Treatment for bowel cancer

Sunday 1 February, 2015

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On this page: SurgeryChemotherapyTargeted therapies | Radiotherapy | Palliative treatment | Key points


Your medical team will recommend treatment based on:

  • what will give you the best outcome
  • the location of the cancer in the bowel
  • whether the cancer has spread
  • your general health
  • your preferences.

The most common treatment is surgery, usually performed by a colorectal surgeon. You may also have chemotherapy, targeted therapies and radiotherapy, which will be coordinated by your oncologist. Different types of treatment may be combined.

Surgery

There are different types of surgery for bowel cancer. The aim of surgery is to remove all the cancer and nearby lymph nodes. 

Minimally invasive surgery

Minimally invasive surgery, also called keyhole or laparoscopic surgery, means the operation is done with several small cuts (incisions) instead of one large cut (open technique). This may include robotic surgery.

The surgeon passes a thin tube (laparoscope) through an incision in the abdomen. The laparoscope has a light and camera. Long, thin instruments are inserted through the other incisions to remove the cancer. Compared to open surgery, the minimally invasive method usually means less pain and scarring and a faster recovery.

There are advantages to both types of surgery – your surgeon will advise which is suitable for you. Whether or not minimally invasive surgery is recommended depends on the size and location of the cancer, and if the surgery is available at your hospital or treatment centre. 

Surgery for cancer in the colon

The most common type of surgery is called a colectomy. There are different types of colectomies depending on where the cancer is located and how much of the bowel is removed (see below).

The surgeon may use an open or minimally invasive technique (see above). You will be given a general anaesthetic, then the surgeon will make a cut in the abdomen to find and remove the part of the colon containing the cancer. Lymph nodes near the colon and some normal bowel around the cancer will also be removed.

The surgeon usually joins the two ends of the bowel back together with stitches or staples. Sometimes the bowel isn’t joined together; instead, one end is brought through an opening made in your abdomen and stitched onto the skin. This procedure is called a colostomy (if made from the colon in the large bowel) or ileostomy (if made from the ileum in the small bowel). The opening – called a stoma – allows faecal waste to be removed from the body.

The surgeon may later be able to do another operation to rejoin the bowel. In some cases, this isn’t possible and the stoma will be permanent. For information about stomas, see having a stoma.

After surgery, you will have a scar. Most people who have open surgery have a scar from above their navel to their pubic area.

Types of colectomies

The area shaded dark blue will be removed. 

Right hemicolectomy

Right hemicolectomy
The right side of the colon is removed.*

Left hemicolectomy

Left hemicolectomy
The left side of the colon is removed.*

Transverse colectomy

Transverse colectomy
The middle part of the colon is removed.

Sigmoid colectomy

Sigmoid colectomy
The sigmoid colon is removed.

Subtotal or total colectomy

Subtotal or total colectomy
Most or all of the bowel is removed.

Proctocolectomy

Proctocolectomy
All of the colon and rectum are removed.

*If the transverse colon is also removed, it's an extended right or left hemicolectomy.

Surgery for cancer in the rectum

If you have rectal cancer, you may be advised to have an abdominoperineal resection (also known as an abdominoperineal excision) or an anterior resection. The abdominoperineal resection is also sometimes used for anal cancer (see below).

A resection or excision is the total removal of something by surgery. Abdomino refers to the abdomen, perineal refers to the area around the anus, and anterior refers to the front of the body. 

The type of operation you have depends on where the cancer is located. This will also determine whether the bowel can be rejoined, and where in the rectum the join can be made. The surgery may be open style or minimally invasive (see below).

Surgery that involves the lower part of the bowel can cause injury to nearby nerves, leading to conditions such as incontinence (accidental loss of urine or faeces) or erectile dysfunction. Speak to your surgeon about any concerns you may have. 

Resections in the large bowel

The area shaded dark blue will be removed.

Abdominoperineal resection or excision

Abdominoperineal resection or excision (APR or APE)

The sigmoid colon and entire rectum and anus are removed. Your surgeon uses the descending colon to create a permanent stoma (known as a colostomy) for faeces to leave the body. The anal area will be stitched up and permanently closed.

High anterior resection

High anterior resection

The surgeon removes the lower left part of the colon and the upper part of the rectum. Nearby lymph nodes and surrounding fatty tissue are also removed. The lower end of your bowel is rejoined to the top of the rectum.

Ultra-low anterior resection

Ultra-low anterior resection

The lower left part of the colon and the entire rectum are removed, along with nearby lymph nodes and fatty tissue. The end of the bowel is joined to the lowest part of the rectum, just above the anal canal. In some cases, the surgeon creates a colonic J-pouch (see right).

 Ultra-low anterior resection

Colonic J-pouch

An internal pouch is made from the lining of the large bowel. This J-pouch will be connected to the anus and work as a rectum. You may have a temporary ileostomy (a stoma from the small bowel, see page 48), which will be reversed once the J-pouch heals.

