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Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Cancer, Rectum


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Medical Codes

ICD-9-CM:
154.0 - Malignant Neoplasm of Rectum, Rectosigmoid Junction, and Anus; Rectosigmoid Junction; Colon with Rectum; Rectosigmoid
154.1 - Malignant Neoplasm of Rectum, Rectosigmoid Junction, and Anus; Rectosigmoid Junction; Rectum; Rectal Ampulla
154.2 - Malignant Neoplasm of Rectum, Rectosigmoid Junction, and Anus; Rectosigmoid Junction; Anal Canal; Anal Sphincter
154.3 - Neoplasm, Anus, Malignant, Unspecified
154.8 - Neoplasm, Other Sites of Rectum, Rectosigmoid Junction, and Anus, Malignant
197.5 - Secondary Malignant Neoplasm of Respiratory and Digestive Systems; Large Intestine and Rectum
230.4 - Carcinoma in Situ of Rectum, Rectosigmoid Junction
235.2 - Neoplasm of Uncertain Behavior of Stomach, Intestines and Rectum

Related Terms

  • Adenocarcinoma of the Rectum
  • Cancer of the Rectum
  • Colorectal Cancer
  • Malignant Neoplasm of Rectosigmoid Junction
  • Malignant Neoplasm of the Rectum
  • Rectal Cancer

Overview

Rectal cancer is a tumor originating in the cells of the lining (mucosa) in the last segment of the large intestine (colon) that terminates at the anus (rectum). The rectum is the last 6 inches of the gastrointestinal tract. It is divided into equal thirds: the upper, middle, and lower rectum.

Cancer of the rectum is classified according to the type of cell found in the tumor (cell of origin). All cancer originates when a certain type of cell begins to divide and reproduce rapidly, producing a growth (lesion) or tumor. Nearly all (98%) of rectal tumors are adenocarcinomas, which means that the cancer originates in the glandular cells that line the inside layer of the wall of the rectum (Cagir). The adenomatous polyposis coli (APC) gene is present in this type of cancer, and its inactivation starts the uncontrolled replication of cells and a series of gene mutations that result in adenocarcinoma of the rectum (Cagir). Another common cancer pathway begins with a mutation in DNA-mismatched repair genes that causes a replication error found in 90% of hereditary non-polyposis colon cancer (HNPCC) cases (Cagir). Rarely, the rectal tumor may be classified as lymphoma (1.3%), carcinoid (0.4%), or sarcoma (0.3%) (Cagir).

Rectal cancer and colon cancer are frequently referred to in combination as "colorectal cancer"; but despite the fact that the rectum and colon are composed of comparable types of tissue, cancers affecting the rectum and colon behave and are treated differently. About 20% of all colorectal cancers occur in the rectum (Cagir). Please refer to Cancer, Colon for more details about cancers of the large intestine.

Rectal cancer is usually preceded by polyps, or growths in the rectal lining. Polyps may be benign, precancerous, or cancerous (malignant). Since polyps are found in 15% to 20% of colorectal cancers, early identification and removal of rectal polyps are important to reduce mortality (Cagir). Screening for rectal polyps usually occurs in conjunction with screening for colon polyps and colon cancer (colorectal screening). Because polyps are uncommon in individuals younger than 50, the American Cancer Society recommends screening for individuals over the age of 50. Screening tests of average-risk individuals may include yearly digital rectal examination (DRE) and fecal occult blood test (FOBT), with proctoscopy, flexible sigmoidoscopy, colonoscopy, or barium enema as needed based on the findings. Individuals with a family history of colon, rectal, or gynecologic cancers or those with a personal history of ulcerative colitis are advised to be screened more regularly.

