Colorectal cancer - your condition and treatment - Leeds Teaching Hospitals NHS Trust

The purpose of this section is to provide information to people who are in any way affected by colorectal cancer. You could be a patient who has been recently diagnosed with colorectal cancer and wanting to find out more about the condition, or a relative who wants more information about bowel cancer.

This section has been designed to help you through the large amount of information on the internet about bowel cancer. We shall provide a short summary of each of the topics involved, and then a series of links to external resources. We hope that the information provided from this information is of use to you.

What to expect when visiting us

As a caring institution we do understand that it may be a stressful time for you and that it may at times require courage for you to attend our colorectal clinics. Our experienced staff at the colorectal department are all very friendly and will support you during your hospital visit, making it a positive experience.

On your arrival

On arrival you will be asked to sit in the waiting area. There may be a wait as clinics often do not run on time. A nurse will call your name and you will be taken to the examination room, where you will be given all the time you need to discuss your condition.

The attending doctor will ask you questions about your health and perform an examination (for example of your abdomen). He will then advise you to have some tests done if deemed necessary.

Routinely performed clinic tests

A lot of useful information can be obtained by performing rigid sigmoidoscopy. This procedure is aimed to get a good view of the lower end of the bowel. Though it can cause discomfort, it will help the doctor reach a diagnosis to help your condition. At times blood tests are also arranged to be performed during the same visit.

Other tests that may require a seperate visit

You may be asked to have one or more of the following additional procedures:

Colonoscopy – this procedure is done to assess the large bowel and help us explain the cause of your symptoms. It is carried out under sedation and a thin tube with an end camera is inserted through the back passage. Photographs and tissue biopsies (sent to the lab) are taken of relevant areas. It is usually a painless procedure.
Flexible Sigmoidoscopy – very similar to the colonoscopic examination but offers a more limited view of the bowel. Performed to assess left sided large bowel symptoms.
CT scan – uses the same technique as an ordinary x-ray but uses much more ‘photographs’ to build a more detailed image of the body.
MRI scan – Unlike x-rays, this imaging technique uses a magnetic field and radiowaves to image the body in finer details
PET scan – this form of imaging help to locate disease in the body by the use of a tracer (substance given at the time of the scan). It is mainly used for cancer diagnosis and treatment.
Ultrasound scan – quick and safe, this scanner uses sound waves to generate pictures on a screen that are representative of the relevant body parts.

What happens next

Once the results are available, you will be called back to the clinic to discuss your treatment options. The doctor will advise you about the treatment options and will help you make an informed choice. Depending on your condition, the following might happen:

You might not need to see us again, in which case your GP will be informed about the outcome via a letter.
We might need more information on your condition before offering any treatment, in which case we will need to see you again in clinic after you have had the recommended additional tests.
Surgery might have been recommended, in which case you will be directed to our pre-operative clinic to assess your fitness for surgery. Depending on your health status, you might need to be seen by an anaesthetist. He will advise you on the steps that need to be taken to make your surgery as safe as possible.

What is Colorectal Cancer?

The digestive system is a long tube extending from the mouth at one end to the anus (bottom) at the other end. The purpose of the digestive system is to break down food that is eaten so that energy and nutrients can be absorbed into the body. It also plays a role in absorption of water and the excretion of some waste products from the body.

The digestive system is divided into many parts along its length. Food which is taken into the mouth is chewed to help to break down the food. It is then swallowed and passes down the oesophagus to the stomach. In the stomach the food is broken down even more with the addition of digestive juices. After being in the stomach the food then passes into the small bowel where all the energy and nutrients are absorbed into the blood stream. Any non-absorbable contents of the small bowel pass into the large bowel. This is where water is absorbed into the body to make the contents of the bowel more solid. The solid contents are finally stored as a stool in the rectum until this is excreted out of the body through the anus when you go to the toilet.

The whole of the bowel is lined by epithelial cells which are a protective coating to the bowel wall. These cells are programmed to constantly replicate and produce new cells as old cells are eroded from the inner edge of the bowel. This replication is a very tightly regulated system, but sometimes damage to the regulation system can cause it to go wrong and cause more new cells to develop than are needed. If this happens then a small outgrowth will develop from the bowel wall, this is called a polyp.

Polyps in themselves are harmless and will not cause any problems. However if they continue to grow they have the potential to develop into a cancer. This means that if any are seen at a colonoscopy (a small camera passed up through your bottom into the bowel) then they will be removed.

If the polyp continues to grow then it can develop into a cancer. When this happens the cells are no longer acting as “normal” bowel cells but are replicating in an uncontrolled manner. Also, the cells develop the ability to invade into other tissue such as other structures nearby, or migrate to distant organs such as the liver or lungs. The cells become immortal and no longer die off and this is part of what makes treatment of cancer so difficult.

