Colorectal cancer is cancer that starts in the colon or the rectum. These cancers can also be referred to separately as colon cancer or rectal cancer, depending on where they start. Colon cancer and rectal cancer have many features in common. They are discussed together in this document except for the section about treatment, where they are discussed separately.

The normal digestive system

The colon and rectum are parts of the digestive system, which is also called the gastrointestinal (GI) system (see picture, below). The first part of the digestive system processes food for energy while the last part (the colon and rectum) absorbs fluid to form solid waste (fecal matter or stool) that then passes from the body. To understand colorectal cancer, it helps to know something about the normal structure of the digestive system and how it works.

After food is chewed and swallowed, it travels through the esophagus to the stomach. There it is partly broken down and then sent to the small intestine, also known as the small bowel. It is called the small intestine because it is narrower than the large intestine (colon and rectum). Actually the small intestine is the longest segment of the digestive system -- about 20 feet. The small intestine continues breaking down the food and absorbs most of the nutrients.

The small intestine joins the large intestine (or large bowel) in the right lower abdomen. Most of the large intestine is made up of the colon, a muscular tube about 5 feet long. The colon absorbs water and salt from the food matter and serves as a storage place for waste matter.

The colon has 4 sections:

• The first section is called the ascending colon. It starts with a small pouch (the cecum) where the small bowel attaches to the colon and extends upward on the right side of the abdomen. The cecum is also where the appendix attaches to the colon.
• The second section is called the transverse colon since it goes across the body from the right to the left side in the upper abdomen.
• The third section, the descending colon, continues downward on the left side.
• The fourth and last section is known as the sigmoid colon because of its "S" or "sigmoid" shape.

The waste matter that is left after going through the colon is called feces or stool. It goes into the rectum, the final 6 inches of the digestive system, where it is stored until it passes out of the body through the anus.

The wall of the colon and rectum is made up of several layers. Colorectal cancer starts in the innermost layer and can grow through some or all of the other layers. Knowing a little about these layers is important, because the stage (extent of spread) of a colorectal cancer depends to a great degree on how deeply it invades into these layers. For more information, please refer to the section, "How is colorectal cancer staged?"

Abnormal growths in the colon or rectum

In most people, colorectal cancers develop slowly over a period of several years. Before a cancer develops, a growth of tissue or tumor usually begins as a non-cancerous polyp on the inner lining of the colon or rectum. A tumor is abnormal tissue and can be benign (not cancer) or malignant (cancer). A polyp is a benign, non-cancerous tumor. Some polyps can change into cancer but not all do. The chance of changing into a cancer depends upon the kind of polyp:

• Adenomatous polyps (adenomas) are polyps that have the potential to change into cancer. Because of this, adenomas are called a pre-cancerous condition.
• Hyperplastic polyps and inflammatory polyps, in general, are not pre-cancerous. But some doctors think that some hyperplastic polyps can become pre-cancerous or might be a sign of having a greater risk of developing adenomas and cancer, particularly when these polyps grow in the ascending colon.

Another kind of pre-cancerous condition is called dysplasia. Dysplasia is an area in the lining of the colon or rectum where the cells look abnormal (but not like true cancer cells) when viewed under a microscope. These cells can change into cancer over time. Dysplasia is usually seen in people who have had diseases such as ulcerative colitis or Crohn's disease for many years. Both ulcerative colitis and Crohn's disease cause chronic inflammation of the colon.

Start and spread of colorectal cancer

If cancer forms within a polyp, it can eventually begin to grow into the wall of the colon or rectum. When cancer cells are in the wall, they can then grow into blood vessels or lymph vessels. Lymph vessels are thin, tiny channels that carry away waste and fluid. They first drain into nearby lymph nodes, which are bean-shaped structures that help fight against infections. Once cancer cells spread into blood or lymph vessels, they can travel to nearby lymph nodes or to distant parts of the body, such as the liver. Spread to distant parts of the body is called metastasis.

Types of cancer in the colon and rectum

Several types of cancer can start in the colon or rectum.

Adenocarcinomas: More than 95% of colorectal cancers are a type of cancer known as adenocarcinomas. These cancers start in cells that form glands that make mucus to lubricate the inside of the colon and rectum. When doctors talk about colorectal cancer, this is almost always what they are referring to.

Other, less common types of tumors may also start in the colon and rectum. These include:

Carcinoid tumors: These tumors start from specialized hormone-producing cells of the intestine. They are discussed in our document, Gastrointestinal Carcinoid Tumors.

Gastrointestinal stromal tumors (GISTs): These tumors start from specialized cells in the wall of the colon called the interstitial cells of Cajal. Some are benign (non-cancerous); others are malignant (cancerous). These tumors can be found anywhere in the digestive tract, but they are unusual in the colon. They are discussed in our document, Gastrointestinal Stromal Tumors.

Lymphomas: These are cancers of immune system cells that typically start in lymph nodes, but they may also start in the colon, rectum, or other organs. Information on lymphomas of the digestive system is included in our document, Non-Hodgkin Lymphoma.

What are the key statistics about colorectal cancer?