COCHIN CARDIAC CLUB: RECTAL CANCER

Cancer?

The news comes like a shock to you when you hear "I’m sorry to tell you, but you have cancer."

Every year, a millions are devastated by news of cancer or another dreaded disease. What soon follows is an avalanche, a tidal wave of emotions: fear, anger, bewilderment, indecision, and the need to reach out to a family member or a loved one for support and encouragement.

Quite often, a person's first reaction is to think, "No way, not me. I’m a good person," as if the cancer resulted as a punishment for unresolved issues. Then comes an overwhelming need to get information. And that is probably why you are reading this and am writing this.

You need to become the best and smartest patient your doctor ever had, simply because you need to be.

For most people, the cancer can be cured or controlled by surgery and, in some cases, by combinations of radiation therapy and chemotherapy. Never before has the outlook for cancer treatment and cure been so hopeful. For a proportion of people, however, the cancer continues to spread. This can be a devastating development. Those coping with cancer can become distracted by feelings of anger and hostility, not only toward the cancer but also toward the doctors and nurses trying to help. This is a normal reaction.

There are those who say: "If the cancer progresses, it must mean that I did not try hard enough." Attitude does matter, but not in the way we often think it does. We have learned from the long-term cancer survivors that it takes social support and connectedness on this journey.

Rectum and Rectal Cancer

The rectum is part of the body’s digestive system. The digestive system removes and processes nutrients (vitamins, minerals, carbohydrates, fats, proteins, and water) from foods and helps pass waste material out of the body. The digestive system is made up of the esophagus, stomach, and the small and large intestines. The first 6 feet of the large intestine are called the large bowel or colon. The last 6 inches are the rectum and the anal canal. The anal canal ends at the anus (the opening of the large intestine to the outside of the body).

Rectal cancer as the name suggests develops in the rectum.It begins as small clumps of cells called adenomatous polyps. Although the vast majority of polyps are benign, some can become cancerous over time. Regular screening to find and remove pre-malignant polyps is the best way to prevent rectal cancer from developing.

What distinguishes rectal cancer from many other types of cancer is that it is often highly preventable.

Risk Factors

The exact causes of rectal cancer are not known. However, studies show that the following risk factors of rectal cancer increase a person's chances of developing this disease:

Age. Colorectal cancer is more likely to occur as people get older. More than 90 percent of people with this disease are diagnosed after age 50. The average age at diagnosis is in the mid-60s. Diet. Studies suggest that diets high in fat (especially animal fat) and low in calcium, folate, and fiber may increase the risk of colorectal cancer. Also, some studies suggest that people who eat a diet very low in fruits and vegetables may have a higher risk of colorectal cancer. More research is needed to better understand how diet affects the risk of colorectal cancer.

Polyps. Polyps are benign growths on the inner wall of the colon and rectum. They are fairly common in people over age 50. Some types of polyps increase a person's risk of developing colorectal cancer.

A rare, inherited condition, called familial polyposis, causes hundreds of polyps to form in the colon and rectum. Unless this condition is treated, familial polyposis is almost certain to lead to rectal cancer.

Personal medical history. Research shows that women with a history of cancer of the ovary, uterus, or breast have a somewhat increased chance of developing colorectal cancer. Also, a person who has already had rectal cancer may develop this disease a second time.

Family medical history. First-degree relatives (parents, siblings, children) of a person who has had colorectal cancer are somewhat more likely to develop this type of cancer themselves, especially if the relative had the cancer at a young age. If many family members have had colorectal cancer, the chances increase even more.

Genetic alterations::Changes in certain genes increase the risk of colorectal cancer.

Hereditary nonpolyposis colon cancer (HNPCC) is the most common type of inherited (genetic) colorectal cancer. It accounts for about 2 percent of all colorectal cancer cases. It is caused by changes in an HNPCC gene. About 3 out of 4 people with an altered HNPCC gene develop colon cancer, and the average age at diagnosis of colon cancer is 44.

Familial adenomatous polyposis (FAP) is a rare, inherited condition in which hundreds of polyps form in the colon and rectum. It is caused by a change in a specific gene called APC. Unless familial adenomatous polyposis is treated, it usually leads to colorectal cancer by age 40. FAP accounts for less than 1 percent of all colorectal cancer cases.