Anal cancer

Anal cancer is a rare cancer that affects the tissues of the anus. About 350 people in Australia are diagnosed with anal cancer every year, and most are 50 to 60 years old.4 Risk factors include smoking and sexually transmitted infections.

Symptoms of anal cancer can be similar to those for bowel cancer, and your doctors may carry out some of the same tests, including blood tests, a proctoscopy or sigmoidoscopy, and scans. Anal cancer is staged using the TNM system. The main treatment for anal cancer is chemotherapy and radiotherapy. Surgery may also be used. Early stage cancer may need only a local resection, which just removes the tumour. More advanced cancer may require an abdominoperineal resection (see above) and a permanent stoma.

Local excision

People who have early stage bowel cancer or are not fit for a major operation may have a local excision. Instead of cutting into the abdomen, the surgeon inserts an instrument into the anus to remove very small tumours from the bowel.

Transanal excision (TAE) and transanal endoscopic microsurgery (TEMS) are local excision techniques for rectal cancer. A less commonly used method is a colonoscopic excision, which can remove small tumours from the colon. The type of surgery you have will depend on the location of the cancer. 

If there are two cancers

In a small number of people, two separate cancers may be found in the large bowel at the same time. The cancers may be discovered through diagnostic tests or during surgery. In this case, there are three options for surgery:

  1. Remove two sections of the bowel. 
  2. Remove one larger section of the bowel, containing both areas with the cancer.
  3. Remove the entire colon and rectum (proctocolectomy) to prevent any chance of another cancer forming.

The type of surgery you have depends on what your doctor recommends and what you want.

Surgery for advanced cancer

If the cancer has spread to other parts of the body (metastasised), you may still be offered surgery. This can help control or slow the growth of the cancer. The surgeon may remove:

  • small secondary cancers (e.g. in the liver or lungs)
  • a blockage in the bowel (see below)
  • cancerous parts of the bowel that are attached to another organ, such as the uterus or bladder – the attachment can be caused by scar tissue that has formed after earlier surgery (adhesions) or by the cancer spreading.

The operation may involve the removal of parts of the bowel along with all or part of other organs. This is called an en-bloc resection. In rare cases, a woman may need to have her uterus removed (hysterectomy). This means she can no longer have children. Your doctor will discuss your fertility with you before the surgery and can refer you to a counsellor or fertility specialist.

Your medical team will advise what kind of follow-up and treatment is recommended after surgery. Regular check-ups have been found to improve survival for people after surgery for bowel cancer, so you will probably have check-ups for several years.

The type of operation used for advanced bowel cancer will depend on your individual situation, so talk to your surgeon about what to expect. You can also call Cancer Council 13 11 20 for information.

Bowel obstruction

Some people can get a blocked bowel (bowel obstruction) as the bowel cancer grows. Because waste matter cannot pass through easily, symptoms may include pain, nausea, vomiting and constipation.

Surgery to remove the cancer may help unblock the bowel. In some cases, you may need a stoma.

Not everyone with a blockage will want an operation or be fit enough to have it. In this case, your surgeon may be able to put in a small tube (stent) to help keep the bowel open. The stent is inserted through the rectum using an endoscope. A stent may also help manage your condition until you are well enough for an operation.

If you are unable to have surgery or a stent, you may be given medication to help control the symptoms of a bowel obstruction.

What to expect after bowel surgery

The recovery time after bowel surgery varies, depending on the type of surgery. You will probably be in hospital for 5–7 days, but it can take 2–3 months to fully recover.

At first, you will need some pain relief. Most people will have patient-controlled analgesia (PCA). The PCA system allows you to press a button to release a measured dose of pain relief. (The system is timed to protect you from overdose.)

Less commonly, pain relief may be given by a slow injection into a vein (intravenous or IV infusion) or by an injection into your spinal column (epidural anaesthetic).

You will receive fluids through a drip (also called an intravenous or IV infusion) until you are able to start eating and drinking again. You may need a drip for a few days.

People who have abdominal surgery need to minimise the risk of developing blood clots in their legs, which can be life-threatening. During surgery, you may need to wear compression stockings to apply pressure to your calves, as well as a special cuff that applies intermittent pressure. Afterwards, you may be given regular injections of a blood-thinning substance. It is important to get out of bed and walk around as soon as you are able, and to move your legs if you cannot get out of bed.

You may also be instructed to do deep-breathing exercises to prevent a chest infection.

Common side effects of bowel surgery
Changes in bowel function

Many people find they have softer and more frequent bowel movements. You may find that you need to go to the toilet as soon as you feel the urge. Bowel function usually improves within a few months but, for some people, it can take longer. It may help to talk to your surgeon, a continence nurse or a dietitian. See coping with dietary and bowel changes for more details.

