Treatment for early bowel cancer

Wednesday 1 February, 2017

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On this page: Surgery | Surgery for a blocked bowel (bowel obstruction) | Radiotherapy | Chemotherapy | Key points


Treatment for early bowel cancer will depend on the type of bowel cancer you have. This is because colon cancer and rectal cancer are treated differently.

Your medical team will recommend treatment based on:

  • what will give you the best outcome
  • where the cancer is in the bowel
  • whether and how the cancer has spread
  • your general health
  • your preferences.

The treatment options you are offered will depend on the guidelines for best practice in treating bowel cancer. For some people, the best option may be to join a clinical trial.

Treatment options by type of bowel cancer
Colon cancer

Surgery is the main treatment for early colon cancer. If cancer has spread to the lymph nodes, you may have chemotherapy after surgery. This is called adjuvant chemotherapy. Radiotherapy is not used for early colon cancer.

Rectal cancer

Surgery is the main option for early rectal cancer. If the cancer has spread beyond the rectal wall and/or into nearby lymph nodes (locally advanced cancer), you will have either radiotherapy or both radiotherapy and chemotherapy (chemoradiotherapy or chemoradiation). This is called neoadjuvant treatment, and the aim is to make the cancer as small as possible before it is removed. This will be followed by surgery and then adjuvant chemotherapy.

How the surgery is done

Different surgical methods may be used for bowel cancer. Each method has advantages in particular situations – your doctor will advise which method is most suitable for you.

Open surgery

Open surgery for Bowel CancerThis involves one long cut (incision) down your abdomen. Open surgery usually means a larger wound and slower recovery. It requires a longer hospital stay.

Open surgery is a well-established technique and is widely available in Australia.

Image: The blue line shows the length and direction of the cut.

Minimally invasive surgery

Minimally invasive surgery for bowel cancerAlso called keyhole surgery or laparoscopic surgery, this method involves several small cuts. It usually means less pain and scarring, a shorter hospital stay and faster recovery.

A thin tube (laparoscope) is passed through a cut in the abdomen. The laparoscope has a light and camera. Long, thin instruments are inserted through other small incisions to remove the section of bowel with the cancer. Robot-assisted surgery is a type of laparoscopic surgery. The instruments are controlled using robotic arms.

Image: The blue dots show the size and position of the cuts.

Surgery

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

Surgery for cancer in the colon

The most common type of surgery is called a colectomy. There are different types of colectomies depending on whether part or all of the colon is removed. Lymph nodes near the colon and some normal bowel around the cancer will also be removed.

The surgeon usually cuts the colon on either side of the cancer and then joins the two ends of the colon back together. This join is called an anastomosis.

Sometimes one end of the bowel 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 and collected into a bag.

The stoma is usually temporary, and the operation is reversed later. In some cases, the stoma is permanent. Advances in surgical techniques have led to very few people needing a permanent stoma. See further information about stomas.

After surgery, you will have a scar. Most people who have open surgery have a scar from above their navel to their pubic area. See below for an illustration of the cut (incision).

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

There are different types of operations for cancer in the rectum. The type of operation you have depends on where the cancer is located, whether the bowel can be rejoined, and where in the rectum the join can be made.

You may have an anterior resection or abdominoperineal resection (also known as an abdominoperineal excision). The surgery may be open style or minimally invasive (see above).

An anterior resection is the most common operation. This will include creating a temporary stoma, which will be reversed later.

An abdominoperineal resection may be recommended if the cancer is near the sphincter muscles or if it is too low to be removed without causing incontinence (accidental loss of urine or faeces) or erection problems. After an abdominoperineal resection you will need a permanent stoma (colostomy). Speak to your surgeon about any concerns you may have.

Resections in the large bowel

The area shaded dark blue will be removed.

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.

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.

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 another way for waste to leave the body.

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 50), which will be reversed once the J-pouch heals.

Other types of surgery
Local excision

People who have very early stage bowel cancer or are not fit for a major operation may have a local excision. The surgeon inserts an endoscope into the anus to remove the cancer. This is called transanal endoscopic microsurgery (TEMS).

If the cancer is very low in the rectum, the surgeon may be able to remove the cancer by passing an instrument up the anus rather than using an endoscope. This is called transanal excision (TAE).

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. The surgeon will also consider your preferences.

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 cancer
  3. remove the entire colon and rectum (proctocolectomy) to prevent any chance of another cancer forming.

The type of surgery your doctor recommends depends on several factors including the location of the tumours in the colon, genetic and other risk factors, and your preferences.

