests according to their preferences and medical history. Colon cancer screening tests are including Fecal Occult Blood Test (FOBT), Fecal Immunochemical Test (FIT), Colonoscopy, Flexible Sigmoidoscopy, Virtual Colonoscopy and Stool DNA test. There are two types of tests, which are stool-based tests and visual tests. Fecal Occult Blood Test (FOBT), Fecal Immunochemical Test (FIT), and Stool DNA test are under stool-based tests, whereas Colonoscopy, Flexible Sigmoidoscopy and Virtual Colonoscopy is under the Visual tests. Thus, when it comes to the third stage of transtheoretical model, which is the preparation, in this stage people are aware on how serious colon cancer can be and they are ready to take action by search for more related information from online sources or some might seek consultation from the doctors (Friman.M., Huck.J., & Olsson.L.E., 2017).

Stool-based tests are one of the screening tests for colon cancer. They are non-invasive colorectal cancer screening options. No special diet or bowel preparation which means no laxatives or enemas is required for a stool-based test. However, if the test does show abnormal signs of blood or a possible cancer or pre-cancer, a colonoscopy will be needed to confirm the result, and possibly to remove any abnormal findings or polyps. It’s important to remember the cause of an abnormal result may be a non-cancerous condition, such as ulcers or haemorrhoids. Stool-based tests are not the best option for everyone. They are recommended for people who have an average risk for colorectal cancer: no personal history of pre-cancerous polyps, no colorectal cancer that runs in the family, or no other risk factors. However, for Visual or structural tests are invasive tests that look inside the colon and rectum for abnormal areas that might be cancer or polyps. If a stool-based test was done first and had an abnormal result, a visual test can help find out why (Simon.S., 2020). When they people gather all the information on how to prevent colon cancer, they will enter the fourth stage of the transtheoretical model, Action. This is when the people start to make overt changes in their behaviour. In this part, the action people will take is going for a yearly check-up and get the most suitable screening tests for colon cancer by recommendation by their doctor or specialist (Friman.M., Huck.J., & Olsson.L.E., 2017).

Fecal Occult Blood Test (FOBT) and Fecal Immunochemical Test (FIT) are non-invasive tests used to find tiny amounts of blood in the stool that could be a sign of cancer or large polyps. People take these tests at home with a kit they receive from their doctor’s office, along with instructions on how to do the test and return it so it can be checked. Each test detects blood differently, but neither test can tell where the blood might be coming from. That’s why any abnormal result will need to be followed up with a colonoscopy. These tests are simply and easy but they need to be done every year. Stool DNA testing is another type of non-invasive test to check for colorectal cancer. It looks for certain DNA or gene changes that often get into the stool and are sometimes found in pre-cancerous growths and cancer cells.  It also checks for blood in the stool, which can be a sign of cancer. If a stool DNA test finds something abnormal, a colonoscopy will be needed to follow-up on the findings. For this test, people use a take-home kit to collect a stool sample and mail it to a lab. Cologuard is the name of the stool DNA test that is currently FDA-approved, and the patient gets it from their doctor’s office. This stool test needs to be done every 3 years (Simon.S., 2020).

As for the visual test normally it will be done if they found an abnormal area might be cancer or polyps when the stool-based test was done previously. For colonoscopy, it uses a flexible lighted tube with a small camera on the end to look at the entire length of the colon and rectum. If polyps are found, they may be removed during the test. To prepare for the test, you may be asked to follow a special diet for a day or two before the test. You will also need to clean out your colon with strong laxatives which are called a bowel prep and sometimes with enemas, as well. Most people are sedated during the test. If nothing is found during the test, you won’t need another one for 10 years. Another screening test under visual test is CT colonography which is also called as virtual colonoscopy, it is a scan of the colon and rectum that produces detailed cross-sectional images so the doctor can look for polyps or cancer. It requires bowel prep, but no sedation. Air is pumped into the rectum and colon, and then a CT scanner is used to take images of the colon. If something is seen that may need to be biopsied, a follow-up colonoscopy will be needed. CT colonography must be done every 5 years. Other than Colonoscopy and CT colonography, another visual test is Flexible sigmoidoscopy. It is not widely used for colorectal cancer screening.  It’s like a colonoscopy, but only looks at a certain part of the colon and rectum instead of looking at the entire length of the colon and rectum. If polyps are found, they may be removed during the test, or you may need to have a colonoscopy later. Bowel prep may be required, but is not as extensive as the one used for colonoscopy. Most people do not need to be sedated during this test. If polyps or suspicious areas are seen, a colonoscopy will be needed to look at the rest of the colon. Flexible sigmoidoscopy must be done every 5 years (Simon.S., 2020).

After explaining several screening tests for colon cancer that we can do in the hospitals or clinics, some people that are too busy to get an appointment for the check-up, do they have other options to get the screening tests for colon cancer prevention? The answer is Yes. According to Richer.J. (2019), colonoscopy is the gold standard for colon cancer screening. Recently, there is a meta-analysis found that fecal blood tests, which are available by prescription and can be done at home, are associated with increased screening rates. However, patients still need a colonoscopy if there is an abnormal result, to diagnose cancer or remove polyps to prevent cancer. In 2016, the United States Preventive Services Task Force updated its colon cancer screening recommendations to state that patients and physicians can choose among available screening tests. Currently, three types of at-home CRC screening tests are approved by the Food and Drug Administration (FDA), which are Guaiac FOBT (gFOBT) uses a chemical to detect a component of haemoglobin, a blood protein in the stool; Fecal immunochemical test (FIT or iFOBT) uses antibodies to detect haemoglobin shed by polyps or colorectal cancer; and Multitarget stool DNA test (FIT-DNA) detects trace amounts of blood and DNA from cancer cells in the stool. For all of these tests, you collect a stool sample at home using a kit, then mail the sample to a doctor or to a laboratory for testing. None require the bowel-clearing prep required for colonoscopy and all the screening tools can get from online (Richer.J., 2019). Thus, these tests can help those who don't have time to get a screening test at home and this can help the individual to be more aware of their health.

