Risk factors

We don’t know what causes most bowel cancers, but we do know that some factors increase your risk of getting the disease. Some of these are things you can’t do anything about, for example, age and genetics. But you can make changes to your lifestyle to lower your risk of getting bowel cancer.

You are more at risk of getting bowel cancer if you have one or more of the following risk factors. This doesn’t mean that you will definitely get bowel cancer. Equally, if you don’t have any risk factors, it doesn’t mean you can’t get bowel cancer.

• 1. Aged over 50
• 2. A strong family history of bowel cancer 
• 3. A history of non-cancerous growths (polyps) in your bowel
• 4. Longstanding inflammatory bowel disease such as Crohn’s disease or ulcerative colitis
• 5. Type 2 diabetes
• 6. An unhealthy lifestyle

Family history

If any of your family members have bowel cancer, you might be worried about your risk of getting the disease. But bowel cancer is common and most people with a family history won’t need any tests or investigations.

Tell your GP if you have:

• One first degree relative (parent, brother, sister or child) diagnosed with bowel cancer before the age of 50, or
• Two or more first degree relatives diagnosed with bowel cancer at any age, or
• One or more relatives with a known genetic (inherited) condition linked to bowel cancer.

Up to a third (30 per cent) of bowel cancers may be caused by a change or fault in one or more genes. The changed gene can be passed down through a family. If you have the changed gene, you have a higher risk of getting bowel cancer at some point in your life. 

We don’t yet know which genes are involved in all of these cases. Around one in every 20 bowel cancers (five per cent) is caused by a change in a gene that we do know about.

The genetic conditions we know about include Lynch syndrome, Familial Adenomatous Polyposis (FAP) and MUTYH Associated Polyposis (MAP). People with these conditions have a much higher chance of developing bowel cancer and they are more likely to be diagnosed at a younger age. 

Reducing your risk

Scientists think around half (54 per cent) of all bowel cancers could be prevented by having a healthier lifestyle. 

You can reduce your risk by:

• 1. Eating a healthier diet {see below}
• 2. Taking more exercise {see below}
• 3. Cutting down on alcohol {see below}
• 4. Stopping smoking {see below}

You may have seen reports in the news about the effect of statins and aspirin on bowel cancer risk.

Speak to your GP if you’d like to know how you can reduce your risk of bowel cancer.

Diet

You can reduce your risk of bowel cancer by taking some simple steps to improve your diet.

• 1. Avoid processed meat and limit red meat
• 2. Eat plenty of fibre from wholegrains, pulses, veg and fruit
• 3. Be a healthy body weight

Red and processed meat

There is strong evidence that eating processed meat and a lot of red meat increases your risk of bowel cancer. 

To reduce your risk, limit how much red meat you eat and avoid processed meats as much as possible.

Red meat includes beef, lamb, pork and goat. If you choose to eat red meat, you do not need to stop but limit                                                                       the amount you eat to 500g or less (cooked weight) per week. 500g of cooked red meat is about the same as 700g of raw red meat. 

Eating more than this may increase your risk of bowel cancer.

How much is that?

• One portion of spaghetti bolognese contains about 140g of cooked minced beef
• One cooked medium pork chop is about 90g
• One cooked medium steak is around 145g

Red meat is a good source of protein but you can also get protein from many other foods such as fish, poultry, beans, lentils, tofu and eggs. You could try using chickpeas or beans to replace some or all of the meat in bolognese or chilli recipes.

Processed meat is preserved by smoking, curing, salting or by adding preservatives. Avoid processed meats such as bacon, ham, sausages and salami as much as possible. Choose them as an occasional treat rather than every day. Hamburgers and minced meats only count as processed meat if they have been preserved with salt and chemical additives. 

Fibre

Fibre is an important part of a bowel healthy diet and is very important in reducing your risk of bowel cancer. Fibre adds bulk to your waste (poo) and makes it easier to travel through the bowel.

There are two types of fibre:

1. Insoluble fibre bulks up poo and helps it move through the gut more quickly. This may help prevent constipation. Good sources of insoluble fibre include wholegrains such as brown rice, wheat and spelt as well as nuts, seeds, potatoes in skins and dried figs.
2. Soluble fibre dissolves in water and forms a gel in the gut. This helps to keep poo soft, making it easier to pass. It can also help lower your cholesterol. Good sources of soluble fibre include oats, barley, beans, peas, lentils, chickpeas, apples and carrots.

You should try to eat at least 30g of fibre every day. 

Eating foods high in fibre will help you feel fuller for longer. This may help if you are trying to lose weight.

Vegetables and fruit may also help to protect against bowel cancer because they contain antioxidants which help to delay or prevent cell damage. Try to eat at least five portions of vegetables and fruit every day. This useful guide shows how you can get your five-a-day.

If you want to increase the amount of fibre in your diet, you should do so slowly, especially nuts and beans. If you find that too much fibre causes pain, wind or bloating, reduce it by a small amount until your body adjusts and gradually increase it over time.

