indiacancer.org - Colorectal Cancer

Colorectal Cancer

		What are the colon and rectum?
		What is Colorectal Cancer and who are the candidates at risk from it?
		How is Colorectal Cancer detected?
		What are the routine tests performed to detect Colorectal Cancer early?
		Is it possible to reduce the risk for developing Colorectal Cancer?
		What are staging and grading?
		How is Colorectal Cancer treated?
		What are the likely side effects in the treatment for Colorectal Cancer?
		What is the importance of regular followup?
		How do we support these patients of Colorectal Cancer?

What are the colon and rectum?

The colon and rectum together form a long muscular tube called the large bowel or the large intestine. The former is the first 6 feet of the large intestine and the latter, the last 8 to 10 inches. The colon and rectum together are parts of the body's digestive system, and serve the function of removing waste products which are solid in nature and derived from food, out of the body.

Digestive System

What is Colorectal Cancer and who are the candidates at risk from it?

The Rectum (Seen from the front) Unopened

Since the colon and the rectum are two adjacent parts of the distal intestine, they often have a cancer pattern, which is quite similar; hence the joint term Colorectal Cancer is often used. Colon cancers are obviously those, which arise in the colon, and the rectal cancers are those, which arise in the rectum.

While exact reasons for developing Colorectal Cancer are unknown, there have been a few indicators to show that the following risk factors increase the probability of a person developing Colorectal Cancer:

Diet. Diet of a particular pattern is associated with Colorectal Cancer, especially those diets, which are fat heavy and calorie high and low in fibers.

Age. Above the age of 50 years, Colorectal Cancer is more likely to occur. In other words, it is an unlikely occurrence in the younger age groups but it has been reported several times even in teenagers.

Polyps. These are small benign growths on the inner wall of the mucosa of the rectum and colon. Fairly commonly seen in pentagenarian patients and above, they definitely increase a person's risk of acquiring Colorectal Cancer. A very rare condition, which is inherited from one's first-degree relatives, is called familial polyposis in which myriads of polyps are found throughout the lengths of the colon and the rectum. Unless this condition is treated surgically, it almost always leads to the development of cancer.

Women with a history of other cancers such as breast cancers or gynecological cancers also have an increased chance of developing Colorectal Cancer. A person who has previously been diagnosed and treated for Colorectal Cancer may develop this disease a second time after a certain number of years.

Family history. There is a strong predilection among certain patients to develop Colorectal Cancer if their first-degree relatives, which includes (parents, children, and siblings,) have had Colorectal Cancer themselves, especially so, if that particular relative had developed it at an extremely young age. More the number of family persons who have had this cancer, greater the likelihood of a person to develop Colorectal Cancer.

Ulcerative colitis. This is a condition, which is more common in Western countries and is seen infrequently in Asia and in India. It is a condition in which the mucosal lining of the large bowel becomes extremely inflamed and is often accompanied by acute attacks of diarrhea often bloody in nature. After a person has had ulcerative colitis for a certain number of years, he has a greater chance of developing Colorectal Cancer.

How is Colorectal Cancer detected?

The complaints in Colorectal Cancer are often very vague and unfortunately are often ignored both by the patient as well as by the patient's general practitioner or even the surgeon because of certain symptoms and signs prevalent in general amongst Indians.

These signs and symptoms include bleeding per rectum which could be bright red fresh blood, otherwise known as hematochezia, or altered blood which is tarry black in color, which is known as melena, or blood-streaked stools.

Often the patient of the subcontinent mistakes these symptoms with those of what is generally known as 'piles' and is also treated in this manner by his general practitioner. Often such patients have an underlying cancer, which goes undetected until it is too late.

The other common symptom that patients of Colorectal Cancer do have is that of altered bowel habits. These patients could have either diarrhea or constipation or constipation and diarrhea alternating with each other. If such symptoms develop all of a sudden then the patient should consult his clinician.

Patients of Colorectal Cancer can also develop symptoms of low abdominal pain or crampy generalized vague pain. There could also be a lump appearing in the abdomen.

