Colorectal Cancer, Metastatic or Recurrent
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This topic is about colorectal cancer that has spread or come back. If you want to learn more about early-stage colorectal cancer, see the topic Colorectal Cancer.
What is colorectal cancer?
Colorectal cancer happens when cells that are not normal grow in your colon or rectum. These cells grow together and form polyps. Over time, some polyps can turn into cancer. This cancer is also called colon cancer or rectal cancer, depending on where the cancer is.
Metastatic cancer is cancer that has spread to other parts of the body. When colon or rectal cancer spreads, it most often spreads to the liver. Sometimes it spreads to the lungs, bones, or other organs in the body.
Colon and rectal cancers often return months or years after treatment. This is called recurrent cancer. If the original cancer was removed before it was able to spread, the chances that it will return are lower.
What causes metastatic or recurrent colorectal cancer?
Doctors don't know the exact cause. But the cancer is more likely to spread or come back if it is in a later, more advanced stage when it is first discovered.
Sometimes cancer cells are too small to be found by tests. These cells may continue to grow and show up later as metastatic cancer, even years after treatment.
What are the symptoms?
The most common symptoms are:
- A change in your bowel habits, such as more frequent stools, thinner stools, or a feeling that your bowels are not emptying completely.
- Blood in your stool or very dark stools.
- Loss of appetite.
- Belly pain, especially gas pains, cramps, or a feeling of fullness.
- Losing weight without trying.
- Constant tiredness (fatigue).
Some people don't have any symptoms.
If your cancer has spread, you may have other symptoms, depending on where the cancer is.
How is metastatic or recurrent colorectal cancer diagnosed?
Colon or rectal cancer that has spread or returned is diagnosed using a physical examination and several tests, including blood tests, chest X-rays, bone scans, ultrasounds, and CT, PET, or MRI scans.
The diagnosis is usually confirmed with a biopsy. During this test, your doctor will take tissue samples from any areas that don't look normal. The tissue will be looked at under a microscope to see if it contains cancer.
If you have been treated for colon or rectal cancer in the past, it's important to have regular checkups to find any new cancer as soon as possible.
How is it treated?
Colon and rectal cancers that have spread or returned may be cured in some cases. Treatment may include surgery, radiation, chemotherapy, and targeted therapy. When the cancer cannot be cured, treatment can help you feel better and live longer.
Learning that you have cancer that has spread or come back can be very hard. Some people find that it helps to talk about their feelings with their family and friends. You may also want to talk with your doctor or with other people who have had this kind of cancer. Your local cancer centre or Canadian Cancer Society chapter can help you find a support group.
Frequently Asked Questions
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The exact cause of colorectal cancer is not known. Most cases start as small growths, or polyps, inside the intestine.
Metastatic and recurrent colorectal cancer is caused when the cancer spreads or comes back, even years after treatment. Sometimes cancer cells are too small to be found and removed. They keep growing and cause problems later.
The most common symptoms are:
- A change in bowel habits, such as narrow stools or frequent diarrhea or constipation.
- Blood in the stool, or stools that look like black tar.
- Loss of appetite.
- Pain in the belly, especially gas pains, cramps, or a feeling of fullness.
- Unexplained weight loss.
- Constant tiredness (fatigue).
Some people don't have any symptoms for some time.
If your cancer has spread, you may have other symptoms, depending on where the cancer is.
How cancer grows and spreads
Cancer is the growth of abnormal cells in the body. These extra cells grow together and form masses, lumps, or tumours. In colorectal cancer, these growths usually start as harmless polyps in the large intestine. If polyps are not found and removed, some of them can turn into cancer.
If the cancer is allowed to keep growing, over time it will invade and destroy nearby tissues and then spread farther.
- Colon cancer often spreads first to nearby lymph nodes. From there it may spread to other parts of the body, usually to the liver. It may also spread to the lungs, bones, or other organs in the body.
- Rectal cancer may spread directly to the lungs, bypassing the liver.
Recurrent colorectal cancer occurs when the cancer begins to grow again months or years after treatment.
The long-term outcome, or prognosis, for colorectal cancer depends on how much the cancer has grown and spread. Experts talk about prognosis in terms of "5-year survival rates." This means the percentage of people who are still alive 5 years or longer after their cancer was found. It is important to remember that these are only averages. Everyone's case is different. And these numbers don't necessarily show what will happen to you.
