Bowel cancer


Treatment for early bowel cancer

Treatment for early and locally advanced 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, and your preferences.

The treatment options you are offered will depend on the guidelines for best practice in treating bowel cancer. 1 For some people, the best option may be to join a clinical trial (see above).

Treatment options by type of bowel cancer

Colon cancer

  • Surgery is the main treatment for early and locally advanced 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 not used for early colon cancer.

Rectal 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 (locally advanced cancer), before the surgery you will have either radiation therapy or chemotherapy combined with radiation therapy (chemoradiation). After the surgery you may have chemotherapy.

Preparing for treatment

Managing anaemia

Many people with bowel cancer have anaemia or low iron levels. You may be given iron as tablets or intravenously to improve your iron levels and blood count before treatment begins.

Improve diet and nutrition

People with bowel cancer often lose a lot of weight and may become malnourished. A dietitian can provide advice on ways to reduce the weight loss through changes to your diet or liquid nutritional supplements. This will help improve your strength and lead to better treatment outcomes.

Surgery

The type of surgery you have will depend on the location of the cancer in the bowel and your preferences. The aim of surgery is to remove as much of the cancer as possible and nearby lymph nodes.

How the surgery is done

There are two ways to perform surgery for bowel cancer. Each method has advantages in particular situations – your doctor will advise which method is most suitable for you.

Keyhole surgery

Also called minimally invasive or laparoscopic surgery, this method involves several small cuts (incisions) in the abdomen. A thin tube (laparoscope) is passed through one of the cuts. The laparoscope has a light and camera. Long, thin instruments are inserted through other small cuts to remove the section of bowel with the cancer. Keyhole surgery usually means less pain and scarring, a shorter hospital stay and faster recovery.

Open surgery

This involves one long cut (incision) down the middle of your abdomen. Open surgery usually means a larger wound and slower recovery, and it requires a longer hospital stay. Open surgery is a well-established technique and widely available.

Surgery for cancer in the colon The most common type of surgery for colon cancer is a colectomy. It may be done as open surgery or keyhole surgery (see above). There are different types of colectomies depending on which part of the colon is removed (see below). Lymph nodes near the colon and some normal bowel around the cancer will also be removed.

The surgeon usually cuts the bowel on either side of the cancer (with a small border of healthy tissue called the margin) and then joins the two ends of the bowel 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 large bowel) or ileostomy (if made from the small bowel). The opening – called a stoma – allows faeces to be removed from the body and collected in 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 fewer 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.

Surgery for cancer in the rectum

There are different types of operations for cancer in the rectum (see below). 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.

The surgery may be performed using an open or keyhole approach. You may have an anterior resection or abdominoperineal resection (also known as an abdominoperineal excision).

Anterior resection

This is the most common operation. It may include creating a temporary stoma, which will be reversed later. See further information about stomas.

Abdominoperineal resection

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

Other types of surgery

Local excision

People who have very early stage rectal cancer or are not fit for a major operation may have a local excision. The surgeon inserts an instrument 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).

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 several options for surgery:

  • remove two sections of the bowel
  • remove one larger section of the bowel, which includes both areas with cancer
  • 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 your age, the location of the tumours in the bowel, 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 found and cleared during the surgery to remove the cancer. In other cases, the bowel obstruction will mean you have to have emergency surgery to clear the blockage.

It may be possible to rejoin 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 and to allow time for staging scans of the cancer or chemoradiation before surgery, to make sure the cancer is removed completely.

Not everyone with a blockage will want to have surgery or be fit enough to have it. To help keep the bowel open so that stools can pass through again, your surgeon may be able to insert a small hollow tube (stent) inside the colon. A stent may also help manage the blockage until you are well enough to have an operation. Your surgeon will use a colonoscope to find the blockage and place the stent.

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

Risks of bowel surgery

Your surgeon will talk to you about the risks and complications of bowel surgery. As with any major operation, bowel surgery has risks. Complications may include infection, bleeding, blood clots, damage to nearby organs, or leaking from the joins between the removed parts of the bowel. You will be carefully monitored for any side effects afterwards.

Most hospitals in Australia have programs to reduce the stress of surgery and improve your recovery. These are called enhanced recovery after surgery (ERAS) or fast track surgical (FTS) programs, and they encourage you to play an active part in your care through pre-admission counselling, and education about pain control, diet and exercise so you know what to expect each day after the surgery.

What to expect after surgery

This is a general overview of what to expect. The process varies from hospital to hospital, and everyone will respond to surgery differently.