As the people continue the habit of doing the yearly check-up on getting the screening of colon cancer, they will live a healthy life and this will help to prevent them from getting colon cancer, because the tests will show the condition of their colon. Thus, this part can be known as the fifth stage of the transtheoretical model, which is maintenance. In this stage, people will maintain their habits and it helps to improve their health (Friman.M., Huck.J., & Olsson.L.E., 2017).

References Dekker, E., Tanis, P.J., Vleugels, J.L.A., Kasi, P.M., & Wallace, B.M. (2019 ). Colorectal Cancer. Journal of The Lancet. Retrieved from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32319-0/fulltext Friman, M., Huck, J., & Olsson, L. E. (2017). Transtheoretical Model of Change during Travel Behavior Interventions: An Integrative Review. International journal of environmental research and public health, 14(6), 581. https://doi.org/10.3390/ijerph14060581 Harvard Medical School. (2016 November). Top screenings to avoid cancer. Journal of Harvard Health. Retrieved from: https://www.health.harvard.edu/staying-healthy/top-screenings-to-avoid-cancer Richter, J. (2019 March 12). Just do it… yourself: At-home colorectal cancer screening. Harvard Health Blog. Retrieved from: https://www.health.harvard.edu/blog/just-do-it-yourself-at-home-colorectal-cancer-screening-2019031216183 Simon, S. (2020 March 02). Colorectal Cancer Screening: What Are My Options? American Cancer Society. Retrieved from: https://www.cancer.org/latest-news/understanding-tests-that-screen-for-colon-cancer.html 

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Having a Healthy Diet (Sherry)

Colorectal cancer is the world’s second deadliest cancer and is a global health problem (Baena & Salinas, 2016).While there are many factors that can increase the risk of getting colorectal cancer, dietary factors have been known to be closely correlated with colorectal cancer (Azeem et al., 2015).  It used to only be found in adults who are age 50 and above. However, due to the amount of processed food that is produced, the percentage of people contracting CRC below age 50 is increasing.  Obesity increases the risk of getting colorectal cancer, most probably through an associated hormonal dysregulation and chronic inflammatory state. O’Keefe (2016) found that obesity is also commonly associated with changes in gut microbiota composition as microbiomes associated with obesity had an increased capacity to harvest energy from the diet, based on an experiment.

According to Baena & Salinas (2016), 50% of colorectal cancer could be prevented by having a healthier diet, decreasing red meat and processed meat intake and reducing the consumption of alcohol intake. Smart food choices can help lower the risk of getting colorectal cancer. Maintaining a healthy diet since young has its benefits because it can help you maintain a healthy body weight, reduce the risk of getting chronic diseases and promote your overall health. Therefore, anyone can be prone to this disease. If colorectal cancer is detected at an early stage, the survival rate after 3 years is 93%. But if detected at a later stage, the survival rate is only 16% after 3 years (Vega et al., 2015).

Baena & Salinas (2016) found that dietary patterns that indicate the adoption of a “Western dietary pattern” increases the risk of colorectal cancer. It is the high intake of red meat, processed meat, high-fat dairy products, fast food, refined grains, sweet food and drinks.According to O’ Keefe (2016), the best way to prevent colorectal cancer is by minimizing your exposure to cigarettes and alcohol, red and processed meat, MSG and other artificial flavor enhancers as it is associated to have a significant increased risk in getting colorectal cancer. Consuming too much red meat- like steak, pork and hamburger increases the risk of colorectal cancer. However, processed meat like bacon, sausage and bologna raises the risk even more (8 Ways to  Prevent Colon Cancer, 2019).  A high-fiber diet with lots of fruits and vegetables, fish oils and calciums are associated with a lower risk of getting colorectal cancer  (O’Keefe, 2016).

It is hypothesized that the influence of body fat on colorectal cancer risk is based on its direct effect on certain hormone levels, such as insulin, estrogens and IGF-1, that produces a favorable environment for cancer (Baena & Salinas, 2016).There are two kinds of ‘bad fat” that must be avoided as it increases body fat - trans fat and saturated fat. Trans fat appears in foods that contain partially hydrogenated vegetable oils. It can be found in food like fried food (french fries, fried chicken), margarine and processed snacks. Saturated fats are mostly found in high-fat  dairy products and in high-fat meats. For example, it can be found in tropical oils and lard. About 90% of the food we consume is absorbed in the small intestine and nutrients are distributed to maintain general body health. Residues of the food entering the colon are mainly complex carbohydrates , also known as fibre, but it also contains protein residues and primary bile acids secreted by the liver in response to fat ingestion (O’Keefe, 2016).  

According to Baena & Salinas (2016), Heterocyclic aromatic amine (HAA) formation happens when meat is cooked at high temperature and it increases with cooking time (Azeem et al., 2015).  Low-heat cooking or baking (less than 240 degrees) helps prevent oils or fats from turning carcinogenic. Instead of deep-frying, pan-frying, and sautéing, opt for healthier methods such as baking, boiling, steaming, or broiling (Cancer Prevention Diet ,2020). This is because red meat could contain nitrate preservatives or other substances used in the processing of the meat. Therefore, it is recommended to limit red and processed meat in your diet to no more than three servings each week.

Fish and seafood are well-known for having high n-3 fatty acid content, and it has been long believed that  omega-3 fatty acids are capable of preventing carcinogenesis. Other than omega-3 fatty acids, fish also contains vitamin D and selenium, which are also known to have anti-cancer properties (Azeem et al., 2015). This takes into account how the fish is cooked and also the type of fish. However, there were also reports saying that excessive amounts of preserved fish and fish rich in cholesterol can increase the chances of getting colorectal cancer. Having enough selenium in your diet is critical to detox your system and minimizes your risk of cell mutation. Tuna for example, contains a huge amount of selenium. Including tuna in your diet also supplies you with significant amounts of essential omega-3 and omega-6 fatty acids. These are good fats and it is important for our health, our hearts and it also prevents cancer (7 foods to avoid in a colon cancer diet,2020). Omega-3 fats can also be found in fish like salmon, mackerel, herring, lake and rainbow trout and  sardines. 