If rectal cancer is discovered, the diagnosis is confirmed by diagnostic tests, imaging, and microscopic examination of tumor cells by a pathologist. The tumor location and size are evaluated along with the cell type and extent of spread (metastasis). Then the cancer is staged and treated according to the degree of invasiveness. The more recent staging system is the TNM (Tumor, Node, Metastasis) system from the American Joint Committee on Cancer (AJCC) which describes progressive stages in increments designated as T0 through T4, N0 through N3, and M0 through M1; the TNM system defines the following grouped stages: stage 0, known as carcinoma in situ, is a localized tumor found only in the lining of the rectum; stage I is cancer that has grown into epithelial and submucosal layers and the inner wall of the rectum; stage II is cancer that extends through the layers of the rectal wall and may have invaded nearby tissue; stage III is cancer that has also spread to nearby lymph nodes; and stage IV is cancer that has spread to distant organs (metastasized). The Duke's classification system (Duke's A, B, C, and D), which essentially parallels stages I through IV, may also be used. When rectal cancer is found in the early stages it is often curable, as the potential outcome (prognosis) correlates closely to whether the cancer is localized, has penetrated through the wall of the rectum (local metastasis), or has metastasized to distant organs.

Incidence and Prevalence: The peak incidence of cancer of the rectum occurs in adults in their fifties (Cohen 1535); 90% of those diagnosed with the disease are older than 50 (“Detailed Guide”). Among racial groups in the US, the highest incidence and mortality are found in blacks (“Detailed Guide”). Colorectal malignancies are slightly higher among men than women (Cagir); about 22,620 new cases were anticipated to be diagnosed in 2010 among men and 17,050 among women (“Detailed Guide”).

The incidence of rectal cancer is 44 new cases per 100,000 population, or about 34,000 new cases annually (Cohen 1535). Colon and rectal cancers are the third most common cancers diagnosed in both men and women in the US. The American Cancer Society estimates that 39,670 new cases of rectal cancer would be diagnosed in 2010, (“Detailed Guide”).

About 1 million individuals are diagnosed annually worldwide; the highest incidence is found in industrialized countries, including the US, Canada, Japan, Eastern Europe, Israel, New Zealand, and Australia (Cagir). Although incidence is decreasing generally, increases in numbers of cases have been recorded in Japan, China, and Eastern Europe (Cagir). Among ethnic groups, Eastern European Jews have the highest incidence worldwide, believed to be associated with a specific inherited gene mutation that increases risk (“Detailed Guide”).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Risk factors for rectal cancer are similar to those for colon cancer, and may be both hereditary and lifestyle-related (i.e., poor diet, inactivity, smoking, and heavy alcohol consumption), although in 75% of cases no direct cause is identified (sporadic cancer) (Cagir). Research indicates that diets high in fat, red meat, and total calories and low in fiber correlate with the incidence of rectal cancer.

A personal or familial history of colorectal polyps has been shown to increase the risk of developing rectal cancer. Also, gene mutations associated with certain inherited syndromes, such as familial adenomatous polyposis (FAP, which includes Gardner syndrome and Turcot syndrome), and hereditary nonpolyposis syndromes, may predispose individuals to developing colorectal cancer.

Other risk factors include obesity, type 2 diabetes, inflammatory bowel disease (Crohn's disease or ulcerative colitis), and treatment for a previous cancer such as prostate or testicular cancer (“Detailed Guide”).

Source: Medical Disability Advisor



Diagnosis

History: The most commonly reported symptom of rectal cancer is rectal bleeding, which occurs in 60% of individuals (Cagir). Individuals may also report a change in bowel habits, blood in the stool, loss of appetite (anorexia), nausea and/or vomiting, and steady, gnawing rectal or abdominal pain. Weakness and fatigue may be reported due to chronic blood loss (anemia), and constipation may alternate with increased frequency and loose stools (diarrhea). Occasionally, the individual will report no symptoms at all until the tumor grows so large that it causes a bowel obstruction or rupture of the intestine.

A personal and/or family history of colorectal polyps, familial adenomatous polyposis (FAP), hereditary non-polyposis colon cancer (HNPCC), or inflammatory bowel disease (Crohn disease or ulcerative colitis) is associated with high risk and can be important to the diagnosis. Obtaining the individual’s history of tobacco and alcohol use is also important.

