Bowel Cancer

When your doctor talks about bowel cancer (also known as bowel cancer) they are referring to cancer of the colon or rectum.

Bowel cancer is a malignant growth that develops in the lining of the large bowel. 

Most bowel cancers develop from tiny growths called ‘polyps’.  Not all polyps become cancerous. 

Over time some polyps can become cancerous.  Cancer can narrow and block the bowel or cause bleeding.  In more advanced cases, the cancer can spread beyond the bowel to other organs.

As most bowel cancer start as polyps, all polyps should be removed to reduce your risk of developing the disease.  Almost all polyps can be removed without an operation during the procedure of colonoscopy.

Once removed from the bowel, the polyp can no longer develop into cancer.  Even if a polyp develops into cancer, in its early stages it can be cured by surgery.

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Bowel Cancer – the facts

Bowel cancer is the most frequently occurring cancer in Australia to affect both men and women.

Around 12,536 Australians are told they have bowel cancer every year.

Bowel cancer is Australia’s second biggest cancer killer after lung cancer, claiming the lives of around 4,372 Australians every year.

The good news is that bowel cancer is one of the most curable types of cancer if detected early.

If bowel cancer is detected before it has spread beyond the bowel, the chance of surviving for at least five years after diagnosis is 90% and most people are able to return to their current lifestyle.

However, most cases are detected at a later stage and so, overall, close to 60% of people diagnosed with the disease survive five years.

Early detection offers the best hope of reducing the number of Australians who die each year from bowel cancer.

Based on current trends, 1 in 12 Australians will develop bowel cancer before age 85.

Both men and women are at risk of developing bowel cancer.
The risk is greater if you –

• are aged 50 years and over;

• have had an inflammatory bowel disease, such as Crohn’s disease or ulcerative colitis;

• have previously had special types of polyps, called adenomas in the bowel; or

• have a significant family history of bowel cancer polyps.
  You are considered to have a significant family history of bowel cancer if a close relative (parent, brother, sister or child) developed bowel cancer at a young age (under 55 years) or if more than one relative on the same side of your family has had bowel cancer.

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National Bowel Cancer Screening Program

The National Bowel Cancer Screening Program is being phased in over a number of years by the Commonwealth Government, commencing August 2006.

Initially, screening will be offered to Australians turning 55 and 65 years of age between 1 May 2006 and 30 June 2008, and those who were involved in the Pilot Program that ran from November 2002 to June 2004.

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 to a laboratory for analysis.  There is no cost in completing the FOBT.  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 effectively.

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 www.cancerscreening.gov.au or the It’s Crunch Time www.itscrunchtime.org websites.

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Bowel Cancer - Risks
Information courtesy of the National Cancer Institute.   

Age and health history can affect the risk of
developing bowel cancer.

Risk factors include the following:

• Age 50 or older.

• A family history of bowel cancer.

• A personal history of cancer of the colon, rectum, ovary, endometrium, or breast.

• A history of polyps in the colon.

• A history of ulcerative colitis (ulcers in the lining of the large intestine) or Crohn's disease.

• Certain hereditary conditions, such as familial adenomatous polyposis and hereditary non-polyposis colon cancer (HNPCC; Lynch Syndrome).

Age 50 or older
If you are 50 or older, you should talk to your doctor about how to minimise your risk of developing bowel cancer.  This may mean having an occult blood test every couple of years or a colonoscopy.

A Faecal Occult Blood Test (FOBT) detects blood which can leak from the surface of bowel cancers or large polyps in amounts too small to be visible in the stool. 

Positive tests don't always indicate cancer and not all cancers or polyps produce a positive occult blood test.  A positive test will probably require further tests to determine the cause of bleeding.

A family history of bowel cancer
If you have a family history of bowel cancer, it is advisable to have regular checkups and you should consult your doctor.

Having relatives, especially first degree relatives such as parents, brothers, sisters or children with bowel cancer significantly increases your risk of developing the disease. 

