Colorectal Cancer- All you need to know about prevention, screening, and treatment.

What is Colorectal Cancer? Understanding the anatomy…!!!

Colon is part of our digestive system, which absorbs nutrients such as vitamins, minerals, carbohydrates, fats, proteins, and water from food and discards waste material out of our body. Our entire digestive system starts from the mouth, followed by the esophagus, stomach, small intestine, colon, and finally rectum and anal canal. The colon is about 5 feet long, and the rectum and anal canal together contribute last 6-8 inches. The anal canal ends as the anus, which opens our digestive system to the outside of the body.

 

Do Indians need to worry about colorectal cancer?

Colon and rectal cancers are rising at an alarming rate in India. The average age at diagnosis in Indians is about a decade earlier compared to Western countries. In the last decade (2004-2014), colorectal cancers in India increased by 20%. This increase can be due to change in our lifestyles, including a diet rich in calories and low in fibre, excess red meat and processed food, and physical inactivity. Early recognition of risk factors and warning signs can help diagnose colorectal cancers early, thereby improving survival.

 

What is the cause of Rising Colorectal cancer incidence in India?

There are many risk factors for colorectal cancers. These risk factors can be either modifiable or non-modifiable.

Non Modifiable risk factors: These factors are not under our control. However, knowledge of these is important as early stages of cancer can be identified by regular screening, leading to better survival.  These are

a.     Age: Above 50 years of age, the risk of colorectal cancer increases.

b.     Family history: A person’s risk of colorectal cancer almost doubles if a parent, brother, sister, or child has colorectal cancer.

c.      Inherited cancers: Certain known genetic mutations like familial adenomatous polyposis (FAP) or hereditary nonpolyposis colon cancer (HNPCC or Lynch Syndrome) increase the risk of colorectal cancers significantly.

d.     Race: Increased risk of colorectal cancer and death in African Americans.

e.     Personal History of Cancers: 

 

·       Previous history of colorectal cancer.

·       High-risk adenomatous polyps (1 cm or larger or that have cells that look abnormal under a microscope).

·       Ovarian cancer.

·       Inflammatory bowel disease (such as ulcerative colitis or Crohn's disease).

 

Modifiable risk factors: These factors can be controlled and improved to decrease the risk of colorectal cancers. These are

a.     Alcohol: Drinking 3 or more alcoholic beverages per day increases the risk of colorectal cancer. Drinking alcohol is also linked to the risk of forming large colorectal adenomas (benign tumors).

 

b.     Cigarette smoking: Cigarette smoking is linked to an increased risk of colorectal cancer and death from colorectal cancer. Smoking cigarettes is also linked to an increased risk of forming colorectal adenomas. Cigarette smokers who have had surgery to remove colorectal adenomas are at an increased risk for the adenomas to recur (come back).

 

c.      Obesity: Obesity is linked to an increased risk of colorectal cancer and death from colorectal cancer.

 

Protective Factors:

a.     Physical activity: A lifestyle that includes regular physical activity is linked to a decreased risk of colorectal cancer.

 

b.     Aspirin: Studies have shown that taking aspirin lowers the risk of colorectal cancer and the risk of death from colorectal cancer. The decrease in risk begins 10 to 20 years after patients start taking aspirin.

 

c.      Polyp removal: Most colorectal polyps are adenomas, which may develop into cancer. Removing colorectal polyps larger than 1 centimeter (pea-sized) may lower the risk of colorectal cancer. It is not known if removing smaller polyps reduces the risk of colorectal cancer.

 

d.      Nonsteroidal anti-inflammatory drugs (NSAIDs) other than aspirin: It is unknown if the use of nonsteroidal anti-inflammatory drugs or NSAIDs (such as sulindac, celecoxib, naproxen, and ibuprofen) lowers the risk of colorectal cancer conclusively.

 

e.     Calcium: It is not known if taking calcium supplements lower the risk of colorectal cancer significantly.

 

f.       Diet: It is unknown if a diet low in fat and meat and high in fiber, fruits, and vegetables lowers the risk of colorectal cancer. However, a diet rich in fiber and fruits improved overall gut health and immunity. Some studies have shown that a diet high in fat, proteins, calories, and meat increases colorectal cancer risk, but other studies have not.

