There is no denying it, for even the most positive of people, being diagnosed with bowel cancer will come as a terrible shock. Many bowel cancer patients describe everything being ‘a bit of a blur’ after they are told.

This chart shows a typical ‘patient pathway’. This is just a guide and may vary from patient to patient. If you have recently been diagnosed with bowel cancer, the next step will be to determine the stage of the disease and to agree your treatment plan. Just as everyone is different, so the treatment given to them will be the best possible for their individual circumstances. Your specialist will discuss the options open to you, including when and where treatment will take place, the process you will go through, what drugs will be available for your treatment if required, and who will be treating you at every stage.

Prevention

While no cancer is completely preventable, you can lower your risk of bowel cancer by eating a healthy diet and exercising regularly.

Enjoy a wide variety of nutritious foods -

• eat plenty of vegetables, legumes (dried beans, peas or lentils), fruits & cereals (breads, rice, pasta & noodles), preferably wholegrain.
• include lean meat, fish and poultry.
• include milks, yoghurts and cheeses.  Reduced fat varieties should be chosen where possible.
• drink plenty of water.

Take care to -

• limit saturated fat and moderate total fat intake.
• choose foods low in salt.
• limit your alcohol intake if you choose to drink.
• consume only moderate amounts of sugars and foods containing added sugars.

And -

• quit smoking.

 

 

Eating for protection

There is growing evidence that increasing fruit, vegetables and fibre in your diet can reduce the risk of some cancers.

Most Australians eat only half the amount of fruit and vegetables recommended for good health.  Health authorities recommend you eat at least 2 serves of fruit and 5 serves of vegetables every day.

To find out more, visit the Go for 2&5 website.

 

 

2 serves of fruit & 5 serves of vegetables – every day

Why are fruit and vegetables protective?

The reason why fruit and vegetables have so many benefits is that they contain a wide variety of substances known to have health benefits including carotenoids, vitamin C, vitamin E and dietary fibre.  They also contain many complex plant components - phytochemicals - such as flavonoids. Some of the vitamins and phytochemicals are also antioxidants, destroying harmful free radicals in the body.

The benefits of fruit and vegetables stem not only from the rich cocktail of individual components, but also the interactions between these components. This is why dietary supplements containing isolated vitamins or minerals do not appear to have the same beneficial effects as fruit and vegetables themselves.

How do fruit and vegetables fit into a healthy diet?

Health authorities recommend that consumers eat a varied, balanced diet low in fat, salt and added sugars.  This means a diet which contains plenty of fruit, vegetables and starchy foods such as rice, pasta and potatoes, moderate amounts of milk and dairy foods and meat and alternatives, and only small amounts of foods which contain a lot of fat or added sugars or salt.  This should provide all the nutrients that most people require.

How much is 1 serve of fruit?

One serve of fruit (150 grams) is, for example, 1 medium-sized apple, or 2 small apricots, or 1 cup canned or chopped fruit, or ½ cup (125mL) 100% fruit juice, or 4 dried apricot halves.

A glass of 100% fruit juice only counts once a day, irrespective of how much you drink.  One serve of dried fruit counts, but other types of fruit and vegetables should be eaten to meet the rest of the five-a-day target.


How much is 1 serve of vegetables?

One serve of vegetables (75 grams) is, for example, 1 medium potato, or 1 cup salad vegetables, or ½ cup of cooked vegetables, ½ cup cooked legumes (dried beans, peas or lentils).

Beans and other pulse vegetables, such as kidney beans, lentils and chick peas only count once a day, however much you eat.


Can't I just get the same benefits from supplements?

No.  Dietary supplements do not have the same benefits as eating more fruit and vegetables, as fruit and vegetables contain additional beneficial substances, such as fibre.  Some people are advised to take a supplement, in addition to eating a varied, balanced diet. 


Does it matter if I eat the same fruit and veg every day?

Different fruits and vegetables contain different combinations of fibre, vitamins, minerals and other nutrients.  So you should aim to include a variety of fruit and vegetables to get the most benefit.

Pulses contain fibre, but they don't give the same mixture of vitamins, minerals and other nutrients as fruit and vegetables.  So in order to get a healthy balance, it is important to ensure that you get a variety of fruit and vegetables.

 

 

Fibre

A high fibre diet is particularly recognised for reducing the risk of constipation, irritable bowel syndrome and for helping combat bowel cancer.


What is fibre?

Fibre is indigestible plant material such as cellulose, lignin and pectin, found in fruits, vegetables, grains and beans.  There are two types of fibre – soluble and insoluble.

The soluble fibre in foods such as apples, citrus fruits, oats, dried peas, beans and lentils, dissolves in water, forming a thick gel in your stomach, slowing the rate of digestion and absorption.  In moderation, these fibres feed the intestinal bacteria and nourish the cells of the large intestine, which is believed to stimulate healing and reduce the development of cancer.

Insoluble fibre from foods such as wheat bran, whole grains and some vegetables does not feed bacteria well.  However, it is believed to deactivate intestinal toxins and a high intake may decrease the risk of bowel cancer.

Fibre provides bulk to your food, helps it pass easily through the gut, and retains water so it makes you feel full and eat less.


How much fibre is enough?

Reports suggest you should be eating 30g of fibre each day, yet most of us probably eat around 10-12g.  A banana contains 1.8g of fibre, as does 1 slice of wholemeal bread.


How do you build fibre into your diet?

• Replace lower fibre foods with high fibre foods.
• Eat vegetables and fruit raw, whenever possible.  Boiling too long can cause up to one half of the fibre to be lost in the water.  Steam or stir-fry them, if you cook them.
• Replace fruit or vegetable juice with the whole fruit – fruit skins and membranes are a particularly good source of fibre.
• Always start your day with a bowl of high-fibre cereal – one that has five or more grams per serving
• Add fresh fruit to your cereal for an extra fibre dose.  Sprinkle wheat germ or bran on top of cold cereals.  Mix wheat germ or bran with hot cereals while they are cooking.
• Add bran cereal to muffins, breads and casseroles.
• Buy and eat only whole grains.

Eating more fibre

Try substituting the lower fibre foods in your diet for the high fibre alternatives to the left.

HIGHER FIBRE FOODS	LOWER FIBRE FOODS
Whole grain breads – e.g., 100% whole wheat, cracked wheat, multigrain, pumpernickel or dark rye	White bread
Whole grain cereals containing bran, oatmeal, barley, bulgar, cracked wheat; also shredded wheat, multigrain or granola cereals	Refined cereals
Foods made with whole grain flours – e.g., whole wheat, rye, graham (e.g. biscuits, muffins, cookies)	Foods made with white flour
Whole grain pastas, brown rice or wild rice	Refined pastas, instant or polished rice
Fresh fruits and vegetables (especially if eaten with the skin and membranes when appropriate)	Fruit juice
Salads made from a variety of raw vegetables	Plain lettuce salads
Baked beans, cooked lentils and split peas	Meat, fish, poultry
Nuts, popcorn, seeds, dried fruit	Crisps and similar snacks

 

 

Dietary Guidelines for Australian Adults

The National Health & Medical Research Council's Dietary Guidelines for Australian Adults are based on the best available scientific evidence and provide information for health professionals and the general population about healthy food choices.

The use of the guidelines will encourage healthy lifestyles that will minimise the risk of the development of diet-related diseases within the Australian population.

Click here to view the dietary guidelines which highlight the groups of foods and lifestyle patterns that promote good nutrition and health.

 

 

Exercising for Protection

It is recommended that to help reduce the risk of cancer, you should aim to engage in physical activity of at least moderate intensity, for approximately 30 minutes three times a week.

It is also evident that being obese can significantly increase your chances of developing bowel cancer.  1 in 2 Australian adults is overweight.  Irrespective of your height or build, if your waistline is getting bigger it could mean you are at increased risk of chronic diseases.

To find out more, visit the How do you measure up? website

There are tremendous benefits to getting even a small amount of physical activity each day, both mentally and physically.  Being active gives you more energy, helps you sleep better, reduces the risk of depression and can help to prevent a range of chronic diseases.

You don’t have to exercise to the point of collapse in order to get health benefits.  Start out by making small changes, and as you get used to them, gradually add more changes or activities.  Aim to build up to 30 minutes (or more) of moderate-intensity physical activity every day.

A good example of moderate-intensity activity is brisk walking; that is, at a pace where you are able to talk comfortably, but not sing.

If you’re worried you don’t have the time, keep in mind that you don’t have to do it all at once – you can accumulate your 30 minutes or more of moderate-intensity activity by combining a few shorter sessions of about 10 to 15 minutes each throughout the day. Research has shown that accumulated short bouts of moderate-intensity activity are just as effective at improving health factors such as blood pressure and blood cholesterol.

Getting motivated and keeping momentum

• Schedule at least three 30-minute exercise sessions as part of your weekly activities - don't let anything else take priority.
• Use exercise as a stress management technique - walk to clear your head and help you make decisions about work and home.
• Exercise with a friend or family member.  It’s sometimes easier when you have someone else encouraging you, and is easier to keep the "exercise habit" going because you've made a commitment.
• Be a role model for your kids.  Involving children in your physical activity regime is a great way to instil healthy habits and prevent childhood obesity.
• Track your progress by keeping an exercise log and recording your weekly activity.
• Motivate yourself by remembering how good you feel after you've completed a workout and how good you feel knowing that you are taking care of yourself.