For example, if either of your parents is diagnosed with bowel cancer before age 55, you have a 6-fold increase in the risk of developing the disease.  If two of your close relatives are diagnosed with bowel cancer (at any age), your risk increases by a similar amount. 

Your risk of developing bowel cancer doubles if you have one close relative who is diagnosed with the disease aged 60 or 70.

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Polyps
Information courtesy of the National Cancer Institute. 

In many cases, if detected early, bowel cancer can be treated successfully as it begins as a benign growth, called a ‘polyp’ in the lining of the large bowel. 

Polyps can be detected in a number of ways including colonoscopy and barium x-ray of the bowel.  Almost all polyps can be removed without an operation during the procedure of colonoscopy.  Once removed from the bowel, the polyp can no longer develop into a cancer.  Even if a polyp develops into a cancer, in its early stages it can be removed by surgery.

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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 change in bowel habit (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;

• Weight loss for no known reason;

• 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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Screening

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

Tests that examine the rectum, rectal tissue and blood are used to detect and diagnose bowel cancer.  The following tests and procedures may be used:

• Faecal occult blood testing (FOBT)
• Digital Rectal Exam
• Barium Enema
• Sigmoidoscopy
• Colonoscopy
• 'Virtual colonoscopy'

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Faecal Occult Blood Test (FOBT)

A test to check stool (solid waste) for blood that can only be seen with a microscope.  Small samples of stool are placed on special cards and returned to the doctor or laboratory for testing.

There are two main types of Faecal Occult Blood Test (FOBT) - immunochemical tests and traditional chemical (guaiac) tests.

The immunochemical FOBT has been selected as the preferred testing method for the National Bowel Cancer Screening Program (www.itscrunchtime.org/ict/html/screening.htm), in contrast to the guaiac FOBT, as it has no restrictions on diet or medication.

InSure® kits are available from the Institute.  Please note - the kit costs $34.00 (payment required on return of kit to Enterix) which includes provision of the test, return postage, pathology analysis and result reporting to the patient and doctor.

Guaiac FOBTs require a person not to consume red meat, specific fruit and vegetables (for example, raw broccoli,) vitamin C supplements, aspirin or anti-inflammatory drugs for three days prior to taking the first test sample and throughout the testing period.

A guaiac FOBT can generally be purchased from chemists and will cost approximately $15.00.

Rotary Bowelscan uses a Hemoccult II Guaiac FOBT, which can be purchased from the Institute for $8, which includes provision of the test, pathology analysis and result reporting to patient and doctor.   

The Institute sponsors Rotary Bowelscan in Districts 9680, 9710 9750, 9690 - covering Sydney, the NSW Central Coast, Blue Mountains, Southern Highlands, ACT, Goulburn, NSW South Coast and the Snowy Mountains.

For more information regarding screening for bowel cancer,
talk to your doctor.

Digital Rectum Exam

An exam of the rectum.  A doctor or nurse inserts a lubricated, gloved finger into the rectum to feel for lumps or anything else that seems unusual.

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Barium Enema 

A series of x-rays of the lower gastrointestinal tract.  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. This procedure is also called a lower GI series.

A white substance which shows up on x-rays and is used in x-ray examinations called barium meals, where it is swallowed, or barium enemas, where it is inserted into the large bowel via a tube passed into the rectum via the anus.

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Sigmoidoscopy

A procedure to look inside the rectum and sigmoid (lower) colon 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.

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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.  Polyps or tissue samples may be taken for biopsy.  Polyps can be removed by a procedure known as polypectomy.  A bowel preparation is given prior to the procedure and patients are sedated. 

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Virtual colonoscopy

A procedure that uses a series of x-rays called computed tomography to make a series of pictures of the colon. A computer puts the pictures together to create detailed images that may show polyps and anything else that seems unusual on the inside surface of the colon. This test is also called colonography or CT colonography.

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Diagnosis
Information courtesy of the National Cancer Institute. 

