Colorectal Cancer

Quick Reference

Updated February 2021: Open a 2-page quick reference summary of the therapies best supported by evidence for use with colorectal cancer:

quick reference document

Key Points

  • Early detection, allowing for early treatment, is very important with colorectal cancer. 
  • Eating Well and Moving More, two of our 7 Healing Practices, pack a powerful one-two punch in potentially improving treatment outcomes, enhancing quality of life and/or reducing risk of recurrence in colorectal cancer. 
  • Conventional treatments are readily available. Complementary therapies can be useful to enhance conventional treatment effects, improve quality of life and possibly even extend life for those with colorectal cancer.
  • An observational study and a case study provide examples of integrative approaches. See Examples of Integrative Approaches.
  • A number of natural products; off-label, overlooked, or novel cancer approaches (which we call ONCAs); and other therapies show benefits in four domains:
    • Treating the cancer
    • Managing side effects and promoting wellness
    • Reducing risk of both cancer onset and recurrence
    • Optimizing your body terrain
  • The microbes in your gut influence colorectal cancer development and might influence the success of treatment.
  • Choices for pain relief during and after surgery can impact treatment outcomes and risk of recurrence.

Authors

Laura Pole, RN, MSN, OCNS, BCCT Senior Researcher

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Nancy Hepp, MS, BCCT Project Manager

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Reviewer

Barry D. Elson, MD, BCCT Advisor

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Last updated September 3, 2021.

Colorectal cancer is a term used to include several types of cancers of the colon and/or rectum. Common types of colorectal cancers:1

  • Adenocarcinomas of the colon and rectum
  • Gastrointestinal carcinoid tumors
  • Primary colorectal lymphomas
  • Gastrointestinal stromal tumors
  • Leiomyosarcomas
  • Melanomas of the colon or rectum

The evidence presented here for screening, diagnosis, treatment and reducing risk relates to carcinomas, of which the great majority are adenocarcinomas. The other cancer types are much less common, and behave quite differently.

Colorectal cancer begins when healthy cells in the lining of the colon or rectum change and grow out of control. These cells form a mass called a tumor, which can be cancerous or benign. A cancerous tumor is malignant, meaning it can grow and spread to other parts of the body. A benign tumor can grow but will not spread. These changes usually take years to develop.2

Colorectal Cancer: Signs, Symptoms and Screening

Signs and symptoms from the American Cancer Society:3

  • A change in bowel habits—such as diarrhea, constipation or narrowing of the stool—that lasts for more than a few days
  • A feeling that you need to have a bowel movement that's not relieved by having one
  • Rectal bleeding with bright red blood
  • Blood in the stool, which might make the stool look dark brown or black
  • Cramping or abdominal (belly) pain
  • Weakness and fatigue
  • Unintended weight loss

Read more

Read more

Integrative Care in Colorectal Cancer

Before investigating integrative care in colorectal cancer, we recommend reviewing integrative cancer care in general.

Our goal is to help you live as well as you can for as long as you can. We provide information about using an optimal integrative combination of conventional and complementary therapies and approaches. In this handbook, we present a wide range of complementary therapies that have been studied for their effectiveness in colorectal cancer.

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Healing and Curing

Many of the integrative approaches in this handbook promote healing, which is not the same as curing. Healing is an inner process through which a person becomes whole. Healing can take place at physical, emotional, mental and spiritual levels. An example of physical healing is when a surgical incision heals. 

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Learn More

Integrative Approaches and Surgery

Surgery may be part of the recommended treatment for this cancer type. We provide helpful information about how integrative approaches can coordinate with surgery below in the section titled Surgery and Colorectal Cancer.

We recommend these resources to introduce you to conventional therapies and the science behind them:

Read more

Clinical Practice Guidelines

Screening Guidelines

For Health Professionals: Surveillance Schedule

Recommended schedule of surveillance for colon and rectal cancer (AJCC stage I (at increased risk for recurrencea), stage II, stage III, and stage IV (when isolated metastases are resected for cure)10

Colon

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Rectumb

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Notes and Definitions

Read more

Guidelines following Curative Treatment

Other Professional Recommendations

The US Preventive Services Task Force recommends initiating low-dose (81 mg) aspirin use for the primary prevention of cardiovascular disease (CVD) and colorectal cancer in adults aged 50 to 59 years who have a 10 percent or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years.11 Use is not recommended for others, as risks from taking aspirin may outweigh benefits. Even those not at risk may experience catastrophic gastrointestinal bleeding.

