Colorectal Cancer Patient Advice in Essex, UK

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Patient Advice and Information

Colorectal Cancer
by Dr Panayiotopoulos, Consultant Vascular and General Surgeon Essex.

1. How common is cancer of the large bowel [colon]?

Carcinoma of the colon [the large bowel segment inside the abdomen] and rectum [the last 15cm than open at the anus] is the most common visceral cancer in the Western world. After skin cancer [the most common cancer in both sexes] colorectal cancer ranks second in incidence in to lung cancer in men and breast cancer in women. It is more likely to affect people 60-70 years. Cancer of the colon is slightly more common in women, while rectal cancer is more common in men.

In over 60% of the cases the cancer is located in the left side of the abdomen, and in half of these it affects the terminal part [rectum]. In 30% it affects the right sided colon.

2. What causes colorectal cancer?

A variety of factors are involved, both genetic [inherited] and acquired.

. Genetic factors. There is no absolute genetic inheritance but some families have a high incidence of colorectal cancer.

. Environmental factors. Food intake and chemicals are implicated. High fat and low fibre diet, chronic constipation and increased bile acids in the faeces have been put forward as explanations.

. Chronic inflammation of the bowel, like ulcerative colitis.

. Presence of polyps [small lumps that come of the lining of the colon, usually benign], and especially some specific types of polyps.

3. How is it diagnosed?

. Symptoms depend on the side of the growth.

· On the right side symptoms are anaemia, chronic blood loss and loss of weight.

· On the left side the tumour causes constipation, signs of obstruction and alteration in bowel habits.

· Cancer of the rectum often presents with blood from the bottom passage.

Both require the bowel to be cleaned and emptied before the test!! [e.g. use of Picolax].

. FOB test that checks stool for blood is an extremely helpful test, especially in patients with ahistory suggestive of cancer.

. Sigmoidoscopy [examination of the last 15-30cm of the bowel] and colonoscopy [examination of the whole large bowel] with a special telescope is the best diagnostic test.

. Special x-rays [barium enema] is also a valuable test.

. Screening programmes for high risk patients [either FOBs or colonoscopy]

4. What is it an FOB test?

A Fecal Occult Blood test [FOB] is done to detect whether there is any invisible blood present in the stools as a result of internal bleeding. The FOB is very sensitive to the presence of blood, therefore, in order to avoid misleading results, certain precautions should be taken . You will be provided with FOB test by the hospital or your GP and you should follow the instructions as given to you for obtaining the stool sample.

5. What is colonoscopy?

This procedure is a method by which the rectum and colon [large bowel] can be examined by the telescope [under direct vision] and if necessary samples can be taken from its lining [mucosa] to be examined under the microscope or sent for culture.

During this examination a flexible tube [colonoscope] is passed through the anus and upward along the large bowel. In 90-95% of the patients it is possible to examine the whole of the rectum and colon. In 5-10% the shape of the bowel or problems such as adhesions or the effect of previous surgery prevent the colonoscope being passed along the entire length of the bowel. In these circumstances other forms of bowel examination such as x-rays [barium enema] may be required to examine the portions of the bowel inaccessible to the colonoscope. In most cases colonoscopy is done as an outpatient procedure under mild sedation.

In order to carry out the examination it is necessary to have the bowel completely empty and clear of faeces. If the bowel is not clear it may be impossible for the colonoscope to visualise the bowel accurately and in these circumstances the examination may need to be abandoned. The bowel is therefore thoroughly cleared prior to examination by strong laxatives which will be provided along with instructions when your appointment is sent.

During the examination, in addition to visualising the bowel lining, the colonoscope enables two other procedures to be undertaken:

a. Samples [biopsies] may be taken of any abnormalities seen during the procedure.

b. Abnormalities such as polyps [small, usually benign, non-cancerous lumps] on the lining of the bowel can be removed or destroyed during colonoscopy and sent for subsequent analysis. Most but not all polyps can be dealt with in this manner, avoiding thus more major surgery.

Colonoscopy is generally a safe and well tolerated examination. Like any other procedure it can be accompanied by problems and these must be considered when deciding whether it is justified to subject the patient to this procedure.

