Journal of Surgical Oncology Supplement 2:92-103 (1991) zy Perspectives in Colorectal Cancer zyx LEMUEL HERRERA, MD, MA, PEDRO LUNA, MD, JOSE R A M O N VILLARREAL, MD, MICHAEL BROWN, MD, JOSE SORRENTINO, MD, AND YlHAD KHALEK, MD zyxwv From the Division of Surgical Oncology, The Medical Center of Delaware, Wilmington (L.H., M.B., zyxwvutsrqpo I.S., Y.K.); Department of Surgery, lefferson Medical College, Philadelphia, Pennsylvania (L.H.); Hospital de Oncologia SlCLO XXI, Centro Medico Nacional IMSS, Mexico City (P.L.), and the Department of Medical Oncology, Hospital Universitario San Jose, Monterrey NL, Mexico (J.R.V.) zyxwvu This paper presents an overview of recent developments pertaining to colorectal adenocarcinoma. It is aimed toward the practicing clinician. Topics discussed include epidemiologic observations; genetic predisposi- tions; molecular biology findings; screening and early detection programs; endoscopy; principles of surgical resection; laser and radioimmunoguided surgery; staging; selection of patients for adjuvant chemotherapy; and considerations regarding biologic response modifiers and pain control in the advanced-disease setting. KEY WORDS: colorectal adenocarcinoma, screening programs, adjuvant chemotherapy INTRODUCTION This paper is an attempt to bring to practicing clini- cians some of the salient, clinically relevant points of recent advances and investigations in colorectal adeno- carcinoma. Epidermoid carcinoma of the anal canal and other rarer large bowel malignancies are not discussed. EPIDEMIOLOGIC CONSIDERATIONS In a recent article based on data from the Connecticut Tumor Registry, Vukasin et al. noted the increasing incidence of cecal and sigmoid carcinoma in the last 50 years [l]. In men, the incidence of cecal carcinoma has increased from 3.6-16.7 cases per 100,000 population per year, and in women, it has increased from 4.9-14.2 cases per 100,000 population per year. The incidence of sigmoid carcinoma has increased from 8.7-1 8.7 cases per 100,000 population per year in men and from 7.7-12.8 cases per 100,000 population per year in women. The by-site distribution of colon cancer re- mained constant and the age-adjusted incidence increased at a constant rate, whereas the incidence of rectal cancer remained unchanged. The incidence of colon cancer continues to be higher in men than in women. These observations have led these authors to suggest that colon cancer is a twentieth-century epidemic and that its incidence will continue to increase. We strongly believe that this observation, although zyxwvu 0 1991 Wiley-Liss, Inc. possibly correct, should be qualified, as proper reporting systems became available and the life expectancy at which this cancer would have a high prevalence was reached in the United States only after the 1930s [2]. On the other hand, these data reported from the Connecticut Tumor Registry compare well with data from an Italian study that demonstrated incidences of colorectal cancer at Trieste of 73.3 cases per 100,000 population per year in men and 56.2 cases per 100,000 population per year in women, and at Modena of 35.2 in men and 31.1 in women [3]. This supports the conclusion that as the population under medical surveillance continues to age and survive into decades at risk for colon cancer, the incidence of the diagnosis of colon cancer also will rise. Less clear is the comparative incidence in different races and possibly in individuals of different sexes or religions or with different sites of residence and diets. Certainly, the fact that there are specific countries and populations with a low incidence of colorectal cancer (e.g., Spaniards [Navarra], 8.1 cases; South Americans, 6.3 cases; and Filipinos, 4.1 cases, all age-standardized per 100,000 Accepted for publication May 30, 1991. Address reprint requests to Dr. Lemuel Herrerd, Division of Surgical Oncology, Department of Surgery, The Medical Center of Delaware, 501 West 14th Street, Wilmington, DE 19806. This study was partially supported by an educational grant from IVONYX.