The earlier Colorectal Cancer is picked up, better is the chance of longer survival and even the possibility of a cure.

The other vaguer symptoms of Colorectal Cancer could be:

The Rectum (Seen from the front) Opened

A constant feeling of tiredness or fatigue.

Weight loss for no discernible reason.

Constant tiredness.

Vomiting.

These symptoms and signs are mimicked by certain benign conditions as well, so do not panic. Take your clinician's opinion.

What are the routine tests performed to detect Colorectal Cancer early?

The first thing which a clinician will do and the simplest thing which even a general practitioner can perform is a DRE or a digital rectal examination in which the doctor will introduce a lubricated, gloved finger into the rectum and feel for abnormal areas or lesions.

The most often performed investigation is the fecal occult blood test or the FOBT, which is performed to detect hidden blood in stools. Not all lesions, which bleed in the colon or the rectum, are cancers. Even polyps can bleed. The FOBT is capable of picking up small microscopic amounts of bleeding.

The other routine investigation which is performed by the clinician for diagnosing rectal cancer is called a proctoscopy in which a lubricated, stainless steel tube is introduced into the rectum and the rectal mucosa is visualized directly under an external light source. Any lesion, which is visualized or identified, is biopsied, which means that a small tissue piece is removed from the particular lesion and is sent for examination under a microscope to a pathologist.

This is known as histopathological diagnosis, and this is the confirmatory proof for the diagnosis of a cancer.

The next test which is usually performed is called a sigmoidoscopy. A sigmoidoscope is a fiberoptic flexible scope, which is introduced into the rectum and the lower colon, otherwise known as the sigmoid colon. This scope has got a light at the end of a visual apparatus, which allows the clinician to look directly at the mucosal lining of the colorectum and identify or biopsy any lesions seen.

The colonoscope is a longer form of the sigmoidoscope and can extend much further than the sigmoidoscope and cover the entire length of the large intestine or the colon.

Sometimes sigmoidoscopy and colonoscopy can be attached to a video camera and shown on a short-circuit TV. This is known as video endoscopy and if such a facility is available then you can ask your doctor to give you a recorded video cassette of the same in case you would like to go in for a second opinion.

A useful investigation which has been going on for quite some time is a double contrast barium enema. It consists of a series of radiographs of the colon and rectum after an enema containing barium sulfate, is introduced into the colon and rectum. At various intervals of time, the clinician will take x-rays of your bowel ,which show filling defects in case there are any problems in your colon.

Is it possible to reduce the risk for developing Colorectal Cancer?

Although not very commonly practiced in our country, in Western civilizations where Colorectal Cancer is quite common, you have screening projects in which the normal population is screened for signs of Colorectal Cancer or lesions which predispose for the same.

As we have discussed before, one of the causes of Colorectal Cancer are benign polyps, which can later turn malignant. Early detection and removal of these polyps may help to prevent Colorectal Cancers.

Sometimes cessation of smoking, change in the diet quality, changing from high-fat diets and low-fiber diets to higher fiber supplements can help prevent Colorectal Cancer. Decreased alcohol consumption, increased physical activity and a diet low in fat and calories and high in fiber are some of the hallmarks of the steps taken or suggested to people who want to prevent Colorectal Cancer.

Very rarely, as mentioned before, Colorectal Cancers can present in families. If a particular family has got two or more patients of Colorectal Cancer then it is advisable that other family members go in for routine screening as early as possible. This is even more important if the erstwhile-mentioned family members have developed Colorectal Cancer before the age of 50 years.

What are staging and grading?