The 5-year survival rate:
- Is 69% for people whose cancer has spread to nearby organs or lymph nodes.footnote 1 This means that about 69 out of 100 people are still alive 5 years or longer after their cancer was discovered.
- Is 12% for people whose cancer has spread farther away to other parts of their bodies. footnote 1 This means that about 12 out of 100 people are still alive 5 years or longer after their cancer was discovered.
These numbers are taken from reports that were done at least 5 years ago, before newer treatments were available. So the actual chances of your survival are likely to be higher than these numbers.
What Increases Your Risk
Even after treatment that seems successful, colorectal cancer may come back (recur). But this depends on the stage of the cancer before treatment.
Your risk for recurrent or metastatic cancer depends on how aggressive your cancer is and how well treatments work.
When To Call a Doctor
You may be seeing a doctor regularly to check for symptoms, but symptoms might start between visits. Be aware of what is normal for you, and tell your doctor about any changes right away. Be sure to let your doctor know if you feel even very small changes.
Call your doctor if you have any of these symptoms:
- A change in bowel habits, such as constipation or diarrhea
- Pain or bloating in your belly
- Weight loss, loss of appetite, or severe tiredness
- Persistent shortness of breath or cough (especially coughing up blood)
- Bone pain
- Confusion or memory problems that get worse
Who to see
- A gastroenterologist.
- An internist.
- A colon and rectal surgeon.
- A medical oncologist.
- A radiation oncologist.
To prepare for your appointment, see the topic Making the Most of Your Appointment.
Examinations and Tests
Tests to help your doctor see if colorectal cancer has spread or come back include:
- An abdominal ultrasound to find the cause of pain or swelling in your belly.
- A colonoscopy to see if cancer has returned to your intestine.
- Blood tests to find out if cancer has returned (CEA) or to find the cause of symptoms such as weakness, fatigue, fever, bruising, or weight loss (complete blood count).
- A chest X-ray to find the cause of symptoms such as persistent coughing, coughing up blood, chest pain, or trouble breathing.
- A CT scan, an MRI, or a PET scan to see if colorectal cancer has spread into the chest or organs in the belly or pelvis.
- A brain CT scan or MRI to look into symptoms such as confusion, paralysis, numbness, vision problems, vertigo, or headaches.
- A biopsy, such as a liver biopsy or a lung biopsy, to find out where the cancer cells have spread.
- A bone scan to find out if cancer cells have spread to the bones.
If metastatic cancer is found, you may also have genetic tests before your doctor recommends a treatment plan. These tests look for gene changes (mutations) that can occur with colorectal cancer. They can show which chemotherapy medicines will help.
Your treatment for colorectal cancer that has spread or come back may include:
- Surgery. If cancer has come back in your intestine or another part of your body, surgery may be used to remove it. To learn more, see Surgery.
- Chemotherapy. These medicines kill cancer cells that have spread to other parts of your body. They also can relieve pain caused by the cancer. To learn more, see Medications.
- Radiation therapy. X-rays can be used to shrink colorectal tumours that may be causing blockages. They can also reduce bleeding or pain. To learn more, see Other Treatment.
- Targeted therapy. This treatment uses medicines called monoclonal antibodies to treat colorectal cancer. It is often given along with chemotherapy. To learn more, see Medications.
- Clinical trials. These are studies of new or different ways to treat cancer.
Colorectal cancer often comes back, even after treatment that seemed successful. Your cancer may return even if you do everything you can to prevent it. If this happens, focus on what you and your doctor can do to treat your symptoms to help you feel better and live longer.
Your treatment will depend on specific information about the cancer, your preferences, and your health.
Some cases can still be cured. When the cancer can't be cured, treatment can help you feel better and live longer.
Pain is one of the main concerns of people who have cancer. But cancer pain can almost always be controlled. There are several ways to control your pain, such as using strong medicines like opioids. Or you can have treatments that shrink tumours and block nerve pain.
As your cancer gets worse, you may want to think about hospice palliative care. Hospice palliative care can improve your quality of life-not just in your body but also in your mind and spirit. Hospice palliative care providers will work to help manage pain and other symptoms or side effects. They may help you decide what treatment you want or don't want. And they can help your loved ones understand how to support you.
