Colorectal Cancer- Patient information
What is Colorectal cancer?
Colorectal cancer is cancer that occurs in the large intestine and rectum.
Most colon cancers (about 70%) are found in the first six feet of the large intestine. The other 30% occur in the last 10 inches of the large intestine (rectum). Collectively they are referred to as colorectal cancers
How does colorectal cancer develop?
The colon is divided into four sections: the ascending colon, transverse colon, descending colon, and sigmoid colon. Most colorectal cancers arise in the sigmoid colon -- the portion just above the rectum. Most colorectal cancers grow slowly over a period of several years, often beginning as small benign growths called polyps.
What are the causes of developing colorectal cancer?
About 80% of colon cancer cases are sporadic, meaning that cause is nonspecific or undetermined. The other 20% of colon cancers are hereditary. People who have a first-degree family member with colon cancer are more likely to be affected themselves.
What are the risk factors for developing colorectal cancer?
- OLDER AGE : About 90 percent of people diagnosed with colon cancer are older than 50. Colon cancer can occur in younger people, but it is less frequent.
- A HISTORY OF COLORECTAL CANCER OR POLYPS. If you've already had colon cancer or adenomatous polyps, you have a greater risk of colon cancer in the future.
- INFLAMMATORY INTESTINAL CONDITIONS. Long-standing inflammatory diseases of the colon, such as ulcerative colitis and Crohn's disease, can increase your risk of colon cancer.
- INHERITED SYNDROMES : Genetic syndromes like familial adenomatous polyposis , hereditary nonpolyposis & Lynch syndrome.
- FAMILY HISTORY of colon cancer and colon polyps. You're more likely to develop colon cancer if you have a parent, sibling or child with the disease. If more than one family member has colon cancer or rectal cancer, your risk is even greater. In some cases, this connection may not be hereditary or genetic.
- History of cancer of endometrium, breast or ovary
- LOW-FIBER, HIGH-FAT DIET. Colon cancer and rectal cancer may be associated with a diet low in fiber and high in fat and calories. Some studies have found an increased risk of colon cancer in people who eat diets high in red meat and processed meats.
- SEDENTARY LIFESTYLE : Getting regular physical activity may reduce your risk of colon cancer.
- DIABETES : People with diabetes and insulin resistance may have an increased risk of colon cancer.
- OBESITY : Obese People have an increased risk of colon cancer and an increased risk of dying from colon cancer when compared with people with normal weight.
- SMOKING : Smokers may have an increased risk of colon cancer.
- ALCOHOL : Heavy use of alcohol may increase your risk of colon cancer.
- RADIATION THERAPY FOR CANCER : Radiation therapy directed at the abdomen to treat previous cancers may increase the risk of colon cancer.
What is risk of an individual person developing colorectal cancer?
o Average risk : > 50 yr with no history of adenoma, cancer or inflammatory bowel disease.
o Increased risk : history of adenomas, sessile polyps, cancer, inflammatory bowel disease and family history of colorectal cancer.
o High risk : family history of Lynch syndrome or FAP (familial adenomatous polyposis)
What are the symptoms of colorectal cancer?
1. A change in your bowel habits, including diarrhea , constipation or a feeling that your bowel doesn't empty completely
2. Change in the consistency of your stool for more than a couple of weeks.
3. Blood (either bright red or very dark) in the stool
4. Persistent abdominal discomfort, such as cramps, gas or pain
5. Weakness or fatigue
6. Unexplained weight loss
7. Loss of appetite
Many people with colon cancer experience no symptoms in the early stages of the disease. Any of these symptoms which persist for more than two weeks, see your doctor.
What tests are performed for diagnosing colorectal cancer?
- Digital Rectal Exam: The doctor inserts a gloved finger into the rectum to feel for polyps or other irregularities.
- Fecal Occult Blood Test (FOBT): A stool sample is examined for traces of blood not visible to the naked eye. If you do see blood in your stool, contact your doctor immediately.
- Double Contrast Barium Enema (DCBE): Barium is a chemical that allows the bowel lining to show up on X-ray. A barium solution is administered by enema; then the patient undergoes a series of X-rays
- Sigmoidoscopy: A tiny camera with flexible plastic tubing is inserted into the rectum, providing a view of the rectum and lower colon. This procedure can also be used to remove suspicious tissue for examination.