The 30-Minute Exercise Guide

Exercising doesn’t have to mean expensive gym membership and treadmills, alternatives can include -

• Washing your car
• Washing windows or floors
• Vacuuming
• Walking or jogging to work
• Walking the dog
• Running up and down stairs
• Cycling with the kids
• Swimming or water aerobics
• Aerobics or keep fit classes

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Bowel Cancer Screening

Screening involves a test for bowel cancer in people who do not have any obvious symptoms of the disease.  The aim is to find any polyps or to find cancer early when they are easier to treat and cure.

Bowel cancer can develop without any early warning signs. The cancer can grow on the inside wall of the bowel for several years before spreading to other parts of the body. Often very small amount of blood leak from these growth and pass into the bowel motion before any symptoms are noticed.

A test called a Faecal Occult Blood Test (FOBT) can detect these small amounts of blood in your bowel motion. The FOBT looks for blood in your bowel motion, but not for bowel cancer itself.

The FOBT is a simple test that you can do at home. It involves placing small samples of stool on special cards and sending them to a pathology laboratory for analysis. The results are then sent back to you and your doctor.

Faecal Occult Blood Test (FOBT) kit to check for blood in stool.
Image courtesy of the National Cancer Institute.

Your FOBT result is negative if no blood is found in your samples and it is recommended that you repeat a FOBT at least every two years.  However, this does not mean that you do not have, or can never develop, bowel cancer, since some bowel cancers do not bleed or only bleed on and off.

In between times, if you develop any symptoms of bowel cancer, see your doctor immediately.

Your FOBT result is positive if blood is present in your samples.  If blood is detected, you should contact your doctor immediately to discuss the result.  The presence of blood may be due to conditions other than cancer, such as polyps, haemorrhoids, or inflammation of the bowel, but the cause of bleeding needs to be investigated.

There are currently two types of FOBT available.  One type, called guaiac FOBT, uses the chemical guaiac to detect heme in the stool.  Heme is the iron-containing component of the blood protein haemoglobin.  

The other type of FOBT, called immunochemical FOBT, uses antibodies to detect human haemoglobin protein in the stool.

Studies have shown that FOBT, when performed every 1 to 2 years in people aged 50+, can help reduce the number of deaths due to bowel cancer by 15 to 33 percent.

The immunochemical FOBT has been selected as the preferred testing method for the National Bowel Cancer Screening Program, in contrast to the guaiac FOBT, as it has no restrictions on diet or medication.

We encourage all Australians who are aged 50 and over, who do not have symptoms
or a family history of bowel cancer, to undertake bowel cancer screening.

 

 

BowelScreen Australia^TM

BowelScreen Australia^TM is a pharmacy-based bowel cancer awareness, education and screening program for the Australian community using a clinically proven, sensitive and reliable immunochemical faecal occult blood test. 

BowelScreen Australia^TM is a collaboration between Bowel Cancer Australia and the Pharmacy Guild of Australia, with the support of Enterix Australia (manufacturer and accredited pathology laboratory for the InSure^® immunochemical test).

BowelScreen Australia^TM recommends annual bowel cancer screening for Average Risk Patients. These include men and women 50 years and over; with no symptoms; and with no personal or family history of bowel cancer or polyps.

Click here to visit the BowelScreen Australia^TM website to locate your nearest participating pharmacy or request a kit below from Bowel Cancer Australia. 

                                                                                                             

 

 

Request a Kit

Screening involves a test for bowel cancer in people who do not have any obvious symptoms of the disease.  The aim is to find any polyps or to find cancer early when they are easier to treat and cure.

We encourage Australians to participate in appropriate screening for bowel cancer.  Bowel Cancer Australia distributes kits upon request.

 

 

 

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Bowel Cancer Screening Pathway

We encourage Australians to participate in appropriate screening for bowel cancer.  The pathway below sets out your bowel cancer screening options.

 

 

Family History

Most people who develop bowel cancer have no family history of bowel cancer.  However, people with a history of bowel cancer or in one or more first degree relatives (parents, siblings, children) are at an increased risk.

This risk is increased even further in people with a history of bowel cancer in:

• one or more first degree relatives (parents, siblings, children) younger than age 55
• two or more first degree relatives (parents, siblings, children) at any age

Do you know if anyone in your family has had bowel cancer?  Talk to your family and make sure you all know your family history.

Genetic inheritance

In addition to families where bowel cancer “runs in the family”, there are also people who have an inherited, genetic susceptibility to bowel cancer. The two most common inherited syndromes linked with bowel cancers are:

Familial adenomatous polyposis (FAP)

FAP is an inherited condition which affects the large bowel.  It is a serious condition unless it is detected early when it can be treated.  People with FAP develop hundreds of polyps (which are like small cherries on stalks) inside their large bowel.  There are different types of polyps but these particular polyps are called adenomas, which in time, will almost certainly turn into cancer (usually by the age of 50).  This is why it is so important to make sure anyone at risk of inheriting FAP is examined by a specialist.  Appropriate treatment can be undertaken early as a preventative measure before bowel cancer can develop.

Hereditary non-polyposis colorectal cancer (HNPCC)

HNPCC (also known as Lynch syndrome) pre-disposes people due to a mutation in certain genes, to bowel cancer as well as a number of other cancers.

Each person inherits genes from both their parents.  HNPCC is caused by a fault in one of the genes known as the ‘mismatch repair’ genes.  Someone who inherits HNPCC from their parents has a normal gene and a ‘faulty’ gene, which increases their risk of developing bowel cancer and other types of cancer.

HNPCC accounts for 1-5% of bowel cancers and the criteria for identifying families at risk of having HNPCC are:

• Three or more relatives with confirmed bowel or other HNPCC related cancer (endometrial, ovarian, some urinary), one being a first degree relative (parent, child or sibling) of the other two.
• At least two consecutive generations affected.
• At least one bowel or related cancer diagnosed before the age of 50.

Think you have a strong family history of bowel cancer?

If you think that you have a strong family history of bowel cancer, you should make an appointment with your doctor to talk about your concerns. If your doctor agrees with you, they will refer you to a specialist genetics service. The genetic specialist will go through your family history with you in great detail and ask you to provide accurate information about who has been affected, how old they were when they were diagnosed, and the site where their cancer developed. You may also have to have blood tests as part of this investigation.

If the genetic specialist agrees you are at increased risk, you will be referred to a bowel specialist to talk about what types of screening and/or surveillance they would recommend, at what age you (and/or other family members) should commence screening and/or surveillance and how often. Regular screening and/or surveillance will ensure that any signs of bowel cancer are picked at the earliest possible stage.

 

 

National Bowel Cancer Screening Program

The National Bowel Cancer Screening Program is being phased in over a number of years by the Australian Government.

Free bowel cancer screening tests are being offered to Australians turning 50, 55 or 65 between 1 January 2008 and 31 December 2010.

People eligible to participate in the Program will receive an invitation through the mail to complete a simple test called a Faecal Occult Blood Test (FOBT) in the privacy of their home and mail it to a laboratory for analysis.

The immunochemical FOBT has been selected as the preferred testing method for the National Bowel Cancer Screening Program, in contrast to the guaiac FOBT, as it has no restrictions on diet or medication.  The type of immunochemical FOBT being used in the Program is called Detect™ (Siemens Medical), but is not available for purchase by the public.

The test looks for blood in bowel motions, which may be a sign of bowel cancer.

These screening tests have been shown in overseas clinical trials and in the Bowel Cancer Screening Pilot Program to be simple to use and highly effective.

Participants with a positive FOBT will be advised to discuss the result with their doctor, who will generally refer them for further investigations, usually a colonoscopy.

For more information visit the National Bowel Cancer Screening Program or the It’s Crunch Time websites.

Please see below, as you may be eligible to participate in the Program and receive a free bowel cancer screening test kit.

• If you are turning 50, 55 or 65 before 31 December 2010, you are eligible to receive a free bowel cancer screening test kit from the Australian Government’s National Bowel Cancer Screening Program.  The test should arrive in the mail around the time of your birthday.  If not, contact the Program on
  1300 738 365.
• If you turned 50, 55 or 65 after 1 January 2008 and you have not received or would like to request a replacement free bowel cancer screening test kit, contact the Program on 1300 738 365.
• If you turned 55 or 65 after 1 May 2006 and you have not received or would like to request a replacement free bowel cancer screening test kit, contact the Program on 1300 738 365.
  
• If you are not yet eligible to receive a free bowel cancer screening test, see above to request a BowelScreen Australia^TM test kit.

 

 

Symptoms

Possible signs of bowel cancer include a change in bowel habit or blood in the stool.

In its early stages, bowel cancer often has no symptoms.  This is why it is important to screen. Like most diseases, bowel cancer can often cause symptoms which are similar to other unrelated conditions.

If you experience any of the following symptoms, you should consult your doctor.

