Colorectal Cancer Treatment

What is the Colon and Rectum?

The colon and rectum (known as the large intestine or large bowel) are parts of the digestive system. The colon is the first 4 to 5 feet of the large intestine, and the rectum is the last six inches. The purpose of the colon is to absorb water from the digestive system and to hold stool (waste). The rectum is the last 6 inches of the large intestine (colon). The waste is then excreted from the anus.

What is Colon and Rectal Cancer?

Colon and Rectal cancer is one of the most common cancers in the United States (3rd most), in 2012 more than 103,000 people in the United States were diagnosed with colon and rectal cancer. Roughly 5% of Americans will develop colon or rectal cancer. A cancer is when normal body cells transform during the normal body process of cell turnover into an aberrant type of cell known as a cancer cell. These cancer cells grown and proliferate causing the condition of "cancer". They can spread to distant organs and lymph nodes as well. A cancer that starting in the colon is known as "colon cancer", likewise, if the cancer comes from the rectum it is a "rectal cancer".

What Are the Risk Factors for Colon and Rectal Cancer?

Unfortunately, the actual cause of colon and rectal cancer is unknown. However, through our current medical research, physicians have learned a great deal about the factors that historically increase a patients' change to develop colon and rectal cancer. We know for certain that you cannot "catch" the disease from someone, however there is a strong family association with colon and rectal cancer.

Common Risk Factors

  • Age over 50
    Colorectal cancer is more likely to occur as people get older. More than 90% of people with this disease are diagnosed after age 50. The average age at diagnosis is 72. Unfortunately, we are seeing more patients who develop cancer prior to the area of 50 years old. Recent screening guidelines recommend screening colonoscopies at the age of 45 now.
  • Diet
    Studies suggest that diets high in fat (especially animal fat) and low in calcium, folate and fiber may increase the risk of colorectal cancer. Unfortunately, dietary studies are often conflicting. More research on this topic is clearly needed. It is generally recommended to have a diet high in fiber with fresh fruits and vegetables.
  • Colorectal polyps
    Polyps are growths on the inner lining of the colon or rectum. They are common in people over age 50, however we are seeing polyp formation in younger patients. Most polyps are benign (not cancerous), but some polyps can progress to become cancer. During a colonoscopy, these polyps are biopsies and usually removed.
  • Family history of colorectal cancer
    First-degree relatives (parents, brothers, sisters, or children) of a person with a history of colorectal cancer are at an increased risk to develop this disease themselves, especially if the relative had the cancer at a young age. If several close relatives have a history of colorectal cancer, the risk is even greater and there may be a genetic alteration in this patient.
  • Genetic alterations
    Changes in certain genes increase the risk of colorectal cancer.
    • Hereditary nonpolyposis colon cancer (HNPCC) is the most common type of inherited (genetic) colorectal cancer. However, it only accounts for a small percentage of all colorectal cancer cases. It is caused by changes in a specific gene. Most people with an altered HNPCC gene develop colon cancer, and the average age at diagnosis of colon cancer is 44.
    • Familial adenomatous polyposis (FAP) is a rare, inherited condition in which hundreds of polyps form in the colon and rectum. It is caused by a change in a specific gene called the APC gene. Unless FAP is treated, it usually leads to colorectal cancer by age 40. FAP accounts for less than 1 percent of all colorectal cancer cases.
    • Genetic testing is an important part of patient prevention and treatment.
  • Personal history of cancer
    A person who has already had colorectal cancer may develop colorectal cancer a second time, so it is important to follow-up closely with your treating physicians after undergoing treatment. Also, women with a history of cancer of the ovary, uterus, or breast are at a somewhat higher risk of developing colorectal cancer. Additionally, cancer recurrence is a common cause of death in patients with a previous history of cancer. Close surveillance is recommended.
  • Ulcerative colitis or Crohn's disease
    A person who has had these conditions that cause inflammation of the colon for many years is at increased risk of developing colorectal cancer.
  • Cigarette smoking
    A person who smokes cigarettes may be at increased risk of developing polyps, colorectal cancer, other cancers, and generally contribute to overall poor health.

Can Colon and Rectal Cancer be Prevented?

For the most part, colon cancer is largely preventable. The most important step in preventing colon cancer is getting a screening test. Colon cancers are thought to be slow growing so a screening colonoscopy should be able to detect most early cancers and unwanted polyps. Addressing the risk factors that affect each patient are important and will guide each physician in their prevention strategies.

