General & Laparoendoscopic Surgery - Colorectal Services

Learn more: Intro to colorectal disease | Colorectal surgical services | What is a board-certified colorectal surgeon?

What is colon & rectal cancer?

Cancer of the colon or rectum is found in about 130,000 Americans each year. Although the incidence is decreasing very slowly it is still the second leading cause of death from cancer second only to lung cancer.

Cancer of the colon or rectum is an abnormality of the inside lining of the colon or rectum. The colon and rectum (also called the large intestine) are tube-like structures in the body, which serve to absorb ingested water and store fecal material until it is time to evacuate. The colon is about 5 - 6 feet long. The rectum is about 6 - 8 inches long.

When an area of these cells grows rapidly or out of control it is a tumor. If these cells begin to invade surrounding tissues or gain the ability to move to other parts of the body these cells are called malignant or cancerous. When a cancer moves to another part of the body the new tumor is called a metastasis. Usually colorectal cancers metastasize to the liver, lungs, or bone.

Benign tumors or polyps are similar to malignant tumors or cancers in that they grow rapidly too. However, polyps or benign tumors don't invade tissues or move to other parts of the body. Studies show that if polyps or benign tumors are left untreated they can become cancers. Therefore being checked is important to prevent colon cancer. The best way to check or screen for polyps or colon cancer is a colonoscopy.

SCREENING AND DETECTION

Screening is looking for cancer in patients without signs or symptoms. Screening is the best way to detect cancers. The earlier a cancer is detected the better the chance for complete cure with minimal treatment. Also if polyps are found and removed cancer can often be prevented altogether.

In an average risk patient screening should begin at age 50. Recently, it has been found that African Americans should be considered for screening early. People who may be at a greater than average risk for colon cancer should discuss an earlier screening. Screening schedules should be individualized for each person depending on their signs, symptoms and history. An open discussion with the physician is the best way to determine when to be screened for colon cancer.

There are several ways to detect colon or rectal tumors early. Regular visits to the doctor for a family and personal history review and general physical examination are very important. As well, there are several tests that are used in different combinations to find colorectal tumors.

Digital rectal examination: Physicians can sometimes feel tumors that are low in the rectum or anal canal. This should be a part of each examination during regular checkups. For this exam, the doctor inserts a lubricated, gloved finger into the rectum and feels for growths.

Fecal occult blood test: Samples of stool are taken and tested for blood. Tumors sometimes bleed slowly. This test detects blood on the microscopic level sometimes before blood can be seen with the naked eye. Fecal occult blood tests can be positive due to other substances in the stool such as blood from red meat or vitamins. Therefore, this test is rarely used alone to indicate that treatment is needed. Most insurance companies pay for this type of screening.

Flexible sigmoidscopy: The physician uses a flexible tube with a camera on the end to visualize the last half of the colon and rectum. Flexible sigmoidoscopy is performed as an outpatient in the doctor's office or at the hospital's endoscopy department. Outpatient, physician facilities also offer this procedure. Patients prepare for the test by using laxatives and / or enemas to clean the last half of the colon so that the doctors can see well. Most insurance companies pay for this type of screening.

Colonoscopy: Colonoscopy is similar to flexible sigmoidoscopy except the entire colon is visualized. This is usually performed in the hospital's endoscopy department. The procedure can be performed at other physician facilities. The procedure is usually performed as an outpatient.

Patients cleanse the bowel with an oral beverage the day before surgery. Patients are given medications to reduce discomfort during the procedure. If a polyp is found it can be completely or partially removed. The pathologist then determines whether it is cancerous or has the potential to become cancer by examining it under the microscope.

Most insurance companies pay for this in high risk patients. This is the best test or procedure because polyps can be identified and possibly removed preventing cancer in the first place.

Barium enema: This study is performed by a radiologist. A catheter is placed in the rectum then the colon is filled with air and X-ray contrast material. Xrays are then taken at different angles to visualize any tumors or polyps. This procedure is performed as an outpatient. Usually patients cleanse the bowel with an oral beverage the evening before. No biopsies can be taken or polyps removed with this test. No medications are given to reduce the discomfort of the procedure.

Virtual Colonoscopy or CT colonography: This is a new test that screens for colon cancer. It uses X-ray technology and computers to ìlookî inside the colon. It is very similar to both a colonoscopy and barium enema. A beverage is used to clean the bowel. A catheter is placed in the rectum and the colon filled with X-ray contrast and air. The special CT equipment takes pictures of the abdominal cavity and the colon and the computer reforms the pictures giving the appearance of the inside surface of the colon.

It can be performed as an outpatient. However, no medications are given for discomfort. Just like a barium enema, if a polyp or cancer is seen, the patient must undergo a second procedure or colonoscopy to determine if the virtual colonoscopy is accurate.

Very few centers offer this procedure; it is felt to be experimental in general. Most patients pay for the procedure out of pocket.

PREVENTION

The best prevention is early detection and removal of polyps. Scientists continue to work on other ways to prevent colorectal cancer.

A diet high in fiber (fruits and vegetables) and low in fat may help reduce the risk of colon cancer. Certain vitamins and medications may also help prevent colon cancer. The exact mechanism is currently being studied.