Family members of people who have HNPCC or FAP can have genetic testing to check for specific genetic changes. For those who have changes in their genes, health care providers may suggest ways to try to reduce the risk of colorectal cancer, or to improve the detection of this disease. For adults with FAP, the doctor may recommend an operation to remove all or part of the colon and rectum.

Ulcerative colitis or Crohn's disease.A person who has had a condition that causes inflammation of the colon (such as ulcerative colitis or Crohn's disease) for many years is at increased risk of developing colorectal cancer.

Cigarette smoking. A person who smokes cigarettes may be at increased risk of developing polyps and colorectal cancer.

Symptoms

A common symptom of colorectal cancer is a change in bowel habits. Symptoms include:

Having diarrhea or constipation
Feeling that your bowel does not empty completely
Finding blood (either bright red or very dark) in your stool
Finding your stools are narrower than usual
Frequently having gas pains or cramps, or feeling full or bloated
Losing weight with no known reason
Feeling very tired all the time
Having nausea or vomiting

Most often, these symptoms are not due to cancer. Other health problems can cause the same symptoms. Anyone with these symptoms should see a doctor to be diagnosed and treated as early as possible.

Usually, early cancer does not cause pain. It is important not to wait to feel pain before seeing a doctor.

Diagnosis

In making a diagnosis of rectal cancer, your doctor will first start by recording your medical history, asking about any symptoms you may be experiencing and conducting a thorough physical examination. He or she also may recommend one or more of the following diagnostic tests:

Digital Rectal Exam — This exam involves the doctor or nurse inserting a gloved, lubricated finger into the rectum to feel for an abnormalities.

Barium Enema — Also known as a lower gastrointestinal series, this test involves taking X-rays of the large intestines.

Fecal Occult Blood Test — This is a noninvasive test that detects the presence of hidden, or occult blood in the stool. Such blood may arise from anywhere along the digestive tract. Hidden blood in the stool is often the first, and in many cases the only, warning sign that a person has colorectal cancer.

Sigmoidoscopy — Sigmoidoscopy is performed to see inside the rectum and the lower colon and remove polyps or other abnormal tissue for examination under a microscope.

Colonoscopy — Colonoscopy is performed to see inside the rectum and the entire colon and remove polyps or other abnormal tissue for examination under a microscope.

Polypectomy — Polypectomy is performed during a sigmoidoscopy or colonoscopy to remove polyps.

Biopsy — In a biopsy, a small amount of tissue from the suspected area is removed for examination by a pathologist to make a diagnosis.

Staging

If you are diagnosed with rectal cancer, your doctor needs to learn the stage or extent of your disease. Staging is a careful attempt to find out whether the cancer has spread and if so, to what parts of the body. This information also helps your doctor develop the best and most effective treatment plan for your condition. More tests — in particular an endorectal ultrasound (ERUS) or a magnetic resonance imaging (MRI) — may be performed to help determine the stage.

The various stages of rectal cancer include:

Stage 0: The cancer is very early. It is found only in the innermost lining of the rectum.

Stage I: The cancer involves more of the inner wall of the rectum.

Stage II: The cancer has spread outside the rectum to nearby tissue, but not to the lymph nodes. Lymph nodes are small, bean-shaped structures that are part of the body's immune system.

Stage III: The cancer has spread to nearby lymph nodes, but not to other parts of the body.

Stage IV: The cancer has spread to other parts of the body. If it spreads, rectal cancer tends to spread to the liver and lungs.

Recurrent: Recurrent cancer means the cancer has come back after treatment. The disease may recur in the rectum or in another part of the body.

Treatment

Treatment for rectal cancer may include surgery, radiation therapy or chemotherapy, or a combination of these approaches.

Surgery

Surgery is the main treatment for all stages of rectal cancer, although radiation, chemotherapy, or both are often recommended in combination.

Some patients who undergo surgery for rectal cancer require a permanent colostomy — a surgically created opening in the abdominal wall through which waste is excreted. If you have a colostomy,specially trained nurses will help you learn how to manage the colostomy and incorporate it into your lifestyle.

Depending on the location, stage and size of your tumor, your doctor will remove your cancer with one of the following methods:

Local excision — This surgical approach is used for very early stage cancers. It involves inserting a tube through the rectum into the colon and removing the cancer, rather than making a cut in the abdominal wall. If the cancer is found in a polyp, the procedure is called a polypectomy.

