Rectal Cancer (Bowel Cancer)

Introduction

Bowel cancer is a general term for cancer that begins in the large bowel. Depending on where the cancer starts, bowel cancer is sometimes called colon cancer or rectal cancer.

Symptoms of bowel cancer include blood in your stools (faeces), an unexplained change in your bowel habits, such as prolonged diarrhoea or constipation, and unexplained weight loss.

Cancer can sometimes start in the small bowel (small intestine), but small bowel cancer is much rarer than large bowel cancer.

Who is affected by bowel cancer?

Bbowel cancer is the third most common type of cancer.

Approximately 72% of bowel cancer cases develop in people who are 65 or over. Two-thirds of bowel cancers develop in the colon, with the remaining third developing in the rectum.

Who's at risk?

Things that increase your risk of getting bowel cancer include:

• Age – around 72% of people diagnosed with bowel cancer are over 65
• Diet – a diet high in fibre and low in saturated fat could reduce your bowel cancer risk, a diet high in red or processed meats can increase your risk
• Healthy weight – leaner people are less likely to develop bowel cancer than obese people
• Exercise – being inactive increases the risk of getting bowel cancer
• Alcohol and smoking – high alcohol intake and smoking may increase your chances of getting bowel cancer
• Family history and inherited conditions – aving a close relative with bowel cancer puts you at much greater risk of developing the disease.
• Related conditions – having certain bowel conditions can put you more at risk of getting bowel cancer

Bowel cancer screening

Currently, everyone between the ages of 60 and 69 should go for bowel cancer screening every two years.

Screening is carried out by taking a small stool sample and testing it for the presence of blood (faecal occult blood test).

In addition, an extra screening test is being introduced over the next three years for all people at age 55. This test involves a camera examination of the lower bowel called a flexible sigmoidoscopy.

Screening plays an important part in the fight against bowel cancer because the earlier the cancer is diagnosed, the greater the chance it can be cured completely.

Treatment and outlook

Bowel cancer can be treated using a combination of surgery, chemotherapy, radiotherapy and, in some cases, biological therapy. As with most types of cancer, the chance of a complete cure depends on how far the cancer has advanced by the time it is diagnosed.

If bowel cancer is diagnosed in its earliest stages, the chance of surviving a further five years is 90%, and a complete cure is usually possible. However, bowel cancer diagnosed in its most advanced stage only has a five-year survival rate of 6% and a complete cure is unlikely.

Signs and symptoms of bowel cancer 

Early bowel cancer may have no symptoms and some symptoms of later bowel cancer can also occur in people with less serious medical problems, such as haemorrhoids(piles).

See Dr. B C Shah if you notice any of the symptoms below.

The initial symptoms of bowel cancer include:

• Blood in your stools (faeces) or bleeding from your rectum
• A change to your normal bowel habits that persists for more than three weeks, such as diarrhoea, constipation or passing stools more frequently than usual
• Abdominal pain
• Unexplained weight loss

As bowel cancer progresses, it can sometimes cause bleeding inside the bowel. Eventually, this can lead to your body not having enough red blood cells. This is known as anaemia.

Symptoms of anaemia include:

• Fatigue
• Breathlessness

In some cases, bowel cancer can cause an obstruction in the bowel. Symptoms of a bowel obstruction include:

• A feeling of bloating, usually around the belly button
• Abdominal pain
• Constipation
• Vomiting

When to seek medical advice

Visit Dr. B C Shah if you have any of the symptoms above. While the symptoms are unlikely to be the result of bowel cancer, these types of symptoms always need to be investigated further.

Causes of bowel cancer

Cancer occurs when the cells in a certain area of your body divide and multiply too rapidly. This produces a lump of tissue known as a tumour.

Most cases of bowel cancer first develop inside clumps of cells on the inner lining of the bowel. These clumps are known as polyps. However, if you develop polyps, it does not necessarily mean you will get bowel cancer.

Exactly what causes cancer to develop inside the bowel is still unknown. However, research has shown several factors may make you more likely to develop it.

Family history

There is evidence that bowel cancer can run in families. Around 20% of people who develop bowel cancer have a close relative (mother, father, brother or sister) or a second-degree relative (grandparent, uncle or aunt) who have also had bowel cancer.

It is estimated that if you have one close relative with a history of bowel cancer, your risk of getting bowel cancer is doubled. If you have two close relatives with a history of bowel cancer, your risk increases four-fold.

Diet

A large body of evidence suggests a diet high in red and processed meat can increase your risk of developing bowel cancer. For this reason, the Department of Health advises people who eat more than 90 grams (cooked weight) of red and processed meat a day to cut down to 70 grams.

There is also good evidence that a diet high in fibre and low in saturated fat could help reduce your bowel cancer risk. Cancer experts think this is because this type of diet encourages regular bowel movements.