There may come a time when treatments to cure your cancer are no longer working. Or you may decide that you want to spend the time you have left in other ways and only have medical care that keeps you comfortable. If so, talk to your doctor about hospice palliative care. Hospice palliative caregivers help to enhance the quality of your remaining life by keeping you as alert and comfortable as possible in a familiar environment with family and friends.
You may also want to:
- Discuss health care and other legal issues that arise near the end of life with your family and your doctor.
- State your health care choices in writing (with an advance care plan) while you are still able to make and communicate these decisions.
- Choose a substitute decision-maker in case you become unable to speak for yourself.
To learn more about supportive care, see:
There is no sure way to prevent colorectal cancer from coming back or spreading to other parts of your body.
But there are lifestyle changes that can help you after treatment. Research shows that these things may help:footnote 3
- Quit smoking, if you smoke.
- Keep a healthy body mass index (BMI).
- Get regular exercise.
- Eat more whole grains, fruits, vegetables, poultry, and fish.
- Eat less red meat, refined grains, and sweets.
Initial treatment for colorectal cancer is followed by regular doctor visits and screening to help find the cancer if it returns.
Managing side effects
During your treatment, you can help manage your side effects and symptoms at home. If your doctor has given you instructions or medicines to treat these problems, be sure to also use them.
Try home treatments for:
- Nausea or vomiting, such as ginger tea, peppermint candy or gum. Be sure to drink enough fluids so that you don't get dehydrated.
- Pain, such as over-the-counter pain relievers, heat packs, or cold packs. Talk to your doctor before using any home treatment for pain. To learn more, see the topic Cancer Pain.
- Diarrhea, such as taking small, frequent sips of water and bites of salty crackers.
- Constipation, such as getting plenty of water and fibre in your diet. Don't use a laxative without first talking to your doctor.
Other problems that can be treated at home include:
- Sleep problems. If you have trouble sleeping, try having a regular bedtime, getting exercise daily, and avoiding caffeine late in the day.
- Feeling very tired. If you lack energy or become weak easily, try to get extra rest. Plan your schedule to make the most of the energy you have.
- Mouth sores. Watch what you eat and drink. Rinse your mouth regularly with mouthwash or a liquid antacid.
In general, healthy habits such as eating a balanced diet and getting enough sleep and exercise may help control your symptoms.
Having cancer can be very stressful. Finding new ways to handle stress may help you feel better.
For example, you could:
- Try techniques to reduce your stress, such as yoga and visualization exercises.
- Talk about your feelings. Your cancer treatment centre may offer counselling services and support groups.
- Ask your doctor to help you find other sources of support and information.
Your feelings about your body may change after treatment. Dealing with your body image may involve talking openly with your partner about your worries and discussing your feelings with a doctor.
Contact your local cancer centre or chapter of the Canadian Cancer Society to find a support group. Talking with other people who have had similar experiences can be very helpful.
Having cancer can change your life in many ways. For help with managing these changes, see the topic Getting Support When You Have Cancer.
Chemotherapy is the use of medicines to stop cancer's growth or relieve symptoms. Sometimes chemotherapy may be used to shrink tumours in the liver so they can be removed with surgery.
The medicines may be given through a needle in your vein, as pills you can swallow, or as a shot (injection).
The most commonly used medicines are:
- Bevacizumab (Avastin).
- Capecitabine (Xeloda).
- Fluorouracil (5-FU).
- Irinotecan (Camptosar).
- Oxaliplatin (Eloxatin).
Cetuximab (Erbitux) and panitumumab (Vectibix) may be used for colorectal cancer that has spread and has not improved during or after treatment with other drugs. These kinds of medicines, called monoclonal antibodies, may not work for some people. So before you have this treatment, your tumour tissue will be checked for certain gene changes (mutations).
Your doctor may prescribe medicines to control nausea and vomiting.
Surgery may be used to remove cancer from the colon or rectum. Or it may be done to remove cancer that has spread to other organs in the body. The type of surgery chosen depends upon the stage of the cancer.
- Bowel resection.The surgeon cuts out the cancer in the colon or rectum as well as the parts of the colon or rectum that are next to it. Then the two healthy ends of the colon or rectum are sewn back together.
- Liver resection. The surgeon cuts out cancer that has spread to the liver, as well as parts of the liver that are next to the cancer. If the cancer in your liver is too large to remove with surgery, you may be given chemotherapy. It can shrink the tumour so it can be removed.
- Lung, adrenal, or ovarian resection, depending on where the cancer has spread and whether you are a good candidate for this surgery.