RISK FACTORS FOR DEVELOPING COLORECTAL CANCER

There are several risk factors for colon or rectal cancer. The higher the risk the more important it is to seek the advice of a doctor and to begin early screening. Risk factors include:

• Personal history of colorectal or other cancers
• Previous or current history of polyps
• Age over 50
• Male or African American race
• Family history of colorectal or other cancers
• Familial polyposis or inherited colon cancer
• Diet low in fiber and high in fat
• Ulcerative colitis or Crohn's disease

Colorectal cancer can cause many symptoms. Even though other diseases can cause similar symptoms warning signs should not be ignored. Immediately seek the advice of a doctor for any symptom associated with colon cancer. Signs and symptoms may include:

• Change in bowel habits
• Frequents stools or the urge to pass stool
• Diarrhea or constipation
• Blood in or on the stool
• Stools that are narrower than usual
• General stomach discomfort (pain, bloating, fullness, and/or cramps)
• A feeling that the bowel does not empty completely
• Weight loss with no known reason
• Constant tiredness with no known reason

TREATMENT

There are several ways to treat colon or rectal cancer. This includes surgery, chemotherapy and radiation depending on the type of cancer, location and stage. Usually, a team of doctors and nurses work together to treat the cancer. Physician specialists who treat this disease include surgeons, medical oncologists, gastroenterologists, and radiation oncologists.

Treatments are usually used in combinations. However, the earlier cancers are detected the less treatment is needed and the more effective it is. The choice of treatment for each patient depends upon the stage of the disease, the location of the disease and the patient's general state of health.

It helps if the patient learns as much as possible about the treatment options. Feel free to make a list of questions to ask the treatment team. Second opinions are appropriate if the patient wishes.

Surgery: Surgery to remove tumors is the most important part of treatment. The type of surgery depends on the location and stage of the tumor. The part of the colon with the tumor is removed or resected as well as some of the surrounding tissue. Nearby lymph nodes are removed so that a pathologist can examine them under a microscope. If cancer has reached the nodes, additional treatment may be needed. If the cancer is detected early enough, surgery is often the only treatment needed for colorectal cancer. The normal portions of the colon or rectum can usually be reconnected. That part of the procedure is called making an anastomosis. When the bowel cannot be anastomosed, the doctor creates an opening called a stoma in the abdominal wall. This procedure is called a colostomy, ileostomy or stoma. A colostomy may or may not be needed depending on the stage and invasiveness of the tumor. Most often this colostomy is reversible and temporary. If a colostomy or stoma is needed, the patient then uses a special bag to collect the waste. Enterostomal nurses help patients manage this special bag.

Usually an abdominal incision is used to remove rectal cancers. If the cancer is in the low or middle rectum and it is found early, surgery can be performed through the anal canal. This avoids an abdominal incision.

If necessary an abdominal incision is used. Often the tumor can be resected and the bowel placed together or anastomosed. This allows natural defecation. If the tumor is extensive or very low the entire rectum and anus are removed and a permanent stoma placed.

Minimally invasive surgery is being investigated as a new procedure to remove certain colon or rectal tumors. Laparoscopic surgery reduces the pain and recovery time from surgery to resect part of the colon. Studies show that laparoscopic or minimally invasive surgery is being increasingly performed for colon cancer.

Chemotherapy: Chemotherapy is giving medications to reduce the size of the cancer or treat metastasis. They work by decreasing the rate of growth of the cells in the cancer. They are usually given intravenously. Chemotherapy can be used after surgery to help prevent the cancer from spreading or possibly destroying cancer cells left over.

Oncologists are specialists that treat patients with chemotherapy drugs. Depending on the stage of the cancer, chemotherapy may or may not be given. Side effects include but are not limited to diarrhea, nausea and hair loss. New chemotherapy studies are underway.

Radiation: Radiation is given for the treatment of rectal cancers. Radiation therapy is the use of high-energy rays to treat cancer. Special machines are design to generate then concentrate the radiation beam to the area of the cancer. Radiation reduces the size of tumors by reducing the growth rate. It may be given before or after surgery for rectal cancer. Side effects include but are not limited to bleeding and dermatitis or inflammation of the area.

Sometimes, a combination of radiation and chemotherapy are used to shrink the tumor before it is surgically removed or to destroy remaining cancer cells after surgery. Radiation therapy can also be used to alleviate pain when tumors cannot be removed with surgery.

FOLLOW-UP OF COLON CANCER

Regular follow-up exams are very important after treatment for colorectal cancer. The cancer can recur at or near the site of the original tumor or can spread to another area of the body. The spread may not become evident for years.

The doctor will continue to check closely so that, if the cancer comes back, it can be treated again as soon as possible. Often, a social worker or enterostomal therapist at the hospital or clinic can suggest groups that can help with rehabilitation, emotional support, financial aid, transportation, or home care.

CLOSING

This written information does not replace a discussion with your doctor or nurse. Patients will receive care based on their specific history. Feel free to contact your physician or other healthcare specialist to ask questions.