Definition of colorectal cancer

Colorectal cancer “is a cancer that develops in the large intestine. Colon cancer refers to cancer that develops in the colon, the longest part of the large intestine. Rectal cancer develops in the rectum, the final straight part of the large intestine that ends in the anus” (ESMO Clinical Practice Guidelines 2016 (pdf)) . Of colorectal cancers, approximately two-third originate from the colon and one-third from the rectum and the rectosigmoid junction. Most colorectal cancers develop from an adenomatous polyp that may slowly progress to invasive cancer (The Cell, A Molecular Approach ,  IARC 2019) .

Symptoms (such as change in bowel habits, unexplained weight loss, anaemia) are not colorectal cancer specific and appear in a more advanced stage of the disease' (The Cell, A Molecular Approach , WHO 2017 (pdf) .

An earlier stage at diagnosis can allow more effective treatment to be delivered and may lead to a better prognosis. Rectal cancer is usually detected earlier than colon cancer (due to earlier appearance of symptoms) and the stage at diagnosis is an important determinant of survival (The Cell, A Molecular Approach) .

Prevalence and incidence of colorectal cancer in the European Union

Colorectal cancer prevalent cases in the European Union are estimated to be 2 839 442, or around 12% of the cancer cases covered by the EU registries (ECIS 2022). The age-standardised proportion of prevalent cases per 100 000 population is 598.6 (386.1 for colon, 220 for rectum). 

Colorectal cancer is estimated to be among the most commonly diagnosed cancers (2nd in females and 3rd in males) in the European Union in 2022 (ECIS 2022). It is estimated to contribute to 13% of all new cancer cases (excluding non-melanoma skin cancer) and to account for more than 356 thousand new cancer cases in 2022 (ECIS 2022).

The age-standardised incidence rate for colorectal cancer for both sexes combined is estimated in 73.5 per 100 000 (47.3 for colon and 24.1 for rectum). The rates were at least 1.5 times higher in males than in females (respectively 58.4 vs. 38.8 per 100 000 for colon cancer; and 32.5 vs. 17.2 per 100 000 for rectal cancer).

Table 1 presents the estimated number of new cases and age-standardised incidence rates for colon and rectal cancer by sex and per country of the European Union in 2022 (ECIS 2022).

Table 1: Estimated number of new cases (incidence) and age-standardised incidence rates (ASR) for colon and rectal cancers in 2022 

About 43% of the estimated new colorectal cancer cases in the European Union in 2022 occurred in people aged 75 years and older and about 55% in people aged 45–74 years (ECIS).

Factors related to colorectal cancer

Colorectal cancer can be linked to both modifiable and non-modifiable risk factors. Non-modifiable risk factors include older age, genetic susceptibility and medical history (e.g. personal or family history of colorectal cancers, adenomatous polyps, personal history of chronic inflammatory bowel disease (World Cancer Research Fund/American Institute for Cancer Research 2018) over a long time period (The Cell, A Molecular Approach , World Cancer Report 2020) , and adult attained height (as a marker for genetic, environmental, hormonal and nutritional growth factors affecting growth during the period from pre-conception to completion of linear growth) (World Cancer Research Fund/American Institute for Cancer Research 2018) .

Modifiable risk factors for colorectal cancer include unhealthy diet, alcohol use, physical inactivity and tobacco use (Table 2). Other important risk factors for colorectal cancer are type 2 diabetes, and excess body adiposity (ESMO Clinical Practice Guidelines 2016 (pdf) , IARC 2018)

Additionally, it has been shown that 'Long-term use (five years or more) of at least 75 mg per day of the non-steroidal anti-inflammatory drug aspirin can reduce the risk of colorectal cancer' while 'hormone therapy in postmenopausal women also decreases colorectal cancer risk' (World Cancer Research Fund/American Institute for Cancer Research 2018) .

Table 2: Modifiable factors related to colorectal cancer 

The presented data is not exhaustive but provides a body of evidence on the modifiable factors linked to colorectal cancer risk. Additional information from international and national institutions about the associations between dietary factors with colon or rectal cancers, and health can be found in the chapters dedicated to each dietary factor.

Disease and economic burden related to colorectal cancer

Disease burden related to colorectal cancer

According to the Global Burden of Disease (GBD 2019) study over 213 thousand deaths (nearly 114 thousand in men and over 99 thousand in women) and over 3.8 million Disability Adjusted Life Years (DALYs; over 2.2 million in men and over 1.6 million in women) in the European Union in 2019 were attributable to colorectal cancer (IHME 2020) . Over 70% of colorectal cancer deaths were observed in persons 70 years and older (IHME 2020) .

Table 3 presents mortality rates due to colorectal cancer by sex and country in 2022. Average age-standardised mortality rates for colorectal cancer in the European Union in 2022 were higher for men (42.8 per 100 000 population) than for women (24.6 per 100,000 population) (Table 3).

Mortality rates estimated for EU in 2022 were also higher for colon (22.1 per 100 000 population) than rectal (9.6 per 100,000 population) cancer (ECIS 2022) .

Table 3: Age-standardised mortality rates attributed to colorectal cancer in the EU in 2020 

According to the Global Burden of Disease 2019 study, dietary risks (i.e. low intakes of fibre, milk and calcium, and high intakes of red and processed meats) were responsible for nearly a third of deaths and DALYs from colorectal cancer, while smoking was the second important risk factor  (GBD tool) .