There is some evidence that a high fiber, low fat diet might help prevent colorectal cancer.

What are the Symptoms of Colon and Rectal Cancer?

Many cancers are without symptoms. The most common symptom of colorectal cancer is a change in bowel habits (ie: change in the size or consistency of stool).

Symptoms of colon cancer may include:

  • Having diarrhea or constipation
  • Feeling that your bowel does not empty completely
  • Finding blood (either bright red or very dark) in your stool
  • Finding your stools are narrower than usual
  • Frequently having gas pains or cramps, or feeling full or bloated
  • Losing weight with no known reason
  • Fatigue
  • Having nausea or vomiting

Typically, early cancer does not cause pain. Patients with the above symptoms should consult their doctor.

How is Colon and Rectal Cancer Diagnosed?

colonoscopy is the most common method for diagnosing colon. During the colonoscopy, biopsies can be taken and sent to a pathologist. The confirmation of colon cancer is then made. Currently, there are no reliable blood tests for diagnosing colon cancer. Often times for rectal cancer an in-office proctoscopy is performed to measure the distance from the tumor to the opening of the anus.

Are there Different Types of Colon and Rectal Cancer?

Yes, however, more than 95% of all colorectal cancers are called adenocarcinomas. These cancers arise from cells in the lining of the colon or rectum. Other much less common tumor types include carcinoid tumors, gastrointestinal stromal tumors (GISTs), lymphomas and sarcomas.

How is Colon and Rectal Cancer Evaluated and Staged?

Once the diagnosis of colon cancer is made, a cascade of workup modalities are undertaken. Typically, patients will have a CT Scan of the chest, abdomen, and pelvis to look for distance sites of cancer spread. Colon and Rectal cancer typically spread to the surrounding lymph nodes, liver, and lungs. Additionally, blood tests are performed to look for the CEA level (carcinoembryonic antigen) which is useful to trend for the recurrence of cancer. In low rectal cancers MRI and PET may be used to help with surgical staging. Finally, a consultation to a surgeon is conducted. The final staging is obtained once the cancer is surgically removed and reviewed by the pathologist.

Colorectal cancer is staged in this format:

  • Stage 0
    The cancer is found only in the innermost lining of the colon or rectum. “Carcinoma in situ” is considered to be Stage 0 colon cancer.
  • Stage I
    The tumor has grown into the inner wall of the colon or rectum. The tumor has not grown through the wall.
  • Stage II
    The tumor extends more deeply into or through the wall of the colon or rectum. It may have invaded nearby tissue, but cancer cells have not spread to the lymph nodes.
  • Stage III
    The cancer has spread to nearby lymph nodes, but not to other parts of the body.
  • Stage IV
    The cancer has spread to other parts of the body, such as the liver or lungs.

Often, final staging is not complete until after surgery to remove the tumor, when the lymph nodes can be evaluated for cancer under a microscope.

How is Colon and Rectal Cancer Treated?

Surgery is the standard of care. For colon cancer, usually surgery is performed with the possibility of chemotherapy and or radiation (rarely) after surgery. For low rectal cancers, chemotherapy and radiation my be used both before and after surgery.

How is Surgery for Colon Cancer Performed, and What is the Recovery?

Surgical removal is the standard of care and most common treatment for colorectal cancer. The two main surgical approaches are Minimally Invasive Surgery or Open Surgery.

Under the care of Dr. Schultzel, 99% of patients will have a Minimally Invasive Surgical resection. Dr. Schultzel has a conversion rate of less than 1%. Dr. Schultzel is a world expert in Single Incision Surgery. He also employs the use of the robot for Robotic Surgery as well. During surgery, small incisions (or one very small incision) will be made. With a special camera and special tools, the cancer will be surgically removed. After the cancer is removed the colon and or rectum is reconnected to the digestive system. In some cases (rare) an ileostomy is required in order to protect the new connection. In some patients whom are too high risk for a connection, a colostomy bag can be created. In addition to advanced minimally invasive surgery, Dr. Schultzel performs specialized ultrasound guided nerve blocks in order to reduce pain after surgery. The TAP Block (transverse abdominus plane), provides significant decrease in post-surgical pain after surgery. Dr. Schultzel is one of the only surgeons in the region personally performing these blocks.