	These are terms with which you must become familiar if you are dealing with any form of cancer. When we stage a cancer we try to establish carefully the degree of spread of the cancer and if indeed there is spread, to what extent and involving which organs. The grading of a cancer is a microscopic issue, in which the pathologist lets you know how aggressive this particular type of cancer is. Well-differentiated means less aggressive, moderately differentiated intermediately aggressive, and poorly differentiated more aggressive. Both grading and staging help your clinician to establish the prognosis of how serious your disease is and what is going to be the likely outcome. Staging may require additional imaging tests such as CT scan, MRI, sonography, intravenous urography, bone scan, or chest X-ray. Knowing the stage of the disease helps the doctor plan his further treatment. The various stages of Colorectal Cancer are as follows:
	Stage 0. A very early cancer involving only the innermost lining of the colorectum.
	Stage I. The cancer involves a little more of the inner wall of the colorectum.
	Stage II. The cancer has now invaded tissues outside the colon and rectum but has not gone to the lymph nodes, which are small reniform structures that are part of the body's immune system.
	Stage III. The cancer is now in the neighboring lymph nodes but has not gone to other parts of the body.
	Stage IV. The cancer has spread to distant parts of the body. The usual place of spread is either the liver and/or the lungs.
	Recurrent colorectal cancer is that cancer which comes back after the treatment is over. The disease may recur in the colorectum or it may come in other parts of the body.

How is Colorectal Cancer treated?

A lot depend's on the patient's constitution, the grade of his disease and its stagings. Patients are usually treated by a team of specialists.

The best chance for a patient's cure is if the tumor can be removed in total. The oncosurgeon endeavours to remove the offending portion of the large bowel, along with a margin of healthy bowel for added safety, along with the associated lymph nodes to which the tumor cells may drain. This operation is called a colectomy.

Usually, the surgeon is able to rejoin the remaining segments of the bowel together. But sometimes, especially in cases of rectal cancers, no distal bowel remains for re-joining, and a new pathway for the passage bowel contents is on the anterior abdominal wall. This surgical procedure for the rectum is called abdomino-perineal resection. The new opening is called a colostomy, where stoma basically means mouth and since it involves the colon, therefore called colostomy. All the waste material and stools which are formed, leave the body through the colostomy and are collected in a special bag equipped with a flatus filter. This bag is called a colostomy bag. Because of the flatus filter, the colostomy does not give any offensive odor.

Some patients who present with either an obstruction or a perforation of the colon near the tumor or through the tumor and are brought to hospital in an emergent condition, may require a temporary proximal colostomy in order to protect the anastomosis or rejoining of the bowel segments, which is performed after excision of the tumor. This temporary colostomy after a period of 3 months is returned back and re-anastomosed inside the body as a healthy portion.

The alternative local therapy to surgery is radiation therapy. This involves the use of high energy, penetrative rays to destroy cancer cells. It also affects cancer cells only in the zone treated.

Radiation therapy is also employed for palliation, that is control of symptoms alone in an advanced Colorectal Cancer. Radiation therapy may be given as a neoadjuvant treatment, that is, before surgery in case of a bulky tumor.

Besides local therapy, the best attempt to control cancer cells circulating in the body and lodged at places other than the colon is by using systemic therapy (therapy which affects the entire systems of the body), which is in the form of injections or oral drugs. This form of treatment is called chemotherapy.

It is given in a cyclical manner (each set of drugs is repeated usually after every 3 to 4 weeks). Chemotherapy is given to destroy any malignant cells remaining in the body after surgery. It is also given to control symptoms of the disease which is advanced, and to control tumor growth. The drugs enter the blood stream and travel through the entire body attacking cancer cells wherever encountered. Unfortunately chemotherapy also attacks all other normal rapidly developing cells, such as bone marrow cells or cells lining the walls of the healthy gut, which may result in certain side effects.

Colorectal Cancer also employs another form of treatment called biological therapy, otherwise known as immunotherapy, and this uses the body's own immune system to fight the cancerous growth. The immune system has a natural tendency to fight the cancer cells circulating in the body and it tries to destroy them. Immunotherapy attempts to augment, stimulate, or repair the immune system's natural anticancer function. It may be, like radiation or chemotherapy, given either neoadjuvant, that is, before surgery, or in combination with chemotherapy or radiotherapy, or by itself.

Most of the biological therapies are given intravenously.

What are the likely side effects in the treatment for Colorectal Cancer?

