Colorectal Cancer Treatment
Colorectal Cancer Treatment
Richard E. Gould (Hematologist/Oncologist, Cedars-Sinai Outpatient Cancer Center) gives expert video advice on: How is colon cancer treated?; What are the treatments if colon cancer has spread?; How is rectal cancer treated? and more...
How is colon cancer treated?
The treatment for colorectal cancer depends upon the stage of the colorectal cancer. For early stage colorectal cancer -stages one, two and three - the standard treatment is surgery that removes the part of the colon that is affected by the cancer. In addition, it's important to remove the lymph nodes to help to appropriately stage the cancer. If the colorectal cancer is stage one, two, or three, based upon an individual's risk of relapse from that stage, there may be further treatment that can help reduce this risk. The benefit is usually in stage two and stage three cancers only. Stage one colorectal cancers can usually be treated by surgery alone. For stage four colorectal cancer, there may or may not be a role for surgery. The lesion in the colon - the primary lesion - may be causing symptoms of bleeding, obstruction or pain, and because of that there may be an indication to surgically remove that part of the colon to get the colorectal cancer out.
What are the treatments if colon cancer has spread?
Usually colorectal cancer will spread to the liver first. If there is no cancer in the liver there usually is no cancer elsewhere in the body. If there are just one or two metastases in the liver, sometimes it can be treated surgically and that can be removed too. If somebody is able to get all their colorectal cancer surgically removed, even with metastatic disease they can still be cured. At that point, after surgery, there is a role for adjuvant chemotherapy which can then improve the patient's chances for a cure. If somebody has a stage 4 colorectal cancer - which means they have cancer outside of the colon, in other solid organs and it is not able to be surgically resected - unfortunately the only treatments that we have to offer are chemotherapy; treatments that to help to control the cancer, help people live longer, but live longer feeling better.
How is rectal cancer treated?
Rectal cancer is treated slightly differently than colon cancer and that's because of the different blood flow that happens to the rectum. It's in a very tight area of the body where the blood flow does not necessarily go back into the liver and goes outside into the general circulation. The patterns of relapse for a rectal cancer are different than those for a colon cancer. For colon cancer, relapses usually occur in the liver or spread as at first to the liver. For rectal cancer there is a greater risk for a local cancer, in other words, in the tissues where the cancer was resected. Due to that, there's a role for radiation for rectal cancer whereas for colon cancer there usually is not a role for radiation. When somebody is diagnosed with a rectal cancer, usually they are started on neoadjuvant treatment which means treatment before surgery with both chemotherapy and radiation together. The radiation is given just locally to the rectum where the cancer is. The chemotherapy is usually given through the vein to help the radiation work better. After this neoadjuvant treatment, an individual goes to surgery because the rectal cancer then has been shrunk. Therefore surgery at that point is usually a less extensive surgery and depending upon the location of the rectal cancer, hopefully the anal sphincter can be spared.
What is "radiation therapy"?
Radiation therapy is the use of high energy X-ray beams that are shot right at the cancer. The goal is to kill any fast dividing cells, which cancer cells are, right where the cancer started, as well as in the tissues just surrounding the cancer. Even though we see the cancer in one spot, we know that there are cells that are starting to spread in the tissues just around the cancer. So the radiation therapy focuses right on that area to do maximal damage to the cancer cells themselves. For colorectal cancer, healthy tissues end up getting radiated. It can cause irritation to the skin in the rectal area, as well as irritation of the lining of the rectum, which can cause burning, or something called mucositis. This can be very painful. People can get diarrhoea, and it's something that happens not only while somebody's getting radiation therapy but for several weeks afterwards, due to the time is takes for the body to heal. Radiation therapy continues to work for up to four to six weeks after it stops. As a result, the healing after radiation usually occurs over several months.
Why is chemotherapy important after colorectal surgery?