Resection and anastomosis — This approach is used for larger and more advanced cancers and involves removing the portion if the rectum containing the cancer, as well as the fatty tissue that surrounds the rectum and contains the lymph nodes. Afterwards, the doctor will sew the colon to the remaining rectum or the anus, during a procedure called an anastomosis.

Resection and colostomy — This approach is used when the rectum cannot be sewn back together. In these cases, a colostomy is performed, in which an opening outside of the body for waste to pass through is created, called a stoma. A bag is then placed around the stoma to collect the waste. The colostomy may be temporary, although if the entire rectum is removed, it is permanent.Specially trained nurses will help you learn how to manage your colostomy and incorporate it into your lifestyle.

Radiation Therapy

Radiation therapy is the use of X-rays or other high-energy rays to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body, or external radiation therapy, or from putting materials that contain radiation through thin plastic tubes, called internal radiation therapy, in the intestine area. Radiation can be used alone or in addition to surgery and chemotherapy.

Radiation therapy may be used after surgery to kill any remaining areas of cancer or before surgery to shrink the tumor. Radiation also can be used to prevent cancer from coming back to the place it started and to relieve symptoms of advanced cancer.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy may be taken by pill, or it may be put into the body by inserting a needle into a vein. A patient may be given chemotherapy through a tube that will be left in the vein while a small pump gives the patient constant treatment over a period of weeks.

Chemotherapy is called a systemic treatment because the drug enters the bloodstream, travels through the body, and can kill cancer cells outside the rectum.

If the cancer has spread, the patient may be given chemotherapy directly into the artery going to the newly infected part of the body. If the doctor removes all the cancer that can be seen at the time of the operation, the patient may be given chemotherapy after surgery to kill any cancer cells that are left. Chemotherapy given after an operation to a person who has no cancer cells that can be seen is called adjuvant chemotherapy.

Biological Treatment

Biological treatment, also called immunotherapy, tries to make your body fight against your cancer. It uses materials made by the body or made in a laboratory to boost, direct, or restore the body's natural defenses against disease.

Goal of cancer treatment

The goal of rectal cancer treatment is to permanently cure the cancer or to bring about a complete remission of the disease. Remission means that there is no longer any sign of the disease in the body, although it may recur or relapse later. Early rectal cancers may be treatable with surgery alone. More advanced rectal cancers may warrant additional treatment with radiation therapy and chemotherapy.

Prevention

Appropriate colorectal screening leading to the detection and removal of precancerous growths is the only way to prevent this disease.Screening tests for rectal cancer include fecal occult blood test and endoscopy.

If a family history of colorectal cancer is present in a first-degree relative (a parent or a sibling), then endoscopy of the colon and rectum should begin 10 years before the age of the relative's diagnosis or at age 50 years, whichever comes first.

Prognosis

Rectal Cancer patients and their loved ones face many unknowns. Some people find it easier to cope with the disease when they know the statistics. Other people find statistical information confusing and frightening, and they think it is too impersonal to be of use to them. The doctor who is most familiar with a patient's situation is in the best position to discuss the rectal cancer prognosis and to explain what the statistics may mean for that person. At the same time, it is important to understand that even the doctor cannot know exactly what to expect. In fact, a person's prognosis may change if the cancer progresses, or if treatment is successful.

Seeking information about the rectal cancer prognosis is a personal decision. It is up to each patient to decide how much information he or she wants and how to deal with it.Hence i wont be writing about the prognosis of this illness.

Life Goes On

Don’t let the rest of your life unravel while you deal with cancer. Understand that you have only so much energy, and this energy needs to be divided into dealing with the cancer but also paying the bills and being attentive to the normal mundane chores of daily living. Life when you are healthy is a full-time job. Be realistic. Cut back. Slow down and smell the roses.

Nobody can go through it alone, and now is the time to reach out and seek help from friends and neighbors. Acknowledge the importance of a support system. Lots of studies show that friends, families, colleagues, and even pets can enhance the well-being of anyone who is ill—and perhaps increase survival, although the latter point is somewhat controversial. A friend can be an anchor during some stormy times. Don’t ignore the resources of your religious group, if you have one.