Colorectal Cancer: Sometimes Lethal
She didn't have symptoms — most people don't — not until Christmas Day 2000. That was when she noticed blood in her stool.
The following week, Cathy Ansay went to see her doctor. She was 40, active, a near vegetarian who never smoked and drank only moderately. She survived uterine cancer at age 34 and her great-grandmother had stomach cancer, but Cathy had no other family history or risk factors.
At first, Cathy's doctor thought it might be related to occasional bouts of constipation, but when Cathy's symptoms continued, her doctor referred her to a gastroenterologist who performed a colonoscopy.
Cathy, a former nurse, says, "During the colonoscopy, the room got very quiet. I looked at the screen and told the nurse, 'I see it.' It was a tumor." Her diagnosis was rectal cancer. That colonoscopy was the first step in saving Cathy's life.
"Colorectal cancer is a common, sometimes lethal and preventable disease," says Colm O'Loughlin, MD, Medical College of Wisconsin gastroenterologist. "If a colonoscopy detects — and your doctor removes — benign polyps, your chances of developing colon cancer are less than 10 percent. It is 90 percent preventable."
The facts are eye-opening. Colorectal cancer is the third most common cancer, and the second most common cause of cancer death. It's highly treatable when diagnosed early, but about one in three who develop colorectal cancer die from it, so preventing or catching it early is critical. The colonoscopy, a procedure allowing doctors to examine the inside of your colon using a long, flexible scope, also allows collection of tissue samples and removal of abnormal growths.
Having a colonoscopy can prevent colon cancer by detecting and removing polyps before they become cancerous. If there were a screening test that could not only detect — but prevent — breast, lung or prostate cancer, would you ask to have it? So, why don't more have screening colonoscopies at age 50?
Some people may have had a bad experience or are uncomfortable with the idea. "But it's far worse," says Dr. O'Loughlin, "to find out 15 years later you have metastatic colon cancer."
Fears about colonoscopies are unfounded, says Dr. O'Loughlin. "Most people who undergo a colonoscopy don't realize when the test is over."
The Role of Radiation OncologyCathy was lucky enough to have her rectal cancer detected by colonoscopy. Dr. O'Loughlin referred her to Gordon Telford, MD, a Medical College of Wisconsin surgeon, who saw her right away and scheduled her for surgery two months later.
"I remember saying to him, 'Can't you fit me in any earlier?'" Cathy recalls. But he first wanted her to see Beth Erickson, MD, a Medical College of Wisconsin radiation oncologist, who explained the cancer team would shrink the tumor with radiation and chemotherapy so it would be easier to resect (operate on) without the need for a colostomy.
Both types of cancer benefit from a multidisciplinary approach to treatment — that is, radiation therapy and/or chemotherapy and surgery — all working together to achieve the best possible outcome.
Radiation oncology plays a bigger role in treating rectal cancer than colon cancer, because of the rectum's location. "The rectum lives in a narrow space, because of the pelvic bone," explains Dr. Erickson, "in particular, the sacrum. That can make surgery difficult, because there isn't much healthy tissue available to remove with the rectum to gain a clear negative margin." (This margin is called the "radial margin" and is very important in explaining recurrence when radiation is not used.) "However, by shrinking the tumor, radiation with chemotherapy improves the radial margin — making surgery easier and the risk of cancer recurrence in the pelvis much lower."
"The hope is that the surgeon will be able to remove the cancerous segment of the rectum, while avoiding a colostomy.We call this approach sphinctersparing surgery, and it's a big premise of how we approach rectal cancer," says Dr. Erickson.
The radiation/chemotherapy approach can also reduce chances of recurrence.When patients choose surgery alone for rectal cancer that has invaded through the rectal wall, there is a 30-50 percent pelvic recurrence rate. When they are treated with radiation and surgery, the recurrence rate drops by at least half.
This multidisciplinary approach works well at Froedtert & Medical College of Wisconsin because of the specialized expertise available. "Teams of doctors here treat site-specific malignancies," Dr. Erickson explains. "There's constant communication between different services to assure that the best combination of treatment modalities is used.
More Chemotherapy Options Than Ever BeforeMedical oncology plays a major role in treating colon and rectal cancers, says Paul Ritch, MD, Medical College of Wisconsin medical oncologist. In addition to shrinking a tumor, chemotherapy might be used after surgery to reduce the risk of recurrence.
"In the last five years, we've seen substantial improvements in the management of colon cancer — primarily because of new drugs," Dr. Ritch explains.
Two new chemotherapy drugs and two new targeted therapy drugs, plus an oral version of the original drug are available. These new medications have extended the median survival rate for advanced, metastatic colon cancer to more than two years for patients treated with all three methods. And, says Dr. Ritch, "there are many exciting investigational agents on the horizon."
The targeted therapy drugs, says Dr. Ritch, are now a standard of care for advanced colon cancer, and they're being investigated for use in earlier stage cancers. "When given along with chemotherapy, they have significantly improved the effectiveness of chemotherapy alone."
Suregery Doesn't Have to Mean ColostomySurgery, another vital discipline in this team approach, is key in treating colon and rectal cancers. "The multidisciplinary approach," Dr. Telford says, "is largely responsible for the increase in long-term survival rates."
For many colon cancers, surgery is the initial therapy, Dr.Telford says. Still, patients may face complex decisions, such as choosing a permanent colostomy (an opening on the outside of the body for waste to pass through into a colostomy bag) or one of the alternatives available today. Colostomy alternatives — preserving the sphincter or substituting the sigmoid colon for the rectum — aren't without their own challenges.
"Ultimately, it's a patient-doctor decision," Dr. Telford says. "Either option can involve big changes. A fair number of patients choose colostomies." The key is to learn about your options and to make a decision based on what's best for you and your lifestyle.
Dr.Telford, like his colleagues, stresses the importance of early screening for colorectal cancer. "The majority of people with colon cancer have no symptoms. The more symptoms you have, the more likely it is to be difficult to treat. You should have a rectal exam once a year when you hit 40. At 50, you should have your first colonoscopy."
As for Cathy, the Froedtert & Medical College of Wisconsin team was ultimately successful in shrinking her tumor enough to surgically remove it. She's had four and a half years of clean colonoscopies and won't need another for two to three years.
Source: Froedtert Today
Date: December 2005