Symptoms can include:

• A recent, persistent change in bowel habit to looser, more diarrhoea-like motions, going to the toilet more often, or trying to go (ie. irregularity in someone whose bowels have previously been regular)
• Blood (either bright red or very dark) in the stool
• Diarrhoea, constipation, or feeling that the bowel does not empty completely
• Frequent gas pains, bloating, fullness or cramps
• Stools that are narrower than usual
• A lump or mass in your tummy
• Weight loss for no known reason
• Persistent, severe abdominal pain, which has come on recently for the first time (especially in an older age group)
• Feeling very tired
• Vomiting

If you have any of these symptoms, it does not mean that you have bowel cancer, but it is very important you discuss them with your doctor.

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Positive FOBT

Your FOBT result is positive if blood is present in your stool samples.  If blood is detected, you should discuss the result with your doctor, who will generally refer you for further investigations, usually a colonoscopy.

The presence of blood may be due to conditions other than cancer, such as polyps, haemorrhoids, or inflammation of the bowel, but the cause of bleeding needs to be investigated.

 

Visiting Your Doctor

If you have been experiencing any bowel cancer symptoms, or received a positive FOBT result, you should make an appointment to see your doctor.

Don’t be embarrassed or scared.  Your doctor is used to talking about all sorts of conditions every day and will have heard it all before.

It is better to visit your doctor early and be reassured and treated than to hope symptoms will disappear or get better without treatment.  A visit to your doctor could save your life!

The more information you can give to your doctor about your bowel habits, the easier it will be for them to make an accurate diagnosis – so don’t be shy.

Before you go to the GP

Write a symptom diary recording the symptoms you have been experiencing, and for how long.  It may also be worth printing this page, considering your answers to the below questions and take it with you to your appointment.

At the doctor’s surgery

Below is a list of routine questions which your doctor should ask to establish a diagnosis for your symptoms.

• Have you had a recent, persistent change in bowel habit to looser, more diarrhoea-like motions, going to the toilet more or trying to go?
• If you haven’t had a change of bowel habit but have bleeding from the bottom, have you any other symptoms like straining, soreness, pain and itchiness? (If the answer to this is yes, it may be that you have piles but it’s still important for you to get this confirmed by your GP).
• Have you got any history of bowel cancer in the family?
• Have you experienced any abdominal pain?
• Have you lost weight or become more tired recently?

Your doctor should also ask you additional questions on:

• your lifestyle and diet (to determine any other possible risk factors)
• your past medical history
• current medications (including pain killers, indigestion remedies, antibiotics and laxatives)

Examinations/investigations

In addition to asking questions about your symptoms, your doctor should undertake a rectal examination which is a painless examination with a gloved finger to feel for any suspicious lumps in the bottom or rectum.

If your doctor does not examine you, you should ask why they have chosen not to.

Your doctor may also choose to undertake a blood test to see if you have anaemia or anything else that may help with a diagnosis.

What next?

If your doctor can confidently rule out piles (following a rectal examination) and you are experiencing symptoms, you should be referred to your local hospital for further investigations.

Being referred to the hospital

Most people referred for further investigation will not turn out to have bowel cancer but it should be ruled out by further investigations.

• REMEMBER: However old you are, you should never be told by your doctor that you are too young to have bowel cancer.  Whilst bowel cancer is more common in the 50 years + age group, bowel cancer increasingly affects all age groups.

  If you have higher-risk symptoms, do not accept ‘you’re too young to have bowel cancer’ as an explanation for your symptoms – ask your doctor to be referred for further investigations.

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Being Referred For Investigations

If your doctor suggests that you are referred for further investigations, this does not mean you have bowel cancer.  It means that further tests are needed to clarify what is causing your symptoms. 

If you have several higher-risk symptoms which could be suspected bowel cancer, you should receive an urgent referral and be seen within two weeks.  If symptoms are not considered higher-risk, you will receive a routine referral.  The waiting list for routine referrals varies around Australia.

Further investigations will usually take place at a clinic in your local hospital.  The specialist will ask you questions about your symptoms (similar to questions asked by your doctor), your general health and other medical conditions you might have. 

You will sometimes be given the results from investigative tests immediately, or you will be called back to the hospital at a later date to receive the results.  If the tests for bowel cancer are negative, you may be diagnosed with another common gastrointestinal condition and given appropriate treatment.

If you test positively for bowel cancer, you will meet with a specialist who will put together your treatment plan.

The following investigations are used in the diagnosis of bowel cancer:

 

Barium Enema

This is a special x-ray examination and will be done in the x-ray department.  A liquid that contains barium (a silver-white metallic compound) is put into the rectum.  The barium coats the lower gastrointestinal tract and x-rays are taken.  Any abnormal areas show up as black against the white liquid.

Barium enema procedure. The patient lies on an x-ray table. Barium liquid is put into the rectum and flows through the colon. X-rays are taken to look for abnormal areas.
Image courtesy of the National Cancer Institute.

 

 

Sigmoidoscopy

A procedure to look inside the rectum and sigmoid (lower) colon (the first 60cm of the bowel) for polyps, abnormal areas, or cancer.  A sigmoidoscope is inserted through the rectum into the sigmoid colon.  

A sigmoidoscope is a thin, tube-like instrument with a light and a lens for viewing.  It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer.

Sigmoidoscopy. A thin, lighted tube is inserted through the anus and rectum and into the lower part of the colon to look for abnormal areas.
Image courtesy of the National Cancer Institute.

 

 

Colonoscopy

A procedure to look inside the rectum and colon for polyps, abnormal areas, or cancer.  A colonoscope (a thin, lighted tube) is inserted through the rectum into the colon.

You will need to empty your bowel completely before this procedure so you will be asked to stop eating some time the day before (liquids are allowed) and to take a bowel preparation.

A colonoscopy will take around an hour and you will be given sedation to help you relax.  This may sometimes mean you are completely unaware of the procedure but even if you are still awake, it should not be painful.  Because of the sedation, you should arrange for someone to collect you and take you home.

Polyps or tissue samples may be taken for biopsy during a colonoscopy.  Polyps can also be removed by a procedure known as polypectomy.

Colonoscopy.  A thin, lighted tube is inserted through the anus and rectum and into the colon to look for abnormal areas.
Image courtesy of the National Cancer Institute.

 

 

Virtual Colonoscopy

Virtual colonoscopy (also called CT colonography or a computerised tomography colonography) is a new method that allows doctors to look at the large bowel (colon) to detect polyps and signs of cancer.

The CT scanner uses x-rays to produce two-dimensional and three-dimensional images of the whole of the colon and rectum.  If the detailed images shows polyps and anything else that seems unusual on the inside surface of the colon and your doctor wishes to perform a biopsy, you will need to have a normal colonoscopy.

 

 

MRI

An MRI (Magnetic resonance imaging) scan uses magnetism to build up cross-sectional pictures of your body.  Before the scan, you may be given an injection of dye into a vein in the arm, to improve the image.

The scan takes about 30 minutes, during which time you will lie inside a chamber which is often long and narrow.  This can feel claustrophobic so talk to the doctor or nurse if you are feeling scared.

People who have heart monitors, pacemakers or certain types of surgical clips cannot have an MRI because of the magnetic fields.

 

 

Advantages & Disadvantages

The following table outlines some of the advantages and disadvantages, including potential harms, of the bowel cancer screening tests and investigations.

Test / Investigation	Advantages	Disadvantages
Digital Rectal Exam	Often part of a routine physical examination. No cleansing of the colon is necessary. The test is usually quick and painless.	The test can detect abnormalities only in the lower part of the rectum. Additional procedures are necessary if the test indicates an abnormality.
Faecal Occult Blood Test (FOBT)	No cleansing of the colon is necessary. Samples can be collected at home. The cost is low compared with other colorectal cancer screening tests. FOBT does not cause bleeding or tearing/perforation of the lining of the colon.	This test fails to detect most polyps and some cancers. False-positive results (the test suggests an abnormality when none is present) are possible. Dietary restrictions and changes, such as avoiding meat, certain vegetables, vitamin C, iron supplements, and aspirin, and increasing fibre consumption, are often recommended for several days before a guaiac FOBT. These restrictions and changes are not required for immunochemical FOBT. Additional procedures, such as colonoscopy, may be necessary if the test indicates an abnormality.
Barium Enema	This test usually allows the doctor to view the rectum and the entire colon. Complications are rare. No sedation is necessary.	The test may not detect some small polyps and cancers. Thorough cleansing of the colon is necessary before the test. False-positive results are possible. The doctor cannot perform a biopsy or remove polyps during the test. Additional procedures are necessary if the test indicates an abnormality.
Sigmoidoscopy	The test is usually quick, with few complications. For most patients, discomfort is minimal. In some cases, the doctor may be able to perform a biopsy (the removal of tissue for examination under a microscope by a pathologist) and remove polyps during the test, if necessary. Less extensive cleansing of the colon is necessary with this test than for a colonoscopy.	This test allows the doctor to view only the rectum and the lower part of the colon.  Any polyps in the upper part of the colon will be missed. There is a very small risk of bleeding or tearing/ perforation of the lining of the colon. Additional procedures, such as colonoscopy, may be necessary if the test indicates an abnormality.
Colonoscopy	This test allows the doctor to view the rectum and the entire colon. The doctor can perform a biopsy and remove polyps or other abnormal tissue during the test, if necessary.	This test may not detect all small polyps, non-polypoid lesions, and cancers, but it is one of the most sensitive tests currently available. Thorough cleansing of the colon is necessary before this test. Some form of sedation is used in most cases. Although uncommon, complications such as bleeding and/or tearing/perforation of the lining of the colon can occur.
Virtual Colonoscopy	This test allows the doctor to view the rectum and the entire colon. This is not an invasive procedure, so there is no risk of bleeding or tearing/perforation of the lining of the colon.	This test may not detect all small polyps, non-polypoid lesions, and cancers. Thorough cleansing of the colon is necessary before the test. If a polyp or non-polypoid lesion 6 to 9 millimetres in size or larger is detected, standard colonoscopy, usually immediately after the virtual procedure, will be recommended to remove the polyp or lesion or perform a biopsy.