Recovery time

  • Your recovery time after the operation will depend on your age, the type of surgery you had and your general health.
  • You will probably be in hospital for 4–7 days, but it can take 2–3 months to fully recover.
  • You will have to wear compression stockings while you are in hospital to help the blood in your legs to circulate.
  • You will also be given a daily injection of a blood thinner to reduce the risk of developing blood clots.
  • Some people also wear a special cuff that applies intermittent pressure to the legs.
  • Some people may have to wear the stockings and have the injections for a couple of weeks after the surgery.

Pain relief

  • You will have some pain and discomfort for several days after surgery, but you will be given pain-relieving medicines to manage this.
  • Pain relief may be given in various ways:
    • by an injection near your spinal column (epidural or spinal anaesthetic)
    • through a drip which you can control with a button (PCA – patient controlled analgesia)
    • as pills or tablets
    • through little tubes giving local anaesthetic near your wound (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.

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.
  • In most centres, 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.
  • In some centres, you will not have anything to eat or drink for several days after the surgery.

Activity/exercise

  • Your health care team will encourage you to walk the day after the surgery.
  • You will need to 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 speed up a return to usual activities.

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. See more details. Erection problems can also be an issue for some men after rectal cancer surgery. See Sexuality, Intimacy and Cancer.

Changes to your diet

Fatigue

It is normal to feel tired after surgery. Although it's a good idea to stay active and do gentle exercise as recommended by your doctor, you may find that you tire easily and need to rest during the day. Take breaks if you feel tired, and follow your doctor's advice about restrictions, such as avoiding heavy lifting. You might have to remind your family and friends that it may take several months to recover from surgery.

Temporary or permanent stoma

Radiation therapy

Also known as radiotherapy, this treatment uses a controlled dose of radiation, such as focused x-ray beams, to kill or damage cancer cells. The radiation is targeted to the specific area of the cancer, and treatment is carefully planned to do as little harm as possible to your normal body tissue near the cancer. Radiation therapy is often combined with chemotherapy (chemoradiation). This is because chemotherapy makes cancer cells more sensitive to radiation.

Radiation therapy is not generally used to treat locally advanced colon cancer. Commonly, a short course of radiation therapy or a longer course of chemoradiation is used to shrink the tumour before surgery for locally advanced rectal cancer. The aim of this treatment is to make the cancer as small as possible before it is removed. This means it will be easier for the surgeon to completely remove the tumour and reduces the risk of the cancer coming back.

Occasionally, if the rectal cancer is found to be more advanced than originally thought, radiation therapy may be used after surgery to destroy any remaining cancer cells.

External beam radiation therapy is the most common type of radiation therapy for rectal cancer. Newer techniques deliver the dose to the affected area without damaging surrounding tissue. These improvements have reduced the side effects from radiation therapy.

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.

There will be a break between radiation therapy and surgery to allow the treatment to have its full effect. If radiation therapy is given with chemotherapy, you will have it once a day for 5–6 weeks, then there will be a gap of 6–12 weeks before surgery. If radiation therapy is given by itself, you will have a shorter course, usually for five days, then a shorter gap before surgery. See Understanding Radiation Therapy.

Side effects of radiation therapy

The side effects of radiation therapy vary. Most are temporary and disappear a few weeks or months after treatment. Radiation therapy for rectal cancer is usually given over the pelvic area, which can irritate the bowel and bladder.

Common side effects include feeling tired, needing to pass urine more often and burning when you pass urine (cystitis), redness and soreness in the treatment area, diarrhoea, constipation or faecal urgency and incontinence. Radiation therapy can cause the skin or internal tissue to become less stretchy and harden (fibrosis). It can also affect fertility and sexual function (see below).

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

Radiation proctitis

Radiation to the pelvic area can damage the lining of the rectum, causing inflammation and swelling (known as radiation proctitis). This can cause a range of symptoms including diarrhoea, the need to empty the bowels urgently and loss of control over the bowels (faecal incontinence). When treating rectal cancer, these side effects may appear shortly after radiation therapy, but are generally not a problem long term because the rectum is removed during surgery. Your treatment team will talk to you about your risk of developing radiation proctitis. See also some ways to cope with bowel changes.

Effects on fertility and sexual function

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

For men

  • Radiation therapy can damage sperm or reduce sperm production. This may be temporary or permanent.
  • Most doctors suggest that men use contraception and don't have unprotected sex during and for one month after radiation therapy.
  • You will be able to store sperm at a hospital or fertility clinic before treatment starts. Talk to your doctor about this.
  • Because radiation therapy can damage blood vessels and nerves that produce erections, some men may have erection problems. Your doctor may prescribe medicine or refer you to a specialist clinic to manage this problem.