Fruit and vegetables are crucial in a healthy diet. The positive effects provided by high fruits and vegetables intake come from the great number of  protective substances they contain cause a reduction in the colorectal cancer risk. This is due to the fact that they are rich in fiber content, vitamins, minerals and antioxidants (Azeem et al., 2015). Some of the effects include shortening of the time taken for  feces to transit by fiber, which reduces contact time with the colonel wall. Hence, it has lesser exposure to potential carcinogens. Selenium, which is found in cereals,helps prevents oxidative tissue damage and suppresses cancer cell proliferation. Folic acid which can be found in fruits helps with DNA nucleotide synthesis, which is important to repair and replicate DNA(Azeem et al., 2015). Baena & Salinas (2016) also found in their study that those with a balanced diet that consumes more fruit and vegetables showed a 14% risk reduction in colorectal cancer risk.

Calcium is also a protective nutrient against colorectal cancer as it is capable of acting at multiple tiers of colonic cell organization by manipulating a complex series of signaling events, preventing colorectal carcinogenesis(Azeem et al., 2015). Besides calcium, Vitamin D also plays a role in colorectal cancer prevention as it aids in the absorption of calcium and exerts anti-cancer properties by regulating apoptosis, proliferation and differentiation of cells. According to Azeem et al.(2015), only milk exerts this protective effect as other dairy products actually can increase the risk of colorectal cancer. Different dairy products contain different compositions and are produced differently.

It is important to have a balanced diet because the gut microbiota have a genetically determined need for food residues that derive from a healthy balanced diet (O’Keefe,2016).This is because an imbalanced diet will lead to disturbance in the structure and function of the gut microbiota, increasing the risk of neoplasia and inducing inflammation. O’Keefe (2016) finds that excessive meat consumption will induce inflammatory and proliferative effects, and can be prevented only if we balance it out with vegetables and fruits. 

Here are some ways to build our colorectal cancer prevention diet:

Best and Worst Foods to Prevent Colorectal Cancer. (n.d.) found several studies agreed that dairy products rich in calcium can lower the risk of adenomas growing in our colon and can prevent colorectal cancer. Next is whole grains where they are packed with fiber and nutrients, not to mention it is a  good source for magnesium. Having a diet rich in fiber is important because they keep our stools moving along our colon. It can also keep cancer-causing compounds from moving through our digestive tract before they have the chance to cause any harm (Cancer Prevention Diet , 2020). Having 90 grams of whole grains daily can be beneficial to us, whether it is oatmeal, brown rice and whole wheat bread. Our diet should also include colourful fruits and vegetables as they have natural substances called phytochemicals that may block the growth of cancer cells and can fight inflammation that can fuel cancer. Some fruits and vegetables that are recommended would be cabbage, broccoli and orange. Broccoli and cabbage contain cancer fighting properties, but broccoli is rich with sulforaphane. This compound boosts the body's protective enzymes and flushes out cancer-causing chemicals, and it also targets cancer stem cells (6 Cancer-Fighting Superfoods, (n.d.)). Garlic has phytochemicals that can halt the formation of nitrosamines and carcinogens that form in the colon. According to a study by Iowa’s Women’s Health Study, women with the highest amount of garlic in their diet had 50% lower risk of getting colorectal cancer, compared to women who ate the least (6 Cancer-Fighting Superfoods, (n.d.)). It is commonly known that berries are the ultimate superfood as they are packed with cancer-fighting phytonutrients. Blackberries however, contain high amounts of concentrations of anthocyanins, which can help slow down the growth of premalignant cells and keep new blood vessels from forming. 

As mentioned as the above, it is best to reduce consumption of red meat and processed meat. This is because processed meat tends to contain higher nitrate and nitrites, preservatives that can be very harmful to your colon if consumed in large amounts. Red meat should be consumed less because meat and cheese can be linked to contain saturated fats. If you consume food rich in saturated fats you are more prone to obesity, a big cancer predictor. Finally, prevent foods that are high in pure sugar like bubble tea, sweets, desserts. These are good and tasty but cancer is also attracted to sweet,sugary stuff. One of the tips to have a healthy balanced diet is by going on to Youtube to search for easy, healthy balanced diet recipes. There are tons of recipes online that you can find to ensure that you are eating clean and healthy. You can be creative with your meal preparations and at the same time have a different variety of food every day. It’s like killing two birds with one stone. Also, it is important to educate yourself on the importance of having a healthy diet (Hatami et al., 2017). 

 Dietary interventions are difficult to develop and evaluate because they frequently require changes in complex behaviours. By providing nutrition education based on HBM, it is found to significantly improve knowledge and attitude Therefore, a theory that has increasingly been used to guide nutrition research to improve intervention efficacy is the Health Belief Model. According to Hatami et al. (2017), they found several studies that indicate dietary compliance is related to an individual’s perceptions and beliefs. There are several concepts that predict why people take action to prevent behaviours as this health behavior is determined by personal beliefs or perceptions about a disease/health condition and the strategies available to decrease its occurrence:

Perceived susceptibility to disease/disability

Perceived severity of the disease/disability

Perceived benefits of health-enhancing behaviours

Perceived barriers to health-enhancing behaviours

Based on this model, the first concept is when people believe they are susceptible to colorectal cancer. According to a study done by Hatami et al. (2017), it is estimated that 30%–40% of CRC cases are linked to nutrition and other lifestyle factors. There is also convincing evidence that suggests risk of colon cancer is increased by processed and unprocessed meat consumption but suppressed by fibre-rich foods (O’Keefe,2016). Not only that, with the pace of the society is going, fast food is inevitable. It is cheap, easily accessible, and also delicious. This could also be one of the main factors on why colorectal cancer kept increasing.  Next, it is important for people to understand the depth of risk and severity of colorectal cancer complications in their life. According to Baena & Salinas (2015), colorectal cancer is the third most common diagnosed cancer in men (746,000 new cases per year) and the second in women (614,000 new cases per year) worldwide. It is proven that the risk of colorectal cancer increases with age (Cancer.net,2019). There is a 80%-90% survival rate in Stage I colorectal cancer. Stage II tumors have survival rates ranging from 55 to 80 percent. stage III has about a 40 percent chance of cure while a patient with a stage IV tumor has only a 10 percent chance of a cure (Azeem et al., 2015). It is important to undergo colonoscopy every 5 years but one of the downfalls of this test is that it is painful. But it is important to undergo it to prevent recurrence. The third concept is when people consider healthy eating can decrease risk or severity of colorectal cancer. By knowing and understanding the benefits of having a healthy diet, they will be more motivated and determined to eat a healthy diet that consists of less red meat and more in vegetables and fruits. Finally, when they are able to overcome obstacles for action, including cost and difficulty of healthy eating ,people are more likely to participate in this healthy eating practice (Hatami et at., 2017). By having a balanced diet, it not only prevents them from getting colorectal cancer but also a whole lot of diseases as well. Your overall health would be improved and can also maintain a healthy body weight. It is important to be educated on colorectal cancer because it is something that can affect many people unknowingly. Therefore the aim of this blog is to educate the public on colorectal cancer and how to prevent it.

