Treatment
Bowel cancer
Whether a person has metastases or not, surgical treatment of the primary tumour is almost always carried out. The reason for this is that bowel obstruction often develops if the primary tumour is left untreated and this is an unpleasant mode of death. Secondly preventing the development of bowel obstruction in advanced disease can give at least several months of good quality life. When assessing a case always try to work out if metastases are present or not, and whether the surgery removed the primary tumour. If there are no metastases and the primary tumour has been removed a return to health is expected. If metastases are present deterioration can be expected and you should make your award accordingly. The exception to this is where aggressive treatment of colorectal cancer with isolated, localised or solitary liver metastases are to be treated with liver resection. These people can be expected to recover fully or be in remission for a long time after treatment. Rectal cancer is treated slightly differently and the surgery is more extensive than for the other sorts of bowel cancer. It will be considered separately below.
Surgery
The main treatment of bowel cancer is surgery. For the majority of people the cancer will have been found early and the surgery will be potentially curative. Some people having this type of surgery will need to have a course of chemotherapy after surgery to reduce the risks of recurrent disease. The basic principle of surgery for bowel cancer is to remove the tumour with a cuff of healthy bowel and some local lymph nodes. The two cut ends of the bowel are sewn together again at the end, restoring the continuity of the bowel. The join is called an ‘anastomosis’.
People with advanced disease are also very likely to have surgery to prevent bowel obstruction and prolong quality of life; these people may also have a course of chemotherapy for the same reasons.
After the operation a person stays in hospital until they are able to eat, drink, attend to their own personal care and mobilise safely around the bedside. This takes about a week. Names of operations used for colon cancer include:
- Right hemicolectomy
- Transverse colectomy
- Left hemicolectomy
- Sigmoid colectomy
- Subtotal colectomy
Palliative operations for bowel cancer may include any of the operations for bowel cancer listed above and ‘bypass’ operations which do not remove the tumour but bypass the potential blockage preventing bowel obstruction.
In some cases the hospital stay may be longer than a week, the usual reasons are:
- The person has other disabilities or health conditions which makes recovery more arduous for them.
- Complications develop and also require treatment e.g. pneumonia
- The operation was an emergency
- A stoma has been fashioned and although recovery has taken place in terms of self care and mobilisation, extra time is needed to learn to care for and feel confident about going home with the stoma
Further recovery after surgery takes place at home, this recuperation takes a minimum of six weeks and often three months, at this point someone who works may go back to work. Tiredness and problems with loose bowel habit may persist but will gradually resolve. Although these are frustrating problems they should not interfere with normal function and activities. This may be the end of treatment for some people. For some people further treatment including chemotherapy will be advised based on the features of their primary tumour.
Rectal cancer
Rectal cancers are treated differently to other cancers of the colon. The surgery is different because of the location of the rectum close to the anus, and radiotherapy is often used before surgery.
The rectum is in the pelvis and is closely applied to the wall of it. It is easier for rectal tumours to spread locally than it is for other tumours higher up in the bowel. In the past rectal tumours grew back at their original site in the pelvis quite frequently, this was very difficult to treat and a cause of severe pain and ultimately death for patients. Strategies have been developed to prevent this and it is these strategies to improve outcome for rectal cancers that make their treatment different to cancers higher up the bowel.
The second important difference is that the rectum ends at the anus; the anus is an important ring of muscle that keeps a person continent. Faecal incontinence is a socially crippling problem. If possible a surgeon will try to save the anus and completely remove the cancer. The difficulty here is that joins (anastomoses) in the bowel close to the anus tend to leak more frequently than joins higher up, these leaks are life threatening complications of surgery on the bowel. When it is not possible to save the anus or the cancer has invaded it, then it is removed. In these cases instead of the bowel ending at the anus it is brought out onto the skin of the anterior abdominal wall to form a permanent stoma.
This diagram demonstrates removal of rectum for bowel cancer with preservation of the anus - courtesy of the artist Therese Winslow
Operations for rectal cancer are:
- Total Mesorectal Excision (TME) this is simply a term used to describe the anatomical removal of fat around the rectum, with the rectum itself. A temporary stoma may be in place for up to a few months after this operation.
- Anterior Resection – removal of the rectum preserving the anus and therefore faecal continence. A temporary stoma may be in place for up to a few months after this operation.
- Abdomino-perineal resection - this operation involves complete removal of the rectum and anus and this means the patient will have a permanent colostomy or stoma.
Temporary stomas after surgery
Some patients may have a temporary stoma or ileostomy formed to protect the join (anastomosis) in the bowel during the healing process. This works by diverting the faecal stream out through the stoma avoiding the join. These stomas are closed easily with a small operation a few weeks or months later once the join in the bowel has healed. Closing a stoma is a relatively minor operation with maximum recovery time of six weeks.
Radiotherapy
Before surgery a course of radiotherapy may be given to reduce the risk of local recurrence of rectal cancer. Radiotherapy treatment is not used like this for cancers higher up in the bowel. Radiotherapy may be given for up to 6 weeks prior to surgery. Occasionally radiotherapy is given to the pelvis after surgery for rectal cancer.
Chemotherapy
Adjuvant chemotherapy is given after other treatment such as surgery. Standard chemotherapy regimes take about 6-9 months to complete. Chemotherapy is given in cycles with treatment one week and several weeks of recovery before the next treatment week. Cycles are usually 3-4 weeks long. See general notes for side effects of chemotherapy.
The commonest chemotherapy drug used to treat colorectal cancer is 5-Fluorouracil (5FU). This can be given as an injection or infusion or in tablet form, names of tablets containing this drug include: Capecitabine (Xeloda) and Tegafur with Uracil (Uftoral). In particular persons at high risk of recurrence, the 5FU is often combined with another drug called Oxaliplatin as this is more effective than 5FU on its own.
In recurrent and advanced bowel cancer chemotherapy is also likely to be used. Other chemotherapy drugs may be given with 5FU or instead of it including Irinotecan (Campto) and Oxaliplatin.
Intraperitoneal chemotherapy not part of routine clinical practice.
Metastatic or Secondary disease
If metastases occur they can usually be controlled for a time by a combination of chemotherapy to reduce growth and radiotherapy to the disease site. Not all metastases are suitable for radiotherapy treatment. Strong pain killers to control pain may be necessary and these may have side effects of their own – see general notes. Eventually the metastases escape control and cause death.
The exception to this is isolated liver metastases which can be removed surgically. Once removed a course of chemotherapy may be given to remove any tiny hidden metastatic cells and a proportion of people are cured of their disease. Only a small proportion of people with liver metastases from colorectal cancer will be able to have this treatment.
Amended February 2009
