Treatment for early bowel cancer

• Surgery is the main treatment for colon cancer.
• If the cancer has spread to the lymph nodes, you may have chemotherapy after surgery. This is called adjuvant chemotherapy.
• Radiation therapy is rarely used for colon cancer.

• Surgery is the main treatment for early rectal cancer.
• If the cancer has spread beyond the rectal wall and/or into nearby lymph nodes, it is common to have chemotherapy combined with radiation therapy (chemoradiation). Most often this takes place before surgery. This is called neoadjuvant treatment.
• Some people may have radiation therapy or chemotherapy on its own before surgery.
• After surgery you may have further chemotherapy.

Sometimes one end of the bowel is brought through an opening made in your abdomen and stitched to the skin. Called a stoma, it lets faeces out to be collected in a bag. The stoma is usually temporary, and the operation is reversed later.

In some cases, the stoma is permanent. Improved surgical techniques mean fewer people need a permanent stoma. 

There are different types of colectomies depending on which part of the colon is removed. The surgery may be done as open or keyhole surgery.

This is the most common operation. You may have a high anterior resection or an ultra-low anterior resection. As part of the procedure, the surgeon may create a temporary stoma (which will usually be reversed later). 

This procedure may be recommended if the cancer is near the anal sphincter or it is too low to be removed without causing incontinence (loss of control over bowel movements).

After an abdominoperineal resection, you will need a permanent stoma (colostomy). Speak to your surgeon about any concerns you may have.

Used for larger benign polyps. Some very early cancers that involve only the inner lining of the bowel may be suitable for endoscopic resection (also called endoscopic mucosal resection or EMR).

This involves cutting out the tumour during a colonoscopy. A bowel resection may also still be needed.

People who have very early-stage rectal cancer or are not fit for a major operation may have a local excision.

The surgeon puts instruments into the anus to remove the cancer from the lining of the rectum, along with a margin of healthy tissue, without cutting into the abdomen.

Methods include transanal excision (TAE), transanal endoscopic microsurgery (TEMS), and transanal minimally invasive surgery (TAMIS).

There are different types of operations for cancer in the rectum. The surgery may be done as open or keyhole surgery.

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 tests or during surgery. In this case, there are several options for surgery, including to remove: 

• two sections of the bowel
• one larger section of the bowel that includes both areas with cancer
• all of the colon and rectum (proctocolectomy) to prevent any chance of another cancer forming.

In some locally advanced cancers, other organs that the bowel cancer is attached to may also be removed along with the bowel containing the cancer.

The type of surgery your doctor recommends depends on several factors, including your age, where the tumours are in the bowel, genetic and other risk factors, and your preferences.

If only one area of the bowel is blocked or you are not fit enough for major bowel surgery, you may have a small hollow tube (stent) put in to help keep the bowel open and relieve symptoms.

A stent may be permanent, or it can be used to help manage the blockage until you are fit enough to have a colectomy or resection. The stent is inserted through the rectum using a colonoscope.

A dietitian or your surgeon or stomal therapist may suggest you take a stool softener or add more fluid to your diet to help food or waste pass through the blockage or stent more easily.

Other people may be advised to eat low-fibre foods. Talk to a dietitian about suitable foods for your situation. If you are unable to have bowel surgery or a stent, you may be given medicine to help control the symptoms of a bowel obstruction.

• In hospital you will have to wear compression stockings to keep the blood flowing in your legs.
• You will also be given a daily injection of a blood thinner to reduce the risk of developing blood clots.
• Some people also wear special cuffs around the legs to keep the calf muscles moving.
• Some people may have to wear the compression stockings and have the injections for a couple of weeks after the surgery.
• You will need to avoid driving after the surgery until you can move freely without pain. Discuss this issue with your doctor. Check with your car insurer for any exclusions about major surgery and driving.

• You will have some pain and discomfort for several days after surgery, but this can be controlled with pain medicines.
• Pain medicines may be given: by an injection under the skin; through a drip you can control with a button (patient-controlled analgesia or PCA); by an injection near your spinal column (epidural or spinal anaesthetic); as pills or tablets; through little tubes giving local anaesthetic near the wound (transversus abdominis plane or TAP block catheters).
• Let your doctor or nurse know if you are in pain so they can adjust the medicines to make you as comfortable as possible. Do not wait until the pain is severe.

• You will be given fluids through a drip (also called an IV or intravenous infusion) until you start drinking and eating again. You may need to have 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.
• In most hospitals, you will be given water to drink a few hours after the surgery, and you will usually start on solid foods the day after the surgery (or even on the day of the surgery if you feel well). You may also be given nutritional supplements to drink.