· The major complications of colonoscopy are

· Bleeding and perforation

· 0.1% for diagnostic, 3% for therapeutic

6. How is the bowel cleaned?

Before colonoscopy a simple mechanical cleansing with cathartics suffices. Before surgery, cleansing should be thorough, so more measures are necessary.

. Clear liquid diet for 24 hours

. Mechanical cleansing with oral cathartics [Picolax]the previous day [not when there is obstruction]

. Enema on the morning of examination

. Some prefer whole gut washing [via a tube through the nose] the day before surgery [risk of overload and dehydration]

. Oral erythromycin base [1gr] the night before surgery

. Metronidazole, 500mg tds the day before surgery

7. What are the treatment options?

When the diagnosis is certain [either by X-Ray picture or histological proof] your specialist will have a chat with you at the outpatients department.

· Surgery is the mainstay of treatment.

It may be either curative [for early cancers] or palliative, to avoid complications [bleeding, obstruction, perforation] that will certainly happen if the tumour is left inside. The affected part is removed and the bowel ends are usually joined together. The side of the bowel to be removed, [left, right hemicolectomy, sigmoidectomy, anterior resection, abdominoperineal resection, etc], depends on the position of the cancer and the blood vessels that supply the relevant part of the bowel; it is mandatory to remove all the lymph nodes that accompany the blood vessels, in order to reduce the risk of metastatic spread.

Occasionally a temporary colostomy [bringing the bowel out in the surface of your abdomen [stomach] may be necessary. For cancers of the rectum, sometimes the whole final part may have to be removed, having as a result a permanent colostomy [abdominoperineal resection].

· Radiotherapy is necessary only when the rectum is totally removed. In many cases, especially when the cancer is locally spread, your oncologist will recommend radiotherapy for other types of colectomies.

· Chemotherapy is also helpful, not only for advanced cancers. There are many trial in progress and you may be asked to participate in one.

· You will be informed about all these adjuvant treatments by your oncologist, when you see him in the clinic following surgery

8. What is the prognosis?

Prognosis does not correlate well with the size and side of the growth, but does correlate with histological extent.

· For patients with early cancer [Dukes A stage] the chance of survival is 70-100%,

· falling to 43-65% for patients with intermediate extent cancer [B1 and B2],

· while it is only 15% at 5 years for people with extensive cancer [Dukes C2].

It is evident that it is a challenge to discover these neoplasms early, so a curative resection can be performed. High risk patients [with a family history of cancer] should therefore be screened.

Patients with family history of cancer	One 1^st degree relative < 40 years or 2 or more 1^st & 2^nd degree relatives	Colonoscopy every 4 years, starting 10 years earlier than the youngest relative affected
	One 1^st degree relative > 40 years	Flexible sigmoidoscopy & FOB every 5 years. Colonoscopy if: 1. Polyp >10mm 2. Villous tubulovillous adenoma 3. More than 5 adenomas/polyps 4. Positive FOBs

9. What is the follow-up protocol for patients who had a curative resection for colorectal cancer?

	Sigmoidoscopy	Liver Ultrasound	FBC/LFTs & CAE	Colonoscopy
After anterior resection	+
4-6 weeks	+
6 months	+
9 months	+
12 months	+	+	+	+ for <75 years with Dukes A & B
18 months	+
2 years	+	+	+	+ for Dukes C & less then 75 years
3 years	+	+		+ for <75 years with Dukes A & B
4 years	+
5 years	+	+	+	+ if <75 years
After colectomy or abdominoperineal resection
4-6 weeks	+
12 months	+	+		+ for <75 years with Dukes A & B
2 years	+	+	+	+ for Dukes C & less then 75 years
3 years	+	+		+ for <75 years with Dukes A & B
4 years	+
5 years	+	+	+	+ if <75 years
After 5 years	+
The patient is discharged from the clinic after discussion with consultant and is scheduled for colonoscopy every 5 years until the age of 75.

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Please note:
A written referral from a general practitioner is helpful but is not essentially required in order to make an appointment to see a consultant specialist.

This page was last updated on 01/10/2006