Fatigue

Try to get plenty of rest and only do what is comfortable. You may have to remind your family and friends that you are still recovering, even several months after surgery.

Changes in your diet

See dietary and bowel changes for information about your diet after an operation for bowel cancer. To find out more about surgery, call 13 11 20 and ask for a copy of Understanding Surgery.

Chemotherapy

Chemotherapy is the treatment of cancer with anti-cancer (cytotoxic) drugs. It aims to kill cancer cells while doing the least possible damage to healthy cells. If the cancer is contained inside the bowel, it can usually be treated with surgery alone and chemotherapy is not needed.

If you have chemotherapy, the drugs may be injected into a vein (given intravenously) or supplied in tablet form. Some people have a small medical appliance called a port-a-cath or infusaport placed beneath their skin through which they receive chemotherapy. You will probably have sessions of chemotherapy over several weeks or months. Your medical team will work out your treatment schedule. You may be advised to use contraception during chemotherapy because of the effects of the drugs.

Chemotherapy may be used at different times: 

  • Neo-adjuvant therapy: Some people who have surgery have chemotherapy (and/or radiotherapy) beforehand to shrink the tumour and make it easier to remove during surgery. This is known as neo-adjuvant therapy.
  • Adjuvant chemotherapy: Chemotherapy is often used for people after surgery if the cancer has spread through the bowel wall or into nearby lymph nodes. This adjuvant chemotherapy aims to reduce the chance of the cancer coming back by eliminating any cancer cells still present after surgery.
    If you have chemotherapy after surgery, you will probably have 4–6 weeks to recover from the surgery before starting the treatment. Chemotherapy can begin only when your wounds are healed and you are strong enough.
  • Palliative treatment: If the cancer has spread to other organs, such as the liver or bones, chemotherapy may be used to reduce your symptoms and make you more comfortable. Palliative chemotherapy may shrink the tumours and extend life, but it is not able to cure the disease. 
Side effects of chemotherapy

Some chemotherapy drugs can cause side effects. The side effects depend on the drugs used and the dosage levels. Common side effects include:

  • tiredness
  • feeling sick (nausea and vomiting)
  • diarrhoea
  • mouth sores and ulcers
  • hair loss
  • loss of appetite
  • a drop in levels of blood cells (your blood count), which may increase the risk of infection
  • sore hands or feet
  • pins and needles or numbness in the fingers and toes, particularly after using a chemotherapy drug called oxaliplatin
  • skin peeling and increased sensitivity to sunlight, particularly after using a chemotherapy drug called fluorouracil (or 5FU).

People react to treatment differently – some people have few side effects, while others have many. Most side effects are temporary, and there are ways to prevent or reduce them. Your doctor may prescribe medication to manage the side effects, arrange a break in your treatment, or change your treatment.

Keep a record of your chemotherapy treatment handy. This will save time if you become ill and need to visit the emergency department.

To find out more about chemotherapy, call 13 11 20 and ask for a copy of Understanding Chemotherapy.

During chemotherapy, you will have a higher risk of bleeding and of getting an infection. Tell your doctor if you feel more tired than usual, or if you bruise or bleed easily. If you have a temperature over 38°C, contact your doctor or go to the emergency department.  

Targeted therapies

New drugs known as targeted therapies are used for bowel cancer only when the disease is advanced (metastatic). These drugs work differently from chemotherapy drugs by destroying or stopping the growth of cancer cells while minimising harm to healthy cells. Targeted therapies may be used together with chemotherapy or alone. They are usually injected into a vein.

Not all cancers respond to targeted therapies. Your doctor may arrange a RAS biomarker test. RAS genes play a key role in cell growth, so the test can help predict which therapies might help you.

Side effects of targeted therapies

The side effects of targeted therapies vary depending on the drugs used. The most common side effects include:

  • high blood pressure
  • protein in the urine (your doctor may test your urine for protein and adjust your treatment if levels become too high)
  • rash
  • diarrhoea
  • delayed wound healing
  • tiredness. 

Radiotherapy

Radiotherapy uses high-energy x-rays or electron beams (radiation) to kill or damage cancer cells. The radiation is targeted to cancer sites in your body, and treatment is carefully planned to do as little harm as possible to your normal body tissue around the cancer.

Often part of the treatment for rectal cancer, radiotherapy can be given:

  • before or after surgery, to reduce the chance of the cancer coming back
  • instead of surgery, if you are not well enough for an operation
  • at the same time as chemotherapy (chemoradiation).

 Radiotherapy is also used as a palliative treatment for both colon and rectal cancer.

During treatment, you will lie under a machine that delivers x-ray beams to the treatment area. Each treatment takes only a few minutes once it has started, but setting up the machine and seeing the radiation oncologist may take more time.