Information courtesy of the National Cancer Institute.
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A Bowel Cancer Diagnosis

There’s no denying it, for even the most positive of people, being diagnosed with cancer will come as a terrible shock. Many bowel cancer patients describe everything being ‘a bit of a blur’ after they are told.  If possible, it is important not to make too many decisions about what happens next, in your initial diagnosis session.

First, you’ll need to let the news sink in, and seek support from friends and family.

As the news does sink in and you are ready to move onto considering treatment options, the most important thing to remember is that it is your body you are discussing.  Certainly, your medical team are the experts in the disease but it is your life, your illness, your body.

Don’t be rushed into making decisions before you’ve had a chance to consider them and don’t be frightened to ask about things you don’t understand.  Be confident to ask about the choices available to you, and seek a second opinion to gain more information before making any decision. 

So, when you’re ready, here’s a guide to what you can expect to happen next.

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Bowel Cancer Staging

If you are diagnosed with bowel cancer, you will firstly need to have tests to determine the size of the cancer tumour, its position and whether it has spread.  This process is known as ‘staging’.

Your doctor needs to know the extent (stage) of the disease to plan the best treatment.  The stage is based on whether the tumour has invaded nearby tissues, whether the cancer has spread and, if so, to what parts of the body.

Your doctors may order some of the following tests:

• Blood tests: Your doctor checks for carcinoembryonic antigen (CEA) and other substances in the blood.  Some people who have bowel cancer or other conditions have a high CEA level.  You may also have blood test that measures chemicals that are normally found in your liver, known as a Liver Function Test. An abnormal result can be a sign the cancer has spread to the liver.
• Colonoscopy: If colonoscopy was not performed for diagnosis, your doctor checks for abnormal areas along the entire length of the colon and rectum with a colonoscope.
• Endorectal ultrasound: An ultrasound probe is inserted into your rectum.  The probe sends out sound waves that people cannot hear.  The waves bounce off your rectum and nearby tissues, and a computer uses the echoes to create a picture.  The picture may show how deep a rectal tumour has grown or whether the cancer has spread to lymph nodes or other nearby tissues.
• Chest x-ray: X-rays of your chest may show whether cancer has spread to your lungs.
• CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of areas inside your body. You may receive an injection of dye.  A CT scan may show whether cancer has spread to the liver, lungs, or other organs.

Your doctor may also use other tests (such as MRI) to see whether the cancer has spread. Sometimes staging is not complete until after surgery to remove the tumour.

In Australia, the staging system for bowel cancer is the Australian ClinicoPathological Staging (ACPS) system.

As bowel cancer progresses from Stage AO to Stage D, the cancer cells grow through the layers of the colon wall and spread to lymph nodes and other organs. 
Images courtesy of the National Cancer Institute.

Stage A0 (Carcinoma in Situ)
In stage A0, the cancer is found only in the innermost lining of the bowel.  Stage A0 cancer is also called carcinoma in situ.

Stage A
In stage A, the cancer has spread beyond the innermost tissue layer of the bowel but is confined to the inside of the bowel wall.

Stage B
In stage B, the cancer has spread to the outer surface of the bowel wall.  

Stage C
In stage C, the cancer is found in the lymph nodes in the area of the bowel.

Stage D (also known as metastatic bowel cancer)
In stage D, the cancer has spread from where it started in the colon or rectum, to other organs, especially the liver or lungs.

Recurrence
This is cancer that has been treated and has returned after a period of time. The disease may return in the colon or rectum, or in another part of the body.

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Lab Tests Online

 

During your journey, you may wish to find out more about the types of pathology tests being performed. You can find out about a range of tests at www.labtestsonline.org.au which can help explain what is being tested and why.

Having the right information and an understanding of what is happening can help you play an active part in your health care, and help you better understand your treatment and medication.

The website is commercially independent and has been developed by the Australasian Association of Clinical Biochemists with support from the Royal College of Pathologists of Australasia and has received development funding from the Australian Government.

Please note: the information contained on www.labtestsonline.org.au is not to be regarded as a substitute for medical advice from your GP or specialist.

 

 

Prognosis

Prognosis means the expected course of the disease and a patient’s chance of recovery.

The earlier bowel cancer is detected, diagnosed and treated, the better the likely prognosis. However, when bowel cancer has spread to other organs, such as the liver or lungs, many treatments can help, but a cure is more difficult.

Survival statistics have shown that 88% of people with Stage A bowel cancer; 70% of people with Stage B bowel cancer; 43% of people with Stage C bowel cancer; and 7% of people with Stage D or metastatic bowel cancer will be alive five years after their diagnosis.

Overall, around 60% of people who have had their bowel cancer successfully removed are alive five years after their diagnosis.

These survival statistics represent the average number of people alive five years after their diagnosis and do not represent a single persons’ chance of survival.  Talk to your specialist about your prognosis as many factors can influence your situation.

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Putting Together Your Treatment Plan

Shortly after diagnosis and these further tests, you will discuss with your specialist the options open to you, including when and where treatment will take place, the process you will go through, what drugs will be available for your treatment, if required, and who will be treating you at each stage.

The specialist will put together a treatment plan with you.  This is developed depending on a number of factors such as:

• the type and size of the cancer
• what stage the cancer is at
• your personal health condition and age

It is very important to discuss with your doctors the advantages and disadvantages of what is being suggested so that your individual needs may be fully considered.  You may want to know the possible effects of treatments on your fertility or sexual function.  If you are told you will need a colostomy or ileostomy you should be able to discuss this fully before surgery and have an indication of whether it may be reversible.  

Many people with bowel cancer want to take an active part in making decisions about their medical care.  It is natural to want to learn all you can about your disease and treatment choices. However, shock and stress after the diagnosis can make it hard to think of everything you want to ask your doctor.  It often helps to make a list of questions before an appointment.

To help remember what your doctor says, you may take notes.  You may also want to have a family member or friend with you when you talk to your doctor -- to take part in the discussion, to take notes, or just to listen.

You do not need to ask all your questions at once.  You will have other chances to ask your doctor or nurse to explain things that are not clear and to ask for more details.

Your doctor may refer you to a specialist who has experience treating bowel cancer, or you may ask for a referral. 

Health professionals who treat bowel cancer include –

• Gastroenterologists (doctors who specialise in diseases of the digestive system and colonoscopy)
• Surgeons (colorectal surgeons or general surgeons who specialise in bowel cancer)
• Medical oncologists (responsible for chemotherapy)
• Radiation oncologists (responsible for radiotherapy)
• Dietitians (who recommend best eating plans to follow while you are in treatment and recover)
• Cancer Care Coordinators (who facilitate the continuity and quality of your care and support you and your family throughout your treatment)

If these health professionals work together to plan your treatment, they become known as your multidisciplinary care team.

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Treatment for Colon Cancer

Most patients with colon cancer are treated with surgery.  Some people have both surgery and chemotherapy.  Some with advanced disease receive biological therapy.

A colostomy is seldom needed for people with colon cancer.

Although radiation therapy is rarely used to treat colon cancer, sometimes it is used to relieve pain and other symptoms.

 

 

Treatment for Rectal Cancer

For all stages of rectal cancer, surgery is the most common treatment.  Some patients receive surgery, radiation therapy, and chemotherapy.  Some with advanced disease receive biological therapy.

About 1 out of 8 people with rectal cancer need a permanent colostomy.

Radiation therapy may be used before and after surgery.  Some people have radiation therapy before surgery to shrink the tumour, and some have it after surgery to kill cancer cells that may remain in the area.

At some hospitals, patients may have radiation therapy during surgery.  Patients may also have radiation therapy to relieve pain and other problems caused by the cancer.

 

 

Getting a Second Opinion

Before starting treatment, you might want a second opinion about your diagnosis and treatment plan.

There are a number of ways to find a specialist for a second opinion:

• your doctor may refer you to one or more specialists;
• the White Pages® or the Yellow Pages®;
• a nearby hospital, or a medical school can usually provide the names of specialists.

 

 

Treatment Methods

The choice of treatment depends mainly on the location of the tumour in the colon or rectum and the stage of the disease.  Treatment for bowel cancer may involve surgery, chemotherapy, biological therapy or radiation therapy.  Some people have a combination of treatments.  These treatments are described below.