Smoking

People who smoke cigarettes are 25% more likely to develop bowel cancer, other types of cancer and heart disease than people who do not smoke.

Alcohol

A major study, called the EPIC study, showed alcohol was associated with bowel cancer risk. Even small amounts of alcohol can put you at higher risk of getting bowel cancer. The EPIC study found that for every two units of alcohol a person drinks each day, their risk of bowel cancer goes up by 8%.

Obesity

Obesity is linked to an increased risk of bowel cancer. Obese men are 50% more likely to develop bowel cancer than people with a healthy weight. Morbidly obese men, who have a body mass index (BMI) of over 40, are twice as likely to develop bowel cancer.

Obese women have a small increased risk of developing the condition, and morbidly obese women are 50% more likely to develop bowel cancer than women with a healthy weight.

Inactivity

People who are physically inactive have a higher risk of developing bowel cancer. You can help reduce your risk of bowel and other cancers by being physically active every day. Your risk could be cut by up to one-fifth if you do an hour of vigorous exercise every day or two hours of moderate exercise (such as vacuum cleaning or brisk walking).

Digestive disorders

Some conditions may put you at a higher risk of developing bowel cancer. People with Crohn’s disease are 2-3 times more likely to develop bowel cancer. The risk of developing bowel cancer is much higher in people with ulcerative colitis, and as many as 1 in 20 of these people will go on to develop it.

Genetic conditions

There are two rare inherited conditions that can cause bowel cancer. They are:

• Familial adenomatous polyposis (FAP)
• Hereditary non-polyposis colorectal cancer (HNPCC), also known as Lynch syndrome

FAP affects 1 in 10,000 people. The condition triggers the growth of non-cancerous polyps inside the bowel. Although the polyps are non-cancerous, there is a high risk that, over time, at least one will turn cancerous. Almost all people with FAP will have bowel cancer by the time they are 50 years of age.

People with FAP have such a high risk of getting bowel cancer, they are often advised to have their large bowel removed by surgery before they reach the age of 25. Families affected can find support and advice from the FAP registry at St Mark’s Hospital, London.

HNPCC is a type of bowel cancer caused by a mutated gene. An estimated 2-5% of all cases of bowel cancer are due to HNPCC. Around 90% of men and 70% of women with the

As with FAP, removing the bowel as a precautionary measure is usually recommended in people with HNPCC.

Diagnosing bowel cancer

When you first see Dr. B C Shah he will ask about your symptoms and whether you have a family history of bowel cancer.

Dr. B C Shah  will then carry out a physical examination known as a digital rectal examination (DRE). A DRE involves Dr. B C Shah gently placing a finger into your anus, and then up into your rectum.

A DRE is a useful way of checking whether there is a noticeable lump inside your rectum. This is found in an estimated 40-80% of cases of rectal cancer.

A DRE is not painful, but some people may find it a little embarrassing.

If your symptoms suggest you may have bowel cancer, or the diagnosis is uncertain, you will be referred to your local hospital for further examination. 

Further examination

Two tests are commonly used to confirm a diagnosis of bowel cancer:

• A sigmoidoscopy is an examination of your rectum and some of your large bowel.
• A colonoscopy is an examination of all of your large bowel.

Sigmoidoscopy

A sigmoidoscopy uses a device called a sigmoidoscope, which is a thin, flexible tube attached to a small camera and light.

The sigmoidoscope is inserted into your rectum and then up into your bowel. The camera relays images to a monitor. This allows the doctor to check for any abnormal areas within the rectum or bowel that could be the result of cancer.

A sigmoidoscopy can also be used to remove small samples of suspected cancerous tissue so they can be tested in the lab. This is known as a biopsy.

A sigmoidoscopy is not usually painful, but can feel uncomfortable. Most people go home after the examination has been completed.

Colonoscopy

A colonoscopy is similar to a sigmoidoscopy except a longer tube, called a colonoscope, is used to examine your entire bowel.

Your bowel needs to be empty when a colonoscopy is performed, so you will be given a special diet to eat for a few days before the examination and a laxative (medication to help empty your bowel) on the morning of the examination.

You will be given a sedative to help you relax, after which the doctor will insert the colonoscope into your rectum and move it along the length of your large bowel. As with a sigmoidoscope, the colonoscope can be used to obtain a biopsy, as well as relaying images of any abnormal areas.

A colonoscopy usually takes about one hour to complete, and most people can go home once they have recovered from the effects of the sedative. After the procedure, you will probably feel drowsy for a while, so arrange for someone to accompany you home.