People with existing bowel conditions or a history of bowel cancer may not be able to tolerate some high fibre foods.

Keep hydrated

We need to drink about 1.6 to 2 litres of fluid (6-8 cups) every day to stop us getting dehydrated. Water, low fat milk and herbal teas are healthy choices. Avoid sugary drinks such as cola, lemonade and juice or squash with added sugar.

Fibre attracts water to help bulk it up so it's very important to make sure your body has enough water.  

Be a healthy body weight

Being overweight or obese and carrying a lot of weight around your waist can increase your risk of bowel cancer. 

It is estimated that 13 out of 100 bowel cancers (13%) in the UK are linked to being overweight or obese.

Measuring your BMI (Body Mass Index) is a simple way of finding out if you’re a healthy weight for your height. Your nurse, GP or dietitian can let you know or you can check your BMI at wcrf-uk.org

Take action if you start to gain weight. As well as being physically active, here are a few tips to reduce your calorie intake if you need to lose weight.

• Choose reduced fat versions of food such as milk and dairy products, but take care that they do not include sugar as this adds extra calories.
• Avoid sugary drinks such as cola, lemonade and juice or squash with added sugar. 
• Even unsweetened fruit juice is high in natural sugar so stick to one small glass (150mls) a day.
• Alcohol is high in calories so limit the amount you drink.
• Be aware of portion sizes and don’t overload your plate. If you are still hungry, have some fruit after your meal or wait about half an hour for your meal to ‘settle’.Be wary of ‘large’ or ‘value-sized’ offers, they often give you more food than you need, leading to weight gain.

The energy in the food we eat is measured in kilocalories, often shortened to calories. The recommended daily calorie intake is around 2,000 calories each day for women and 2,500 for men. 

If you are very overweight and have other health problems, speak to your GP before beginning a weight management and exercise programme.  

Exercise

People who are more physically active, have a lower risk of bowel cancer. 

Being active can help you maintain a healthy body weight and makes you feel good. 

Try to do at least 30 minutes of physical activity such as brisk walking, five times a week. As fitness improves, aim for 60 minutes. If you don’t do much exercise, try starting with 10 minutes and increase the time gradually. Exercise doesn't have to be about working out in a gym. Enjoy it!

You can be more active by:

• 1. Taking the stairs instead of the lift or escalator
• 2. Walking to the shops
• 3. Doing the housework
• 4. Walking the dog
• 5. Getting off the bus a few stops earlier

Many people spend a lot of time sitting still, either at work or in front of the TV and this can affect your health even if you exercise regularly. Reduce the amount of time you spend sitting at home and at work, and try building more active hobbies into your life such as: 

• 1. Dancing
• 2. Swimming
• 3. Hiking
• 4. Cycling

If you have an office job, try not to sit for longer than one hour at a time, stand up while talking on the phone and take a walk at lunchtime if you can. Wearing a pedometer or using a phone app to count the number of steps you take could really motivate you to walk further.

Don't forget, if you miss a few days, don't give up, just start again tomorrow. Physical activity can really help to reduce your risk of bowel cancer.

If you are very overweight, or have health problems, speak to your GP.

Alcohol and smoking

Alcohol is linked to seven types of cancer including bowel cancer. It is estimated that about 11 out of 100 bowel cancers (11%) in the UK are linked to alcohol.

The World Cancer Research Fund recommends avoiding alcohol as much as possible to help prevent cancer.

In January 2016, after looking at all the evidence, the government introduced new guidelines on alcohol consumption. To keep health risks from alcohol as low as possible, both men and women should drink no more than 14 units of alcohol a week. If you do drink, try to spread it out over the week. 

Also cutting down could make a real difference.

What is a unit of alcohol?

• A pint of average strength beer or lager = 2.8 units
• One standard glass of wine (175ml) = 2.3 units
• One measure of spirits = 1 unit 

Smoking

An estimated 8% of bowel cancer cases in the UK are linked to tobacco smoking. 

Bowel cancer risk increases with the number of cigarettes smoked per day.

We know that smokers are more likely to develop polyps (non-cancerous growths in the bowel) which could turn into cancer if not discovered.

If you want to give up smoking, your GP can help, advise and refer you to an NHS Stop Smoking service. 

These services offer the best support for people who want to give up smoking.

Adenocarcinomas 

This type of bowel cancer make up 95 percent of all colorectal cancer {bowel cancer} cases. In the gastrointestinal tract, adenocarcinomas develop in the cells of the lining inside the colon and/or the rectum. They typically start as a growth of tissue called a polyp. 

A particular type of polyp called an adenoma may develop into cancer. 

Polyps are often removed during a routine colonoscopy before they may develop into cancer.

Of the rarer types of colorectal cancer, gastrointestinal carcinoid tumors grow slowly, form in the neuroendocrine cell and make up 1 percent of all colorectal cancers, whereas primary colorectal lymphomas develop in the lymphatic system and account for 0.5 percent of colorectal cancers.