Symptoms of Colorectal Cancer

There are a number of symptoms that are suggestive of colorectal cancer. You may have only one or two of these symptoms but to rule out colorectal cancer they will all need to be investigated.

However, having these symptoms does not necessarily mean that you have colorectal cancer as a number of other conditions can present with similar symptoms.

Symptoms of Colorectal cancer

Change in bowel habit – this may mean that you are going to the toilet more or less frequently than usual, or that you have developed a bowel habit that varies from diarrhoea to constipation.

Blood in or around the stool – you may have noticed that there is blood in your stool or that your stool is darker than usual.

Pain in the abdomen.

Pain on opening your bowels.

A feeling of not having properly emptied the bowel after going to the toilet
Weight loss for no apparent reason.

Loss of appetite.

An increased feeling of tiredness and lethargy.

There are also indications from tests that your doctor has done such as:

Anaemia – this is where you have not got enough red blood cells in your blood, these are the cells that carry oxygen around the body. If you are anaemic it could be that you are bleeding from somewhere that is not noticeable.
Positive Faecal Occult Blood test (see below for details).

Many other non-cancerous conditions can also have these symptoms e.g:

Haemorrhoids (piles)
Irritable Bowel Syndrome
Ulcerative colitis
Crohn’s disease

Investigations

There are a number of different tests used in the diagnosis and treatment of bowel cancer. These are:

This is an examination of your back passage. This will involve the doctor inserting a lubricated, gloved finger into your back passage to assess the inside surface of your rectum. The examination is usually painless and can provide a lot of vital information to the doctor.

The test for faecal occult blood involves providing a stool sample to be tested in a laboratory. The sample is tested to see if there is any hidden blood in the stool. If you receive a positive faecal occult blood test then that means that somewhere in your bowel there may be some bleeding. The cause of this bleeding will then need to be investigated.

The inside of the rectum can be looked at by using a rigid sigmoidoscope. This is a rigid tube about 1cm in diameter. It is passed through the back passage with the aid of lubrication. The doctor can then look at the bowel wall and if appropriate can take a biopsy (tissue sample from the bowel wall).

A flexible sigmoidoscope is a flexible tube camera which can be passed into the bowel via the back passage to look at the inside of the lower portion of the large bowel. It is about the thickness of your index finger and there is a video camera which enables the person performing the test to see inside your bowel. It is usually carried out as an outpatient procedure, with an enema given beforehand to clear out stool from the lower part of the bowel to allow a thorough examination.

A colonoscopy is used to look at the inside of the whole of the large bowel. Similar to a flexible sigmoidoscopy, a flexible tube camera is passed through your bottom and into the bowel. The day before this test, in order to fully clean the bowel, you will need to drink special ‘bowel preparation’ drinks. It is still usually carried out as an outpatient procedure, but often requires a mild sedative and pain killer to be administered. For this reason you will need to be accompanied to the test and have someone to take you home and stay with you for 24 hours afterwards. An alternative to the sedation is ‘gas and air’, which has fewer restrictions for you afterwards. The options will be fully discussed with you by the staff from the Endosopy department.

If the person performing the flexible sigmoidoscopy or colonoscopy sees anything of note on the video screen then they are able to perform a number of procedures by passing instruments through the telescope. For example, they are able to take biopsies (small amounts of tissue for analysis under a microscope) or often can remove any polyps that are found.

A barium enema is a way in which an X-ray picture of the bowel can be obtained. It involves having an enema of barium liquid which shows up on an X-ray. This is inserted via a tube in your bottom whilst you are lying on your side, as well as air. During this procedure X-rays will be taken which will show the bowel in detail.

A CT scan is a method of looking at structures inside the body which uses X-rays to build a 3D picture. The scanner looks a bit like a giant doughnut or polo mint; you will have to lie on a narrow bed which will then pass through the scanner. All that you will need to do whist on the scanner is to lie still and follow any instructions given by the radiologist operating the scanner. It may be necessary to inject some contrast medium into a small needle in your arm or the back of your hand. This is to make certain structures inside the body show up better on the scan. In colorectal cancer it is particularly useful at looking for any spread of the cancer, as well as looking at the tumour itself.

There is also a specialised CT scan called a CT Colonography which looks at the large bowel and can be used in the elderly or those who are not fit enough to have a colonoscopy.