Further testing

If a diagnosis of bowel cancer is confirmed, further testing is usually carried out for two reasons:

• to check if the cancer has spread from the bowel to other parts of the body
• to help decide on the most effective treatment for you

These tests can include:

• A computerised tomography (CT) scan or magnetic resonance imaging (MRI) scan to provide a detailed image of your bowel and other organs 
• Ultrasound scans, which can be used to look inside other organs, such as your liver, to see if the cancer has spread there
• Chest X-rays, which can be used to assess the state of your heart and lungs
• Blood tests to detect a special protein, known as a tumour marker, released by the cancerous cells in some cases of bowel cancer 

Staging and grading

Once the above examinations and tests have been completed, it should be possible to determine the stage and grade of your cancer. Staging refers to how far your cancer has advanced. Grading relates to how aggressive and likely to spread your cancer is.

• Stage 1 – the cancer is still contained within the lining of the bowel or rectum
• Stage 2 – the cancer has spread into the layer of muscle surrounding the bowel
• Stage 3 – the cancer has spread into nearby lymph nodes
• Stage 4 – the cancer has spread into another part of the body, such as the liver

This is a simplified guide. Stage 2 is divided into further categories called A and B and stage 3 is divided into A, B and C.

There are three grades of bowel cancer:

• Grade 1 is a cancer that grows slowly and has a low chance of spreading beyond the bowel
• Grade 2 is a cancer that grows moderately and has a medium chance of spreading beyond the bowel
• Grade 3 is a cancer that grows rapidly and has a high chance of spreading beyond the bowel

If you are not sure what stage or grade of cancer you have, ask your doctor.

Treating bowel cancer

People with bowel cancer should be cared for by a multidisciplinary team (MDT). This is a team of specialists who work together to provide the best treatment and care.

The team often consists of a Dr. B C Shah, an oncologist (a radiotherapy and chemotherapy specialist), a radiologist, pathologist, radiographer and a specialist nurse. Other members may include a physiotherapist, dietitian and occupational therapist, and you may have access to clinical psychology support.

When deciding what treatment is best for you, your doctors will consider:

• The type and size of the cancer
• Your general health
• Whether the cancer has spread to other parts of your body
• What grade it is

There are several treatments for bowel cancer, including:

• Surgery
• Chemotherapy
• Radiotherapy
• Biological therapy

Surgery is usually the main treatment for bowel cancer, but in about one in five cases, the cancer is too advanced to be removed by surgery. If you have surgery, you may also need chemotherapy, radiotherapy or biological therapy, depending on your particular case.

Your treatment plan

Your recommended treatment plan will depend on the stage and location of your bowel cancer.

If the cancer is confined to your rectum, radiotherapy will usually be used to shrink the tumour, then surgery may be used to remove the tumour. Sometimes, radiotherapy is combined with chemotherapy, which is known as chemoradiation.

If you have stage 1 bowel cancer, it should be possible to surgically remove the cancer and no further treatment will be required.

If you have stage 2 or 3 bowel cancer, surgery may be used to remove the cancer and, in some cases, nearby lymph nodes. Surgery is usually followed by a course of chemotherapy to stop the cancer returning.

It is not usually possible to cure stage 4 (advanced) cancer. However, symptoms can be controlled and the spread of the cancer can be slowed using a combination of surgery, chemotherapy, radiotherapy and biological therapy where appropriate.

Preventing bowel cancer

There are several ways to reduce your risk of developing bowel cancer.

Diet

Research suggests a low-fat, high-fibre diet that includes plenty of fresh fruit and vegetables (at least five portions a day) and wholegrains can help reduce your risk of getting bowel cancer. It can also reduce your risk of developing other types of cancer and heart disease.

It is recommended you do not eat a lot of processed meat and red meat. The Department of Health advises people who eat more than 90 grams (cooked weight) of red and processed meat a day to cut down to 70 grams. .

Exercise

There is strong evidence to suggest regular exercise can lower the risk of developing bowel and other cancers.

It is recommended adults exercise for at least 150 minutes (2 hours and 30 minutes) of moderate-intensity aerobic activity (i.e. cycling or fast walking) every week.

Healthy weight

Try to maintain a healthy weight. Changes to your diet and an increase in physical activities will help keep your weight under control. Find out if you are a healthy weight with the Healthy weight calculator.

Smoking

If you smoke, giving up will reduce your risk of developing bowel and other cancers.

Dr. B C Shah can also provide help, support and advice if you want to give up smoking.

How screening for bowel cancer works 

Bowel cancer can be present for a long time before any symptoms appear. If bowel cancer is detected before symptoms appear, it is easier to treat and there is a better chance of surviving the disease.

Screening for bowel cancer called an FOBt (faecal occult blood test) is done at a pathology Lab. A  tiny stool samples on a special card. The card is then checked at the laboratory  for traces of blood.