"Adeno" is a prefix meaning glands. "Carcinoma" is a type of cancer that grows in epithelial cells that line the surfaces inside and outside the body. Colorectal adenocarcinomas develop in the lining of the colon or rectum, which make up the large intestine. They tend to start in the inner lining and then spread to other layers.

There are two less common subtypes of adenocarcinoma:

• Mucinous adenocarcinoma is made up of approximately 60 percent mucus. The mucus may cause cancer cells to spread more quickly and become more aggressive than typical adenocarcinomas. Mucinous adenocarcinomas account for 10 percent to 15 percent of all colon and rectal adenocarcinomas.
• Signet ring cell adenocarcinoma accounts for less than 1 percent of adenocarcinomas. Named for its appearance under a microscope, signet ring cell adenocarcinoma is typically aggressive and may be more difficult to treat.

Gastrointestinal carcinoid tumors

Carcinoid tumors cells are slow-growing and may develop in the lungs and/or gastrointestinal tract. 

They account for 1 percent of all colorectal cancers and half of all cancers found in the small intestine.

Other types of rare colorectal cancers combined account for less than 5 percent of all cases and include:

• Primary colorectal lymphomas: 
• A type of non-Hodgkin lymphoma (NHL), this cancer type develops in the lymphatic system, specifically in cells called lymphocytes. Lymphocytes are a type of white blood cell that helps the body fight infections. 
• 
  
• NHL may develop in many parts of the body, including the lymph nodes, bone marrow, spleen, thymus and the digestive tract. 
• Primary colorectal lymphomas account for just 0.5 percent of all colorectal cancers and about 5 percent of all lymphomas. 
• This colorectal cancer type usually occurs later in life, and is more common in men than women.
• 
  
• Gastrointestinal stromal tumors: 
• Also known as GISTs, this is a rare type of colorectal cancer that forms in a special cell found in the lining of the gastrointestinal (GI) tract called interstitial cells of Cajal (ICCs). More than 50 percent of GISTs develop in the stomach. 
• 
  
• While most other GISTs form in the small intestine, the rectum is the third most common location. GISTs are classified as sarcomas, or cancers that begin in the connective tissues, which include fat, muscle, blood vessels, deep skin tissues, nerves, bones and cartilage.
• 
  
• Leiomyosarcomas: 
• Another form of sarcoma, leiomyosarcoma essentially means “cancer of smooth muscle.” The colon and rectum have three layers of the type of muscle affected by leiomyosarcoma, and all three work together to guide waste through the digestive tract. 
• This rare type of colorectal cancer accounts for about 0.1 percent of all colorectal cases.
• 
  
• Melanomas: 
• Though most commonly associated with the skin cancer, melanomas may occur anywhere, including the colon or rectum.

The three main symptoms of bowel cancer are:

• 1. Persistent blood in the stools – that occurs for no obvious reason or is associated with a change in bowel habit.
• 
  
• 2. Persistent change in your bowel habit – which usually means going more often, with looser stools
• 
  
• 3. Persistent lower abdominal (tummy) pain, bloating or discomfort – that's always caused by eating and may be associated with loss of appetite or significant unintentional weight loss

The symptoms of bowel cancer can be subtle and don't necessarily make you feel ill.

However, it's worth waiting for a short time to see if they get better as the symptoms of bowel cancer are persistent.

If you're unsure whether to see your GP, try the bowel cancer symptom checker.

Bowel cancer symptoms are also very common, and most people with them don't have cancer.

For example:

• 1. Blood in the stools when associated with pain or soreness is more often caused by piles (haemorrhoids)
• 2. Change in bowel habit or abdominal pain is usually the result of something you've eaten
• 3. Change in bowel habit to going less often, with harder stools, is not usually caused by any serious condition – it may be worth trying laxatives before seeing your GP

These symptoms should be taken more seriously as you get older and when they persist despite simple treatments.      

Tell your GP if you have noticed any changes in your bowel habit that have lasted three weeks or more, especially if you also have bleeding from your back passage. You may have looser poo and you may need to poo more often than normal. 

Or you may feel as though you’re not going to the toilet often enough or you might not feel as though you’re not fully emptying.

Seeking medical advice

Your doctor may decide to:

• 1. Carry out a simple examination of your tummy and bottom to make sure you have no lumps
• 
  
• 2. Arrange for a simple blood test to check for iron deficiency anaemia – this can indicate whether there's any bleeding from your bowel that you haven't been aware of
• 3. Arrange for you to have a simple test in hospital to make sure there's no serious cause of your symptoms

Make sure you see your doctor if your symptoms persist or keep coming back after stopping treatment, regardless of their severity or your age. You'll probably be referred to hospital.

Deciding which treatment you need

A team of doctors and other professionals discuss the best treatment and care for you. They are called a multidisciplinary team (MDT).