For women

  • Radiation therapy can lead to the vagina becoming shorter and narrower, making sexual intercourse painful. Your doctor may suggest you use a vaginal dilator after radiation therapy is finished to help gradually widen the entrance and prevent the side walls sticking together. Using dilators can be challenging. Your doctor or a physiotherapist can provide practical advice on using a dilator.
  • Talk to your doctor about creams and moisturisers to help with vaginal discomfort and dryness.
  • In some cases, radiation therapy can stop the ovaries producing female hormones. This can cause menopause and infertility.
  • Menopause can be managed by hormone replacement therapy, which can be taken if you've had rectal cancer. After menopause you will not be able to conceive a child.
  • Share your feelings about an
  • fertility issues with your partner, a counsellor or a fertility specialist.

See Fertility and Cancer and Sexuality, Intimacy and Cancer.

Chemotherapy

Chemotherapy uses drugs to kill or slow the growth of 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 may be recommended:

Before surgery (neoadjuvant)

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

After surgery (adjuvant)

Chemotherapy may be used after surgery for either colon or rectal cancer to get rid of any remaining cancer cells and reduce the chance of the cancer coming back. If your doctor recommends chemotherapy, you will probably start as soon as your wounds have healed and you've recovered your strength, usually within eight weeks.

On its own

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

You may have chemotherapy through a liquid drip into a vein (intravenously) or as tablets. It may also be given through a thin plastic tube called a central venous access device. Some people have chemotherapy at home through a portable bottle called an 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

People react to chemotherapy differently – some people have few side effects, while others have many. The side effects depend on the drugs used and the dose. Your medical oncologist or nurse will discuss the likely side effects with you, including how they can be prevented or controlled with medicine. It is uncommon to need a break or change in your treatment.

Common side effects include tiredness; feeling sick (nausea and vomiting); diarrhoea; mouth sores and ulcers; changes in appetite, taste and smell; sore hands and feet; and hair loss or thinning. You may also be more likely to catch infections.

Pins and needles, numbness, redness or swelling in the fingers and toes are more common if using the chemotherapy drug called oxaliplatin. Skin peeling and increased sensitivity to sunlight are more common if using the chemotherapy drug called fluorouracil (or 5-FU).

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. See Understanding Chemotherapy.

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 about treating early bowel cancer

Treatments for early colon cancer

  • The main treatment is surgery to remove part or all of the colon (colectomy).
  • There are different types of colectomies depending on where the cancer is located.
  • If cancer has spread from the colon to nearby lymph nodes, you may have chemotherapy after surgery.

Treatments for early rectal cancer

  • The main treatment is surgery to remove all or part of the rectum (resection).
  • There are different types of resections depending on where the cancer is located.
  • If cancer has spread from the rectum into nearby tissue or lymph nodes, you will usually have radiation therapy or chemoradiation before the surgery.
  • A local excision to remove the cancer may occasionally be used for very early stage rectal cancer.

How surgery is done

  • Surgery for bowel cancer may be done as keyhole surgery (several smaller cuts) using a tiny surgical instrument with a camera and light, or open surgery (one large cut).
  • During bowel surgery, the surgeon cuts the bowel on either side of the cancer and joins the two ends 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.

Expert content reviewers:

A/Prof Craig Lynch, Colorectal Surgeon, Peter MacCallum Cancer Centre, VIC; Prof Tim Price, Medical Oncologist, The Queen Elizabeth Hospital, Adelaide, and Clinical Professor, Faculty of Medicine, The University of Adelaide, SA; Department of Dietetics, Liverpool Hospital, NSW; Dr Hooi Ee, Gastroenterologist, Sir Charles Gairdner Hospital, WA; Dr Debra Furniss, Radiation Oncologist, Genesis CancerCare, QLD; Jocelyn Head, Consumer; Jackie Johnston, Palliative Care and Stomal Therapy Clinical Nurse Consultant, St Vincent's Private Hospital, NSW; Zeinah Keen, 13 11 20 Consultant, Cancer Council NSW; Dr Elizabeth Murphy, Head, Colorectal Surgical Unit, Lyell McEwin Hospital, SA.

Cancer Council Australia Colorectal Cancer Guidelines Working Party, Clinical practice guidelines for the prevention, early detection and management of colorectal cancer, Cancer Council Australia, Sydney, 2017. Available from: https://wiki.cancer.org.au/australia/Guidelines:Colorectal_cancer (accessed 22 August 2018).

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