If radiotherapy is given along with chemotherapy, you will most likely have it once a day, Monday to Friday, for about 5–7 weeks. You may have a shorter course of radiotherapy if it is given by itself. The number of treatments you have depends on your radiation oncologist’s recommendation.

To find out more about radiotherapy, call 13 11 20 and ask for a copy of Understanding Radiotherapy.

Side effects of radiotherapy

Common side effects of radiotherapy may include:

  • bleeding
  • diarrhoea
  • nausea
  • tiredness
  • mild headaches
  • urinary or faecal incontinence
  • redness and soreness in the treatment area
  • reduced fertility (see below)
  • problems with sexual function (see below).

People react to treatment differently, so some people may have few side effects, while others have many. Your treatment team can give you advice about how to manage radiotherapy side effects.

Effects on fertility and sexual function

Radiotherapy to the pelvis and rectum can affect the ability to have children (fertility) and sexual function.

For men, radiotherapy can damage sperm or reduce sperm production. This may be temporary or permanent. Most doctors suggest that men use contraception or abstain from unprotected sex for six months after radiotherapy. You may be able to store sperm at a hospital or fertility clinic before treatment starts.

Because radiotherapy can damage blood vessels, some men may have erection problems. Your doctor may prescribe medication or refer you to a specialist clinic to manage this problem.

For women, radiotherapy may lead to damage and shrinking of the vagina, making sexual intercourse difficult. It can also cause early menopause and infertility if the ovaries receive radiation.

If the treatment causes sudden menopause and you are no longer able to have children naturally, you may feel upset and worry about the impact on your relationship. Even if your family is complete, you may have mixed emotions. Talking to your partner, a counsellor or a fertility specialist about your concerns can help.

To find out more, call Cancer Council 13 11 20 and ask for free copies of Fertility and Cancer and Sexuality, Intimacy and Cancer

Palliative treatment

Palliative treatment aims to reduce symptoms without trying to cure the disease. It can be used at any stage of advanced cancer to improve quality of life. It is not just for people who are about to die and does not mean you have given up hope. Rather, it is about living for as long as possible in the most satisfying way you can.

As well as slowing the spread of cancer, palliative treatment can relieve pain and help manage other physical and emotional symptoms. Treatment may include radiotherapy, chemotherapy, targeted therapies or other medication.

To find out more, see our palliative care page or call Cancer Council on 13 11 20 and ask for our free booklet on palliative care.

Key points

  • The most common form of treatment for bowel cancer is surgery. You may also have chemotherapy, targeted therapies or radiotherapy.
  • The type of surgery you have depends on where the cancer is in the bowel, the type and size of the cancer, and whether it has spread.
  • The most common surgery for colon cancer is a colectomy. There are different types of colectomies depending on the tumour’s location.
  • Operations for rectal cancer include abdominoperineal and anterior resections.
  • During bowel surgery, the surgeon removes the section affected by cancer and, where possible, joins the two ends of the bowel back together. If the bowel cannot be joined together again, the surgeon may create a stoma, an opening to the outside of the body. Waste (faeces) will pass through this stoma into a bag.
  • Sometimes a temporary stoma is made to give the bowel time to heal. It is usually reversed later.
  • In some cases, you may be able to have minimally invasive surgery (keyhole or laparoscopic surgery) or a local excision.
  • Chemotherapy is treatment with drugs. It may be used before or after surgery, if the cancer has spread, or to stop the cancer coming back.
  • Targeted therapies are new drugs that target cancer cells and minimise harm to healthy cells. They are used only for advanced bowel cancer.
  • Radiotherapy is treatment with x-rays. It is often used to treat rectal cancer. 

Reviewed by: Mr Chip Farmer, Colorectal Surgeon, The Alfred Hospital, Cabrini Hospital and The Avenue Hospital, VIC; Mervyn Bartlett, Consumer; Dr Andrew Haydon, Medical Oncologist, The Alfred Hospital and Cabrini Hospital, VIC; Jackie Johnston, Palliative Care and Stomal Therapy Clinical Nurse Consultant, St Vincent’s Private Hospital (Darlinghurst), NSW; Dr Shahrir Kabir, Fellow in Colorectal Surgery, Royal Brisbane and Women’s Hospital, QLD; Steve Pratt, Nutrition and Physical Activity Manager, Cancer Council WA; Cassie Riley, Cancer Nurse Coordinator – Colorectal, WA Cancer and Palliative Care Network, WA; Mary Shanahan, Cancer Genetics Nurse Coordinator, Peter MacCallum Cancer Centre, VIC; A/Prof Andrew Stevenson, Head of Colorectal Surgery, Royal Brisbane and Women’s Hospital, University of Queensland; Pat Walls, Clinical Nurse Consultant Stomal Therapy/Wound Management, Holy Spirit Northside Private Hospital, QLD.

Updated: 01 Feb, 2015