References

6 Cancer-Fighting Superfoods. (n.d.). Retrieved from https://www.health.com/condition/cancer/6-cancer-fighting-superfoods?slide=89f0ab1d-0f21-4fb7-b0ef-10c4b5ab5bf8#89f0ab1d-0f21-4fb7-b0ef-10c4b5ab5bf8

Azeem, S., Gillani, S. W., Siddiqui, A., Jandrajupalli, S. B., Poh, V., & Sulaiman, S. A. S. (2015). Diet and Colorectal Cancer Risk in Asia - a Systematic Review. Asian Pacific Journal of Cancer Prevention, 16(13), 5389–5396. doi: 10.7314/apjcp.2015.16.13.5389       

Best and Worst Foods to Prevent Colorectal Cancer. (n.d.). Retrieved from https://www.webmd.com/colorectal-cancer/ss/slideshow-foods-prevent 

Cancer Prevention Diet. (2020,February 16). Retrieved from https://www.helpguide.org/articles/diets/cancer-prevention-diet.htm

Colorectal Cancer - Stages. (2019, January 6). Retrieved from https://www.cancer.net/cancer-types/colorectal-cancer/stages

Diddana, T. Z., Kelkay, G. N., Dola, A. N., & Sadore, A. A. (2018). Effect of Nutrition Education Based on Health Belief Model on Nutritional Knowledge and Dietary Practice of Pregnant Women in Dessie Town, Northeast Ethiopia: A Cluster Randomized Control Trial. Journal of Nutrition and Metabolism, 2018, 1–10. doi: 10.1155/2018/6731815

Hatami, T., Noroozi, A., Tahmasebi, R., & Rahbar, A. (2018). Effect of Multimedia Education on Nutritional Behaviour for Colorectal Cancer Prevention: An Application of Health Belief Model. Malaysian Journal of Medical Sciences, 25(6), 110–120. doi: 10.21315/mjms2018.25.6.11

O’Keefe, S. J. D. (2016). Diet, microorganisms and their metabolites and colon cancer. Nature Reviews Gastroenterology & Hepatology, 13(12), 691–706. doi:10.1038/nrgastro.2016.165  Sieri, S., Agnoli, C., Pala, V., Grioni, S., Brighenti, F., Pellegrini, N., … Krogh, V. (2017). Dietary glycemic index, glycemic load, and cancer risk: results from the EPIC-Italy study. Scientific Reports, 7(1). doi: 10.1038/s41598-017-09498-2    

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Reduction of alcohol consumption and smoking (Cheah Wai Kit, Winson)

It is normal for people to get sick or develop certain illnesses. However, some people might develop serious illnesses due to environmental factors or genetic factors (Fagunwa et al., 2017) and some of them might develop a disease that they are not aware of. One of the most common serious diseases is colorectal cancer. Colorectal cancer which also known as colon cancer has been said to be one of the most common causes of death rate and incidence rate around the world (Siegel, Naishadham & Jemal, 2012) (as cited in Gonzalez-Saenz de Tejada et al., 2015). According to the Ministry of Health Malaysia (2007), the report indicated that colorectal cancer is known to be the second major cancer in Malaysia. According to the Ministry of Health Malaysia (2014), colorectal cancer is also found to be second major cancer in males and third major in females. The entire morbidity rate for colorectal cancer is 21.3 cases as per 100,000 individuals in Malaysia and it was 1.33 higher among males as compared to females from 2008 to 2013. From 2008 to 2013, the mortality rate for colorectal cancer is 9.8 cases per 100,000 individuals. It is also being said that it is more likely to survive from this cancer if it is detected in early stage, so awareness of risk factors, symptoms and warning signs act as factors for early detection of colorectal cancer (as cited Sindhu et al., 2019).  

There are many reasons that contribute to the development of cancer disease, one of the most common reasons is lifestyle. World Cancer Research Fund (2011); Kushi et al. (2012) showed that lifestyle such as physical activity, smoking, alcohol, diet and body weight are interconnected with the risk of colorectal cancer (as cited in van Zutphen, 2017). There are many health related behaviors that can be executed to prevent colorectal cancer, one of them is maintaining a healthy lifestyle. In order to maintain a healthy lifestyle, people can make changes in diet, enhance physical activity. However, the targeted health behaviors that are going to be suggested are only the reduction of alcohol consumption and tobacco usage and the target population is those who have not developed colorectal cancer and having habits of smoking and alcohol consumption. 