Examples of Integrative Approaches

Bastyr Integrative Oncology Research Center (BIORC)

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Life Over Cancer System

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Integrative Programs, Protocols and Medical Systems

For more information about programs and protocols, see our Integrative Programs and Protocols page.

Traditional Medicine Therapies

Throughout this summary, you will find examples of therapies used by, and in many cases created by, traditional medical systems. Foods and herbs such as medicinal mushrooms, soy and curcumin are part of traditional systems.

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Integrative Therapies in Colorectal Cancer

7 Healing Practices: The Foundation

Top 5 Lifestyle Interventions following Colorectal Cancer Treatment

The authors of After Cancer Care: The Definitive Self-Care Guide to Getting and Staying Well for Patients with Cancer recommend these lifestyle interventions,24 which we’ve matched to the 7 Healing Practices:

Read more

Any of the 7 Healing Practices are a good beginning. Eating Well and Moving More pack a powerful one-two punch in potentially improving treatment outcomes, enhancing quality of life and/or reducing risk of recurrence in colorectal cancer. Moreover, evidence shows that Managing Stress, Sleeping Well, Creating a Healing Environment, Sharing Love and Support and Exploring What Matters Now can help patients and survivors. Ultimately, let your intuition guide you in choosing where to start with these healing practices.

Bundling Practices Leads to Better Results

People who followed the World Cancer Research Fund/American Institute of Cancer Research recommendations on diet, physical activity, and body fatness prior to a diagnosis of colorectal cancer showed better overall and cancer-specific survival after diagnosis. The more recommendations that were followed, the better the outcomes.25  

A 2018 study of almost 1000 colorectal cancer survivors found a 42 percent reduction in death at five years for those who followed the American Cancer Society nutrition and physical activity guidelines most closely, compared to those who followed them least.26

Eating Well

Treating the Cancer

Ask for Guidance

A small study of colorectal cancer survivors in the United Kingdom found that most—more than 2/3—reported receiving no nutritional advice from their doctors and care teams.27 We have no reason to believe the situation is much better anywhere else.

If your team doesn't provide guidance, ask your doctor for a referral to a dietician or nutritionist who specializes in counseling cancer patients and survivors. Even better, seek out an integrative healthcare provider (medical doctor, ostopathic doctor, naturopath, nurse or physician assistant who practices an integrative approach) if you'd like specific guidance about what to eat to improve your outcomes and manage side effects.

Some food choices are associated with better or worse survival:

Higher Survival Lower Survival
  • Plant-rich, low-carbohydrate diet in patients with nonmetastatic colorectal cancer28
  • Diet rich in omega-3 fatty acids29
  1. The association is for colon cancer only; no association was found between processed meat intake and overall survival or disease-free survival for rectal cancer.32

Flax seeds, garlic, green tea and mushrooms and are among the plant foods most commonly used by oncology naturopaths for colorectal cancer.33

An observational study of patients with stage 3 colon cancer treated with surgery and adjuvant chemotherapy found a link between eating two or more weekly servings of tree nuts and improved disease-free survival and overall survival compared to no nut consumption.34

The ability of foods to influence inflammation may also impact survival. A diet with more anti-inflammatory potential improved overall survival among postmenopausal women diagnosed with colorectal cancer.35 Foods and food components with anti-inflammatory properties:

Read more

Managing Side Effects and Promoting Wellness

Higher intake of dietary magnesium is associated with less prevalent and less severe chemotherapy-induced peripheral neuropathy in colorectal cancer patients.36 Foods high in magnesium include these:37

Show list

The Cancer.Net Editorial Board of the American Society of Clinical Oncology recommends a balanced diet that includes specific nutrients such as B vitamins (including B1 and B12, folic acid) and antioxidants (see Antioxidants and Cancer Outcomes below) to reduce pain from peripheral neuropathy. They also recommend reducing alcohol consumption.38

These foods are among those rich in B vitamins:39

Show list

Reducing Risk

Western dietary patterns—such as eating large amounts of processed meats and refined grains and low quantities of vegetables and fruits—has been associated with higher risk of tumor recurrence and mortality in colorectal cancer.40 More than 52,000 new colorectal cancer cases in the United States in 2015 were estimated to be associated with suboptimal diet among US adults.41 The American Institute for Cancer Research recommends a plant-based diet with a variety of fruits, vegetables, beans and whole grains to lower risk.42