Colon cancer sometimes is treated differently from rectal cancer.  Treatments for colon and rectal cancer are described separately below.

Your doctor can describe your treatment choices and the expected results.  You and your doctor can work together to develop a treatment plan that meets your needs.

Cancer treatment is either local therapy or systemic therapy:

• Local therapy – surgery and radiation therapy are local therapies.  They remove or destroy cancer in or near the colon or rectum.  When bowel cancer has spread to other part of the body, local therapy may be used to control the disease in those specific areas.
• Systemic therapy – chemotherapy and biological therapy are systemic therapies.  The drugs enter the bloodstream and destroy or control cancer throughout the body.

Because cancer treatments often damage healthy cells and tissues, side effects are common. 

Side effects depend mainly on the type and extent of the treatment.  Side effects may not be the same for each person, and they may change from one treatment session to the next.  Before treatment starts, your health care team will explain possible side effects and suggest ways to help you manage them.

You may want to ask your doctor these questions before treatment begins –

• What is the stage of the disease?
• Has the cancer spread?
• What are my treatment choices?
• Which do you suggest for me?
• Will I have more than one kind of treatment?
• What are the expected benefits of each kind of treatment?
• What are the risks and possible side effects of each treatment?
• How can the side effects be managed?
• What can I do to prepare for treatment?
• How will treatment affect my normal activities?
• Am I likely to have urinary problems?
• What about bowel problems, such as diarrhoea or rectal bleeding?
• Will treatment affect my sex life?
• What will the treatment cost?
• Is this treatment covered by my private health insurance?

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Surgery

Unlike some other cancers where many treatment choices are available, surgery is the most common treatment for removing the cancer from your bowel.

However, some people will also require chemotherapy and radiotherapy to reduce the size of the tumour and prevent progression of the disease.  If surgery is not an option, then chemotherapy and radiotherapy are offered to halt progression of the disease and to help control the symptoms.


What happens during surgery?

During the operation the piece of bowel that contains the cancer is removed and the two open ends are joined together.  The lymph nodes near the bowel may also be removed because this is the first place to which the cancer may spread.

You will usually stay in hospital for about 10 days after surgery, and will be given antibiotics to prevent any infection.

You may want to ask your doctor these questions before having surgery –

• What kind of operation do you recommend for me?
• Do I need any lymph nodes removed?
• Will other tissues be removed?
• Why?
• What are the risks of surgery?
• Will I have any lasting side effects?
• Will I need a colostomy?
• If so, will the stoma be permanent?
• How will I feel after the operation?
• If I have pain, how will it be controlled?
• How long will I be in the hospital?
• When can I get back to my normal activities?

Colon cancer surgery with anastomosis. Part of the colon containing the cancer and nearby healthy tissue is removed, and then the cut ends of the colon are joined. 
Image courtesy of the National Cancer Institute.

Will you need a colostomy bag?

Most people diagnosed with bowel cancer do not need a colostomy bag.  However, in some cases, the bowel cannot be rejoined straight away, and one end if brought out onto the skin of the abdominal wall.  This is called a colostomy, and the opening of the bowel is known as a stoma.  Bowel motions pass through the stoma into a colostomy bag, which is worn over the stoma.

For most people, the stoma is temporary and can be reversed after a few months.  It is needed only until the colon or rectum heals from surgery.  After healing takes place, the surgeon reconnects the parts of the bowel and closes the stoma.   
Only a very small number of people with bowel cancer cannot have a stoma reversal.  Some people, especially those with a tumour in the lower rectum, need a permanent stoma.

If you do need a colostomy bag after surgery, you will be given support and advice from specialist stoma care nurses.  People who have a colostomy bag may have irritation of the skin around the stoma.  Your doctor or nurse can teach you how to clean the area and prevent irritation and infection.  Life can carry on as normal with a stoma, including sporting activities.

Colon cancer surgery with colostomy. Part of the colon containing the cancer and nearby healthy tissue is removed, a stoma is created, and a colostomy bag is attached to the stoma. 
Image courtesy of the National Cancer Institute.

Open surgery or keyhole surgery?

Open surgery is currently the most common form of surgery for bowel cancer patients.  In the majority of cases, open surgery to remove bowel cancer is highly successful and can be completely curative if the cancer is caught at an early enough stage.

After open surgery you will have a wound (incision) that goes in a straight line from just below the breastbone for a variable length down to the pelvis.  However, this scar will heal and fade over time.  You can expect to be in hospital for an average of 8-10 days.

The time it takes to heal after surgery is different for each person.  You may be uncomfortable for the first few days.  Medicine can help control your pain.  Before surgery, you should discuss the plan for pain relief with your doctor or nurse.  After surgery, your doctor can adjust the plan if you need more pain relief.

It is common to feel tired or weak for a while.  Also, surgery sometimes causes constipation or diarrhoea.  Your health care team monitors you for signs of bleeding, infection, or other problems requiring immediate treatment.

National Health & Medical Research Council guidelines recommend laparoscopic (or keyhole) surgery, in experienced hands, as a safe and feasible alternative to open surgery for benign bowel cancer.  

The decision about whether to use open or laparoscopic surgery should be made after informed discussion between the patient and the surgeon.  In particular, they should talk about whether the patient’s condition is suitable for laparoscopic surgery, the risks and benefits of the two procedures, and he surgeon’s experience.

Laparoscopic surgery involves carrying out an operation through small cuts in the abdomen.  This type of procedure is often called keyhole surgery.  The surgeon inserts a narrow telescope attached to a camera and other special instruments through the cuts to remove the part of the bowel with the tumour.  Most of the operation is performed through these small cuts, but a slightly larger opening is needed to remove the section of bowel from the body.

Laparoscopically assisted surgery is similar, but involves using the larger opening to carry out part of the surgery as well as to remove the section of bowel.  Both procedures need smaller cuts than open surgery.

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Chemotherapy

Chemotherapy uses anti-cancer drugs to kill cancer cells.  The drugs enter the bloodstream and can affect cancer cells all over the body.

Chemotherapy is used at several different stages of treatment –

• ‘Neo-adjuvant’ – to shrink the tumour(s) before surgery in order to get a better outcome following the operation.
• ‘Adjuvant’ – to destroy any microscopic cancer cells that may remain after the cancer is removed by surgery and reduce the possibility of the cancer returning.
• 'First-line' – chemotherapy that has been shown, through extensive clinical trails and research, to be the best option for the type of cancer being treated.
• 'Second-line' – chemotherapy that has been shown, through extensive clinical trials and research, to be the best option if the disease has not responded to first-line chemotherapy or has recurred.
• 'Palliative' – to relieve symptoms and slow the spread of the cancer, if a cure is not possible.

In order for the chemotherapy to destroy cancer cells in the body, the drugs have to be absorbed into your blood and carried throughout your body.

The chemotherapy drugs can be given in different ways, for example -

• Oral chemotherapy – if your chemotherapy drug is available as a tablet which you swallow, this can be taken at home.  You would only need to go to the hospital for routine outpatients' appointments, which would include a blood test.  As oral chemotherapies can cause side effects it is important to be aware of these and report them to your medical team immediately.
• Intravenous (IV) injection – the treatment is injected into a vein - either over a few minutes, up to 30 minutes, or over the course of a couple of hours.  IV chemotherapy can be given via 4 different methods:
  
  1. Cannula: a small tube inserted into a vein in the back of your hand, or your arm.
  2. Central Line: a thin, flexible tube inserted though the skin of the chest into a vein near the heart.
  3. PICC Line (a peripherally inserted central catheter): a thin, flexible tube passed into a vein in the bend or upper part of your arm and threaded through the vein until the end of the tube lies in a vein near the heart.  PICC lines can stay in place for many months.
  4. Portacath: a thin, soft plastic tube that is put into a vein.  It has an opening (port) just under the skin on your chest or arm.

If your oncologist believes you will benefit from chemotherapy, they will discuss the proposed treatment plan with you.  You may be prescribed one drug or a combination of drugs.  Ask your specialist about what they are recommending for you, how the chemotherapy will be given and the choices you have.

The side effects of chemotherapy depend mainly on the specific drugs and the dose. The drugs can harm normal cells that divide rapidly –

• Blood cells – these cells fight infection, help blood to clot, and carry oxygen to all parts of your body.  When drugs affect your blood cells, you are more likely to get infections, bruise or bleed easily, and feel very weak and tired.
• Cells in hair roots – chemotherapy can cause hair loss.  Your hair will grow back, but it may be somewhat different in colour and texture.
• Cells that line the digestive tract – chemotherapy can cause poor appetite, nausea and vomiting, diarrhoea, or mouth and lip sores.

Chemotherapy for bowel cancer can cause the skin on the palms of the hands and bottoms of the feet to become red and painful.  The skin may peel off.

Your health care team can suggest ways to control many of these side effects.  Most side effects usually go away after treatment ends.

You might want to ask your oncologist these questions before having chemotherapy therapy –

• What drugs will I have?
• What will they do?
• When will treatment start?
• When will it end?
• How often will I have treatments?
• Where will I go for treatment?
• Will I be able to drive home afterward?
• What can I do to take care of myself during treatment?
• How will I know the treatment is working?
• Which side effects should I tell you about?
• Will there be long-term side effects?