Chemotherapy can play an important role after surgery in colorectal cancer. The reason is that even though all of the colorectal cancer that we can see has been removed surgically, there are small cancer cells that can be left behind, because if we can't see them we can't take them out. This is called micro-metastatic disease - small cancer cells that may be in other organs in the body. Sometimes the body's own immune system can fight these cancer cells and kill them, but other times the cancer cells can lay dormant and years down the line can grow and cause a relapse. Chemotherapy that is given through the vein or given orally goes into the bloodstream and attacks these cancer cells wherever they may be. Chemotherapy can improve the chances of a cure after surgery. It's important to discuss with your oncologist what your risk of relapse after surgery this, what level of risk you are comfortable with and what chance chemotherapy has of reducing that risk.
How is chemotherapy used to treat colorectal cancer?
Once somebody has med static colorectal cancer, the main safe treatment was chemotherapy. And we have many different active agents, for metastatical colorectal cancer including IBK chemotherapist, oral chemotherapist and new targeting agents basically anti bodies that can fight the colorectal cancer or fight the cell that support the colorectal cancer. When somebody has metastatic cancer it's unfortunately usually not curable at that point, but studies have shown that chemotherapy can help to improve somebody survival and also help them live better feeling better on treatment, because the natural cause of cancer is to grow and people becomes symptomatic from the cancer, but if adequately treated they can help to prevent that cancer from growing and prevent people getting side effect from cancer. This off course has to be balance with the side effect of the chemotherapy and there's no one chemotherapy that is right for everybody and so come the personal discussion and personal choice with you and with your health care team to decide on the treatment plan that is right for you.
What is "brachytherapy"?
Brachytherapy is another way of giving radiation. Instead of using external beam radiation - radiation from a different source going into the body - brachytherapy is where small pellets that have radioactivity within them are implanted in the body. These pellets give off a small amount of radiation to the tissues that surround them. If they are implanted right around the cancer through brachytherapy, they will focus their energy right on the cancer and minimise toxicity to the other surrounding healthy tissues.
What are the types of rectal surgery?
Depending upon somebody's stage of rectal cancer and the location of the rectal tumour, there are different treatment options for surgery. One is a transanal incision, or resection, of the rectal cancer and that's only reserved for stage one rectal cancers and a minority of rectal cancers can be treated this way. The majority of rectal cancers are treated with LARs, or low anterior resections, where basically the area where the cancer is is resected and the anal sphincter is left intact. If the cancer is too far down and too close to the anal sphincter, the anal sphincter is not able to be preserved and at that point, people need what's called an APR, or an abdominal perineal resection, and that is where the same surgery as the LAR is done, except the anal sphincter is taken. Sometimes a more extensive surgery is needed if the cancer is growing into adjacent organs like the bladder or the prostate. Sometimes those people need something called a pelvic exenteration where the majority of the pelvic structures and organs are removed and this is a very large surgery which only a minority of people really need when they are first presented with rectal cancer.
What is a "colostomy"?
A colostomy is where the colon is brought to the abdominal wall, a hole is made in the abdomen and the stool comes out of that hole. Patients then wear what is called a colostomy bag to catch that stool. Sometimes people have a colostomy bag temporarily after colorectal surgery, and later the colon is brought back down the to rectum and they return to normal continence. However, this is not possible if their sphincter had to be removed surgically, and they're left with permanent colostomy.
What is a "urostomy"?
A urostomy is a collection for the urine. A colostomy is a collection for the stool; urostomy is a collection for the urine. People may a urostomy if their bladder needs to be sacrificed during surgery in order to remove all of their cancer. The most important thing with the surgery is that all of the cancer is removed - the goal of the therapy is to cure the cancer, so you really need to get all the cancer out. Sometimes that means sacrificing other pelvic organs, including the bladder, so people may need a urostomy afterwards.
What is "laparoscopic" surgery?
Laparoscopic surgery is where the surgeon does not make a large incision in the abdominal wall, and instead makes several small incisions, but then different cameras and tools are put in through those small holes into the abdomen. So the surgeon performing the laparoscopy is then watching on a screen to see what's going on in the abdomen, and uses that as a guide to perform the laparoscopic surgery. Laparoscopic surgery, in general, has a shorter recovery time afterwards. People have less pain after laparoscopic surgery. Their bowel function improves faster after laparoscopic surgery. They're out of the hospital usually a day or two faster, but in the big picture, open versus laparoscopy,the most important thing is making sure that all the cancer is removed appropriately.