Surgery for a blocked bowel (bowel obstruction)

Sometimes as the bowel cancer grows it completely blocks the bowel. This is called bowel obstruction. Waste matter cannot pass through the blocked bowel easily, and may cause:

  • bloating and abdominal pain
  • constipation
  • nausea and vomiting.

Sometimes the obstruction is cleared during surgery to remove the cancer. In some cases, the bowel obstruction will mean you have to have emergency surgery. It may be possible to close up the bowel during the surgery, but some people may need a stoma. Sometimes a stoma is made ‘upstream’ from the obstruction to relieve the blockage to allow time for staging scans of the cancer or chemoradiotherapy before surgery, to make sure the cancer is removed appropriately.

Not everyone with a blockage will want an operation or be fit enough to have it. To help keep the bowel open so that bowel motions can pass through again, your surgeon may be able to put in a small tube (stent). A stent may also help manage the blockage until you are well enough for an operation. A flexible tube with a light at the end, called an endoscope, is passed through the rectum. This helps the surgeon see the blockage, and the stent is inserted through it.

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

What to expect after surgery
Recovery time

This 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.

Drips and tubes

You will be given fluids through a drip (also called an intravenous or IV infusion) until you can start eating and drinking again. You may need a drip for a few days. You may also have other tubes – from your bladder to drain urine (catheter) or from your abdomen to drain fluid from around the surgical area.

Pain relief

At first, you will need some pain relief. You will have patient-controlled analgesia (PCA), which delivers a measured dose of pain relief medicine when you push a button. Pain relief may also be given by a slow injection into a vein (intravenous or IV infusion) or by an injection into your spinal column (epidural or spinal anaesthetic).

Breathing exercises

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

Blood clots

To reduce the risk of developing blood clots in your legs, you may wear compression stockings during surgery to apply pressure to your calves. Some people also wear a special cuff that applies intermittent pressure.

Side effects of bowel surgery
Changes in bowel and sexual function

Many people find that their bowel and bladder functions change. These usually improve within a few months but, for some people, it can take longer. Erection problems are also an issue for some men.

Changes to your diet

See information about dietary changes.

Fatigue

It is normal to feel tired after surgery. Try to rest and only do what is comfortable. You might have to remind your family and friends that it may take several months to recover from surgery.

Temporary or permanent stoma

See information about having a stoma.

Radiotherapy

Radiotherapy (also known as radiation therapy) uses radiation, such as protons, to kill cancer cells. The radiation is targeted to the specific site of the cancer, and treatment is carefully planned to do as little harm as possible to your normal body tissue near the cancer.

Commonly, radiotherapy is used before surgery for locally advanced rectal cancer. It is often combined with chemotherapy and radiotherapy (called chemoradiotherapy or chemoradiation). This is because chemotherapy makes cancer cells more sensitive to radiotherapy, and reducing the number of cancer cells will make it easier for the surgeon to completely remove the tumour. Radiotherapy is not used to treat early colon cancer.

Radiotherapy can be delivered in different ways, including IMRT (intensity-modulated radiation therapy) and VMAT (volumetric modulated arc therapy). These techniques deliver a dose to the affected area without damaging surrounding tissue. These improvements have reduced the side effects from radiotherapy.

During treatment, you will lie on a treatment table under a machine called a linear accelerator. Each treatment takes only a few minutes, but a session may last 10–20 minutes because of the time it takes to set up the machine.

If radiotherapy is given with chemotherapy, you will have it once a day for 5–6 weeks. You may have a shorter course of radiotherapy if it is given by itself, usually for five days, Monday to Friday. To find out more, see Understanding Radiotherapy or call Cancer Council 13 11 20.

Side effects of radiotherapy

Common side effects of radiotherapy include:

  • diarrhoea
  • tiredness
  • 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 more. Your treatment team will give you advice about how to manage radiotherapy side effects.

Effects on fertility and sexual function

Radiotherapy to the pelvis and rectum can affect your 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 during and after radiotherapy for one month.
  • You will be able to store sperm at a hospital or fertility clinic before treatment starts. Talk to your doctor about this.
  • Because radiotherapy can damage blood vessels and nerves that produce erections, 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 narrowing of the vagina, making sexual intercourse painful. The use of a vaginal dilator can help to gradually widen the entrance and prevent the side walls sticking together. Ask your doctor or a physiotherapist for advice on how to use a dilator.
  • In some cases, radiotherapy can affect the ovaries and stop them producing female hormones. This can cause menopause and infertility. Menopause can be managed by hormone replacement therapy, which is safe for rectal cancer. After menopause you will not be able to conceive a child. Share your feelings about any fertility issues with your partner, a counsellor or a fertility specialist.