In up to 20% of operations Nation-wide for colon and rectal cancer, the surgery cannot safely be accomplished with laparoscopy, so an open operation is performed or a laparoscopic surgery is converted to an open surgery at the same time as the laparoscopic operation.

Dr. Schultzel employs two advanced minimally invasive techniques for the treatment of very low rectal cancers: TAMIS and TATME. Dr. Schultzel is the only private surgeon in San Diego who performs the TATME procedure.

TAMIS

Transanal minimally invasive surgery (TAMIS) is a technique that was originally devised as a hybrid between Transanal Endoscopic Microsurgery (TEM) and single-site laparoscopy for resection of rectal lesions. Patients whom are appropriate candidates for TAMIS may not require a rectal resection or even entrance into the abdomen for surgery. Inquire with your physician if you are a candidate.

TATME

Transanal Total Mesorectal Excision (TATME) is a  technique that combines abdominal and transanal endoscopic approach to overcome limitations and facilitate standard laparoscopic total mesorectal. Patients whom are appropriate candidates for TATME may not require a permanent colostomy bag. This surgery is typically performed for patients whom have a lesion very low in the rectum near or involving the anus. Inquire with your physician if you are a candidate.

Post Operative:

On average you will remain in the hospital from roughly 2-4 days. You pain will be controlled via the Enhanced Recovery After Surgery protocol (ERAS). Dr. Schultzel will perform a TAP Block (Transverse Abdominus Plane) on the patient while under anesthesia. This will allow for a significant decrease in post-operative pain after surgery and will facilitate a more comfortable stay in the hospital. Typically, most patient will return home between 2-4 days after surgery. The national average length of stay is 5-9 days. After surgery patients are placed on a clear liquid diet and ware walking the same day of surgery. Once the patient begins passing gas their diet is advanced and they may be discharged.

What Are the Risks of Surgery for Colon and Rectal Cancer?

Overall, surgery for colon cancer is very safe, with survival in the immediate period after surgery of over 95%.

Per nation wide date roughly 1 in 5 patients can have a complication from surgery. These can range from minor to serious complications. The most common complications are wound infections, bleeding, damage to surrounding structures within the abdomen, Deep vein thrombosis, intra-abdominal infection, and breakdown or failure of the anastomosis (intestinal leakage). Some patients may require blood transfusions, antibiotics, or repeat surgery if a complication occurs.

Under the care of Dr. Schultzel, less than 1% of patients will have a complication. This includes, bleeding, infection, anastomotic leaks, risk to surrounding structures. Complications are not likely, however, they can happen even under the best circumstances.

After Surgery, What Additional Therapy is Needed for Colon and Rectal Cancer?

Patients in whom colon cancer is found in the lymph nodes (stage III) or distant locations (stage IV) are normally recommended to undergo chemotherapy after surgery if medically-fit. Some patients may require radiation (rarely for colon cancer, more likely for rectal cancer). Dr. Schultzel works closely with his Oncology colleagues and will help coordinate the surgical after care.

What Factors Influence Outcome After Treatment?

Primarily staging. Early staging carries a better prognosis. Other factors such as colon perforation or obstruction, or cancer involvement of other organs, lead to a worse outcome. Additionally the cell type, makeup, and differentiation all weight into the algorithm for treatment outcomes. For rectal cancer where the cancer is located and its distance to the opening of the anus has a significant impact on surgical treatment and outcome.

What is the Follow-Up After Treatment for Colon and Rectal Cancer?

After surgery most patients will follow up with Dr. Schultzel between 10-14 days. After this visit the patient will have a follow up with their oncologist. Usually post-surgical treatments occur around a month after surgery. Dr. Schultzel will see his a patients a second time one month after surgery. Then based on the type and location of the cancer, the patient will be seen in close follow up every 3-6 months with Dr. Schultzel. A separate schedule with the oncologists will be set up as well where typically lab tests (CEA test), colonoscopy, x-rays, CT scans, or other tests. Routine exams generally occur every 3-6 months for a few years, while CT scans or other imaging tests and colonoscopy are performed 1 year after surgery.  The frequency of subsequent exams is based upon results of the prior exam.

Conclusion

Colon and Rectal cancers are very common malignancies that affect a great number of Americans. They are largely preventable through our current screening methods. Survival has been greatly improved due to advances in both medical and surgical treatment modalities. Dr. Schultzel looks forward to providing care to those suffering from these terrible conditions.