	Unfortunately, cancer treatment being quite radical is not without its own complications and side effects. It basically depends on the modality of treatment which is given to the patient, the condition of the patient before, during, and after the treatment is completed, and the radicality of the procedure performed. Patients have every right to inquire from their treating doctor as to what is going to be the side effect of the therapy concerned. A lot of the side effects also have a profound psychological basis. If a patient is psychologically better prepared to accept the side effects, often it is seen that the side effects are definitely decreased in degree in such patients. This is especially true for systemic therapy like chemotherapy. The following are the side effects associated with surgery:
		Tenderness in the area of the operation. Pain postoperatively.
		Temporary constipation or diarrhea.
		Itching around the stoma. Dermatitis or inflammation of the skin around the stoma.
		Poor adjustment of the colostomy bag due to wrong positioning of the stoma leading to frequent leaks of the colostomy bag and social as well as domestic embarrassment.
	The serious problems of surgery such as infection or bleeding may occur occasionally but in today's circumstances with good antibiotics and skillful advanced training of surgeons such scenarios are becoming more and more uncommon. Radiation therapy causes problems dependent upon the degree of radiation to which the patient is exposed, given over what period of time, and what are the sizes of the fractions or total dose of radiation per sitting which is given to the patient. The usual side effects of treatment include:
		Skin changes and dermatitis or inflammation of the skin in the area of the treatment.
		Nausea.
		Diarrhea, sometimes even bloody diarrhea.
		Loss of appetite.
		Feeling of extreme tiredness.
	As far as biological therapy is concerned, the side effects vary with the specificity of the type of treatment. You may get influenza-like symptoms such as chills, fevers, bone pains, weakness, nausea, and an overall feeling of being unwell.

What is the importance of regular followup?

The importance of regular followup after primary treatment is over cannot be overemphasized. One must never assume that once the primary treatment is over and the cancer is removed, that it will never come back. Cancers have a notorious predilection of recurring and the only way to tackle them is if we catch them early. This is possible only with the help of regular checkups at intervals dictated to you by your clinician.

These checkups include a detailed history, a physical examination, a fecal occult blood test, sometimes a colonoscopy, chest x-rays, ultrasonographies, and lab tests which include specifically liver function test and CEA or carcinoembryonic antigen.

The CEA is a very specific antigen known as a tumor marker, which picks up the return or the presence of Colorectal Cancer very early indeed. In fact it can sometimes pick up Colorectal Cancer when the disease is subclinical, which means that the disease cannot be detected by routine clinical methods.

Between scheduled checkups, it is important for a patient to realize that if there is any alteration of health he should not wait for the next checkup, but visit his clinician as soon as possible.

How do we support these patients of Colorectal Cancer?

Cancer patients have a mountain to climb. Besides all the medical challenges they have to face they have social problems, economic problems, and definite mental and psychological problems.

Some patients find this emotional burden too heavy a load to carry. These emotional problems dominate over the physical and practical aspects of their disease.

Tragically, many clinicians and family members never really have time to pay attention to what the patient is going through mentally. It is very important that the entire health care system including the surgical oncologist, the patient's general physician, the nursing staff, the family members, all get together to form an emotional support team and help improve the quality of the lives of such hapless patients by making them feel less alone.

There are cancer support groups in certain parts of the country, but the distribution is not very uniform. So the onus really falls back on the group mentioned before.

Colorectal Cancer patients who have been treated with a permanent colostomy have an additional burden to carry emotionally. Many of them adjust very poorly to the fact that their fecal route has been transferred to the abdominal wall and it may turn out to be an ever-present danger of causing unbearable social embarrassment. At this point in time, very early after the procedure, if the family and the doctor can convince the patient that it is really not a big problem and he can go about by passing just one motion a day and adjust emotionally, then the patient if convinced, will never have any problems in life as far as the colostomy is concerned.

In fact, many patients who adjust very well, even do not need a colostomy bag and after passing one single regular motion in the morning, walk around and work around the whole day with just a small gauze piece covering the colostomy. On the other hand, if at this point in time, the patient is not given adequate emotional support, then he or she may never ever be able to adjust to the colostomy and will be forever stuck with the bag, the social burden, and emotional problems.