April is Bowel Cancer awareness month. Bowel cancer, or colorectal cancer, is the third most common cancer worldwide and the second most common cause of cancer death in the UK overall, after prostate cancer in men and breast cancer in women. The incidence increases with age, affecting two age groups: between 45-64 years or in the 75+ age group. Colorectal cancer includes cancer of the large bowel (colon), which is responsible for water absorption and storing waste material; and rectal cancer (rectum), the last part of the lower digestive system, where faecal matter produced from the colon is stored until the body is ready to eliminate the waste through the process of defecation.
The development of colorectal cancer follows a distinctive pattern in most cases, with the earliest lesion being a microscopic focus of a mass (a polyp) with ulceration that spreads by direct infiltration through the bowel wall. Polyps can be considered pre-cancerous, but not all polyps develop into cancer. Bowel cancer can involve the lymphatics (the vessels that are responsible for removing excess fluid from the tissues), and blood vessels, with subsequent spread most commonly to the liver and the lung.
There are several factors that have been linked to an increased risk of colorectal cancer:
• Increasing age
• Saturated animal fat and red meat consumption
• Sugar consumption
• Obesity (body and abdominal)
• Chronic inflammatory bowel disease – long-standing ulcerative colitis
• Family history of colon cancer or colonic polyps. Polyps are precursors of tumours in the colon
• Genetics – hereditary cancer syndromes like hereditary on-polyposis colon cancer (HNPCC) and familial adenomatous polyposis (FAP)
Interestingly, there are also some factors that have been associated with a decreased risk of bowel cancer:
• Vegetable, garlic, milk, calcium consumption
• Exercise (linked to a decreased risk of colon cancer)
• Aspirin (including low dose)
Colorectal cancer is rare before the age of 50. Early cancers of the colon may remain entirely asymptomatic. Large masses and cancers may bleed in small amounts over time, causing anaemia. Larger tumours may cause overt rectal bleeding/blood mixed with faeces, and constipation associated with diarrhoea. Intestinal obstruction, abdominal pain and weight loss occur when the disease is further advanced.
Screening & Diagnosis
The prognosis of bowel cancer is associated with early diagnosis. In the UK, NHS offers bowel cancer screening to people aged 55 or over. This may involve bowel scope screening using colonoscopy, where a thin and flexible tube with a camera is inserted at the end to look for and remove any polyps inside the bowel; or a home testing kit, where a sample of faeces is collected and sent to a laboratory to check for microscopic blood. If there is known family history or long-standing inflammatory bowel disease, these patients are usually offered surveillance.
When it comes to diagnosing, colonoscopy is usually the first investigation, as it allows clinicians to take a sample if necessary and send it off for testing. Other diagnostics can involve using computed to
mography (CT) scanning to evaluate the tumour size and to assess if the tumour has spread. Your doctor may also check your blood to see if you have anaemia.
Treatment and Management
Surgery is the most common form of treatment in most cases of colorectal cancer. All patients who have surgery have colonoscopy performed before surgery to look for additional lesions. The extent of how much bowel is resected depends on where the tumour is. Post-surgery, annual CT scans may be performed to monitor for tumour spread.
Prognosis after surgery depends on the microscopic (histological) findings of the cells in the specimen, as the tumour is graded according to Dukes’ criteria. The Dukes’ staging is loosely divided into three stages, A, B and C. In stage A, the tumour is limited to the bowel wall, with an approximately 95-100% five-year survival rate after surgery. On the other hand, a stage C tumour has already spread to the lymphatics or other organs, with a five-year survival of 30-40% or <1%, respectively.
Postoperative chemotherapy improves disease-free survival in patients diagnosed with stage B and C cancers, and these patients benefit from regular colonoscopy as a follow up.
Living with Bowel Cancer
A diagnosis of colorectal cancer can have huge consequences for the patient, their close ones and friends. It is encouraged to gather help or support in a range of ways and not be limited to medical issues.
Bowel cancer and its treatment can make you feel fatigued, and it is probably unlike any other kind of tiredness you may have experienced before. It can affect your everyday life. Try selecting healthier ready meals, or cook in bulk and then freeze them in meal-size portions. You can boost your iron intake with lots of green vegetables, beans and breakfast cereals. The treatment along with constipation and diarrhoea may also affect your appetite and cause you to lose weight. Again, eating four-six small meals a day can help you gain more calories and aid easy digestion. Regular gentle exercise can help to build up muscle strength.
The treatment and management for bowel cancer can tire you not only physically but also emotionally and psychologically. You may feel constantly reminded of your diagnosis and treatment as your body changes. These unexpected feelings may leave you feeling anxious or vulnerable, especially whilst on holiday or in an intimate setting with a loved one. If you feel self-conscious, you may want to refer to The Sexual Advice Association, which has a great booklet on Intimacy & sexuality for cancer patients and their partners. Macmillan Cancer support can also provide more information.
Regular diet and physical activity can help to reduce some side effects such as extreme tiredness. It can help you stay healthy and improve your quality of life. You may find it easier to eat several smaller meals a day instead of three larger ones. Keeping active can improve your mood and help with digestion. You can start off with a walk around house, and then move on to a short walk outside, building up as you get your strength and energy back. Your physiotherapist can also give you advice on when would be appropriate to start exercising and what exercises would be best for you.
Aim for at least five portions of fruit and vegetables each day, as they are a good source of fibre which will help to keep your digestive system working well. You can have food such as oats, root vegetables like carrot, or beans and pulses like chickpeas and baked beans, as they contain soluble fibre that dissolves in water, creating a sticky gel that helps to soften the bowel movements, making it easier to pass. Food items such as muesli, brown rice and wholemeal pasta contain insoluble fibre. This type of fibre isn’t digested by the body, though it adds bulk to waste and helps waste pass through the digestive system. You should aim to have a diet that incorporates both types of fibre as this will help with constipation and wind. Avoid processed meat like bacon, ham and sausages as they may contain preservatives and chemical additives.
You may have a stoma – where a section of bowel is brought out through an opening on your stomach, and the waste is collected in a pouch or bag attached to the skin around the stoma. Your hospital team should give you advice on diet, but try to eat a balanced healthy diet, and drink plenty of fluids.
Diarrhoea can become difficult to manage as it can be caused by chemotherapy and even medications like antibiotics. You need to drink enough liquid to avoid getting dehydrated. Try and stay clear of sugary or fizzy drinks, as well as beverages that contain caffeine like tea and coffee, as these can irritate the bowel and worsen the diarrhoea. Here low fibre cereals, white rice and bread are helpful, especially in the first few weeks and months after surgery.
For more support, you can always join organisations or local groups. At Vida, we are keen to support you and help you cope with symptoms related to your diagnosis. We will ensure that the carers that will look after you have had experience and training with stoma care and make sure they are supportive of your dietary needs and requirements.