As mentioned above, the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons recommends a balanced diet after curative treatment of colon and rectal cancer.43 One such balanced diet—the Mediterranean diet, and specifically its components olive oil, red wine, and tomatoes—is associated with clinically reduced cancer initiation and progression.44

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Optimizing Your Terrain
Beneficial Foods
  • Butyrate (from fiber, see above) is a potent anti-inflammatory. It lessens inflammation related to colitis in both rodents and humans.70
  • Green tea consumption decreased fasting glucose and glycated hemoglobin (HbA1c) concentrations.71
  • Cocoa is antioxidative and anti-inflammatory72
Foods to Avoid
  • Diets high in cholesterol (WebMD) are linked to increased inflammation.73

See Eating Well.

Moving More

Treating the Cancer

Participating in regular physical activity reduces mortality:

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Managing Side Effects and Promoting Wellness

Physical activity benefits some side effects and overall quality of life:

Read more

Reducing Risk

The Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons recommends regular exercise after curative treatment of colon and rectal cancer.89

Read more

See Moving More.

Managing Stress

Reducing Risk

Higher perceived stress is associated with increased risk of rectal cancer, but not colon cancer.93

See Managing Stress.

Sleeping Well

Treating the Cancer

Sleep duration and timing may impact survival:

Read more

Managing Side Effects and Promoting Wellness

Read more

Reducing Risk

The Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons recommends regular sleep after curative treatment of colon and rectal cancer.102

Read more

Improving Sleep

Read more

See Sleeping Well for more information.

Creating a Healing Environment

Reducing Risk

Several environmental exposures are associated with increased risk of colorectal cancer:108  

Read more

See Creating a Healing Environment.

Sharing Love and Support

Managing Side Effects and Promoting Wellness

In a systematic review, emotional support and reassurance when trying to deal with fear of cancer recurrence featured as the most prominent supportive care need of colorectal cancer patients, regardless of clinical stage or phase of treatment.110

Read more

Reducing Risk

Read more

See Sharing Love and Support.

Exploring What Matters Now

Managing Side Effects and Promoting Wellness

Read more

See Exploring What Matters Now.

Beyond the 7 Healing Practices: Further Integrative Therapies

The Ultimate Guide to Cancer: DIY Research

This guide from Ralph Moss, PhD, BCCT advisor and leading chronicler of integrative cancer treatments, shows you how to use four of the main tools that doctors use to decide on the best cancer treatments. It will help you learn why some cancer treatments that look good in clinical trials may not work for “real world” patients. It will help you answer key questions that the doctor may be hesitant to answer in the detail you need to decide about treatment:

  • What are my chances of actually living longer if I take your treatment?
  • What are the likely side effects, and how long will they last?
  • What other treatment options are available?

Also see The Moss Reports for comprehensive guidance on treating colorectal cancer.

Conventional treatments are readily available. Complementary therapies can be useful to enhance conventional treatment effects, improve quality of life and possibly even extend life for those with colorectal cancer. Many complementary therapies―when chosen thoughtfully, reviewed with your oncology treatment team and used alongside conventional therapies—can become part of your integrative cancer care approach.

Therapies are grouped according to their effects:

  • Treating the cancer
  • Managing side effects and promoting wellness
  • Reducing risk
  • Optimizing Your Terrain

We present natural products in six groups:

  1. Good clinical evidence of efficacy & safety, easy access
  2. Good clinical evidence of efficacy & safety, limited access
  3. Limited clinical evidence of efficacy but good safety, used in leading integrative programs
  4. Limited clinical evidence of efficacy, or significant cautions, but potential significant benefit
  5. Especially promising preclinical or emerging clinical evidence of efficacy and safety
  6. Evidence of no efficacy or may be dangerous

Off-label, overlooked and novel cancer approaches (ONCAs) are grouped separately:

  • Group A: Good clinical evidence of efficacy
  • Group B: Limited clinical evidence of efficacy
  • Group C: Promising preclinical evidence only
  • Group D: Evidence of no efficacy or may be dangerous

Within each section, we list only groups containing applicable therapies.