Results

 There are three types of result:

• Normal: no blood was found in the samples. Screening will be offered again in two years’ time.
• Unclear: there were possible traces of blood that could be caused by factors other than cancer, such as haemorrhoids (piles) or stomach ulcers. If you have an unclear result, you will be asked to repeat the test kit up to twice more.
• Abnormal: blood was definitely found in the samples. Again, this could be from piles or bowel polyps(small growths not usually cancerous). If you have an abnormal result, you will be offered an appointment with Dr. B C Shah to discuss having an examination of the bowel, called a colonoscopy.

Colonoscopy

A colonoscopy is an investigation of the lining of the large bowel (colon). A thin flexible tube with a tiny camera on the end is passed into your bottom and guided around the bowel. Only around 2 in every 100 people completing the FOBt kit will have an abnormal result and will be offered a colonoscopy. Of those who have a colonoscopy, only about one in 10 will have cancer.

New screening test

As well as the FOBt described above, an additional screening test is being rolled out by 2016. This involves inviting people at age 55 to have a one-off flexible sigmoidoscopy test to examine the lower bowel with a camera.

If the flexible sigmoidoscopy shows polyps, the person will then be offered a full colonoscopy . Both FOBt and flexible sigmoidoscopy screening tests have been shown to reduce the risk of dying of bowel cancer.

Living with bowel cancer

Being diagnosed with cancer is a tough challenge for most people. There are several ways to find support to help you cope.

Not all of them work for everybody. but one or more should be helpful:

• Talk to your friends and family. They can be a powerful support system.
• Get in touch with others in the same situation as you
• Learn about your condition
• Don't try to do too much at once
• Make time for yourself.

Talk to others

Dr. B C Shah may be able to reassure you if you have questions, or you may find it helpful to talk to a trained counsellor, psychologist . Dr. B C Shah will have information on these.

Having cancer can cause a range of emotions. These may include shock, anxiety, relief, sadness and depression. Different people deal with serious problems in different ways. It is hard to predict how knowing you have cancer will affect you. However, you and your loved ones may find it helpful to know about the feelings that people diagnosed with cancer have reported.

Recovering from colon or rectal surgery

Surgeons and anaesthetists have found that using an “enhanced recovery programme” after bowel cancer surgery helps patients recover more quickly.

Most hospitals now use this programme. It involves giving you more information before the operation about what to expect, avoiding giving you strong laxatives to clean the bowel before surgery, and in some cases giving you a sugary drink two hours before the operation to give you energy. 

During and after the operation, the anaesthetist controls the amount of IV fluid you need very carefully, and after the operation you will be given painkillers that allow you to get up and out of bed by the next day.

Most people will be able to eat a light diet the day after their operation.

To reduce the risk of deep vein thrombosis (blood clots in the legs), you may be given special compression stockings that help prevent blood clots, or a regular injection with heparin until you are fully mobile.

A nurse or physiotherapist will help you get out of bed and regain your strength so you can go home again within a few days.

With the enhanced recovery programme, most people are well enough to go home within five to six days of their operation. The timing depends on when you and Dr. B C Shah  agree you are well enough to go home.

Coping with colostomy

If you need a colostomy, you may feel worried about how you look and how others will react to you. Information and advice about living with a stoma (including stoma care, stoma products and ‘stoma-friendly’ diets) is available via the ileostomy and colostomy topics.

Diet after bowel surgery

If you have had part of your colon removed, it is likely that your stools (faeces) will be looser because one of the functions of the colon is to absorb water from the stools. This may mean that you experience repeated episodes of diarrhoea

You should inform Dr. B C Shah if diarrhoea becomes a problem because medication is available to help control symptoms.

You may find some foods upset your bowels, particularly during the first few months after your operation.

Different foods can upset different people, but food and drink that is commonly known to cause problems include:

• Rich and fatty food
• Fruit and vegetables that are high in fibre, such as beans, cabbages, apples and bananas
• Fizzy drinks, such as cola and beer

You may find it useful to keep a food diary to record the effects of different foods on your bowel.

If you find that you are having continual problems with your bowels as a result of your diet, and/or you are finding it difficult to maintain a healthy diet, you should contact Dr. B C Shah. You may need to be referred to a dietitian for further advice.

Sex and bowel cancers

Having cancer and its treatment may affect how you feel about relationships and sex. Although most people are able to enjoy a normal sex life after bowel cancer treatment, if you have had a colostomy you may feel self-conscious or uncomfortable.

Talking about how you feel with your partner may help you both to support each other. Or you may feel you’d like to talk to someone else about your feelings. Dr. B C Shah will be able to help.

Financial concerns

A diagnosis of cancer can cause money problems because you are unable to work or someone you are close to has to stop working to look after you.

Dealing with dying

If you are told there is nothing more that can be done to treat your bowel cancer, Dr. B C Shah will still provide you with support and pain relief. This is called palliative care. Support is also available for your family and friends.