  According to the World Health Organization (2014), alcohol intake is said to be one of the causes that contributed to public health problems in many countries. In 2012, approximately 5.9% of mortality rate was related to alcohol (as cited in Amin, Siegel & Naimi, 2018). Amin et al. (2018) also stated that there are many studies that showed the possibility that alcohol consumption acted as a risk factor for colorectal cancer. Amin et al. (2018) conducted a study to look for the websites of six different cancer organizations that have the statements connecting to the relationship between cancer risk and alcohol consumption. The results showed that all organizations agreed that alcohol can increase the risk for certain cancer and alcohol has been labeled as group 1 carcinogen except for 2 organizations which are American Cancer Society and Canadian Cancer Society. A Multiethnic Cohort study was done by Park et al. in 2008 to figure out the relationship between alcohol intake with the risk for colorectal cancer based on lifestyle related factors, race, alcoholic beverage type and anatomical subsite. The results indicated that high levels of alcohol intake has a positive relationship with an increased risk of colorectal cancer and the risk predicted it was significant for both men and women with possible confounding variables. The combination of both genders, it was obvious that the risk increased among Native Hawaiian, Latino, Japanese-American and white persons such as those who never use NSAID, people with lower BMI, people with lower intake of dietary fiber and people with lower intake of folate. The alcohol consumption in particular with wine and beer was related to enhanced risk for colorectal cancer and the connection was apparenet for left colon and rectum as compared to right colon tumors. Whitmarsh (2017) tried to figure out the associations between lifestyle risk factors including alcohol consumption with colorectal cancer in the UK Biobank cohort. The UK Biobank is a number of 500,000 men and women at the age between 40-69 and were enrolled between 2006-2010. The participants were followed up for cancer and death registration till 2014 through connection with national datasets. The results showed that there is a connection between alcohol intake and colorectal cancer only for men and with exception of women. As for men, there was an association related to dose-response between alcohol intake and colorectal cancer. Also in the UK Biobank, there was proof shown that the beer intake has relation with the risk for colorectal cancer. A case control study conducted by Wang, Yang, Shen, Ge and Lin in the year of 2017 in the Han Chinese population to find out if there is association between alcohol with the risk for colorectal cancer. The findings indicated that those with heavy alcohol consumption are more likely to increase the risk for colorectal cancer. Naing, Lai and Mak (2017) conducted a study to find out if there is possibility in the reduction in case incidence of colorectal cancer if people apply modifiable risk factors such as alcohol consumption, overweight and physical activity in Malaysia. The results proved that 369 colorectal cancer cases in 2013, a total number of 70 cases would be prevented if Malaysian people have conducted physical exercises, reduction of body weight to normal level and avoid consuming alcohol. It was also found that 66 cases who have the three risk factors for the past decade would have been prevented from this cancer only if they have control over these risk factors through effective prevention methods. Andersson (2018) conducted a study to estimate the number of cancer cases including colorectal that could be prevented by making changes in alcohol consumption based on the Prevent macro-simulation model. The results showed that approximately 83,000 cancer cases could be prevented in the Nordic countries in a period of 30 years if there is entire elimination of alcohol assumption and it was 5.5% of the predicted number of cases for the six types of alcohol related cancer. The number of preventable cases was highest for post-menopausal breast and colorectal cancer. 

Smoking is also one of the risk factors for colorectal cancer and hence the reduction of smoking or tobacco usage can act as health seeking behavior. Whitmarsh (2017) conducted a study to find out the relationship between three lifestyle factors such as adiposity, alcohol intake and smoking in the UK Biobank Cohort. The results for smoking clearly stated that those who have cigarette smoking before were more likely to develop colorectal cancer as compared to those who never smoke as well as there is no certain evidence to show increased risk for those who have cigarette smoking now. Another study that has been done by Richardson et al. in 2016 intended to estimate population attributable fractions (PAF) for six lifestyle factors including smoking that could be changed related to colorectal cancer in New Zealand. As a result, the PAF showed 3% for smoking in New Zealand. The study in the end emphasized that reduction in lifestyle factors including smoking did reduce the risk for colorectal cancer for the people in New Zealand. One population-based case control research that has been done to figure out if utilization of lower Gastrointestinal endoscopy can change the effect of smoking with colorectal cancer (Hoffmeister et al., 2014). The results indicated that former cigarette smokers have positive connection with increased risk for colorectal cancer with no previous endoscopy and former cigarette smokers with increased risk of colorectal cancer can be prevented through detection and removal of adenomas at lower Gastrointestinal endoscopy. The risk of colorectal cancer could be enhanced if those who are at older ages continue to smoke (Hoffmeister et al., 2014).

There are many theories that can be used to apply in assistance of the health related behaviors such as the reduction of alcohol consumption and avoid smoking which will be mainly focused on. One of the theories that can be used is theory of planned behavior. Fishbein and Ajzen (1975) first proposed the theory of reasoned action and later modified and came out with a better model which is the theory of planned behavior (Ajzen, 1991). These theories aimed at modifying and predicting human behavior as well as explaining the psychological processes whereby people possess certain beliefs to carry out a behavior which in the end changes the action of people (as cited in Yzer, 2017). Based on the theory of planned behavior, beliefs that human possesses offer the foundation for attitudes, subjective norms and perception of behavioral control. In particular, behavioral beliefs refer to human’s attitude towards the behavior relies on certain beliefs such as positive thinking or negative outcome might occur if acting out the behavior, normative beliefs refer to subjective norm lies on beliefs about the normative expectations of important people such as family and friends and perceived behavioral control refer to confidence and ability that one possesses and it will affect the likelihood to perform the aimed behavior. If the theory of planned behavior is being used as a theoretical framework, the aim of intervention towards modifying behavioral, normative and perceived control beliefs will ultimately provide motivation to perform the behavior. Successful application of the theory of planned behavior could enhance beliefs on positive consequences, reduce the negative consequences, agreeing the suggestions from friends or family, improve skills and knowledge to act the behavior as well as reduce the challenges that people face (Steinmetz et al., 2016). The application of the theory of planned behavior provides a wide range of choices to plan and act out interventions (Steinmetz et al., 2016). Steinmetz et al. (2016) conducted a meta analysis to investigate the effectiveness of theory of planned behavior towards interventions. The analysis stated that the effectiveness of theory of planned behavior-based intervention achieved a mean effect size of .50 for changes in behavior and effect sizes from .14 to .68 for changes in precedent variables such as behavioral beliefs. The analysis then indicated that the effectiveness of the interventions differs due to multiple behavior change methods. It was said that interventions executed in public and with groups determined to be more successful than in private places or only focus on persons. Tseng et al. (2017) conducted a study to find out the elements that predict the intention of quitting smoking and the following behavior half a year later in Taiwan after using the theory of planned behavior (TPB). The findings showed that the TPB stated that 34% of the variance in intention to quit smoking. Through the addition of perceived susceptibility, the mentioned variance was increased to 40%. The most important factors were perceived behavior control and perceived susceptibility and attitude. Subjective norms did not have influence on the prediction of intention. Attitude and perceived behavioral control influence on the prediction of quitting behavior but subjective norm, intention and perceived susceptibility have no influence. The analysis showed that the TPB in general is an effective framework to predict the intention to quit smoking in Taiwan. The addition of perceived susceptibility did increase the prediction of intention. The act of stopping smoking mainly focuses on strengthening cessation belief, improving the perception of people who smoke and their ability to stop smoking and convince them that they are capable of getting over the barriers to stopping and hence it might improve effectiveness of cessation interventions. Norman et al. (2017) has done research to study whether combining beliefs from the theory of planned behavior that place under binge drinking, a self affirmation manipulation to decrease defensive processing and implementation intentions to decrease alcohol consumption of students for half a year at the university. Participants who got the message from the theory of planned behavior had reduced thoughts on binge drinking, consume less alcohol, less likely to engage in binge drinking and less harm actions of alcohol consumption for half a year in university. The study did support the application of the theory of planned behavior-based interventions to decrease alcohol consumption for students.  