Other integrative therapies and approaches are described but not categorized. See the full summaries as linked for more information on each of these therapies.

Treating the Cancer

 

Avoiding Drug Interactions during Treatment

Potentially life-threatening interactions between drugs are possible. For example, proton pump inhibitors (PPIs) can increase the risk for progression in colorectal cancer patients being treated with adjuvant CAPOX (capecitabine with oxaliplatin) or FOLFOX (leucovorin calcium [folinic acid], fluorouracil, and oxaliplatin). PPIs have a significant effect on both progression-free and overall survival. 

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Working against cancer growth or spread, improving survival, or working with other treatments or therapies to improve their anticancer action

Conventional Treatments

Conventional treatments for colorectal cancer include these:

  • Surgery (also see Surgery and Colorectal Cancer below)
  • Radiofrequency ablation
  • Cryosurgery
  • Chemotherapy
  • Radiation therapy
  • Targeted therapy
  • Immunotherapy

These treatments are explained on the National Cancer Institute website: Colorectal Cancer—Patient Version and Colorectal Cancer—Health Professional Version.

Newer conventional treatments and outcomes:

  • Pressurised intraperitoneal aerosol chemotherapy (PIPAC) is a relatively new treatment for patients with peritoneal metastases. A 2019 review found an objective clinical response of 71–86 percent for colorectal cancer (median survival of 16 months) with PIPAC. Repeated PIPAC did not have a negative effect on quality of life.119
  • Pulsed low-dose rate radiation therapy (PLDR-RT) delivers conventional radiation doses in pulses of small doses with intermittent pauses. A small study involved PLDR-RT for patients with rectal and other cancers of the pelvis. Patients had undergone radiation therapy to the pelvis previously. Twenty-three patients were treated with a curative intent and 15 were treated palliatively. At one year, 59 percent of patients treated for curative intent had a clinical, biochemical or radiographic response, and six of the 23 patients had no evidence of disease at their last follow-up. Among the patients treated palliatively, 61 percent had a clinical or radiographic response.120 This delivery also produces low rates of toxicity, along with reduced damage to noncancerous tissue and decreased repair of DNA damage in tumor cells.

Conventional treatments can be very expensive, and some treatments can cause long-lasting side effects.121 We encourage you to explore the benefits, risks and costs of all options.

Delaying Treatment

Some providers offer a “watch-and-wait” approach for select rectal cancer patients who have had a clinical complete response after neoadjuvant therapy. While this approach has resulted in excellent rectal preservation and pelvic tumor control, a 2019 study found it has also resulted in worse survival and a higher incidence of distant progression in patients with local regrowth compared to those without local regrowth.122 A review and meta-analysis in late 2020 confirmed that delaying colorectal cancer treatment by a month or more increases the risk of dying.123

Factors Influencing the Success of Treatment

Characteristics of both healthcare providers and the patient can impact the likelihood of success in treatment.

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More on Conventional Treatments

We recommend these resources to introduce you to the science of colorectal cancer and conventional therapies:

Natural Products

Antioxidants and Cancer Outcomes

Substances that act as antioxidants can have both antitumor and tumor-promoting effects, depending on several factors:126

  1. The specific antioxidant, plus the dose and format used
  2. Characteristics of the patient: poor nutrition, smoking or high alcohol intakes may cause antioxidants to act as pro-oxidants and promote cancer growth
  3. The tumor site and therapy: antioxidants can act as pro-oxidants in tissues with elevated partial pressures of oxygen. 

Many substances can serve as antioxidants and are abundant in these food sources:

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Group 1: Good clinical evidence of efficacy & safety, easy access

These therapies may be widely used in integrative cancer protocols and traditional medical systems.

Read more

Group 3: Limited clinical evidence of efficacy but good safety, used in leading integrative programs

Read more

Group 4: Potential significant benefit, but either limited clinical evidence of efficacy or significant cautions

May be used in leading integrative oncology programs. Therapies in this group may need more medical oversight and surveillance.

Read more

Other therapies with preclinical evidence only for treating the cancer

Group 5: Especially promising preclinical or emerging clinical evidence of efficacy and safety

Read more

Off-label, Overlooked or Novel Cancer Approaches (ONCAs)

These therapies have exciting potential and/or proven benefits. However, some carry higher risks of side effects, interactions with other treatments and other adverse medical events than other therapies we review. Cautions are noted with each therapy, and we strongly urge you to consult your doctor before using these therapies—even over-the-counter drugs—for cancer treatment. We also note whether a prescription is needed or if a therapy is not widely available.