View visualisation: Disability Adjusted Life Years attributed to colorectal cancer for women in the EU in 2019 - map 

View visualisation: Mortality attributed to colorectal cancer for women in the EU in 2020 - map

View visualisation: Disability Adjusted Life Years attributed to colorectal cancer for men in the EU in 2019 - map 

View visualisation: Mortality attributed to colorectal cancer for men in the EU in 2020 - map 

In the European Union in 2015, mortality from colorectal cancer was with 6 main causes of preventable and amenable (treatable) death; it accounted for 7% of all preventable and 12% of all treatable deaths that could be reduced through earlier detections and more effective and timely treatments, respectively (OECD 2018) . In the European Union in 2016, mortality from colorectal cancer accounted for 16% of overall treatable mortality that could be avoided through optimal quality health care (OECD 2020) .

Economic burden related to colorectal cancer

The economic burden of colorectal cancer in the European Union in 2018 was estimated at €19 billion (€12.2 and 6.8 billion for colon and rectum cancers, respectively) (IHE Report 2020) .

This comprises direct healthcare costs (expenditures that are made within health care system, such as primary care, emergency care, outpatient care, hospital inpatient care, drugs and treatments), informal care costs (services provided by relatives and friends) and indirect costs (productivity loss due to cancer morbidity and mortality, such as costs of sick leave, early retirement, disability).

Colorectal cancer constituted 9% of the total economic cost of cancer in Europe in 2018 (6% for colon and 3% for rectal cancer)( IHE Report 2020 ).

Within the direct cost expenditure, nearly a quarter of expenditure for both colon and rectal cancers was the cost of cancer drugs, as compared to less than 10% for other digestive cancers.

For colon and rectal cancers, the sum of informal care costs and indirect costs was equally large as the direct costs for all countries. Informal care costs contributed around 15 % of the total costs. The figure presents costs of colon and rectal cancers by the cost type in Europe in 2018 ( IHE Report 2020 ).

Figure: Direct and indirect costs (in billion €) of colon and rectal cancer in the EU in 2018 

Policies related to the prevention of colorectal cancer

Many countries across the EU have taken action and established strategies to tackle cancer (Cancer Control 2012 (pdf)) .These primary cancer-prevention actions focus on cancer risk factors and screening programmes.

Primary prevention (cancer risk factors)

As many colorectal cancer risk factors are shared with other chronic diseases, primary prevention strategies that address tobacco control (WHO 2003 (pdf)) (WHO 2015 (pdf)), harmful use of alcohol (WHO 2018 (pdf)), and promotion of healthy diet and lifestyle, target at the same time multiple chronic diseases and cancers (WHO 2007) (WCRF 2018 (pdf)), . Multi-sectoral, integrated approaches are required (WHO 2007 (pdf) , WHO 2017 (pdf)) , to obtain a sizable effect.

Policy recommendations addressing consumption of fats, fibre, protein, salt, fruit and vegetables, whole grain, physical activity and sedentary behaviour, as well as alcoholic beverages, are listed in the relevant chapters of this Health Promotion and Disease Prevention Knowledge Gateway and are regularly updated.

Based on the scientific evidence related to risk factors, cancer-specific prevention recommendations have been developed by public health organisations (ECAC , World Cancer Research Fund) . The recommendations aim to help people live cancer-free lives and help development of policies that reduce cancer incidence.

Secondary prevention (screening)

Colorectal cancer is one of the three cancers (along with cervical and breast cancer) for which population-based screening programmes are justified by scientific evidence of efficacy and hence has been recommended by the European Union Council since 2003 (EC 2003 (pdf)). Indeed, most EU Member States (23 in a 2017 assessment) have established, or are establishing, colorectal cancer screening programmes (EC 2017 (pdf)) .

Effective colorectal cancer screening combined with increased awareness and surveillance programmes for high-risk patients- results in diagnosis at earlier stages.  (IARC 2019)  This is thought to contribute to the reduced colorectal cancer mortality (10% drop on average across EU countries between 2000 and 2015) and increased survival rates (five-year net survival improved from 54% to 60% and 52% to 58% between 2000-04 and 2010-14 for colon and rectal cancer respectively) from colorectal cancer observed in most European countries (OECD 2018) . Colorectal cancer screening may also avert the development of cancer by detecting precancerous lesions that can be surgically removed.

A screening appointment with the healthcare provider can also be a good counselling opportunity to convey evidence-based health and wellbeing messages (World Cancer Report 2020) . The European Commission Initiative on Colorectal Cancer (ECICC) will develop person-centred evidence-based guidelines and a quality assurance scheme for healthcare services involved in the colorectal cancer care pathway, including screening and diagnosis (ECICC 2020 (pdf)) .

Several policy actions were proposed to be considered in the colorectal cancer screening (Digestive Cancers Europe 2019 (pdf)) , including:

• improvement of national colorectal cancer control programmes (from screening to treatment), their implementation and capacity building,

• undertaking consistent and regular EU-wide monitoring of screening programmes adherence and (cost-)effectiveness,

• promoting multi-stakeholder colorectal cancer initiatives and exchange of best practices,

• create educational materials and organise colorectal cancer awareness-raising campaigns and counselling services, such as those in the workplace (Centers for Disease Control and Prevention 2018) :

  • health-related programmes (classes, seminars or competitions) and policies for colorectal cancer screening,

  • employee health surveys in the workplace that assess employee health and present opportunities to educate individual employees to their needs for screening and follow-up,

  • worksite-wide education campaigns to increase use of screening services,

  • providing sick leave or flexi-time for employees who need screening or clinical follow-up.