If cancer that has returned to your intestine is large, more of your colon or rectum may have to be removed. If the ends of your colon or rectum can't be rejoined, you may need a colostomy. Most people don't need a permanent colostomy.
Sometimes surgery is used not to cure your cancer but to make your life more comfortable. For example, the surgeon may create a colostomy to give you relief from symptoms caused by a tumour blocking your colon.
Radiation treatment uses X-rays to destroy colorectal cancer cells. It is often combined with surgery or chemotherapy. Radiation may also be used to reduce the cancer's size when it is blocking the colon or rectum.
Radiation treatments aren't likely to cure metastatic or recurrent colorectal cancer. But they may ease pain and discomfort, slow the spread of the disease, and help you live longer.
Treatment for cancer that has spread to the liver
Sometimes colorectal cancer that has spread to the liver can be removed by surgery. But usually other treatments are needed, such as:
- Radiofrequency ablation. A small wire that sends out radio waves is inserted into the tumour. The radio waves destroy the cancer that has spread to the liver without harming healthy tissue.
- Cryosurgery. This may be done in surgery for cancer that has spread to the liver. Liquid nitrogen is used to freeze and destroy cancer cells.
- Embolization. This shrinks a cancer that has spread to the liver by cutting off its blood supply.
- Interstitial radiation therapy. In this type of internal radiation treatment, radioactive material sealed in needles, wires, seeds, or catheters is placed directly into the tumour or body tissue.
- Intra-arterial hepatic chemotherapy. The surgeon implants a small pump in the belly that delivers chemotherapy right into the tumour. The pump can be left in place as long as needed.
Clinical trials are studies that look for new treatments. If you are interested, ask your doctor if there are trials you can take part in. Your provincial cancer agency or your local chapter of the Canadian Cancer Society can also help you find clinical trials.
People sometimes use complementary therapies along with medical treatment to help relieve symptoms and side effects of treatments. Some of the complementary therapies that may be helpful include:
- Acupuncture to relieve pain.
- Meditation or yoga to relieve stress.
- Massage and biofeedback to reduce pain and ease tension.
- Breathing exercises for relaxation.
These treatments may help you feel better. They can make it easier to cope with cancer treatments. They also may reduce chronic low back pain, joint pain, headaches, and pain from treatments.
Before you try a complementary therapy, talk to your doctor about the possible value and side effects. Let your doctor know if you are already using any such therapies. These treatments aren't meant to take the place of standard medical treatment. But they may improve your quality of life and help you deal with the stress and side effects of cancer treatment.
Other Places To Get Help
- American Cancer Society (2012). Cancer Facts and Figures 2012. Atlanta: American Cancer Society. Available online: http://www.cancer.org/Research/CancerFactsFigures/CancerFactsFigures/cancer-facts-figures-2012.
- Lewis C (2007). Colorectal cancer screening, search date November 2006. Online version of BMJ Clinical Evidence: http://www.clinicalevidence.com.
- National Comprehensive Cancer Network (2012). Colon cancer. NCCN Clinical Practice Guidelines in Oncology, version 3. Available online: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#site.
Other Works Consulted
- Libutti SK, et al. (2015). Cancer of the rectum. In VT DeVita Jr et al., eds., DeVita, Hellman, and Rosenberg's Cancer Principles and Practices of Oncology, 10th ed., pp. 823-841. Philadelphia: Walters Kluwer.
- National Cancer Institute (2011). Colon Cancer PDQ: Treatment-Patient Version. Available online: http://www.cancer.gov/cancertopics/pdq/treatment/colon/Patient.
- National Cancer Institute (2011). Rectal Cancer PDQ: Treatment-Health Professional Version. Available online: http://www.cancer.gov/cancertopics/pdq/treatment/rectal/HealthProfessional/allpages.
- National Cancer Institute (2012). Rectal Cancer Treatment (PDQ)-Patient Version. Available online: http://www.cancer.gov/cancertopics/pdq/treatment/rectal/Patient.
Primary Medical Reviewer E. Gregory Thompson, MD - Internal Medicine
Adam Husney, MD - Family Medicine
Kathleen Romito, MD - Family Medicine
Specialist Medical Reviewer Kenneth Bark, MD - General Surgery, Colon and Rectal Surgery
Current as ofMay 3, 2017
Current as of: May 3, 2017
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