Group A: Good clinical evidence of efficacy

May be used in integrative protocols and programs

Read more

Group B: Limited clinical evidence of efficacy

May be used in integrative protocols and programs

Read more

Group C: Promising preclinical evidence only

Read more

Diets and Metabolic Therapies

Short-term fasting (noteworthy preclinical evidence)

  • As effective as chemotherapy in delaying the progression of a wide range of cancers in animals333
  • Reduced tumor progression in mice with complete fasts of one to two days or alternating fasting and non-fasting days334
  • Synergistic effect with vitamin C in delaying tumor progression in mice with colorectal cancer with the KRAS gene mutation335
  • Enhanced the effect of virus-mediated cell killing in colorectal cancer cells while protecting normal colon cells336
  • Alternate-day fasting inhibited tumor growth in mice without causing weight loss.337
  • Note cautions on the Intermittent Fasting page.

Manipulative and Body-Based Methods

Acupuncture and Electroacupuncture

  • Reduced average tumor size and other indicators of cancer using nanoporous needles in animals (needles that have micro/nano-scale pores on their surface)338

Therapies Using Heat, Sound, Light or Cutting-edge Radiotherapy

Hyperthermia

  • Local or regional hyperthermia:
    • Improved overall survival time of patients with liver metastases from colorectal cancer compared to chemotherapy alone339
    • "Excellent survival outcomes in optimally selected patients" with colorectal cancer who have peritoneal metastases treated with systemic chemotherapy, then cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). Both oxaliplatin and mitomycin C had comparable effectiveness when given in the intraperitoneal cavity. (Report on a presentation at the ESMO 22nd World Congress on Gastrointestinal Cancer)340
    • Greater rates of complete response and regression of the primary tumor341
    • No improved survival and an increased risk of adverse events in colorectal cancer patients when adding HIPEC to cytoreductive surgery compared with receiving cytoreductive surgery alone342
  • Whole-body hyperthermia:
    • Improved response to chemotherapy and potentially improved survival343

Managing Side Effects and Promoting Wellness

 

Inflammation and Side Effects

As integrative oncologist and BCCT advisor Keith Block, MD, explains: Inflammation can bring on cachexia—the severe wasting syndrome common among patients with solid tumors—and, especially, metastases. Cachexia, which is particularly common in cancers of the pancreas, colon and lung, can lead to the rapid breakdown of muscle, including the heart muscle.344  

Inflammation is associated with cachexia,345 as inflammatory cytokines cause reduced appetite and abnormal metabolism of proteins, fats and carbohydrates. All this leads to loss of muscle and weight.346  

Side effects of the cancer and of treatments can dramatically impact your quality of life. A 2009 review summarizes: “Although issues and symptoms were most prominent during the first three years, long-term effects of treatment can persist and include fatigue, sleep difficulty, fear of recurrence, anxiety, depression, negative body image, sensory neuropathy, gastrointestinal problems, urinary incontinence, and sexual dysfunction.”347 Therapies that address side effects can greatly improve your well-being and improve life for you and your caregivers.

Conventional Treatments

Pulsed low-dose rate radiation therapy (PLDR-RT) delivers conventional radiation doses in pulses of small doses with intermittent pauses. A small study involved PLDR-RT for rectal and other cancers of the pelvis. Of the 50 percent of patients who reported pain at the local site before treatment, 68 percent reported an improvement in pain after PLDT-RT.348

Natural Products

Group 1: Good clinical evidence of efficacy & safety, easy access

These therapies may be widely used in integrative cancer protocols and traditional medical systems.

Read more

Group 2: Good clinical evidence of efficacy & safety, limited access

Some may require a prescription, for example.

Read more

Group 3: Limited clinical evidence of efficacy but good safety, used in leading integrative programs

Read more

Group 4: Potential significant benefit, but either limited clinical evidence of efficacy or significant cautions

May be used in leading integrative oncology programs. Therapies in this group may need more medical oversight and surveillance.