The treatment you have depends on:

• 1. Where your cancer is
• 2. How far it has grown or spread (the stage)
• 3.The type of cancer
• 4.How abnormal the cells look under a microscope (the grade)
• 5.Your general health and level of fitness

Your doctor will discuss your treatment, its benefits and the possible side effects with you.

Surgery for early bowel cancer

Most people with early bowel cancer have surgery. You surgeon may be able to take out all of your cancer. 

For some people this might cure the cancer. This means their cancer never comes back. 

Your doctor might suggest you also have chemotherapy or radiotherapy to stop the cancer coming back after surgery.

Chemotherapy for early bowel cancer

People with very early bowel cancer (stage 1) do not need chemotherapy after surgery.

Chemotherapy can be used for cancer in any part of the large bowel (colon) or back passage (rectum). 

It aims to kill any cells left behind after your operation. This is called adjuvant chemotherapy. 

Your surgeon might suggest chemotherapy after surgery as part of a clinical trial if you have a stage 2 bowel cancer. 

You might be at higher risk of cancer coming back if cancer cells are found in lymph nodes or blood vessels near the bowel. Your doctor may offer chemotherapy if your cancer has grown into organs or structures next to the bowel. 

Most people with stage 3 bowel cancer will have chemotherapy after surgery. You might have this as tablets or through a drip into your vein.                 You may have chemotherapy as part of a clinical trial.

Chemotherapy uses drugs to kill cancer cells. You may have chemotherapy to treat bowel cancer, either alone or together with other treatments.

This page describes how chemotherapy treats bowel cancer and which drugs are available.

All treatments carry the risk of side effects, and the most common ones are listed here. During treatment, you will need to use contraception to prevent pregnancy and to protect any sexual partners from the chemotherapy.

Timing of chemotherapy

Doctors give chemotherapy as a course of treatment, made up of several treatment cycles. Treatment usually lasts for up to six months. Ask your healthcare team how long each treatment cycle will last and how many cycles you will have.

You may have chemotherapy a few weeks after surgery if the cancer has spread to the lymph nodes or if there is a high risk of it coming back. This is called adjuvant chemotherapy.

If you have rectal cancer that has spread to the lymph nodes, you may have chemotherapy together with radiotherapy (chemoradiation) to shrink the cancer before surgery. This is called neo adjuvant chemotherapy.

If your cancer has spread to other parts of your body, you may have chemotherapy to keep the cancer under control or ease symptoms. In this case, chemotherapy is unlikely to cure the cancer but it can improve quality of life and survival. This is called palliative chemotherapy.

You may have surgery to remove the cancer if it has only spread to a few small areas of your liver or lungs. You may have chemotherapy before and after this surgery to shrink the cancer and make it easier to remove.

Macmillan Cancer Support and Cancer Research UK have detailed information on how chemotherapy works and how to prepare for treatment.

Chemotherapy drugs

Some chemotherapy drugs are taken as an injection or drip into a vein. Others are tablets that you take by mouth.

The most common chemotherapy drugs are:

Fluorouracil (5FU)

5FU is one of the most common chemotherapy drugs used in the UK and worldwide. You usually have 5FU together with a drug called folinic acid (leucovorin), which makes the chemotherapy work better. You take this drug as an injection or drip into a vein (intravenously). Doctors use 5FU before or after surgery and to treat bowel cancer that has spread to other parts of the body.

Capecitabine (Xeloda®)

Capecitabine is taken as a tablet twice a day. The body absorbs the drug and converts it to 5FU. You may take capecitabine before or after surgery or to treat bowel cancer that has spread to other parts of the body.

Oxaliplatin (Eloxatin®)

Doctors use oxaliplatin together with 5FU and folinic acid. This combination is called FOLFOX. Or you may have oxaliplatin together with capecitabine (XELOX). You take this drug as an injection or drip into a vein (intravenously). You may have oxaliplatin after surgery or to treat bowel cancer that has spread to other parts of the body.

Irinotecan (Campto®)

Irinotecan is taken as an injection or drip into a vein (intravenously). Doctors usually use it together with 5FU and folinic acid. This combination is called FOLFIRI. This drug treats bowel cancer that has spread to other parts of the body.

Side effects

Each chemotherapy drug or combination has its own side effects. Your healthcare team will give you information about the side effects that are most likely to affect you. 

Common side effects of chemotherapy include:

• 1. Loose bowel movements (diarrhoea)
• 2. An increased risk of infection.
• 3. A sore mouth
• 4. Feeling and being sick

Chemotherapy can cause temporary or permanent infertility, depending on the drugs and doses used. 

If you have bowel problems or sickness, you may find our information on diet helpful. 

Oxaliplatin can damage the nerves in your hands or feet. This is called neuropathy. Symptoms usually improve a few weeks or months after treatment ends but they may get worse before they get better. 

Some people have long-term problems with nerve pain. You may become very sensitive to the cold and get pins and needles, weakness or numbness in your hands or feet. This can make it hard to do everyday things like writing, picking up small items and walking. 

Some people wear gloves to protect their hands from the cold, sheepskin boots to help with nerve damage in their feet and heat packs to help with pain in their veins.