- Colonoscopy: A colonoscope is a longer version of a sigmoidoscope, and can examine the entire colon. Patients must be sedated for a colonoscopy.
- Carcinoembryonic Antigen (CEA): A blood test that determines the presence of CEA, a substance, or tumor marker, produced by some cancerous tumors. This test can also be used to measure tumor growth or assess if cancer has recurred after treatment.
How can we know the stage of the disease?
Once you've been diagnosed with colon cancer, your doctor will then order tests to determine the extent or stage of your cancer. Staging helps to determine what treatments are most appropriate for you. Tests include imaging procedures such as chest X-ray, abdominal and chest CT scans. In many cases, the stage of your cancer may not be determined until after surgery.
Staging usually depends on
- Location of the primary tumor,
- Tumor size and number of tumors,
- Lymph node involvement (spread of cancer into lymph nodes)
- Cell type and tumor grade* (how closely the cancer cells resemble normal tissue)
- Presence or absence of metastasis.
What are the chances of recovery after the diagnosis?
1. The stage of the cancer (whether it affects the inner lining of the rectum only, involves the whole rectum, or has spread to lymph nodes, nearby organs, or other places in the body).
2. Whether the tumor has spread into or through the bowel wall.
3. Location of the disease.
4. Whether the bowel is blocked or has a hole in it.
5. Whether all of the tumor can be removed by surgery.
6. The blood levels of carcinoembryonic antigen (CEA-tumour marker) before treatment begins.
7. The patient’s general health.
8. Whether the cancer has just been diagnosed or has recurred (come back).
What is the treatment for colorectal cancer?
The type of treatment your doctor recommends will depend largely on :
- The stage of the cancer.
- Whether the cancer has recurred.
- The patient’s general health.
The three primary treatment options are: surgery, chemotherapy and radiation.
What is the surgical treatment for colorectal cancer?
Surgery for very early-stage colon cancer
Polypectomy: If the cancer is found in a polyp (a small piece of bulging tissue), the polyp is often removed during a colonoscopy.
Local excision: If the cancer is found on the inside surface of the rectum and has not spread into the wall of the rectum, the cancer and a small amount of surrounding healthy tissue is removed.
Surgery for invasive colon cancer
If your colon cancer has grown into or through your colon, your surgeon may recommend a colectomy to remove the part of your colon that contains the cancer, along with a margin of normal tissue on either side of the cancer. Nearby lymph nodes are usually also removed and tested for cancer.
Your surgeon is often able to reconnect the healthy portions of your colon or rectum. But when that's not possible, for instance if the cancer is at the outlet of your rectum, you may need to have a permanent or temporary colostomy. Sometimes the colostomy is only temporary, allowing your colon or rectum time to heal after surgery. In some cases, however, the colostomy may be permanent.
Surgery for very advanced cancer
The goal of palliative surgery isn't to cure your cancer, but to relieve signs and symptoms, such as bleeding and pain.
In specific cases where the cancer has spread only to the liver and if your overall health is otherwise good, your doctor may recommend surgery to remove the cancerous lesion from your liver. Chemotherapy may be used before or after this type of surgery. This treatment may improve your prognosis.
What is meant by adjuvant therapy?
Adjuvant therapy is the treatment given after the surgery, to lower the risk that the cancer will return.
What is the chemotherapy treatment for colorectal cancer?
Chemotherapy destroys the cancer cells after surgery, to control tumor growth or to relieve symptoms of colon cancer. Your doctor may recommend chemotherapy if your cancer has spread beyond the wall of the colon or to the lymph nodes. In people with rectal cancer, chemotherapy is typically used along with radiation therapy. The most common drugs used in chemotherapy are the following:
- 5 Flourouracil – This drug may be given as a bolus (rapid) injection or as an infusion (over 2 days) depending on the regimen. Usually a chemoport is preferred to be used if the infusional regimen is used as it avoids the need for hospitalization. The main side effects of the drug include diarrhea and mucositis (mouth ulcers). A drug called Folinic acid (leucovorin) is administered before 5-FU to enhance the efficacy of the drug.