Read more

Group 5 Especially promising preclinical or emerging clinical evidence of efficacy and safety

Read more

Off-label, Overlooked or Novel Cancer Approaches (ONCAs)

These therapies have exciting potential and/or proven benefits. However, some carry higher risks of side effects, interactions with other treatments and other adverse medical events than other therapies we review. Cautions are noted with each therapy, and we strongly urge you to consult your doctor before using these therapies—even over-the-counter drugs—for cancer treatment. We also note whether a prescription is needed or if a therapy is not widely available.

Group A: Good clinical evidence of efficacy

May be used in integrative protocols and programs

Read more

Group B: Limited clinical evidence of efficacy

May be used in integrative protocols and programs

Read more

Diets and Metabolic Therapies

Read more

Mind-Body, Spiritual and Consciousness-changing Approaches

Read more

Manipulative and Body-Based Methods

Read more

Reducing Risk

Reducing the risk of developing cancer or the risk of recurrence

Risk Factors

Read more

Creating Healthy Habits: Lifestyle Associations

Read more

Natural Products

Group 1: Good clinical evidence of efficacy & safety, easy access

These therapies may be widely used in integrative cancer protocols and traditional medical systems.

Read more

Group 3: Limited clinical evidence of efficacy but good safety, used in leading integrative programs

Read more

Group 4: Potential significant benefit, but either limited clinical evidence of efficacy or significant cautions

May be used in leading integrative oncology programs. Therapies in this group may need more medical oversight and surveillance.

Read more

Group 5: Especially promising preclinical or emerging clinical evidence of efficacy and safety

Other therapies with preclinical evidence only for reducing risk

Expand list

Read more

Group 6: Evidence of no efficacy or may be dangerous

Read more

Off-label, Overlooked or Novel Cancer Approaches (ONCAs)

Group A: Good clinical evidence of efficacy

May be used in integrative protocols and programs

Read more

Group B: Limited clinical evidence of efficacy

May be used in integrative protocols and programs

Read more

Optimizing Your Terrain

Cytokines, Inflammation and Outcomes

Cytokines are proteins with a complex relationship to your immune system and sleep cycles. If your circadian rhythm is disrupted by an external change in the light-dark cycle—such as by night-shift work or staying awake late at night—your immune cells produce a heightened inflammatory response driven in part by cytokine release.601

Read more

Creating an environment within your body that does not support cancer development, growth or spread

See Body Terrain and the Tumor Microenvironment.

Natural Products

Read more

Off-label, Overlooked or Novel Cancer Approaches (ONCAs)

Read more

Other Therapies

Acupuncture and Electroacupuncture

Read more

Short-term fasting

Read more

Your Microbiome and Colorectal Cancer

Antibiotic Use and Colorectal Cancer

Antibiotics can dramatically alter your microbiome. More frequent or oral antibiotic use was linked to a 17% increased risk of colon cancer but a reduced risk of rectal cancer (mostly among women) in a very large observational study.693 In a separate very large study, the increased risk was evident even with minimal use or with use 10 or more years prior to diagnosis, and risk was strongest with antibiotics with anti-anaerobic effects.694

“When asked about the difference between the apparent impact of antibiotic use on the risk of cancer in the colon when compared to the rectum, [senior author Cynthia] Sears commented, ‘We think these differences highlight the differences in biology and likely the microbiome between these two cancer sites. Hence we hypothesize that antibiotics impact disease at these sites differently.’”695

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Surgery and Colorectal Cancer

Key Points: Surgery and Colorectal Cancer

  • Surgery as a treatment for colorectal cancer can greatly improve the prognosis but can involve several complications that can reduce CRC survival and increase the risk of recurrence.
  • Some factors that increase the risk of surgical complications are under the control or influence of the surgical team and/or the patient. Others, such as age, gender or prior abdominal surgery, are not.
  • Numerous negative consequences of surgical complications are possible, so a proactive approach to prevent them is important.
  • Prehabilitation and/or enhanced recovery after surgery (ERAS) programs and interventions are designed to prevent or lessen the complications of surgery.

Colorectal cancer treatment often includes surgery. The surgery may provide long-term benefit regarding cancer outcomes, but risks and complications are also relatively commonplace. We provide a brief overview of issues and integrative approaches surrounding colorectal cancer surgery. General information about surgery with cancer is available on our Integrative Approaches to Surgery page.