Contraception

You should use a condom if you have sex in the first few days after having chemotherapy. This will protect your partner from any chemotherapy that may be in the semen or vaginal fluid.

Both men and women should use contraception during chemotherapy and for about a year after treatment ends. 

This is because these treatments can damage sperm and eggs or harm a developing baby.

Radiotherapy is a possible treatment for rectal cancer, where there is a risk of the cancer coming back after surgery. It is not usually used to treat bowel cancer. This page tells you how you can find a trial and what things to think about before your consent to take part in a trial. We’ve also suggested some questions you might like to ask. 

You may have radiotherapy to try to cure your cancer, either alone or together with surgery or chemotherapy (chemoradiation). If your cancer cannot be cured, you may have radiotherapy to relieve your symptoms. This is called palliative radiotherapy.

There are two main ways of having radiotherapy – externally and internally.

Doctors also use radiotherapy to treat bowel cancer that has spread to other parts of the body. There are two specialised types of treatment - stereotactic radiotherapy and selective internal radiotherapy (SIRT). 

External radiotherapy

External radiotherapy uses high energy X-ray beams to kill cancer cells. Your healthcare team may offer you radiotherapy before surgery if there is a risk of the cancer coming back in the same place.

You may have a short course of five radiotherapy sessions in the week before your operation.

If you have a tumour that has grown through the bowel wall and may not be completely removed with surgery alone,  you may need a longer course of radiotherapy. This is often combined with chemotherapy (chemoradiation) and takes five to six weeks. In this case, you would have a few week breaks between radiotherapy and surgery, to give the tumour time to shrink.

Doctors sometimes use radiotherapy to treat rectal cancer that cannot be cured. This is called palliative radiotherapy. The treatment shrinks the cancer and relives symptoms such as pain.

Chemoradiation

Radiotherapy together with chemotherapy (chemoradiation) shrinks the tumour, making it easier to remove. It also reduces the risk of cancer coming back in the same place, compared with radiotherapy alone. But chemoradiation causes more short-term side effects, like loose and runny poo (diarrhoea). 

If you didn’t have radiotherapy or chemotherapy before surgery, your specialist may offer you chemoradiation after surgery if there is a high risk of the cancer coming back.

Recently, researchers have suggested that up to one in five people treated with chemoradiation can be cured of their cancer without surgery. This is not standard treatment yet and needs more research.  Specialists aren’t yet able to tell who will benefit from this treatment and who will not.

Internal radiotherapy

Your healthcare team may offer you internal radiotherapy (brachytherapy), depending on the size of the cancer and where it is in the rectum.

Brachytherapy involves placing a source of radiation inside the rectum for a few minutes. There are two types of brachytherapy used to treat rectal cancer – low-energy contact X-ray brachytherapy and high dose rate brachytherapy.

Low-energy contact X-ray brachytherapy (Papillon technique) uses X-rays to cure early rectal cancer or stop it spreading. This treatment may be an option for people who cannot have surgery. There isn’t much evidence to show how well it works for people who can have surgery but have chosen not to. Your healthcare team can give you more information about the benefits and risks of this treatment.

The aim of high dose rate (HDR) brachytherapy is to shrink the cancer before surgery. There isn’t enough evidence to show how well it works, either alone or together with external radiotherapy. If this is a treatment option for you, your healthcare team will explain the benefits and risks.

Side effects

All treatments carry a risk of side effects. Your healthcare team should give you written information about the possible side effects. But they won’t be able to tell you in advance which side effects you will get or how long they will last.

If you are having two or more treatments together, the side effects may be worse.

At your hospital appointments, your healthcare team will ask you about the side effects you’re getting. You might want to keep a diary to help you remember the details.

Possible short-term side effects of radiotherapy include:

• 1. Sore skin
• 2. Bowel problems
• 3. Bladder problems
• 4. Sexual problems
• 5. Tiredness
• 6. Difficulty sleeping.

These side effects often get better in the first few months after you finish treatment. But some people have long-term or new side effects that do not get better without support from the healthcare team.

You may have new or long-term changes to the way your bowel works, such as loose and runny poo (diarrhoea), having to open your bowels more or less often than before, being woken from sleep to poo, having less warning to get to a toilet in time or being unable to control the bowel and having accidents.

Tell your healthcare team as soon as possible if you have any new or ongoing side effects. You may need to have some tests to find out what is causing them. Your healthcare team can give you treatments that can improve these side effects.

Radiotherapy may damage the bones in your pelvis (the area between your hips) and can lead to fractures.                                                                           Tell your healthcare tea if you have any pain or stiffness in your pelvis or back.

Radiotherapy can also irritate your bladder and can affect your sexual function. 

Radiotherapy usually causes infertility. But you should still use contraception during treatment and for about a year afterwards in case there is any chance of pregnancy. Radiotherapy can damage sperm and eggs and harm a developing baby.

