Expert Analysis Highlights:

• The decision-making for cancers of the rectum can be more complex than any other cancer
• 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
• 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
• Below are 12 important questions that you will need to go over with your doctors to determine the right treatment plan

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:

• Depth of invasion of the cancer into the rectal wall or invasion into adjacent organs
• Spread of cancer to lymph nodes
• Spread of cancer to distant organs, like the liver or lungs,
• Distance of the lower end of the cancer from the anal sphincter muscles, and
• Size of the pelvis (men have a smaller and narrower pelvis than women)

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:

• Distance of the tumor from the anus
• Depth of invasion of the cancer into the rectal wall or invasion into adjacent organs, or
• Spread of cancer to the surrounding lymph nodes

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.

Colon cancer can be a “silent killer” because it can grow for some time without causing any symptoms. Sometimes a colon cancer can be quite advanced before a person knows it is there. That is the bad news. The good news is that colon cancer is preventable or curable if it is discovered early. The best way to do that is to have a full colonoscopy to visualize the entire length of the colon and biopsy or remove any polyps or abnormalities. Colonoscopy is not a particularly comfortable procedure, but it can be a lifesaver. Typically, the first colonoscopy is recommended at age 50. However, it may be necessary to start at an earlier age, especially for those who have increased risk such as having ulcerative coloitis or a family history of colorectal cancer.

For those of you interested in learning more about screening for colon cancer, this video offers a good overview and dispels some common myths.

Metastasis is a medical term that can strike fear in the minds of cancer patients. It’s the process of cancer cells spreading to vital organs and then interfering with their normal function. This is a 2 minute animation that describes the complex process of cancer circulating to tissues, invading across the blood vessels, acquiring a new circulation (to get oxygen and nutrients), and then growing. The animation is oversimplified, but it may be a start to those who are trying to understand more about how cancer cells function.

Here’s more information from our companion website, patientresource.net:

Cancer cells can spread by growing into the surrounding blood vessels or lymphatic channels and then circulating to the lymph nodes in the region or beyond to vital organs, such as the liver or lungs. Some experts have estimated that less than one cell in a million can survive long enough to help form a metastatic tumor. Cells that do survive begin the growth of another tumor. Sometimes, the tumor cells fall or move to a nearby structure. This occurs most commonly in certain abdominal cancers, such as ovarian cancer or cancer of the appendix. Cells that break off an ovarian tumor may form sheets of cells along the lining of the abdominal cavity and grow on another organ in the abdomen, such as the bladder or the outside of the colon. This process is known as seeding.

Cancer cells that detach from a tumor can also travel through the lymphatic system, a network of vessels connecting lymph nodes, small bean-shaped glands located throughout the body. Lymph nodes are often the first place to which many cancer cells travel. Because of this, during surgery to remove a primary tumor, the surgeon will often remove nearby lymph nodes. A pathologist will examine the nodes with a microscope to determine if cancer cells are present. The presence or absence of cancer in lymph nodes is a factor in determining the stage of cancer, or how advanced it is. When many cancer cells are found in one or more nearby lymph nodes, it is referred to as regional disease or stage III cancer. Cancer cells can also travel to lymph nodes far from the primary tumor or to other organs or tissues in the body, where they collect to form a metastatic tumor. This is sometimes referred to as distant disease or stage IV cancer.

Cancer cells shed directly from the original cancer or from metastases growing in the lymph nodes and enter the body’s main bloodstream, which means that cells can be taken anywhere in the body. However, in order to grow, these cells must be able to lodge in a new tissue, overcome the local defenses and acquire their own blood supply and nutrients. This blood supply is created when tumor cells release substances that attract vascular cells, or cells that form new blood vessels. The formation of a blood supply within the tumor, known as angiogenesis, not only offers a way for cancer cells to travel to the body’s main bloodstream but it also enables the tumor to grow more quickly. This is why some treatment approaches are designed to attract the tumor’s blood supply so it will starve.

Not all cancers spread, but any cancer can spread to any other part of the body. When it does take hold in an organ, it can grow in a disorderly fashion and interfere with the normal function of that organ. When cancer does spread, it more commonly metastasizes to vital organs such as the lungs, liver, bone, and brain. It may take months or even years for a microscopic metastasis to grow large enough to be seen on x-ray images or to cause symptoms. Also, some cancers that spread affect a particular organ or tissue more commonly than others. The cells of a metastatic tumor are derived from those originating in the primary tumor. For example, if colorectal cancer metastasizes to the liver, the tumor in the liver is made up of colorectal cancer cells, not liver cancer cells. This is how a pathologist can identify a tumor as metastatic cancer. Knowing whether a cancer is a metastatic tumor is important because treatment is based on the type of cancer.