Clinical Practice Guidelines

For Healthcare Professionals: Enhanced Recovery after Surgery (ERAS)

ERAS is an approach focusing on counselling before surgery, optimizing nutrition, standardizing approaches to pain relief and getting you (the patient) moving and on your feet following surgery. It draws from several modalities, such as nutrition, medication, movement and counseling.703

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Guidelines for patients from the Enhanced Recovery After Surgery (ERAS®) Society:708

  • Recommendations before hospital admission:
    • Stop smoking at least four weeks before surgery to reduce problems with breathing and wound healing
    • Engage in a prehab activity program (see below) to promote quicker recovery of function and fewer complications, especially if you are less fit
  • Recommendations before surgery:
    • Avoid sedatives such as benzodiazepines if possible; taper a withdrawal if needed.709 Also, see Integrative Approaches and Surgery for a list of supplements to stop taking before surgery.
  • Recommendations following surgery: 
    • When you are allowed to eat, choose healthier foods from the menu. See Integrative Approaches and Surgery for examples of healthy eating when recovering from surgery.
    • If prescribed, use oral nutritional supplements from the day of surgery or as directed by your doctor.
    • Move as much as comfortable, including getting on your feet as soon as you can.

The American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons provide guidelines for the surgical team: Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons.710

Prehab and Surgical Outcomes

Prehabilitation (prehab), “the process of enhancing physical fitness before an operation to enable the patient to withstand the stress of surgery,” can reduce several risk factors for surgical complications, including malnutrition, anxiety and depression, and may also help to manage uncontrolled conditions or comorbidities, including glycemia, diabetes, hypertension and anemia.711

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Surgical Factors Associated with Increased Recurrence Risk

Even though surgery is a routine treatment for solid tumors, surgery itself can promote the development of metastasis by releasing tumor cells into circulation, suppressing important immune defenses such as your cellular immune system and and promoting the development of blood vessels to supply tumors (angiogenesis).713

Type of Surgery: Open or Laparoscopic

The type of surgery—whether open surgery or laparoscopic surgery—has a great impact on the resulting inflammation—greater than the choice of anesthetic and pain management techniques (epidural versus intravenous analgesia). 

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Surgical Conditions

Mild low body temperature (hypothermia) worsens the suppression of your immune response from abdominal surgery.717 Hypothermia may impair your immune system’s ability to stop infection and kill cancer cells. Maintaining your body temperature during surgery will reduce your risk of immune suppression. 

Use of blood transfusion products can cause suppression of your immune response and increase your risk of recurrence.718 Blood transfusion using your own blood (autologous transfusion) may reduce your risk of recurrence.719

Patient Condition at the Time of Surgery

Your stress level and other characteristics around the time of surgery can affect your immune system and may increase your risk of recurrence:

Show list

Reducing Factors around the Time of Surgery that Increase Recurrence Risk

Delaying Surgery and Survival

Delaying surgery may lead to poorer survival, according to a systematic review. Conclusions from the review:724

  • With primarily resected colon cancer, delays of more than 30 to 40 days are associated with lower survival. 
  • With rectal cancer, performing surgery more than seven to eight weeks following neoadjuvant therapy (therapy prior to surgery) was associated with decreased survival.

Combined use of the beta blocker propranolol and the anti-inflammatory etodolac for five days before surgery has been used safely to reduce metastases and mortality. However, this combination may not be safe in patients with asthma, cardiovascular disease, diabetes, bleeding risk, GI ulcers or low blood pressure.725

Taking precautions to prevent blood clots, neutrophil extracellular traps (NETs) and low oxygen levels (hypoxia) may reduce recurrence after surgery.726

See these pages for suggestions for managing stress or anxiety before and after surgery:

Surgical Complications and Infections

Surgical Complications

Colorectal cancer surgery can involve several possible complications:727

During surgery:

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After surgery:

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Infections and complications of surgery not only make recovery more difficult, they may impact your cancer outcomes and even your survival (see sidebar).728

Colorectal surgery is invasive and disrupts the equilibrium of your gut microbiome—the microbes in your gut. A microbial imbalance can impair the function of your local immune response, promote systemic inflammation, and potentially lead to infection following surgery.729 Perhaps due to the large number of bacteria present in the colon and rectum, the number of surgical site infections in patients undergoing colorectal surgery is high—up to 26 percent. 