Many people living with bowel cancer worry about the cancer coming back and about returning to normal life after treatment. Your healthcare team can offer you support. Read our page on worries about the future for more information. 

If you have any new symptoms or have any worries, speak to your healthcare team who can advise you where to find further information or support.

• There were around 41,300 new cases of bowel cancer in the UK in 2014, that’s 110 cases diagnosed every day.
• Bowel cancer is the fourth most common cancer in the UK (2014).
• In males in the UK, bowel cancer is the third most common cancer, with around 22,800 cases diagnosed in 2014.
• In females in the UK, bowel cancer is the third most common cancer, with around 18,400 cases diagnosed in 2014.
• More than 4 in 10 (44%) bowel cancer cases in the UK each year are diagnosed in people aged 75 and over (2012-2014).
• Incidence rates for bowel cancer in the UK are highest in people aged 85-89 (2012-2014).
• Since the late 1970s, bowel cancer incidence rates have increased by 14% in Great Britain. The increase is larger in males where rates have increased by around a fifth (19%), than in females where rates have increased by less than a tenth (3%).
• Over the last decade, bowel cancer incidence rates have increased by a twentieth (5%) in the UK. The increase is larger in females where rates have increased by 6%, than in males where rates have increased by 3%.
• Most bowel cancer cases are diagnosed at a late stage.
• Most bowel cancers occur in the rectum.
• Incidence rates for bowel cancer are projected to fall by 11% in the UK between 2014 and 2035, to 74 cases per 100,000 people by 2035.
• 1 in 14 men and 1 in 19 women will be diagnosed with bowel cancer during their lifetime.
• Bowel cancer in England is more common in males living in the most deprived areas. There is no association for females.
• Bowel cancer is more common in White people than in Asian or Black people.
• In the UK more than 143,000 people were still alive at the end of 2006, up to ten years after being diagnosed with bowel cancer.
• In Europe, around 477,000 new cases of bowel cancer were estimated to have been diagnosed in 2012. The UK incidence rate is 20th highest in Europe for males and 17th highest for females.
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• Worldwide, an estimated 1.36 million new cases of bowel cancer were diagnosed in 2012, with incidence rates varying across the world.

Hospital tests

If your GP thinks you may have a bowel problem, they will refer you to hospital. You will get an appointment for an outpatient clinic where the specialist may decide you need one or more of the following tests:

• 1. Flexible sigmoidoscopy
• 2. Colonoscopy
• 3. Virtual colonoscopy (CT colonoscopy)
• 4. Barium enema

Or you may have been advised to have one or more of these tests after taking part in the bowel cancer screening programme. 

You can find out more about all of these tests and what to expect in our guide to flexible sigmoidoscopy and colonoscopy.

The specialist may repeat some of the tests that you had at the GP surgery. They may also ask you the same questions about your general health, your symptoms and your family history.

You should get your test results in about two weeks. Your family and friends can be a great support during this stressful time. If you have any questions or are worried about anything, speak to your GP.

You may want to take someone with you to your hospital appointments to help you remember what has been said. You could also take along a list of questions that you want to ask and a pen to write down the answers. This can help you remember the information once you get home.

Further tests

If the hospital tests show cancer cells in your colon or rectum, you will need more tests to stage the cancer. This means finding out the size of the cancer, where it is and whether it has spread.

You may have one or more of the following tests.

• 1. CT scan
• 2. MRI scan
• 3. Ultrasound scan
• 4. PET-CT scan

Your doctor will give you the test results at your follow-up appointment. Your healthcare team will describe the stage of your cancer using the TNM or Dukes’ staging systems. 

CT scan

A CT (computerised tomography) scan shows the size of the cancer and whether it has spread to other parts of the body. It uses x-rays to produce 3D pictures of the inside of the body.

The scanning department will give you instructions on how to prepare for your scan. These are normally written in your appointment letter.

You won’t be able to eat or drink for a few hours before the scan. A nurse will give you a drink or injection of a dye that makes the scan pictures clearer. If you are having a rectal scan, you may have a similar liquid passed into your rectum through a tube. Once you are in position you will need to keep as still as possible.

The scan takes between ten and 30 minutes and doesn’t hurt. Most people are able to go home soon after the scan.

MRI scan

An MRI (magnetic resonance imaging) scan uses strong magnetic and radio waves to build up a picture of the inside of your body. It can give more detailed pictures than a CT scan.

You will have an MRI scan if you have rectal cancer. The results will show whether all of the cancer can be removed with surgery or whether you need to have radiotherapy first.

You may also have an MRI scan if you have colon or rectal cancer and your CT scan shows the cancer has spread.

You won’t be able to have an MRI scan if you have a heart monitor, pacemaker or some types of surgical clips. This is because they contain metal and will be affected by the magnets in the scanner.

The scanning department will tell you if you need to do anything to prepare for the scan. They may ask you not to eat or drink before the scan.