Physical exam: Examination of the abdomen with the hands (palpation), or examination with one gloved finger in the rectum and the other hand pressing on the abdomen (bimanual rectal exam), may reveal a mass in the rectum. When rectal cancer is detected with a digital rectal exam (DRE), in 67% to 84% of cases it correctly predicts the stage of the cancer (Cohen 1535). Abdominal palpation may also reveal an enlarged liver, which suggests that the cancer has spread from the rectum to other organs (metastasized). In advanced cases, rectal cancer that has spread can cause enlarged lymph glands near the collarbone (supraclavicular adenopathy), in the groin, or in other areas.

Tests: The fecal occult blood test (FOBT) is positive in 26% of individuals with rectal cancer (Cagir). A fecal immunochemical test may also be done using monoclonal antibodies to identify hemoglobin present in rectal lesions, indicating bleeding. A complete blood count (CBC) is done to rule out anemia; the presence of hypochromic, microcytic anemia suggests iron deficiency. Additional blood tests, including measurement of a molecule that is associated with cancer cells (carcinoembryonic antigen, or CEA test), a cancer antigen (CA) 19-9 assay, and liver function tests, may indicate possible metastasis of the rectal cancer to other organs. Stool DNA screening may be done to evaluate genetic changes that may have led to cancer development.

Colonoscopy performed with a flexible fiberoptic instrument (flexible fiberoptic colonoscopy or FFC) may be the first step in identifying the presence of polyps in the colon or rectum and locating a lesion in the rectal wall; virtual colonoscopy (computed tomography [CT] colonography, or CTC) may be an alternative procedure. Other diagnostic tests for rectal cancer may include a contrast-enhanced x-ray procedure to visualize the rectum (double-contrast barium enema) or direct visualization of the rectum (rigid proctosigmoidoscopy) using a lighted fiberoptic instrument (proctoscope). These procedures help determine the size of the lesion and whether obstruction is present. A small sample of tissue (biopsy) may be taken from the tumor to be examined microscopically to identify and grade the cells (histologic grade) and confirm that the tumor is cancerous (histopathologic confirmation).

X-rays of the chest, abdomen, and pelvis may be performed to look for evidence of metastasis to the lungs, as well as to abdominal and pelvic organs. The extent of cancer invasion in or through the rectal wall and outside the rectum (staging) can be determined using endorectal and pelvic magnetic resonance imaging (MRI), or computer analysis of x-ray data (CT). Ultrasound from within the rectum (endoluminal ultrasound) can provide important information about the extent to which the rectal cancer has infiltrated the bowel wall or has spread to perirectal lymph nodes.

The American Cancer Society recommends fecal occult blood testing on an annual basis and flexible sigmoidoscopy every 5 years after age 50 for average-risk individuals.

Source: Medical Disability Advisor



Treatment

Treatment depends upon the stage of the tumor, whether nearby lymph nodes or other local tissues are involved (local metastases), and whether the cancer has metastasized to distant organs. The goals of the surgery may differ depending on the individual’s age and health status; preserving anal continence, sexual function, and genitourinary function may influence treatment decisions. Sphincter-sparing surgical procedures such as laparoscopic excision are a common consideration.

Stage I and II rectal cancer is usually treated with surgery; surgery for stage I cancer has a high cure rate, and adjuvant chemotherapy or radiotherapy are not often used, but most stage II and III rectal cancers also require radiation and possibly chemotherapy before surgery to shrink the tumor. Sometimes intraoperative radiation is used to improve control of local disease when tumors are especially large and bulky. Surgical removal of the tumor as well as adjacent large intestine (colectomy) tissue and lymph nodes (lymphadenectomy) that lie in close proximity is the treatment of choice for most rectal cancer. Some early cancers higher up in the rectum can be treated with local excision using transanal excision or transanal endoscopic microsurgery (TEM). If the tumor is located in the middle or upper third of the rectum, low anterior resection (LAR) may be the preferred surgical approach because the circular muscles that comprise the anus (anal sphincter) can be left intact. Abdominal perineal resection (APR) is commonly performed for removing lower-third rectal cancers. If the tumor is located further down and the anal sphincter must be removed during surgery, the individual may require an artificial opening (stoma) of the colon through the abdominal wall (colostomy) for the purpose of fecal elimination. Colo-anal anastomosis (CAA) is a surgical procedure sometimes employed for cancers located just above the anus. The procedure allows resection of the tumor without requiring colostomy.