- Oxaliplatin – This drug is used in combination with 5-FU in a regimen called FOLFOX 6 in the adjuvant treatment of Stage 3 colon cancers. The predominant side effects of the drug include an allergic reaction during the infusion and numbness in the hands. To prevent this, an infusion of Calcium and Magnesium is given before oxaliplatin. Such numbness reduces after discontinuation of the chemotherapy but may last for a long time.
- Capeciatabine – This is an oral drug and may be used to substitute for 5-FU. It offers an advantage of oral dosing compared to the prolonged infusion required for 5-FU. It can be offered as a single agent or in combination for adjuvant therapy depending on the stage of the cancer. An unusual side effect observed with this drug is the development of skin changes over the feet and soles called as a Hand Foot syndrome, hence pyridoxine tablets are provided along with the drug to prevent or reduce the severity of the same.
- Irinotecan – This drug is predominanty used for metastatic stage 4 colon cancer singly or in combination with Capecitabine or 5FU. The predominant side effects of the drug are emesis (vomiting) and occasional severe diarrhea.
What is Radiation therapy for colorectal cancer?
Radiation therapy uses X-rays, to kill cancer cells that might remain after surgery, to shrink large tumors before an operation so that they can be removed more easily, or to control bleeding from tumour.
Radiotherapy is more commonly used in rectal cancer, since the rectum does not move as much as the colon and is thus easier to target.
Radiotherapy in Colon cancer
Pain relief and palliation - targeted at metastatic tumor deposits if they compress vital structures and/or cause pain
Radiotherapy in Rectal cancer
Neoadjuvant- This may be given before surgery in patients with tumors that extend outside the rectum or have spread to regional lymph nodes, in order to decrease the risk of recurrence following surgery or to allow for less invasive surgical approaches (such as a low anterior resection instead of an abdomino-perineal resection). In locally advanced adenocarcinoma of middle and lower rectum, regional hyperthermia (remove) added to chemoradiotherapy achieved good results in terms of rate of sphincter sparing surgery.
Adjuvant – This kind of radiotherapy is given after the completion of surgery where a tumor perforates the rectum or involves regional lymph nodes (AJCC T3 or T4 tumors or Duke's B or C tumors). This greatly reduces the chance of local recurrence of the tumor which can occur in more then 1/3rd of the cases.
Palliative - to decrease the tumor burden in order to relieve or prevent symptoms.
What do I understand by targeted therapy in treatment of colorectal cancer?
Drugs that target specific defects that allow cancer cells to proliferate are available to people with advanced colon cancer, including Bevacizumab (Avastin), cetuximab (Erbitux) and panitumumab (Vectibix). Targeted drugs can be given along with chemotherapy or alone. Targeted drugs are typically reserved for people with advanced metastatic colon cancer. Certain drugs like Cetuximab only work when specific mutations are seen in the cancer cells, hence the doctor might suggest to do a K-ras mutational analysis on the tumor specimen before deciding to start such treatment.
Targeted drugs benefit some people, while not others. Researchers are working to determine who is most likely to benefit from targeted drugs. Until then, doctors carefully weigh the limited benefit of targeted drugs against the risk of side effects and the expensive cost when deciding whether to use these treatments.
What are the problems patients might face during chemo-radiotherapy treatment?
Most commonly faced symptoms are – tiredness, loss of appetite, nausea.
Occasionally - loose motions, abdominal pain, vomiting.
What is the care to be taken when we experience nausea and vomiting?
1. Prevent nausea – Try having bland, easy-to-digest foods and drinks that do not upset your stomach, such as:
- Soups: Clear broth, such as chicken, vegetable, or beef
- Drinks: Clear carbonated beverages that have lost their fizz;
Cranberry or grape juice; Fruit-flavored drinks; Fruit punch; Sports drinks; Tea & Water
- Main meals and other foods: Chicken (broiled or baked without its skin);
Porridge/ soft rice; Instant oatmeal; Noodles; Potatoes (boiled without skins); Toasted bread
2. Plan when it's best for you to eat and drink - Some people feel better when they eat a light meal or snack before chemotherapy. Others feel better when they have chemotherapy on an empty stomach (nothing to eat or drink for 2 to 3 hours before treatment). After treatment, wait at least 1 hour before you eat or drink.