Complications can reduce survival through several routes:

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Factors Increasing Risk of Infection and Other Complications

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Preventing Surgical Complications

Reducing the risk of complications: what you and your surgeon can do

Anastomotic Leaks

Anastomotic leaks—occurring at the place where colon sections are joined after a section is removed— can lead to other problems such as longer hospital stays; higher risks of readmission, reoperations or mortality; and a worse quality of life. Patients who have anastomotic leaks following cancer operations also have a higher risk of distant recurrence and long delays in receiving indicated adjuvant (supplemental) chemotherapy.

Recognized or proposed risk factors include these (also see the discussion below of pain control and surgical outcomes):743

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Interventions for the surgical team to reduce the incidence of anastomotic leaks:744

Show list

Interventions for patients:

  • Stop smoking in the period surrounding surgery
What You Can Do

Read more

What Your Surgeon Can Do

Read more

HA/CMC film adhesion barrier: A hyaluronic acid/carboxymethylcellulose (HA/CMC) film adhesion barrier can reduce adhesion formation, but a multicenter study found its use increased the risk of total adverse events and serious adverse events including excess body heat (hyperthermia), abscess in the pelvic area or incision site, urinary tract infection, urinary retention and ileus (bowel or intestinal blockage or paralysis).746

Infection and Treatment Outcomes

Infection may delay cancer treatments such as chemotherapy or radiation, leading to less effective treatment and worse outcomes, including recurrence.747

Some evidence shows that radiochemotherapy before surgery for rectal cancer may increase risk of infection and other complications such as anastomotic leakage.748 However, a 2016 meta-analysis found that radiation therapy alone before radical rectal cancer surgery didn’t increase risk of short-term wound complications,749 although side effects and a decreased quality of life may prolong recovery from surgery.750 Because treatment decreases the risk of local recurrence (but without changing cancer survival outcomes or your risk of distant metastasis), both risks and benefits need to be considered with your oncology team.751

Preventing Infection

Read more

Actions if You Develop an Infection

Read more

Pain Control

Sufficient pain control following surgery is essential to improve the quality of convalescence and speed up recovery.758 However, pain control methods vary considerably in their impact on surgery and cancer outcomes. Wise use of therapies to manage pain is extremely important to optimize both surgical and cancer outcomes. 

Effectiveness of Pain Control Approaches

Drug-based Pain Management

Read more

Non-drug Pain Management

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Also see our Integrative Approaches and Surgery page for further research on pain management in surgery for more cancer types and other settings. 

Impact of Pain Control Methods on Surgical Outcomes

Non‐steroidal Anti‐inflammatory Drugs (NSAIDs)

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Acupuncture and Electroacupuncture

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Movement

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Opioids, Sedatives and Antidepressants

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Impact of Pain Control Methods on Cancer Outcomes

Some approaches to managing pain may increase risks of suppressing your immune system and of cancer growth or recurrence. 

Increased Risk of Immune Suppression and Possible Cancer Growth, Recurrence or Metastasis

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Mixed Results

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No Increased Risk or Reduced Risk

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Recovery and Remission Maintenance

See Integrative Approaches and Surgery for general information about improving your body terrain to make your body less susceptible to infection, quicker to heal wounds and/or less favorable to cancer.

Survivorship

When you have finished treatment, your cancer treatment team should develop a survivorship plan with you, including these components to help you recover and prevent recurrence:

  • Instructions and a schedule for follow-up visits
  • Testing 
  • Guidance on lifestyle and other self-care practices

Post-Treatment Monitoring

The type of testing and monitoring used to assess your response to treatment and detect recurrence will depend on your specific cancer, treatment and risk for recurrence. A valid and reliable test to detect colorectal cancer recurrence early is still needed.

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Potential Upcoming Diagnostic Tests

Talk with your doctor about whether one of these new biomarker tests is available for you. Some integrative oncologists are using these new biomarker tests already, but these tests have not been recognized by conventional oncology as a standard in clinical practice.

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Commentary

Eggs and Cancer

Integrative naturopathic oncologist and BCCT advisor Lise Alschuler, ND, FABNO, and her colleague Karolyn Gazella advise people with risk for colon cancer to consider limiting egg intake to fewer than five eggs a week, while choosing eggs from free-roaming, organically fed chickens. They also advise boiling or poaching eggs, as these methods do not oxidize the yolk fat.806