In conclusion, huge amounts of alcohol consumption and smoking are harmful to people and put people at high risk for colorectal cancer. The application of the theory of planned behavior (TPB) is useful for reduction of alcohol consumption and smoking as supported by studies. Those who have habits of alcohol consumption and smoking can apply TPB as an intervention in order to change their behavior and it will lower the risk for getting colorectal cancer.

References

Amin, G., Siegel, M., & Naimi, T. (2018). National Cancer Societies and their public statements on alcohol consumption and cancer risk. Addiction, 113(10), 1802-1808. doi: 10.1111/add.14254

 Andersson, T. M.-L., Engholm, G., Pukkala, E., Stenbeck, M., Tryggvadottir, L., Storm, H., & Weiderpass, E. (2018). Avoidable cancers in the Nordic countries—The impact of alcohol consumption. European Journal of Cancer, 103, 299-307. doi:10.1016/j.ejca.2018.03.027

 Fagunwa, I. O., Loughrey, M. B., & Coleman, H. G. (2017). Alcohol, smoking and the risk of premalignant and malignant colorectal neoplasms. Best Practice & Research Clinical Gastroenterology, 31(5), 561–568. doi:10.1016/j.bpg.2017.09.012

 Gonzalez-Saenz de Tejada, M., Bilbao, A., Baré, M., Briones, E., Sarasqueta, C., Quintana, J., & Escobar, A. (2015). Association of social support, functional status, and psychological variables with changes in health-related quality of life outcomes in patients with colorectal cancer. Psycho-Oncology, 25(8), 891-897. doi: 10.1002/pon.4022

 Hoffmeister, M., Jansen, L., Stock, C., Chang-Claude, J., & Brenner, H. (2014). Smoking, Lower Gastrointestinal Endoscopy and risk for Colorectal Cancer. Cancer Epidemiology Biomarkers & Prevention 23(3), 525-533. doi: 10.1158/1055-9965.EPI-13-0729-T

 Naing, C., Lai, P., & Mak, J. (2017). Immediately modifiable risk factors attributable to colorectal cancer in Malaysia. BMC Public Health, 17(1). doi: 10.1186/s12889-017-4650-8

 Norman, P., Cameron, D., Epton, T., Webb, T., Harris, P., Millings, A., & Sheeran, P. (2017). A randomized controlled trial of a brief online intervention to reduce alcohol consumption in new university students: Combining self-affirmation, theory of planned behaviour messages, and implementation intentions. British Journal Of Health Psychology, 23(1), 108-127. doi: 10.1111/bjhp.12277

 Park, S., Wilkens, L., Setiawan, V., Monroe, K., Haiman, C., & Le Marchand, L. (2018). Alcohol Intake and Colorectal Cancer Risk in the Multiethnic Cohort Study. American Journal Of Epidemiology, 188(1), 67-76. doi: 10.1093/aje/kwy208

 Richardson, A., Hayes, J., Frampton, C., & Potter, J. (2016). Modifiable lifestyle factors that could reduce the incidence of colorectal cancer in New Zealand. New Zealand Medical Journal, 129(1447), 13-20. Retrieved from https://global-uploads.webflow.com/5e332a62c703f653182faf47/5e332a62c703f6b1202fd059_Richardson%20FINAL.pdf

 Sindhu, C. K., Nijar, A. K., Leong, P. Y., Li, Z. Q., Hong, C. Y., Malar, L., Lee, P. Y., & Kwa, S. K. (2019). Awareness of Colorectal Cancer among the Urban Population in the Klang Valley. Malaysian Family Physician, 14(3), 18–27. Retrieved from https://e-mfp.org/wp-content/uploads/v14n3-original-article-3.pdf

 Steinmetz, H., Knappstein, M., Ajzen, I., Schmidt, P., & Kabst, R. (2016). How Effective are Behavior Change Interventions Based on the Theory of Planned Behavior?. Zeitschrift Für Psychologie, 224(3), 216-233. doi: 10.1027/2151-2604/a000255

 Tseng, Y.-F., Wang, K.-L., Lin, C.-Y., Lin, Y.-T., Pan, H.-C., & Chang, C.-J. (2017). Predictors of smoking cessation in Taiwan: using the theory of planned behavior. Psychology, Health & Medicine, 23(3), 270–276. doi:10.1080/13548506.2017.1378820

 van Zutphen, M., Kampman, E., Giovannucci, E., & van Duijnhoven, F. (2017). Lifestyle after Colorectal Cancer diagnosis in relation to survival and recurrence: A review of the literature. Current Colorectal Cancer Reports, 13(5), 370-401. doi: 10.1007/s11888-017-0386-1

 Whitmarsh, A. (2017). The effects of alcohol intake, adiposity and smoking on the risk of colorectal cancer in UK Biobank. (Doctoral thesis, Division of Population Medicine, Cardiff University). Retrieved from http://orca.cf.ac.uk/101098/1/WhitmarshAPhD.pdf

 Wang, Y., Yang, H., Shen, C.-J., Ge, J.-N., & Lin, J. (2017). Association between alcohol consumption and colorectal cancer risk. European Journal of Cancer Prevention, 1. doi:10.1097/cej.0000000000000355 

 Yzer, M. (2017). Theory of Reasoned Action and Theory of Planned Behavior. The International Encyclopedia of Media Effects, 1–7. doi:10.1002/9781118783764.wbieme0075

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Explanation and Diagnosis of Colorectal Cancer

Colorectal cancer (CRC), also known as colon cancer , is one of the most prevalent cancers that happens to both men and women worldwide. According to O’Keefe (2016), colorectal cancer is the second leading cause of cancer death worldwide. A quick search on the web shows no changes. Most CRC start as polyps growing on the inner lining of the rectum or colon. When these polyps change into cancer, they are called adenomas, also known as a precancerous condition. Adenocarcinomas make up about 96% of colorectal cancers where the cancers start in cells that make mucus to lubricate the inside of the colon and rectum (Cancer.org, n.d). Other types of cancer that occur far less often in the colon or rectum includes carcinoid tumour, gastrointestinal stromal tumour (GIST), small cell carcinoma and lymphoma.