• Your treatment team will encourage you to walk the day after the surgery.
• Avoid heavy lifting (more than 3–4 kg) for about 4–6 weeks.
• A physiotherapist will teach you breathing or coughing exercises to help keep your lungs clear. This will reduce the risk of getting a chest infection.
• Gentle exercise has been shown to help people manage some of the common side effects of treatment and help them return to their usual activities faster.
• See an exercise physiologist or physiotherapist for advice. Visit Exercise & Sports Service Australia to find an exercise physiologist, and visit the Australian Physiotherapy Association to find a physiotherapist.
• Your doctor may advise you to avoid sexual intercourse for a few weeks after surgery. Ask them when you can have penetrative sex again, and explore other ways you and your partner can be intimate, such as massage.

Radiation therapy may be recommended for rectal cancer but is rarely used to treat colon cancer. You may have radiation therapy:

• Before surgery (neoadjuvant) – Radiation therapy is used before surgery to shrink the tumour. This makes it easier for the surgeon to remove the cancer and reduces the risk of the cancer coming back.
• After surgery (adjuvant) – If rectal cancer is more advanced than expected, radiation therapy may be used after surgery to kill remaining cancer. This is only if radiation therapy wasn’t given before surgery.

External beam radiation therapy (EBRT) is the most common radiation therapy for rectal cancer. A machine called a linear accelerator delivers a high dose to the affected area, with lower doses to surrounding tissue, reducing side effects.

You will meet with your radiation oncologist for them to explain details about treatment, the number of sessions you need to have and whether you will have chemotherapy with your radiation treatment.

For your radiation oncologist to design your treatment, a planning CT scan will be done in the treatment position.

Small marks, like a freckle, may be made on your skin to help set you up in the exact same position for each treatment. It may take a few weeks to plan the treatment.

Treatment is given daily, on weekdays. During treatment, you lie on the table of the radiation therapy machine. Each time you have treatment, you lie in the same position as you were in when you had the planning CT scan.

Each treatment only takes a few minutes, but you may be on the treatment table for 10–20 minutes because of the time it takes to set you up accurately. The treatment is painless and can’t be seen or felt.

After finishing neoadjuvant treatment, there will be a break before surgery. This gives time for the radiation therapy to have its full effect.

Most side effects are temporary and go away weeks or months after treatment. Feeling tired is common.

Radiation therapy for rectal cancer is usually given over the pelvic area, which can affect your sexual function and ability to have children (fertility).

Radiation therapy can irritate the bowel and bladder. This may mean:

• needing to pass urine (wee or pee) more often or burning when you do (cystitis)
• redness and soreness in the treatment area
• needing to poo urgently/suddenly or incontinence
• diarrhoea
• constipation, and
• mucus or small amounts of blood coming out of the anus.

Radiation therapy can cause the skin or internal tissue to become less stretchy and harden (fibrosis). It can also inflame the lining of the rectum (radiation proctitis).

People react to radiation therapy differently, so some people may have few side effects, while others have more. Your treatment team will talk to you about possible side effects and how to manage them.

Chemotherapy is usually given through a drip into a vein (intravenously). To avoid repeated needles, you may have it through a device inserted beneath your skin, such as a port-a-cath or peripherally inserted central catheter (PICC).

Sometimes chemotherapy is taken as tablets (orally). Chemotherapy is commonly given as a period of treatment followed by a break. This is called a cycle.

Adjuvant chemotherapy is usually given for 3–6 months, in cycles that last for 2–3 weeks each. Your medical oncologist will explain your treatment schedule.

Usually, you have chemotherapy during day visits to a hospital or treatment centre. Some people have chemotherapy at home through a portable pump.

The side effects of chemotherapy vary, depending on the drugs used and the dose. Your medical oncologist or nurse will talk to you about the likely side effects, including how they can be prevented or controlled.

If side effects are hard to manage, the chemotherapy treatment can be adjusted to reduce the side effects while still giving you a good result.

Side effects may include:

• tiredness
• neutropenia (low white blood cells)
• feeling sick (nausea and vomiting)
• diarrhoea;
• lip and mouth sores
• changes in appetite, taste and smell
• sore hands and feet (peripheral neuropathy), and
• hair loss or thinning.

The chemotherapy drug oxaliplatin may make your hands, feet, mouth and throat sensitive to cold items (e.g. cold food and drinks, air conditioning), causing pins and needles and numbness.

Skin rash and increased sensitivity to sunburn are more common if using the chemotherapy drug fluorouracil or capecitabine.

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

You may also find it helpful to keep a symptom diary when you start chemotherapy, so you can monitor side effects as they occur.

If you are having chemotherapy, you have a higher risk of getting an infection or bleeding. If you have a temperature of 38°C or higher, or the “shivers and shakes”, contact your doctor or go to the emergency department immediately.

Tell your doctor if you feel more tired than usual, or if you bruise or bleed easily.