A MRI scan is another method of looking at structures inside the body. It can show different information to the CT scan due to the different way that it collects the information. The scanner is a long tube in which you will need to lie inside. It is open at both ends, however the scan can feel quite claustrophobic and a buzzer will be given to you for if you feel nervous at any time. When the scanner is running you may hear a loud knocking sound as the scanner goes round. It may be necessary to inject some contrast medium into a small needle in your arm or the back of your hand. MRI scans are particularly useful for looking at cancers in the rectum (back passage).

Treatment

There are a number of different treatment options for bowel cancer, depending on your circumstances. These are:

The aim of surgery for colorectal cancer is to cure the cancer by removing it from the body before it gets the chance to spread elsewhere.The operation is a major operation and will be done under a general anaesthetic. The surgeon will remove the part of the bowel that is cancerous and some of the tissue around it. This is to ensure that there is less chance of the cancer spreading.

The operation may be performed by keyhole surgery (laparoscopically) or may require a larger cut on the tummy (an ‘open’ operation).

Depending on the location of the cancer it may be necessary to create a stoma, either an ileostomy or colostomy. This can either be a permanent or temporary measure depending on the circumstances. If a stoma is required then your surgeon will discuss this with you beforehand.

A Stoma is where the bowel is passed through the abdominal wall to create an opening of the bowel through which faeces can pass out of the body and into a bag for disposal. This is created by the surgeon either as a temporary measure to rest and “defunction” the part of the bowel that has been operated to enable it to heal; or as a permanent fixture if it is not possible to make a join in the bowel, for a variety of reasons.

An Ileostomy is where the final part of the small bowel is brought to the surface. It may be an end ileostomy whereby the bowel finishes there or it may be a loop ileostomy where the bowel continues past the ileostomy to the large bowel.

A colostomy is where the large bowel is brought to the surface to form the stoma.

Having a stoma can take a large amount of getting used to as it is a major alteration of body image and as such you will receive support from the colorectal nurse specialist team both whilst in hospital and on discharge. You may also like to look at the following websites for more information.

Colostomy Association – A small charity concentrating on providing support to people with stomas.

The Ileostomy and Internal Pouch Support group – A network of support groups for people with ileostomies. It is a useful website to explore and to get in touch with other people about living with an ileostomy.

United Ostomy Associations of America – An American organisation with a large amount of information on living with a stoma.

NHS Choices: – Information on having an ileostomy.

NHS Choices: – Information on having a colostomy.

In certain circumstances it may be appropriate that chemotherapy is given. Chemotherapy is the collective term used for all cancer treating drugs. The type of chemotherapy that you will receive largely depends on the reason for chemotherapy. There are several reasons for giving chemotherapy:

Adjuvant chemotherapy – given after surgery in some cases, when the full classification of the cancer has been decided and you have recovered from the surgery. It is intended to remove all traces of the cancer from the body, reducing the chances of the cancer coming back in the future.
Neo-adjuvant chemotherapy – given in some circumstances before surgery to shrink the tumour and increase the chances of successful surgery.
Palliative chemotherapy – when the cancer cannot be cured by surgery chemotherapy may be given to control the cancer and possibly prolong life or to increase the quality of life remaining.

As there are many different types of regimes of chemotherapy in colorectal cancer we will not go into the full details here. Below are a number of websites that go into detail about the different types of chemotherapy available.

Leeds Cancer Centre – Cancer services at Leeds Teaching Hospitals.

Cancer Research UK – Information on chemotherapy for colorectal cancer from a UK charity involved in medical research.

Radiotherapy is the use of radiation to treat cancer. In colorectal cancer it is used in two ways for rectal (back passage) cancer.

Short-course radiotherapy – a week of radiotherapy just before surgery for rectal cancer to help reduce the chance of the cancer coming back.
Long-course radiotherapy – usually combined with chemotherapy, prior to surgery for more advanced rectal cancers to hopefully shrink the cancer and increase the chances of successful surgery.

For more information on Radiotherapy please look at the Leeds Cancer Centre.

In certain circumstance it is no longer appropriate to continue active treatment of the cancer. This is at times when it has become clear that treating the cancer will cause more pain and suffering than not treating the cancer and where it is not possible to cure the cancer. In these circumstances it may become appropriate to plan for dying.

Palliative care is the medical specialty which looks after patients in the final stages of their illness. They are particularly expert at dealing with any symptoms that the cancer may be causing. They are also specially trained to explore with you your attitudes and beliefs with regards to death. They will help you with your wishes concerning your death.

Leeds Cancer Services Palliative Care – Information on Palliative care at Leeds Teaching Hospitals.

St Gemma’s Hospice – Information on a hospice in Leeds providing palliative care.

Marie Curie – A national Charity providing support to people dying of cancer and their relatives.

Colorectal cancer – your condition and treatment