To find out more, see Fertility and Cancer and Sexuality or Intimacy and Cancer or call Cancer Council 13 11 20.

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 has spread outside the bowel to lymph nodes or to other organs, chemotherapy is usually needed. Chemotherapy may be used for several reasons:

Before surgery (neoadjuvant)

Some people with locally advanced rectal cancer have chemotherapy before surgery to shrink the tumour and make it easier to remove during surgery. You are likely to have chemotherapy together with radiotherapy (called chemoradiotherapy or chemoradiation).

After surgery (adjuvant)

Chemotherapy is used after surgery for either colon or rectal cancer to reduce the chance of the cancer coming back by eliminating any cancer cells that may have spread after surgery. You will probably start chemotherapy as soon as your wounds have healed and you’ve recovered your strength, usually within eight weeks.

If the cancer has spread to other organs, such as the liver or lungs, chemotherapy may be used to reduce symptoms and make you more comfortable.

You may have chemotherapy injected into a vein (intravenously) or as tablets. If you have chemotherapy intravenously, you can have the drugs through a thin plastic tube called a central venous access device (CVAD). The CVAD may be placed under the skin with a local anaesthetic. This type of CVAD is called a port-a-cath.

Some people have chemotherapy through a portable bottle called an infusor pump. It is made of hard plastic and looks like a baby bottle. It is usually worn in a bag around your waist or on your hip. The bottle gives a continuous dose over 48 hours while you are at home. You will be shown how to care for the infusor pump.

You will probably have chemotherapy as a course of several sessions (cycles) over 4–6 months. Your medical oncologist will explain your treatment schedule.

Side effects of chemotherapy

Most chemotherapy drugs cause some 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
  • changes in appetite and loss of taste
  • a drop in levels of blood cells (your blood count), which may increase the risk of infection
  • sore hands or feet
  • pins and needles, numbness, redness or swelling in the fingers and toes – more common if using the chemotherapy drug called oxaliplatin
  • skin peeling and increased sensitivity to sunlight – more common if using the chemotherapy drug called fluorouracil (or 5-FU).

People react to chemotherapy 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 will prescribe medication to prevent and manage the side effects. It is uncommon to need a break or change in your treatment.

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

For more information see Understanding Chemotherapy or call Cancer Council 13 11 20.

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

Key points

  • Surgery is the most common treatment for early bowel cancer. You may also have radiotherapy or chemotherapy.
  • 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. Cancer in the colon and cancer in the rectum are treated differently.
  • Colectomy is the most common surgery for colon cancer. There are different types of colectomies depending on whether part or all of the colon is removed.
  • Operations for rectal cancer include anterior resection, but if the cancer is low in the rectum you may have an abdominoperineal resection.
  • During bowel surgery, the surgeon cuts the colon on either side of the cancer and joins the two ends of the bowel back together.
  • If it is not possible to join the bowel back together or if the bowel needs time to heal, a diversion is created for faeces to come through a hole (stoma) in the abdominal wall. Waste (faeces) will be collected into a bag.
  • In some cases, you may be able to have minimally invasive surgery (keyhole, laparoscopic or robotic surgery).
  • Radiotherapy is treatment with radiation. It is used to treat locally advanced rectal cancer. It is given before surgery (neoadjuvant), often with chemotherapy but sometimes alone.
  • Chemotherapy is treatment with drugs. It may be used before or after surgery to reduce the chance of the cancer coming back.

Reviewed by: A/Prof Craig Lynch, Colorectal Surgeon and Chair, Lower Gastrointestinal Cancer Service, Peter MacCallum Cancer Centre, VIC; Merran Findlay, Executive Research Lead–Cancer Nutrition, and Oncology Specialist Dietitian, Royal Prince Alfred Hospital, NSW; Jackie Johnston, Palliative Care and Stomal Therapy Clinical Nurse Consultant, St Vincent’s Private Hospital, NSW; A/Prof Susan Pendlebury, Radiation Oncologist, St Vincent’s Clinic, NSW; Jan Priaulx, 13 11 20 Consultant, Cancer Council NSW; A/Prof Eva Segelov, Professor of Oncology, Monash Health and Monash University, VIC; Heather Turner, Consumer; Lynne Wolowiec, Consumer.

Updated: 01 Feb, 2017