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The list of questions below should make it clear that the management of rectal cancer is very complex and should be performed by doctors who are very experienced and specialized in the treatment of these specific types of cancer. It is a real challenge for the doctors and for the patient to determine the right treatment that removes the cancer while preserving the function of surrounding organs and minimizing the number of complications that can be very debilitating after the treatment.
Here are 12 important questions that you will need to go over with your doctors:
1. What is the best way to stage the extent of the rectal cancer and, in addition, assess any spread to regional lymph glands or distant sites? Endoscopic ultrasound or MRI are the standard to assess the depth of invasion into the rectal wall and lymph nodes. CT scans for the liver and lungs.
2. Which type of surgical specialty should do my surgery (surgical oncologist, general surgeon, or colorectal surgeon)?
3. For the surgeon, how many operations for rectal cancer do you do each year? Should be a minimum of 12 per year.
4. Can the rectum be removed while sparing the anus so that a permanent colostomy is not necessary? Again, for the surgeon, are you trained to do “intersphincteric resections”, and how many have you done?
5. Should I have “minimally invasive” surgery, such as laparoscopic surgery or robotic surgery? Whereas minimally invasive approaches to colon cancer have been found to be as “safe” as an open operation, the same is yet to be determined for rectal cancer. The studies are ongoing. Minimally invasive approaches to rectal cancer is very new and should only be done as part of a clinical trial by surgeons with experience with minimally invasive procedures for the rectum.
6. If the cancer is small and does not invade very far into the rectal wall, is it possible to have a local excision only? (Be very careful with this! There is a lot of controversy over local excision. Local excision has a higher chance of recurring!)
7. Should chemotherapy and/or radiation therapy be given prior to surgery?
8. How much of adjacent pelvic organs need to be sacrificed in order to adequately treat the cancer?
9. Should molecular markers be obtained to help determine the type of chemotherapy which should be given?
10. What would be the side effects of radiation therapy to the pelvis and anus?
11. What are the long-term side effects of these complex treatments with regard to anal sphincter function (i.e. incontinence of stool or soiling) urination, fertility, and sexual function?
12. Do I have distant disease, or spread of cancer to the liver or lungs? If so, should I have systemic chemotherapy prior to an operation on the rectum? If you do have spread to the liver, make sure you are evaluated immediately by a surgeon who has significant experience with liver surgery, and especially liver surgery for colon or rectal cancer which has spread to the liver. These surgeons are usually found at a tertiary care facility or academic medical center. See a liver surgeon before starting chemotherapy!
When cancers of the rectum first present, the decisions about the initial treatment are often very complicated and require the treatment plan and care by oncologists of different specialties including surgery, medical oncology, and radiation oncology. In fact, the decision-making for cancers of the rectum can be more complex than any other cancer. The patient has an important role in the treatment plan because their perception of “quality of life ” is important in deciding the extent of operation that they will accept. Other factors that have a major role include:
Doctors usually make a distinction between the rectum and colon even though they are both part of the large bowel or intestine. In general, the rectum is the end of the large bowel and is situated inside the pelvis. The colon makes up the majority of the large bowel, which is located outside the pelvis. Given the anatomical differences between the colon and rectum, the treatment of their respective cancers is also different.
Cancers of the colon, which occur outside the pelvis, can grow to a large size but usually do not invade surrounding organs. The surgery is fairly straightforward and the surgical excision can take a wide margin or berth of normal tissue, including lymph nodes, without causing many side effects. By taking a margin of normal tissue, the surgeon can assure that all tumor is removed, including any disease that is microscopic. Depending on the pathology, which is determined after the colon cancer is removed, chemotherapy may be given after the operation.
In contrast, cancer arising in the rectum is growing in a small space confined by the pelvic bones, surrounded by organs such as the bladder, prostate in men or the uterus or vagina in women. Cancers growing low in the rectum can be especially difficult because they may be close to the anal sphincter muscles, which make it difficult to get an adequate margin of normal tissue. If the cancer is too low, the anus and anal sphincters may have to be removed as well in order to safely remove all the cancer and reduce the chance of having a recurrence. If the anus and anal sphincter muscles are removed, a permanent colostomy is required, whereby the end of the colon is brought out through the lower abdominal wall and attached to the skin to create a new channel for feces to leave the body into a colostomy bag.
Chemotherapy and radiation therapy may be given prior to an operation depending on:
Chemotherapy and radiation given before the operation may shrink the tumor enough to allow an operation to save the sphincter muscles. In addition, chemoradiation therapy before an operation has been found to be more tolerable than after an operation and reduce the risk of having a recurrence in the pelvis. There are procedures (i.e. intersphincteric resection) that can be done to save the sphincter muscles as well, but these are not safe in every situation and are technically very challenging. These are specialized procedures and should only be done by surgeons with experience using these techniques.
Remember, an informed and educated patient will usually get better care and have a treatment that best fits their risk tolerance to the different types of treatment side effects and recurrence rates.