Most colorectal cancers (about 95%) are considered sporadic. It means the genetic changes develop by chance after a person is born, so there is no risk of passing these genetic mutations to offspring. Inherited colorectal cancers are less common (about 5%) and occur when genetic mutations are passed down from one generation to the next (Cancer.net,2019).

Normally, clinical manifestations of CRC depend on the location of the lesion as both left and right lesions occasionally cause hematochezia (De Rosa et al., 2015).  However, bleeding is often occult and causes anemia and fatigue. Early diagnosis of CRC in symptomatic patients is still a problem because it is a complex process to begin with. When the patient detects the first symptoms, a diagnostic procedure is performed. Then, the patient has to undergo a consultation with a general practitioner, get a referral to see a specialist, and there is also the waiting period for diagnostic procedures like doing a colonoscopy (Vega,Valentin & Cubiella, 2015).

 Lower abdominal symptoms are very common and the public would make frequent visits to the general practitioner when their abdomen hurts. The problem is that symptoms are usually very vague and non-specific, with a poor sensitivity for CRC (Vega,Valentin & Cubiella, 2015). Moreover, the demand for colonoscopy has become a significant problem as endoscopic resources are limited hence these waiting periods also delay the diagnosis of CRC. 

The risk of CRC increases with age, with around 90% of the cases are individuals aged 50 and older. However, it is noted that while the rates of CRC have been declining among adults who are 50 years and older,it is concerning that rates of  CRC are increasing among adults under 50 years old(Colon Cancer Facts,2020). Therefore, this blog is made to raise awareness on what is colorectal cancer and shows ways on how to prevent getting colorectal cancer.

References: 1. Colorectal Cancer - Stages. (2019, January 6). Retrieved from https://www.cancer.net/cancer-types/colorectal-cancer/stages

2. Colon Cancer Facts. (n.d.). Retrieved from https://coloncancercoalition.org/get-educated/what-you-need-to-know/colon-cancer-facts/

3. DE ROSA, M., PACE, U., REGA, D., COSTABILE, V., DURATURO, F., IZZO, P., & DELRIO, P. (2015). Genetics, diagnosis and management of colorectal cancer (Review). Oncology Reports, 34(3), 1087–1096. http://doi:10.3892/or.2015.4108

4.O’Keefe, S. J. D. (2016). Diet, microorganisms and their metabolites and colon cancer. Nature Reviews Gastroenterology & Hepatology, 13(12), 691–706. http://doi:10.1038/nrgastro.2016.165 

5.What Is Colorectal Cancer? (n.d). Retrieved from https://www.cancer.org/cancer/colon-rectal-cancer/about/what-is-colorectal-cancer.html

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Types of Colorectal Cancer

1.Adenocarcinoma

In all forms in colorectal cancer, colon and rectum make up 95 per cent. Rectal and colon adenocarcinomas form inside the large intestine inside the lining cells of the gastrointestinal tract. Colon and rectum adenocarcinomas usually begin as a tissue development, called a polyp. A certain type of polyp called an adenome may grow into cancer. Through daily colonoscopy, polyps are often removed so that they will not develop into cancer.

2. Carcinoid Tumours

Carcinoid tumors arise in nerve cells called neuroendocrine cells, which help control the production of hormones. Such tumors belong to a group of cancers called neuroendocrine (NET) tumors. Cells of the carcinoid tumors expand gradually and can form in the lungs and/or gastrointestinal tract. They  account for 1 per cent of all colorectal cancers and half of all small intestine cancers found.

3. Gastrointestinal Stromal Tumours

A uncommon type of colorectal cancer arising in a special cell located in the gastrointestinal (GI) tract lining, called Cajal interstitial cells (ICCs). Nearly 50 percent of GISTs arise in the uterus. Within the small intestine, while most other GISTs type, the rectum is the third most common site. GISTs are known as sarcomas or cancers starting in connective tissues, including flesh, muscle, blood vessels, deep skin tissues, nerves, bones, and cartilage.

4. Primary Colorectal Lymphoma

A type of non-Hodgkin (cancer that originates in the lymphatic system) lymphoma, this type of cancer occurs specifically in cells called lymphocytes in the lymphatic system. Lymphocytes are a type of white blood cell which helps combat infections in the body. For several areas of the body, lymphoma can form including the lymph nodes, bone marrow, spleen, thymus, and digestive tract. New colorectal lymphomas make up about 0.5% of all colorectal tumors, and only 5% of all lymphomas. Usually this form of colorectal cancer develops later in life, and is more frequent in men than women.

5. Leiomyosarcomas

Leiomyosarcoma, another form of sarcoma, literally means "smooth muscle cancer." The colon and rectum have three layers of the muscle type affected by leiomyosarcoma, and all three function together to direct waste through the digestive tract. This unusual form of colorectal cancer consists about 0.1 percent of all colorectal cases.

References: Cancer Treatment Centers of America, (2020). “Types of Colorectal Cancer: Common, Rare and More Varieties.” Retrieved from: www.cancercenter.com/cancer-types/colorectal-cancer/types.

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Risk Factors

1. Age and gender

People who are aged 50 and above have more likelihood to get colorectal cancer and the percentage is more than 90%. Men happen to have higher chances to get colorectal cancer as compared to women. 