Small tumors in the rectum can be destroyed using the heat generated by a laser beam (laser photocoagulation). This procedure is performed endoscopically and is useful for individuals who are unable to tolerate major surgery. Another surgical option for small, localized rectal tumors is destruction of the tissue using electric sparks (fulguration). Fulguration may be used to reduce the size of some large tumors for individuals with high surgical risk. This procedure may need to be repeated several times to be effective.

Radiation therapy, although not usually considered effective by itself, may be used in addition to surgery for treating rectal tumors. However, endocavity radiation allows a higher dose of radiation to be delivered to a smaller area of the rectum in a shorter period of time and is sometimes the treatment of choice. Radiation is delivered by proctoscope and is performed with only sedation, not general anesthesia, allowing the individual to be discharged on the same day. When 6 high-dose applications are given once weekly for 6 weeks, shrinkage of the lesion is rapid, and an overall survival rate of 83% can be achieved, with 30% recurrence (Cagir). Rectal cancer has a moderate rate of recurrence following surgical removal, but pre- or postoperative radiation therapy may be useful in reducing the recurrence rate. Radiation treatment is used preoperatively to shrink large rectal tumors so they may be removed surgically, or intraoperatively. Radiation may also be administered as palliative therapy when a tumor is not resectable.

Chemotherapy may be used pre- or postoperatively as a supplemental (adjunctive or adjuvant) therapy for rectal cancer. When combined with radiation therapy, chemotherapy improves local control and survival for individuals with rectal tumors. Many effective anti-neoplastic agents are available, and combinations of drugs are believed to improve the response rates, even in patients with distant metastases. Systemic chemotherapy for liver metastasis may have limited effect and low response rates. Liver resection may be recommended, increasing 5-year survival rates to 20% to 40% (Cagir).

Source: Medical Disability Advisor



Prognosis

Overall 5-year survival rates for rectal cancer have improved in recent years, which is believed to be due to better therapy and early detection. The 5-year survival rate is 90% for individuals with stage I rectal cancer, 60% to 85% for stage II, 27% to 60% for stage III, and 5% to 7% for stage IV (Cagir). Stage I patients have a high cure rate and seldom need adjuvant therapy. Local recurrence of rectal cancer occurs in 5% to 30% of individuals (Cagir).

Recent studies indicate that preoperative radiation often allows stage II, III, and IV tumors to be removed surgically, and individuals who receive this treatment in conjunction with surgery may have significantly better survival rates. It has been reported in a study that individuals treated with radiation first and then surgery may have a 5-year survival rate of 58% (Cohen 1541).

Fulguration or laser photocoagulation does not appear to improve the survival rate significantly because these procedures are associated with high rates of recurrence and other complicating factors. For rectal tumors that are localized and show no metastasis, the 5-year recurrence-free survival rates may be as high as 90% following excision (Cagir).

Following surgical treatment, adjusting to a colostomy may produce psychological problems, and as a result, individuals may become anxious and depressed. Individuals with a colostomy usually should avoid odor- and gas-forming foods, and they must learn proper colostomy irrigation technique. Good skin and stoma care is important in preventing infection of the colostomy.

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Colon and Rectal Surgeon
  • Gastroenterologist
  • General Surgeon
  • Oncologist
  • Radiology Oncologist

Source: Medical Disability Advisor



Rehabilitation

A regular exercise routine may be useful in reducing the risk of recurrence of rectal cancer. Also, certain exercises may be performed to reduce postoperative pain and speed recovery. These exercises are especially valuable during the first 48 hours after surgery and may continue until recovery from surgery is complete and pain is no longer noticeable while walking or breathing.