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Monoclonal Antibodies

Some people with bowel cancer that has spread receive a monoclonal antibody, a type of biological therapy and are a different type of treatment to chemotherapy.

• ‘Monoclonal’ means all one type.
• ‘Antibody’ is a protein in your immune system that recognises and attacks foreign substances.

So a ‘monoclonal antibody’ is a treatment designed to recognise and target only one type of foreign substance (e.g. cancer cells).

The development of monoclonal antibody treatments is an exciting development in the treatment of cancer as it may be possible to kill cancer cells without damaging other healthy cells.

The monoclonal antibodies bind to bowel cancer cells.  They interfere with cancer cell growth and the spread of cancer.  People receive monoclonal antibodies through a vein at the doctor's office, hospital, or clinic.  Some people receive chemotherapy at the same time.

During treatment, your health care team will watch for signs of problems.  Some people get medicine to prevent a possible allergic reaction.  The side effects depend mainly on the monoclonal antibody used.  Side effects may include rash, fever, abdominal pain, vomiting, diarrhoea, blood pressure changes, bleeding, or breathing problems.  Side effects usually become milder after the first treatment.

 

 

Monoclonal Antibody Treatments for Advanced Bowel Cancer

There are three MAB treatments for bowel cancer -

• Bevacizumab (Avastin)
• Cetuximab (Erbitux)
• Panitumumab (Vectibix)

These treatments seek out cancer cells that produce too much of a particular growth factor (a substance which stimulates a cell to grow and divide) and block the cell's receptors so the cell can't receive the signal to grow.

You might want to ask your oncologist these questions before having biological therapy –

• What drugs will I have?
• What will they do?
• When will treatment start?
• When will it end?
• How often will I have treatments?
• Where will I go for treatment?
• Will I be able to drive home afterward?
• What can I do to take care of myself during treatment?
• How will I know the treatment is working?
• Which side effects should I tell you about?
• Will there be long-term side effects?

 

 

Pharmaceutical Benefits Advisory Committee (PBAC)

The PBAC is an independent statutory body established under section 101 of the National Health Act 1953 to make recommendations and give advance to the Minister for Health & Ageing about which drugs and medicinal preparations should be made available as pharmaceutical benefits.

No new drug may be made available as a pharmaceutical benefit unless the Committee has so recommended.

The Committee is required by the Act to consider the effectiveness and cost of a proposed benefit compared to alternative therapies.  In making it recommendations the Committee, on the basis of community usage, recommends maximum quantities and repeats and may also recommend restrictions as to the indications where PBS subsidy is available. 

When recommending listings, the Committee provide advice to the Pharmaceutical Benefits Pricing Authority (PBPA) regarding comparison with alternatives or their cost effectiveness.

 

 

Accessing Monoclonal Antibody treatments

On 1 July 2009, Bevacizumab (Avastin) was added to the list of subsidised drugs under Pharmaceutical Benefits Scheme (PBS) for patients with advanced bowel cancer.  The drug was recommended for PBS listing by the PBAC in July 2008.

In July 2009, the PBAC rejected a submission to add Cetuximab (Erbitux) to the list of subsidised drugs under the PBS for patients with advanced bowel cancer, citing the drug’s high cost and uncertain effectiveness when compared with best supportive care.  The (unsubsidised) drug is available to patients via their oncologist.  

In November 2008, the PBAC rejected a submission to add Panitumumab (Vectibix) to the list of subsidised drugs under the PBS for patients with advanced bowel cancer, citing uncertain clinical benefit and the resultant high and highly uncertain cost effectiveness.  The (unsubsidised) drug is available to patients via their oncologist.

Improving the lives of patients with bowel cancer through recognition of the value of prolonged, quality of life is one of the aims of the Bowel Cancer 2012 Challenge, presented to Government on 7 May 2009.

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Radiotherapy

Radiotherapy (also called radiation therapy) uses high-energy rays to kill cancer cells.  It works by destroying the cancer cells in the treated area, and can be given before or after surgery.  Sometimes radiotherapy and chemotherapy are given at the same time.

Doctors use different types of radiation therapy to treat cancer.  Sometimes people receive two types –

• External radiation – the radiation comes from a machine.  The most common type of machine used for radiation therapy is called a linear accelerator.  Most patients go to the hospital or clinic for their treatment, generally 5 days a week for several weeks.
• Internal radiation (implant radiation or brachytherapy) – the radiation comes from radioactive materials placed in thin tubes put directly into or near the tumour.  The patient stays in the hospital, and the implants generally remain in place for several days.  Usually they are removed before the patient goes home.
• Intraoperative radiation therapy (IORT) – in some cases, radiation is given during surgery.

Will you suffer from side effects?

Radiotherapy can destroy cancer cells, but it can also have an effect on some of the surrounding normal cells.

Side effects depend mainly on the amount of radiation given and the part of your body that is treated.  Radiation therapy to your abdomen and pelvis may cause nausea, vomiting, diarrhoea, bloody stools, or urgent bowel movements.  It also may cause urinary problems, such as being unable to stop the flow of urine from the bladder.  In addition, your skin in the treated area may become red, dry, and tender. The skin near the anus is especially sensitive.

You are likely to become very tired during radiation therapy, especially in the later weeks of treatment.  Resting is important, but doctors usually advise patients to try to stay as active as they can.

Although the side effects of radiation therapy can be distressing, your doctor can usually treat or control them.  Also, side effects usually go away after treatment ends.

You may want to ask your doctor these questions about radiation therapy –

• Why do I need this treatment?
• When will the treatments begin?
• When will they end?
• How will I feel during treatment?
• How will we know if the radiation treatment is working?
• What can I do to take care of myself during treatment?
• Can I continue my normal activities?
• Are there any lasting effects?

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Clinical Trials

What is a clinical trial?

Clinical trials are carefully designed and regulated research studies.

Clinical trials are essential for improving cancer care.  They help to determine whether new cancer treatments, diagnostic tests or preventive interventions are effective, and identify best practice cancer care.

Are there different types of trials?

• Diagnosing trials evaluate ways of detecting certain types of disease.
• Prevention trials can either be ‘action studies’ e.g.: does exercising three times a week reduce your risk of cancer, or ‘agent studies’ e.g.: does taking a certain vitamin reduce your risk of cancer.
• Quality of life trials can measure an individual’s sense of well-being and quality of life during treatment.
• Screening trials can find new methods of screening for cancer which would mean that more cases could be diagnosed at an earlier stage.
• Treatment trials look at new ways of treating and managing a specific condition.

Why are clinical trials needed in cancer?

Carrying out clinical trials is the only way to find out if a new approach is better than the approach currently being used and can include –

• Testing new treatments, e.g. new drugs or ways of giving treatment.
• Examining new combinations of treatments, or when/how they are given.
• Looking at the effect of different treatments, such as psychological or complementary therapy.
• Discovering which treatments cause which side effects, and how these can be managed.
• Investigating the convenience of different treatments (e.g. oral tablets versus intravenous injections).
• Studying whether treatment (for example, chemotherapy) should be given before or after surgery.

 

 

Treatment Trials

What are the different phases of treatment trials?
Treatment trials go through a series of ‘phases’ to test whether they are safe and if they work. All new cancer drugs are tested in the laboratory before they are given to people in trials.

Phase 1 trials involve a small number of people, in a specialist research unit, and aim to discover appropriate doses, the effect the drugs have on the body, side effects etc. Researchers start with very small doses and only increase the amount given if the participants experience no or minor side effects.  If the drug is effective and a safe dose is found following a number of phase 1 trials, it will progress to phase 2 trials.

Phase 2 trials, still involving a small number of patients, aim to discover on what types of cancer the treatment is most effective, the side effects, the best dose, and if larger, more extensive phase 3 studies would be appropriate.  Throughout these studies patients are very closely monitored.  Sometimes phase 2 trials may include testing the best way to give a treatment, for example by tablet or injection.

Phase 3 trials aim to compare the effectiveness of the new treatment with current, standard treatment and only start when the treatment has successfully passed through phase 1 and 2 trials.  This phase provides more information on outcomes and side effects.  These trials often last a year or more, and can include hundreds or thousands of patients, from different hospitals, often across several countries.  Phase 3 trials always involve randomisation (see below for details).

Phase 4 trials are carried out after a drug has received a license (meaning doctors can prescribe it outside of trials) and has been demonstrated to be effective.  The studies further investigate long term risks/side effects and how the treatment works outside of clinical trial environments.  Phase 4 studies are not required for every medicine.

What is randomisation?

‘Randomisation’ is a way that a patient is assigned within the trial to either receive the ‘trial’ treatment or the standard ‘best currently available’ treatment.  Randomisation works by chance, is done via a computer, and means that each patient has an equal chance of being given the new treatment.  If the trial you are entering into is randomised, it does mean you may not get access to the treatment being tested.


Should you take part in a clinical trial?