You may have an injection of dye into your arm to improve the image during the test. You will lie on the scanning table, which will pass into the scanner. The machine is very noisy and close to your body. Tell your radiographer if you don’t like closed-in spaces. They can give you ear plugs or headphones and an eye mask to wear. You will be able to speak to the radiographer through an intercom during the scan, which can take up to 45 minutes.

You should be able to go home soon after the scan.

Ultrasound scan

If you have rectal cancer, you may have an ultrasound scan of the back passage (rectum). This scan uses sound waves to build up a picture of the body. It can show the size of the cancer and where it is.

You will need to lie on your side while the ultrasound probe is passed into your back passage. The scan will take about ten minutes and you should be able to go home straight afterwards.

PET-CT scan

If the cancer has spread to your liver or lungs, you may have a PET-CT scan. This uses a PET (positron emission tomography) scan and a CT scan together. It gives more detailed pictures of the body than a CT scan alone. A PET scan uses a low dose of radiation to take pictures of the whole body.

You may have a PET-CT scan if the results of other scans aren’t clear or if the cancer has spread to your liver or lungs. Doctors sometimes use PET-CT scans if there are signs that bowel cancer has come back after treatment.

Usually, you will not be able to eat for six hours before the scan but you will be able to drink water. Your appointment letter will tell you how to prepare for your scan.

At the hospital, you will have an injection of a mildly radioactive drug. You will need to wait for about an hour while the drug spreads throughout your body. You will then have your scan, which will take between 30 minutes and an hour. You will be able to go home straight after the scan.

Staging and grading

Staging a cancer involves describing its size, where it is and whether it has spread. Knowing the stage of your cancer will help you and your doctor decide on the best treatment.

If you have surgery, your doctor will grade the cancer by looking at how normal or abnormal the cells look under a microscope. Grading the cancer can help to show how likely it is to spread and how quickly.

Staging

The most common staging system is the TNM system. You may also hear about the Dukes’ system which is explained below. 

TNM system

• T (tumour) - how far the tumour has grown through the bowel wall
• N (nodes) - whether the cancer has spread to nearby lymph nodes
• M (metastases) - whether the cancer has spread (metastasised) to other parts of the body

T stage

• T1 - the tumour is in the inner layer of the bowel
• T2 – the tumour has grown into the muscle layer of the bowel wall
• T3 – the tumour has grown into the outer lining of the bowel wall
• T4 – the tumour has grown through the outer lining of the bowel wall 

N stage

• N0 – no lymph nodes contain cancer cells
• N1 – cancer cells in up to three nearby lymph nodes
• N2 – cancer cells in four or more nearby lymph nodes 

M stage

• M0 – the cancer hasn’t spread to other parts of the body
• M1 – the cancer has spread to other parts of the body, like the liver or lungs

Dukes’ system

Doctors sometimes use this system to describe the stage of the cancer. The list below shows how the Dukes’ system compares to the TNM system.

Dukes’ A

• TNM stage 1
• T1, N0, M0 or T2, N0, M0

The cancer has grown into the inner layer or muscle layer of the bowel wall. It has not spread to the lymph nodes or other parts of the body.

Dukes’ B

• TNM stage 2
• T3, N0, M0 or T4, N0, M0

The cancer has grown through the muscle layer or outer layer. It may be growing into tissues near the bowel but has not spread to the lymph nodes or other parts of the body. 

Dukes’ C

• TNM stage 3
• Any T, N1 or N2, M0

The cancer is any size and has spread to nearby lymph nodes. It has not spread to other parts of the body.

Dukes’ D

• TNM stage 4
• Any T, any N, M1

The cancer is any size. It may or may not have spread to nearby lymph nodes but it has spread to other parts of the body, like the liver or lungs.

Grading

Grading the cancer helps you and your doctor understand how quickly it may grow and spread. A low grade cancer may grow more slowly and is less likely to spread than a high grade cancer.

• Grade 1 (low grade) - the cancer cells look similar to normal cells (well differentiated)  
• Grade 2 (moderate grade) – the cancer cells look more abnormal (moderately differentiated)
• Grade 3 (high grade) – the cancer cells look very abnormal (poorly differentiated)

Questions to ask your GP

You might like to take a list of questions to your hospital appointment, to help you understand your diagnosis. We have suggested some possible questions here:

• 1. What happens next? 
• 2. Who do I need to see and when?
• 3. Should I be referred for genetic testing?
• 4. Will my treatment cause early menopause or affect my fertility?
• 5. Can you refer me to a fertility clinic?
• 6. What emotional support is available?
• 7. Can you put me in touch with other people my age who have been diagnosed with bowel cancer?
• 8. What support or information is there for my family or children?
• 9. Who can I speak to about getting help with childcare during my treatment and recovery?
• 10. Where can I get information and advice about work and money?

Living with and beyond bowel cancer

These topics below describe how bowel cancer can affect your daily life and where you can get help and advice.

You may also be interested in our page on long term and late side effects.

Body image

Cancer and its treatment can change how you think and feel about your body. You may feel sad, angry or worried about any changes to your body. You may have scarring, numbness or other side effects of treatment that can make you feel self-conscious or affect your confidence. 