2. Hereditary colorectal cancer syndrome

One of the factors that contribute to colorectal cancer or any other types of cancer are the rare inherited conditions in any members of families such as Gardner syndrome, familial adenomatous polyposis and Lynch syndrome. 

3. Personal history of certain types of cancer

Those who have had colorectal cancer in the previous period or women who used to develop ovarian or uterine cancer will have colorectal cancer at a higher risk. 

4. Smoking

Latest research indicated that those who smoke are at a dangerous risk to not survive from colorectal cancer. 

5. Inflammatory bowel disease

Those who have inflammatory bowel disease such as ulcerative colitis are more likely to develop colorectal cancer. 

6. Adenomatous polyps (adenomas)

Those who suffer from adenomas have higher chances to develop colorectal cancer or additional polyps and a regular screening test should apply to them. 

References: Pabla, B., Bissonnette, M., & Konda, V. J. (2015). Colon cancer and the epidermal growth factor receptor: Current treatment paradigms, the importance of diet, and the role of chemoprevention. World journal of clinical oncology, 6(5), 133–141. https://doi.org/10.5306/wjco.v6.i5.133

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Screening Tests

Screening tests for colon cancer is the process of looking for cancer in people who have no symptoms. Several tests can be used to screen for colorectal cancer. One of it is stool-based tests. These tests check the stool faces for signs of cancer. These tests are less invasive and easier to have done, but they need to be done more often. Another test is visual structural tests. These tests look at the structure of the colon and rectum for any abnormal areas. This is done either with a scope, which is a tube-like instrument with a light and tiny video camera on the end then put into the rectum, or with special imaging which is x-ray tests (Vega.P., Valentín.F.,  &  Cubiella, J., 2015).

Tumour Node Metastasis System (TNM)

One of the tool that doctors use to describe the stage is the Tumour Node Metastasis system (TNM). Doctors use the results from diagnostic tests and scans to answer these questions:

Tumour (T): Has the tumour grown into the wall of the colon or rectum? How many layers?

Node (N): Has the tumour spread to the lymph nodes? If so, where and how many?

Metastasis (M): Has the cancer spread to other parts of the body? If so, where and how much?

There are 5 stages in this TNM system, starting from stage 0 (zero) and stages I through IV (1 through 4). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

Tumour (T)

Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe how deeply the primary tumour has grown into the bowel lining. Stage may also be divided into smaller groups that help describe the tumour in even more detail. Specific tumour information is listed below (Cancer.Net., 2019).

TX: The primary tumour cannot be evaluated.

T0 (T plus zero): There is no evidence of cancer in the colon or rectum.

T refers to carcinoma in situ (also called cancer in situ). Cancer cells are found only in the epithelium or lamina propria, which are the top layers lining the inside of the colon or rectum.

T1: The tumour has grown into the submucosa, which is the layer of tissue underneath the mucosa or lining of the colon.

T2: The tumour has grown into the muscular is propria, a deeper, thick layer of muscle that contracts to force along the contents of the intestines.

T3: The tumour has grown through the muscular is propria and into the subserosa, which is a thin layer of connective tissue beneath the outer layer of some parts of the large intestine, or it has grown into tissues surrounding the colon or rectum.

T4a: The tumour has grown into the surface of the visceral peritoneum, which means it has grown through all layers of the colon.

T4b: The tumour has grown into or has attached to other organs or structures.

Node (N)

The "N" in the TNM system stands for lymph nodes. The lymph nodes are tiny, bean-shaped organs located throughout the body. Lymph nodes help the body fight infections as part of the immune system. Lymph nodes near the colon and rectum are called regional lymph nodes. All others are distant lymph nodes that are found in other parts of the body (Cancer.Net., 2019).

NX: The regional lymph nodes cannot be evaluated.

N0 (N plus zero): There is no spread to regional lymph nodes.

N1a: There are tumour cells found in 1 regional lymph node.

N1b: There are tumour cells found in 2 or 3 regional lymph nodes.

N1c: There are nodules made up of tumour cells found in the structures near the colon that do not appear to be lymph nodes.

N2a: There are tumour cells found in 4 to 6 regional lymph nodes.

N2b: There are tumour cells found in 7 or more regional lymph nodes.

Metastasis (M)

The "M" in the TNM system describes cancer that has spread to other parts of the body, such as the liver or lungs. This is called distant metastasis.

M0 (M plus zero): The disease has not spread to a distant part of the body.

M1a: The cancer has spread to 1 other part of the body beyond the colon or rectum.

M1b: The cancer has spread to more than 1 part of the body other than the colon or rectum.

M1c: The cancer has spread to the peritoneal surface.

Grade (G)

Doctors also describe this type of cancer by its grade (G). The grade describes how much cancer cells look like healthy cells when viewed under a microscope.

The doctor compares the cancerous tissue with healthy tissue. Healthy tissue usually contains many different types of cells grouped together. If the cancer looks similar to healthy tissue and has different cell groupings, it is called "differentiated" or a "low-grade tumour." If the cancerous tissue looks very different from healthy tissue, it is called "poorly differentiated" or a "high-grade tumour." The cancer’s grade may help the doctor predict how quickly the cancer will spread. In general, the lower the tumour’s grade, the better the prognosis (Cancer.Net., 2019) .

GX: The tumour grade cannot be identified.

G1: The cells are more like healthy cells, called well differentiated.

G2: The cells are somewhat like healthy cells, called moderately differentiated.

G3: The cells look less like healthy cells, called poorly differentiated.

G4: The cells barely look like healthy cells, called undifferentiated.

References: Cancer.Net. (2019). Colorectal Cancer: Stages. Journal of ASCO. Retrieved from: https://www.cancer.net/cancer-types/colorectal-cancer/stages

Vega, P., Valentín, F., & Cubiella, J. (2015). Colorectal cancer diagnosis: Pitfalls and opportunities. World journal of gastrointestinal oncology, 7(12), 422–433. https://doi.org/10.4251/wjgo.v7.i12.422

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Symptoms of Colon Cancer #1

Changes in stool and bowel habits

diarrhea

constipation

stool size

darkened stool color

blood in stool

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Symptoms of Colon Cancer #2

Overall Physical Changes

Fatigue

Unintended weight loss

Bloating in the abdominal area

Urge to empty bowel