If you have screening test results that suggest cancer or you have symptoms, your doctor must find out whether they are due to cancer or some other cause.  Your doctor asks about your personal and family medical history and gives you a physical exam.  You may have one or more of the tests described in the 'screening' section.

If your physical exam and test results do not suggest cancer, your doctor may decide that no further tests are needed and no treatment is necessary. However, your doctor may recommend a schedule for checkups.

If tests show an abnormal area (such as a polyp), a biopsy to check for cancer cells may be necessary.  Often, the abnormal tissue can be removed during colonoscopy or sigmoidoscopy.  A pathologist checks the tissue for cancer cells using a microscope.

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Staging
Information courtesy of the National Cancer Institute. 

If the biopsy shows that cancer is present, 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.

• 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. (Surgery for bowel cancer is described in the 'Treatment' section.)

Doctors describe bowel cancer by the Australian ClinicoPathological Staging (ACPS) system is the staging system.

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
In stage D, the cancer may have spread to nearby lymph nodes and has spread to other parts of the body, such as the liver or lungs.

Recurrence
This is cancer that has been treated and has returned after a period of time when the cancer could not be detected. The disease may return in the colon or rectum, or in another part of the body.

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Treatment
Information courtesy of the National Cancer Institute. 

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.  Specialists who treat bowel cancer include gastroenterologists (doctors who specialise in diseases of the digestive system), surgeons, medical oncologists, and radiation oncologists.  You may have a team of doctors.

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?

Surgery
Surgery is the most common treatment for bowel cancer.

• Colonoscopy – a small malignant polyp may be removed from your colon or upper rectum with a colonoscope. Some small tumours in the lower rectum can be removed through your anus without a colonoscope.

• Laparoscopy – early colon cancer may be removed with the aid of a thin, lighted tube (laparoscope).  Three or four tiny cuts are made into your abdomen.  The surgeon sees inside your abdomen with the laparoscope.  The tumour and part of the healthy colon are removed.  Nearby lymph nodes also may be removed.  The surgeon checks the rest of your intestine and your liver to see if the cancer has spread.

• Open surgery – the surgeon makes a large cut into your abdomen to remove the tumour and part of the healthy colon or rectum.  Some nearby lymph nodes are also removed. The surgeon checks the rest of your intestine and liver to see if the cancer has spread.

When a section of your colon or rectum is removed, the surgeon can usually reconnect the healthy parts.  However, sometimes reconnection is not possible.  In this case, the surgeon creates a new path for waste to leave your body.  The surgeon makes an opening (stoma) in the wall of the abdomen, connects the upper end of the intestine to the stoma, and closes the other end.  The operation to create the stoma is called a colostomy.  A flat bag fits over the stoma to collect waste, and a special adhesive holds it in place.

For most people, the stoma is temporary.  It is needed only until the colon or rectum heals from surgery.  After healing takes place, the surgeon reconnects the parts of the intestine and closes the stoma.  Some people, especially those with a tumour in the lower rectum, need a permanent stoma.

People who have a colostomy may have irritation of the skin around the stoma.  Your doctor or your nurse can teach you how to clean the area and prevent irritation and infection.  

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.

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?
• Hoe 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?

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

Anticancer drugs are usually given through a vein, but some may be given by mouth.  You may be treated in an outpatient part of the hospital, at the doctor's office, or at home.  Rarely, a hospital stay may be needed.

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.

Biological Therapy
Some people with bowel cancer that has spread receive a monoclonal antibody, a type of biological therapy.  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.

You might want to ask your doctor these questions before having chemotherapy or 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?

Radiation Therapy
Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells.  It affects cancer cells only in the treated area.

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.  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?

Treatment for Colon Cancer
Most patients with colon cancer are treated with surgery.  Some people have both surgery and chemotherapy.  Some with advanced disease get 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 get biological therapy.

About 1 out of 8 people with rectal cancer needs 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.  People also may have radiation therapy to relieve pain and other problems caused by the cancer.

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