Talking about how you feel can help you to cope. You could talk to someone close to you or you could ask your specialist nurse for help.

Changes to your body can lead to sexual problems if you feel self-conscious, you find sex uncomfortable or you are worried about new relationships. The Sexual Advice Association gives practical tips in its booklet, Intimacy & sexuality for cancer patients and their partners.

If you have a stoma, you may feel less attractive or you may worry that other people can see it through your clothes. Until you get used to looking after your stoma, you might worry about smells or leakage. Your stoma care nurse can help you with any worries you may have. 

Having a stoma should not stop you doing the things you enjoy. There are companies that sell attractive underwear, swimwear and other products that can help you feel more comfortable. Ask your stoma care nurse for more information or visit the Colostomy Association website for a list of suppliers.

More information

Macmillan Cancer Support provides information on how cancer treatment affects the way your body looks, works or feels. 

Exercise

You may not feel like exercising when you are having treatment but regular physical activity can help to reduce some side effects, such as extreme tiredness (fatigue).It can help you stay at a healthy body weight and improve your quality of life. Recent research shows that regular exercise may help you live longer after bowel cancer treatment.

Start off gently and, when you are ready, try to build up the amount of activity you do each day. You might start off with a walk around the house and then move on to a short walk outside. As you get your strength and energy back, you’ll be able to do more. Try to build up to 30 minutes or more of moderate exercise, such as fast walking, at least five days a week.

Be careful not to lift anything heavy while you are recovering from treatment. Speak to a physiotherapist if your job involves manual work. They can also give you advice on when you can start exercising and what exercises would be best for you. You might like to try gentle forms of pilates, yoga or tai chi, which can help build strength in your stomach area (abdomen).

Work

As soon as you are diagnosed with cancer, you are protected as a disabled person by the Equality Act 2010. This means your employer must make any reasonable adjustments needed to allow you to continue working. For example, they might allow you to change your working hours or use your sick leave allowance for hospital appointments. If you have had time off work and are thinking of going back, you may want to ask if you can start off with just a few hours, gradually building up your hours when you feel able to.

If you think you’ve been treated unfairly at work, you should speak to your employer first. If there is still a problem, you can contact ACAS (the Advisory, Conciliation and Arbitration Service), Citizens Advice or your union, if you have one.

Macmillan Cancer Support produces detailed information about work and cancer, including information for people with cancer, their partners, the self-employed and employers. 

Money and insurance

You may be worried about money, for example, if you’re unable to work or you need to pay for things like extra childcare and travel to hospital. You can get help with some costs and you might be able to get some benefits or grants.

NHS prescriptions are free in Scotland, Wales and Northern Ireland. If you live in England, you can get free prescriptions if you are having treatment for cancer or the effects of cancer. You will need to fill in a form that you can get from your GP. 

You will then get a certificate that allows you to get free prescriptions for five years. You will be able to renew your certificate if you are still having treatment. You may be able to get free prescriptions even if you are having private treatment. Ask your GP or hospital doctor for more information.

If you have a low family income, you may be able to get help with travel costs for hospital appointments. The NHS in England, Scotland and Wales has a low income scheme. In Northern Ireland, you can also get help with health costs.

If you have an insurance policy, such as critical illness cover, income protection or mortgage payment protection, you may be able to make a claim when you are diagnosed with cancer. You can find out more about this by reading Macmillan Cancer Support’s booklet on insurance from their Financial guidanceseries of information.

Some people have found it hard to get information about what help they can get with money and have had problems claiming benefits. If you need some help, call Macmillan Cancer Support on 0808 808 00 00. They can help with questions about benefits and insurance and can send you booklets with detailed information. They also offer grants to people on low incomes. 

More information

Macmillan Cancer Support provides information on getting insurance and claiming benefits. They also have welfare rights advisors that you can speak to on the phone and they offer grants to people on low incomes.

Childcare

There may be times during your treatment when you need extra help with childcare. Family and friends may be able to help or you may need extra childcare from a nursery or childminder. A social worker will be able to tell you what help is available locally.

More information

Macmillan Cancer Support provides detailed information on childcare.

Diet

Below is a comprehensive information pack, Your diet: living with and beyond bowel cancer, suitable for people during and after bowel cancer treatment. The pack contains information sheets on diet and physical activity with practical hints and tips to help manage the longer-term effects of treatment. Download each factsheet below. (Bowel Cancer UK)

What is a balanced diet

Eating with a low appetite

Managing cancer related fatigue

Fibre after bowel cancer

Managing diarrhoea

Managing constipation

Coping with wind

Changing to a vegetarian or vegan diet

Gaining weight safely

Losing weight safely

Physical activity after bowel cancer

When to seek professional advice

Eating and drinking during treatment

Eating and drinking with metastatic disease

Eating and drinking with an ileostomy

Eating and drinking with a colostomy

Food and symptom diary

Travel