There are a number of reasons why you may wish to take part in a clinical trial.  These include:

• Access to new treatments before they become widely available.
• Contributing to medical knowledge and the research of cancer.
• The potential to be the first to benefit from new methods of treating cancer.
• Receiving healthcare provided by leading clinicians in the field of cancer research.
• Close monitoring of your health during the trial.
• If you wish to do so, discuss the trial with friends, family and your doctor.  It is important that you know that you can leave the trial at any time, without giving a reason.  If, however, you are receiving new treatment as part of the trial, you may not be able to continue to have this treatment if you leave the trial.

What is informed consent?

Informed consent is a process in which you will receive information, either from your doctor or a dedicated research nurse, before you decide whether or not to take part.  You will be told –

• About the trial, why it is taking place and why you have been asked to take part.
• How the trial is going to work (you may or may not get the treatment being trialled).
• The standard treatment available if you do not enter the trial.
• Information on the treatment options, possible risks/benefits and tests.

You will then arrange to meet with your oncologist at a separate appointment to discuss your choice.  At this appointment you will provide written informed consent if you have opted to participate in the trial.  You may have to undergo blood tests/scans to confirm your eligibility and will then be ‘randomised’ into the trial.  You should only agree to take part in a trial if you are completely happy with what you are being asked to do.


Are there any risks of taking part?

Clinical trials involving patients are the end of a long and careful research process.  Potential risks, however, can include -

• Side effects or risks that are as yet unknown to doctors.
• The treatment may be less effective than current approaches.
• Benefits to some patients, but it may not work for you.

How do you get involved in a clinical trial?

Some people are offered to take part in a clinical trial by the medical team treating them, whilst others actively seek to enter a clinical trial to potentially get access to treatment that is not currently available in Australia.

If you want to find out more about current gastrointestinal clinical trials, contact the Australasian Gastro-Intestinal Trials Group (AGITG).

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Life During & After Bowel Cancer

Will the bowel cancer come back?

After you have had successful treatment, you will need to have regular check-ups.  At first these will be every few months, to check that the cancer has not returned.  These check-ups will usually include tests that you had to diagnose the original cancer – such as blood tests and a colonoscopy.  The tests will also check that the cancer did not spread.

If your bowel cancer was diagnosed and treated early, then there is a very good chance that it will not recur after treatment.  If it has taken a long time to diagnose and treat, there is a greater chance that it might recur.  However, even if your cancer does recur, it can still be treated with a combination of further surgery, chemotherapy and radiotherapy, depending on your personal treatment plan.


Emotional support

Many patients describe a rollercoaster of emotions during and after treatment for bowel cancer.  Keeping strong for children and other family members can often be hard when you are going through ups and downs yourself.  Talking to friends and partners can help, but you may also want to ask your doctor about specialist support available to you, such as counsellors.

Bowel cancer can have a major emotional impact, not only for the patient, but also their family, carers and friends.  Click here for a list of organisations that may be able to help.


Practical information

Many cancer patients discover that one of the unexpected side-effects of cancer can be financial difficulties and practical complications with everyday issues, such as benefits, insurance, employment rights and so on.

Click here for a list of organisations that may be able to help.


Patient support groups

You may also find it helpful to meet up with other people who have been through similar experiences to yourself.  Ask at your hospital about local patient support groups.  You may even like to consider setting up a patient support group in your area.  Meeting up, say, once a month for a coffee and a chat can be a huge help when you are going through treatment for the disease, or in the aftermath of treatment.

Bowel Cancer Australia’s ‘Love My Family’ Community is a national patient-to-patient network of people suffering from bowel cancer or for their close relatives.  The Community is informal and you can be as involved as your time and lifestyle allows.  Click here to find out more about the Community.

You may also like to join a discussion about your personal experiences of bowel cancer, whether it be about being diagnosed to the disease, your treatment journey or how you are coping with day-to-day life. Click here to talk to others.


Life after bowel cancer

Many people diagnosed with bowel cancer will undergo successful treatment, and life can soon get back to normal.  Remember, bowel cancer is one of the most curable cancers if caught early enough.  Keeping positive during treatment, and asking for support when you need it, can help you get through the traumatic experience of having cancer.

You will be regularly tested to check that the cancer has not returned.  If after five years, it has not returned, you are considered clear and it’s time to celebrate!  Throw a big party with all your family and friends, or treat yourself and your loved ones to a holiday or a special night out.  You certainly deserve it!

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Stoma Care

Sometimes, during surgery, it may be necessary for the surgeon to form a ‘stoma’ on the wall of your abdomen.  The stoma may be temporary (to allow the bowel time to heal) or permanent.

 

What is a stoma?

‘Stoma’ comes from the Greek word for ‘mouth’ is an artificial opening on your abdomen to collect waste.  There are different types of stoma and, if you need one, the type you have depends on the location of your tumour and the type of surgery you need.

 

Ileostomy

An ‘ileostomy’ is a stoma formed by bringing the end or loop of small bowel (the ileum) out on to the surface of your abdomen.  The intestinal waste passes out of the ileostomy and is collected in an external pouching system (generally known as an ileostomy bag).  Ileostomies can be formed during surgery to allow the colon to rest and heal following your surgery. Usually, following a period of 8 – 10 weeks, the ileostomy is reversed and you go back to using your bowels in the usual way.

 

Colostomy

A ‘colostomy’ is a stoma formed by bringing part of your colon (large bowel) out on to the surface of your abdomen.  The intestinal waste, (which is ‘formed’ having passed through the colon where water is absorbed) passes out of the colostomy and is collected in an external pouching system (generally known as a colostomy bag).  A temporary colostomy can be formed to ‘re-route’ the faeces away from the section of the colon which has been operated on.  A second operation is later carried out to reverse the stoma and allow the patient to resume normal bowel function.  Permanent colostomies also need to be formed for some patients if the surgeon is unable to join the ends of the bowel that are left or if your anus needs to removed due to the location of the tumour.

Colon cancer surgery with colostomy. Part of the colon containing the cancer and nearby healthy tissue is removed, a stoma is created,
and a colostomy bag is attached to the stoma.  Image courtesy of the National Cancer Institute.

Before surgery

Your doctor will tell you before surgery, during the consent process, if you might need a stoma to be formed.  It’s not always possible to know 100% either way as the decision is often made during the surgery once they can see the tumour and what needs to be surgically removed.  You may meet with the stoma care nurse before the surgery who is a specialist in caring for patients who require a stoma. They will discuss with you where the stoma will be on your abdomen and answer any questions or concerns you have.

 

Managing your stoma after surgery

You will meet with the stoma care nurse again after the operation.  They understand it can be very daunting at first and that learning to manage your stoma will take time and practice.  No-one expects you to be an expert overnight.  For the first few days, the stoma care nurse and the nurses on the ward will help you with your stoma.

As soon as you are well enough, the stoma care nurse will show you how to clean your stoma, and how to change the bag.  The stoma care nurse will give you hints and tips on how to independently manage your stoma, including how to be thoroughly prepared before you start changing the bag so you know you have everything you need to hand in the bathroom.  If appropriate, they may also talk to you about irrigation as a method of managing your stoma (colostomies only) instead of wearing a bag.

They will also talk to you about the different types of appliances (bags) that are available and which one might be best for you.  It might be useful to have a relative or friend with you at this time in case you need help or support when you get home.

 

Managing your stoma at home

Once you are able to manage your stoma independently, and the medical team are happy with you, you will be able to go home, with a plentiful supply of stoma bags.  Once you get home, you will be able to order new supplies from your chemist, dispensing doctor or a home delivery company.  You should also ensure you have the contact details of the stoma nurse in case you have any concerns or queries.

 

 

Diet

There are no set rules about foods than you can and can’t eat when you are first diagnosed or have received treatment for bowel cancer.  It is often a matter of experimenting for yourself to find what works for you.

After surgery, your bowel will be highly sensitive and you may find that the high-fibre foods that are usually recommended as part of a healthy diet actually give you looser stools, which can be uncomfortable if you have a colostomy.  Drink plenty of water or fluids if you do have diarrhoea.  You may also find that you are more wind-prone than before and that this can sometimes cause pain.  

The side effects from chemotherapy can also have an affect on your diet – you may find that certain foods aggravate a sore mouth, or bring on diarrhoea, both common side-effects.

Ask your doctor or nurse if they can put you in touch with a hospital dietician if you are experiencing any problems with your diet, as they can give you specialist advice tailored to your individual situation.  

Many patients find that trial and error is the best way to sort out their diet after having a bowel cancer diagnosis.  If you are a patient and have a particular 'top tip' regarding foods, we would love to hear from you so we can pass this on to other patients. Please email your experiences to This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

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Advanced Bowel Cancer

What causes bowel cancer to spread?

If the cancer in the bowel is not detected and removed at an early stage, part of the tumour can break off from the main bowel tumour and spread, usually via the lymphatic system or bloodstream, to nearby lymph nodes or other parts of the body.

Your cancer may be advanced when it is first diagnosed.  Or it may come back some time after you are first treated.

Local spread

If the cancer has broken through the wall of the bowel and cancer cells have spread into surrounding tissues in the abdomen and pelvis, this is known as local spread.

Secondary spread (metastasis)

If the cancer has spread to another part of the body (for example, the liver or lungs) is it called secondary cancer or metastatic cancer.  