Source: Medical Disability Advisor



Comorbid Conditions

  • Crohn's disease
  • Diverticulitis
  • Irritable bowel disease
  • Other diseases that affect major organs (liver, lungs, spleen, and pancreas)
  • Ulcerative colitis

Source: Medical Disability Advisor



Complications

Complications of rectal cancer are related to the stage the disease has reached by the time of diagnosis. Chronic blood loss at the site of the tumor may result in low concentrations of iron in the blood (iron deficiency anemia). In some cases, the tumor can grow so large that it causes bowel obstruction or rupture. Rectal tumors may enter the lymphatic tissue in the wall of the gut, resulting in metastasis of the cancer into lymphoid tissue, which can damage the intestinal wall and nearby lymph nodes. Further metastasis through the lymph system may allow the cancer to spread to neighboring tissues such as the liver and spleen. Recurrence, either local, distant, or both, is found in up to 50% of treated patients (Cagir).

Source: Medical Disability Advisor



Factors Influencing Duration

Factors that might influence the length of disability include the stage at which the cancer was detected, the amount of rectal tissue that was removed during surgery, the presence of a colostomy, the effectiveness of radiation or chemotherapy treatments, and the individual's response to these treatments. Advanced age and concomitant illness may also be a factor: older individuals often require longer recovery times due to poor overall health status and age-related immune dysfunction.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Individuals whose rectal cancer is detected and treated in its early stages may have no special work restrictions or accommodations following recovery and return to work. However, heavy physical labor will be restricted for 5 to 6 weeks following rectal surgery, and possibly longer if postoperative chemotherapy or radiation therapy treatments are necessary. Fatigue may create the need for additional breaks during this period of recovery. Extra time on breaks may be needed by an individual with a colostomy.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Does individual have any other colorectal diseases? Has individual had colorectal polyps diagnosed?
  • Does individual have a family history of colorectal polyps or colon or rectal cancer?
  • What type of diet is individual accustomed to? Is individual overweight?
  • Have bowel habits changed? Does blood appear in the stool?
  • Does individual have a loss of appetite? Nausea or vomiting?
  • Is gnawing rectal or abdominal pain present?
  • Does individual have any weakness or fatigue?
  • Was a fecal occult blood test done? CBC? CEA?
  • Were liver enzymes and kidney function tests done?
  • Has individual had a barium enema? Biopsy? MRI? CT? Ultrasound? Chest x-ray?
  • Were conditions with similar symptoms ruled out?

Regarding treatment:

  • Did individual have a small tumor? Was the tumor in the lower, middle, or upper third of the rectum?
  • Was the tumor treated endoscopically with laser photocoagulation?
  • Was local excision or fulguration used?
  • What type of surgical resection was performed?
  • Was a colectomy with lymphadenectomy done?
  • Did individual have a colostomy?
  • Was radiation used pre-operatively, intraoperatively, or postoperatively?
  • Was adjuvant chemotherapy used? What was the response to chemotherapy?
  • Was individual instructed in colostomy care and diet prior to discharge?

Regarding prognosis:

  • Can individual’s employer accommodate any necessary restrictions?
  • Is individual able to care for the colostomy? Have related psychological problems developed? Would counseling be advisable?
  • Does individual have any conditions that could affect ability to recover?
  • What stage was the cancer when detected?
  • Does individual have any metastatic disease? Liver metastasis?
  • Is individual a candidate for liver resection?
  • Has local or distant disease recurred since treatment?

Source: Medical Disability Advisor



References

Cited

"Detailed Guide: Colon and Rectum Cancer." American Cancer Society. 18 May. 2009. 31 Aug. 2009 <http://www.cancer.org/docroot/CRI/content/CRI_2_4_1x_What_Is_Colon_and_Rectum_Cancer.asp?sitearea=>.

Cagir, Burt, and Douglas R. Trostle. "Rectal Cancer." eMedicine. Eds. Philip Schulman, et al. 29 Jul. 2009. Medscape. 31 Aug. 2009 <http://emedicine.medscape.com/article/281237-overview>.

Cohen, Alfred M., et al. "Cancer of the Rectum." Clinical Oncology. Eds. Martin D. Abeloff, et al. 4th ed. Churchill Livingstone, Inc., 2008. 1535-1553.

Source: Medical Disability Advisor