Case Author(s): Abigail Davies, BA
Specialty/Title: Medical Student, class of 2019
Affiliation(s): The Warren Alpert Medical School of Brown University
Phone: (978) 270-4829
Editor: Alyson J. McGregor MD, MA
Co-Editor: Rebecca Barron, MD, MPH
Case Overview: While colorectal cancer is more prevalent in men, women present with a more aggressive, right-sided cancer that leads to higher mortality and lower 5-year survival. Hormonal and anatomic differences between men and women may both contribute to this discrepancy, making sex an important factor to consider in colorectal cancer diagnosis and prognosis.
Name: Mrs. X
Past medical history was significant for myocardial infarction, congestive heart failure, atrial fibrillation, hypertension, asthma/COPD, colon cancer, diabetes, 3 cardiac stents, colostomy, and hysterectomy.
Current medications: carvedilol, furosemide, atorvastatin, montelukast, glipizide, metformin, oxycodone, magnesium, vitamin D
Social history: Retired. Widowed. Has six children, lives with youngest daughter.
Family history: significant for brother with bladder cancer
Mrs. X was a 77 year-old female with a history of right-sided colon cancer treated with surgery and chemotherapy who presented to the emergency department with worsening non-localized abdominal pain over the past two weeks. She also endorsed night sweats, decreased appetite, fatigue, and nausea, but denied fevers, vomiting, urinary symptoms, and changes in her colostomy output.
On physical exam, Mrs. X was chronically ill appearing. Her abdomen was soft, mildly tender throughout without rebound or guarding, and mildly distended. Her labs were unremarkable. Her CT scan showed metastatic colon cancer.
Metastatic colon cancer.
This patient has previously been treated with surgery and chemotherapy for her colon cancer. As she refused treatment for her cancer at the time of hospitalization, she was discharged into hospice care.
As colorectal cancer has long affected more men than women, sex differences throughout the course of the disease are often not well defined. Although there are some conflicting data, a few trends in particular are relevant to this case.1
Colorectal cancer is the third most common cancer in men and second most common in women worldwide.2 The site of highest incidence rates for males is the rectum, compared to the right colon for women (though this rate is still lower than that for right colon cancer in men).3 It has been suggested that left-sided cancer is less aggressive than right-sided cancer, perhaps in part because right sided colon cancer is usually more advanced at diagnosis.4 This may contribute to the fact that women over 65 with colorectal cancer have higher mortality and lower 5-year survival than age-matched male counterparts, especially when over 70 years old.2, 5 Although this patient’s prognosis at diagnosis was not known, based on these studies, her advanced age and right-sided location both suggest that she may have been at higher risk for poor outcome.
In addition, current screening methods may be insufficient to diagnose some cases of colorectal cancer in women. Researchers have suggested that colonoscopy may be more difficult in women, given that they possess a longer transverse colon compared to men, leading to decreased detection rates.6Also, the fecal occult blood test, which is widely used for early colorectal cancer detection, is less sensitive in women.7 Finally, women report perceiving colorectal cancer as a male disease, decreasing their concern and, therefore, screening.8
Hormones may also play a role in the differences seen between men and women. Studies have suggested that estrogen exposure or hormone replacement therapy may be protective against risk for colorectal cancer.9 The Women’s Health Initiative Clinical Trial demonstrated a 40% decreased in risk in postmenopausal women taking HRT. However, taking HRT at the time of diagnosis was associated with higher grade or stage cancers.10 As the patient presented here had a hysterectomy with no HRT at age 45, it is possible that such hormonal changes increased her risk for colon cancer.
This case highlights a patient who decided to discontinue the treatment of her cancer. Although few data exist on gender differences in such choices, one study showed that women with stage III colon cancer were more likely to discontinue adjuvant chemotherapy after initial treatment, particularly as age increased.11 Although such decisions differ greatly between patients, this is an important factor to consider when discussing next steps.
While this case highlights some of the differences between men and women with regard to colon cancer, it suggests that more data are needed to tease out subtle and overt differences further. From diagnosis to treatment decisions, sex and gender seem to determine much more than just incidence of colorectal cancer.
- Kim SE, Paik HY, Yoon H, Lee JE, Kim N, Sung MK. Sex-and gender-specific disparities in colorectal cancer risk. World Journal of Gastroenterology.2015;21:5167. doi: 10.3748/wjg.v21.i17.5167.
- J. Ferlay J SI, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F.GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No. 11 [Internet] Lyon, France: International Agency for Research on Cancer; 2013.
- 3. Ru-Nie Gao, C. Ineke Neutel, and Elaine Wai. Gender differences in colorectal cancer incidence, mortality, hospitalizations and surgical procedures in Canada. J Public Health (2008) 30 (2): 194-201.
- B. Hansen IO, Jess P. Possible better long-term survival in left versus right-sided colon cancer – a systematic review.Dan Med J.2012;59:A4444.
- F. Park HC, Shin A, Kim BW, Jung KW, Won YJ, Oh JH, Jeong SY, Yu CS, Lee BH. Data on the characteristics and the survival of korean patients with colorectal cancer from the Korea central cancer registry.Ann Coloproctol.2013;29:144–149.
- D. Saunders BP, Fukumoto M, Halligan S, Jobling C, Moussa ME, Bartram CI, Williams CB. Why is colonoscopy more difficult in women?Gastrointest Endosc.1996;43:124–126.
- E. Brenner H, Haug U, Hundt S. Sex differences in performance of fecal occult blood testing.Am J Gastroenterol.2010;105:2457–2464.
- K. Friedemann-Sanchez G, Griffin J, Partin M.Gender differences in colorectal cancer screening barriers and information needs. Health Expectations2006;10:148-60
- G. Slattery ML, Potter JD, Curtin K, Edwards S, Ma KN, Anderson K, Schaffer D, Samowitz WS. Estrogens reduce and withdrawal of estrogens increase risk of microsatellite instability-positive colon cancer.Cancer Res.2001;61:126–130
- H. Ritenbaugh C, Stanford JL, Wu L, Shikany JM, Schoen RE, Stefanick ML, Taylor V, Garland C, Frank G, Lane D, et al. Conjugated equine estrogens and colorectal cancer incidence and survival: the Women’s Health Initiative randomized clinical trial. Cancer Epidemiol Biomarkers Prev.2008;17:2609–2618.
- I. van der Geest LG, Portielje JE, Wouters MW, Weijl NI, Tanis BC, Tollenaar RA, Struikmans H, Nortier JW. Complicated postoperative recovery increases omission, delay and discontinuation of adjuvant chemotherapy in patients with Stage III colon cancer.Colorectal Dis.2013;15:e582–e591.
Key Words: Case Study, colorectal cancer