The liver is second only to the lymph nodes as the most common part of the body for bowel cancer cells to spread to.   The liver is a common site for bowel cancer cells to spread to as the liver receives most of its blood supply from the portal vein (the vein that carries blood from the intestines and spleen to the liver).

If your bowel cancer has spread in this way, you have secondary bowel cancer in your liver – not liver cancer.  Your treatment is dependent on where the cancer started and therefore the treatment you have must work on bowel cancer and not liver cancer cells.

The next most common part of the body for bowel cancer cells to spread to is the lungs.

 

 

Treatment for Advanced Bowel Cancer

Once a bowel cancer has spread to another part of the body, it is unlikely to be curable.  If your cancer is advanced when it is first diagnosed you may be offered chemotherapy to keep it under control.  You may have just one drug or a combination of drugs.

Some people with bowel cancer that has spread receive a monoclonal antibody, a type of biological therapy and are a different type of treatment to chemotherapy.  Ask your oncologist about the choices available to you, and the combination option.

In some circumstances you may have surgery.

The choice of treatment depends on –

• The type of cancer you have
• The size and number of secondaries and where they are in the body
• The treatment you had already had

 

Surgery for Advanced Bowel Cancer

Surgery can be used in some situations to treat advanced bowel cancer -

• To slow the cancer
• When the bowel is blocked
• To remove secondary cancer

Surgery to control the cancer

Sometimes when there is a recurrence of bowel cancer in the bowel, it is possible to remove it.  This is unlikely to cure the cancer because there are usually cancer cells elsewhere in the body.  Removal of the bowel tumour may however relieve any symptoms you may have.  It may also be some time before the cancer starts to grow anywhere else.

Surgery for blocked bowel cancer

Sometimes bowel cancer can grow so that it completely blocks the bowel.  This is called a bowel obstruction.  The waste from the food you have digested cannot get past the blockage.  This can cause a number of symptoms such as feeling bloated and full, pain, feeling sick, vomiting, or constipation.  To relieve symptoms, it is sometimes possible to unblock the bowel by putting in a stent. 
Another way to remove an obstruction is to operate and remove the affected part of the bowel, provided you are fit enough.  It may be possible to close up the bowel again during the operation or you may need to have a colostomy.

Surgery to remove small secondary cancers

If bowel cancer spreads, it often goes to the liver or lungs.  Sometimes when the cancer secondaries in the liver or lungs are small and there are only one or two, you can have surgery to remove them.  This is not suitable treatment in every situation and is done more often for liver secondaries than for lung secondaries.  If you have this type of surgery, you may also have chemotherapy before and after the operation.

To decide if this treatment is suitable for you, your doctor will look at -

• Your general health
• How advanced your cancer was when you were diagnosed
• How quickly your cancer came back
• How many secondaries you have and their size
• Where they are in the liver or lungs
• How close they are to major blood vessels

 

 

Chemotherapy for Advanced Bowel Cancer

Chemotherapy to shrink a cancer and control symptoms is called palliative chemotherapy.  Treatment with chemotherapy at this stage is unlikely to cure your cancer, but it can help you live longer and may shrink the cancer.

For advanced bowel cancer, the aim of chemotherapy is to help you feel better.  If however, you are unhappy about the side effects, you do not have to continue with the treatment.

How do you know if chemotherapy is working?

Your oncologist will arrange a scan before you start treatment and again three months later.  Your oncologist can measure the tumour on the scan and so will be able to see how well the treatment is working.  The tumour may have become smaller or larger or remained the same size.

If it has remained the same size, your oncologist will want to talk to you about whether or not it is worth continuing with your treatment.

If the tumour has become bigger, despite your treatment, your oncologist will stop the chemotherapy and may suggest trying a different treatment.

If it has become smaller, you may have a break and then have more treatment.

 

 

Monoclonal Antibodies (MAB)

Some people with bowel cancer that has spread receive a monoclonal antibody, a type of biological therapy and are a different type of treatment to chemotherapy.

• ‘Monoclonal’ means all one type.
• ‘Antibody’ is a protein in your immune system that recognises and attacks foreign substances.

So a ‘monoclonal antibody’ is a treatment designed to recognise and target only one type of foreign substance (e.g. cancer cells).

The development of monoclonal antibody treatments is an exciting development in the treatment of cancer as it may be possible to kill cancer cells without damaging other healthy cells.

The monoclonal antibodies bind to bowel cancer cells.  They interfere with cancer cell growth and the spread of cancer.  People receive monoclonal antibodies through a vein at the doctor's office, hospital, or clinic.  Some people receive chemotherapy at the same time.

During treatment, your health care team will watch for signs of problems.  Some people get medicine to prevent a possible allergic reaction.  The side effects depend mainly on the monoclonal antibody used.  Side effects may include rash, fever, abdominal pain, vomiting, diarrhoea, blood pressure changes, bleeding, or breathing problems.  Side effects usually become milder after the first treatment.

 

 

Monoclonal Antibody Treatments for Advanced Bowel Cancer

There are three MAB treatments for bowel cancer -

• Bevacizumab (Avastin)
• Cetuximab (Erbitux)
• Panitumumab (Vectibix)

These treatments seek out cancer cells that produce too much of a particular growth factor (a substance which stimulates a cell to grow and divide) and block the cell's receptors so the cell can't receive the signal to grow.

You might want to ask your oncologist these questions before having biological therapy –

• What drugs will I have?
• What will they do?
• When will treatment start?
• When will it end?
• How often will I have treatments?
• Where will I go for treatment?
• Will I be able to drive home afterward?
• What can I do to take care of myself during treatment?
• How will I know the treatment is working?
• Which side effects should I tell you about?
• Will there be long-term side effects?

 

 

Pharmaceutical Benefits Advisory Committee (PBAC)

The PBAC is an independent statutory body established under section 101 of the National Health Act 1953 to make recommendations and give advance to the Minister for Health & Ageing about which drugs and medicinal preparations should be made available as pharmaceutical benefits.

No new drug may be made available as a pharmaceutical benefit unless the Committee has so recommended.

The Committee is required by the Act to consider the effectiveness and cost of a proposed benefit compared to alternative therapies.  In making it recommendations the Committee, on the basis of community usage, recommends maximum quantities and repeats and may also recommend restrictions as to the indications where PBS subsidy is available.  

When recommending listings, the Committee provide advice to the Pharmaceutical Benefits Pricing Authority (PBPA) regarding comparison with alternatives or their cost effectiveness.

 

 

Accessing Monoclonal Antibody Treatments

On 1 July 2009, Bevacizumab (Avastin) was added to the list of subsidised drugs under Pharmaceutical Benefits Scheme (PBS) for patients with advanced bowel cancer.  The drug was recommended for PBS listing by the PBAC in July 2008.

In July 2009, the PBAC rejected a submission to add Cetuximab (Erbitux) to the list of subsidised drugs under the PBS for patients with advanced bowel cancer, citing the drug’s high cost and uncertain effectiveness when compared with best supportive care.  The (unsubsidised) drug is available to patients via their oncologist.   

In November 2008, the PBAC rejected a submission to add Panitumumab (Vectibix) to the list of subsidised drugs under the PBS for patients with advanced bowel cancer, citing uncertain clinical benefit and the resultant high and highly uncertain cost effectiveness.  The (unsubsidised) drug is available to patients via their oncologist.

Improving the lives of patients with bowel cancer through recognition of the value of prolonged, quality of life is one of the aims of the Bowel Cancer 2012 Challenge, presented to Government on 7 May 2009

 

 

Radiotherapy for Advanced Bowel Cancer

Some patients may be given radiotherapy as palliative treatment.  In other words, it will be used to relieve the symptoms of the cancer or to reduce pain.  Radiotherapy is not used much for colon cancers but may be used for rectal cancers.  Internal radiotherapy may be used for secondaries in the liver.

 

 

Surgery & Chemotherapy for Liver Metastases

Only a relatively small number of patients with liver tumours are suitable for surgery, and whether or not this operation is an option for you depends on:

• Whether the tumour in your bowel has been treated / is treatable
• How much of the liver is affected
• The size of the tumour(s)
• Where in the liver the cancer cells are located
• How well the liver is functioning
• Whether there are any tumours outside the liver, their locations and how many there are
• Your general level of fitness

Surgery can only be performed if there is no sign of cancer anywhere else in the body.  If the liver tumour is too large to operate on, you may have chemotherapy to try and shrink the tumour so it can be removed.  If the liver tumour is small, you may have chemotherapy before and after the surgery.

Chemotherapy may be given to improve the ability to undertake surgery, to reduce the number of tumour cells, or to slow their growth to provide symptom relief and extend survival.

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During your journey, you may wish to find out more about the types of pathology tests being performed. You can find out about a range of tests at www.labtestsonline.org.au which can help explain what is being tested and why.

 

Having the right information and an understanding of what is happening can help you play an active part in your health care, and help you better understand your treatment and medication.

 

 

The website is commercially independent and has been developed by the Australasian Association of Clinical Biochemists with support from the Royal College of Pathologists of Australasia and has received development funding from the Australian Government.

 

 

During your journey, you may wish to find out more about the types of pathology tests being performed. You can find out about a range of tests at www.labtestsonline.org.au which can help explain what is being tested and why.