3. Eat small meals and snacks: Instead of 3 large meals each day, you might feel better if you eat 5 or 6 small meals and snacks.
- Do not drink a lot before or during meals.
- Do not lie down right after you eat.
4. Have foods and drinks that are warm or cool (not hot or cold) : Give hot foods and drinks time to cool down, or make them colder by adding ice. You can warm up cold foods by taking them out of the refrigerator 1 hour before you eat or warming them slightly in a microwave.
5. Stay away from foods and drinks with strong smells : These include coffee, onions, garlic, and foods that are cooking.
6. Relax before treatment: You may feel less nausea if you relax before each chemotherapy treatment. Meditate, do deep breathing exercises, or imagine scenes or experiences that make you feel peaceful. You can also do quiet hobbies such as reading, listening to music, or knitting.
7. When you feel like vomiting, breathe deeply and slowly or get fresh air. You might also distract yourself by chatting with friends or family, listening to music, or watching a movie or TV
How should we manage diarrhea (loose motions)?
1. Eat 5 or 6 small meals and snacks each day instead of 3 large meals.
2. Ask your doctor or nurse about foods that are high in salts such as sodium and potassium. Your body can lose these salts when you have diarrhea, and it is important to replace them. Foods that are high in sodium or potassium include bananas, oranges, peach and apricot nectar, and boiled or mashed potatoes.
3. Drink 8 to 12 cups of clear liquids each day. These include water, clear broth, ginger ale, or sports drinks such as Gatorade® or Propel®. Drink slowly, and choose drinks that are at room temperature. Let carbonated drinks lose their fizz before you drink them. Add extra water if drinks make you thirsty or nauseous (feeling like you are going to throw up).
4. Eat low-fiber foods. Foods that are high in fiber can make diarrhea worse. Low-fiber foods include bananas, white rice, white toast, and plain or vanilla yogurt.
5. Stay away from: Drinks that are very hot or very cold; Beer, wine, and other types of alcohol; Milk or milk products, such as ice cream, milkshakes, sour cream, and cheese
Spicy foods, such as hot sauce, salsa, chili, and curry dishes; Greasy and fried foods, such as french fries and hamburgers.
Foods or drinks with caffeine, such as regular coffee, black tea, cola, and chocolate
Foods or drinks that cause gas, such as cooked dried beans, cabbage, broccoli, and soy milk and other soy products
Foods that are high in fiber, such as cooked dried beans, raw fruits and vegetables, nuts, and whole-wheat breads and cereals
Let your doctor or nurse know if your diarrhea lasts for more than 24 hours or if you have pain and cramping along with diarrhea. Your doctor may prescribe a medicine to control the diarrhea. You may also need IV fluids to replace the water and nutrients you lost. Do not take any medicine for diarrhea without first asking your doctor or nurse.
What should be done for the loss of appetite?
- Eat 5 to 6 small meals or snacks each day instead of 3 big meals.
- Set a daily schedule for eating your meals and snacks. Eat when it is time to eat, rather than when you feel hungry
- Drink milkshakes, smoothies, juice, or soup if you do not feel like eating solid foods
- Increase your appetite by doing something active
- Change your routine. This may mean eating in a different place, such as the dining room rather than the kitchen. It can also mean eating with other people instead of eating alone. If you eat alone, you may want to listen to the radio or watch TV. You may also want to vary your diet by trying new foods and recipes.
Where can we get more information regarding the supportive care to be taken during treatment?
Browse through the website of National cancer institute where you can get comprehensive information about cancer treatment and managing side effects along with resources from cancer support groups.
Famous personalities diagnosed with Colorectal cancer
Corazon Aquino, former president of the Philippines
Malcolm Marshall, a West Indian cricketer; primarily a fast bowler.
Pope John Paul II
Harold Wilson, former Prime Minister of the United Kingdom
Rod Roddy, second announcer on The Price is Right who became a spokesperson for early detection of cancer in his last years.