 

How and when do we start screening for colorectal cancer?

The U.S. Preventive Services Task Force (USPSTF) recommends 50 years of age to initiate screening for average-risk patients. In African-Americans (high-risk group), it can be lowered to 45 years of age due to high early-onset incidence. For those with other high-risk attributes (positive family history or cancer syndromes), screening can be initiated from as early as 20 years. Screening for those with a positive family history is recommended to start ten years before the family member's age of diagnosis. USPSTF doesn't recommend routine CRC screening in adults 86 years and older.

What are Screening Modalities?

1.) Stool test :Guaiac FOBT (gFOBT) &Fecal Immune-chemical Test (FIT) 

Frequency of testing: Experts recommend sigmoidoscopy every five years for people at average risk who have had negative test results.

2.) Stool DNA Test

Frequency of testing: The current recommendation is once every three years. If positive on any of the occasions, endoscopic studies such as colonoscopy and sigmoidoscopy are recommended.

3.) Sigmoidoscopy

Screening frequency: Sigmoidoscopy should be performed at five-year intervals from baseline intervention, with gFOBT/FIT every three years.

3.) Colonoscopy

Screening frequency: Patients undergoing colonoscopy should have a 10-year interval between screening colonoscopies if an examination is negative and of adequate quality.

4.) Virtual Colonoscopy using CT scan

Screening frequency: Current USPSTF recommends Virtual colonoscopy with CT scan every five years from baseline CTC or optical colonoscopy. 

 

What are the warning signs of colorectal cancer?

 

·        A persistent change in your bowel habits, including diarrhea or constipation or a change in your stool's consistency.

·        Rectal bleeding or blood in your stool.

·        Persistent abdominal discomfort, such as cramps, gas, or pain.

·        A feeling that your bowel doesn't empty.

·        Weakness or fatigue.

·        Unexplained weight loss.

 

What to do if you get the above symptoms?

 

Contact an accredited cancer specialist (Currently recognized cancer degrees in India are Cancer Surgeons- MCh/DNB Surgical Oncology, Chemotherapy Specialists- DM/DNB Medical Oncology, Radiation specialists- MD/DNB Radiation Oncology).

 

How is the evaluation of colon cancer done?

 

Evaluation of colon cancer must include:

1.     Clinical evaluation

2.     Colonoscopy and biopsy

3.     Blood tests

4.     Workup for local spread and Metastasis (distant spread)

 

1.     Clinical evaluation:

 

Includes complete history taking and physical evaluation that involves digital rectal examination. The cancer surgeon uses his fingers to evaluate the condition of the rectum. If there is any growth inside, it also assesses its characteristics that help to decide the type of surgery required. Most commonly, to determine if sphincters (which enables to hold stool) can be saved or not, in which case a permanent stoma will be required.

 

2.     Colonoscopy and biopsy

This includes viewing the entire colon and rectum using a colonoscope( a camera mounted on a flexible tube). This procedure is performed either awake or in mild sedation. Any suspicious lesion is biopsied and sent for evaluation.

 

3.     Blood tests

Specific blood tests like Serum CEA are raised (not always) in colorectal cancers. These tests help in diagnosis as well as their levels during treatment help to determine treatment effectiveness.

 

4.     Workup for Local spread and distant spread (Metastasis)

 

This is performed to see how much cancer has spread in the body locally (where the colon is situated) and distant spread like liver, lung, bones, brain, and lymph nodes. This can be done either through CT scan or PET scan, or a combination of both.

 

How to proceed with the treatment?

 

Treatment for colorectal cancer is primarily surgery. Chemotherapy/ Radiotherapy can either be preceded by Chemotherapy/Radiotherapy to decrease the volume of disease or followed by Chemotherapy/Radiotherapy to increase the benefits of surgery.

 

Is there an option of Laparoscopic Surgery for Colorectal Cancer?

 

Laparoscopic Surgery/ Keyhole Surgery/ Minimally invasive surgery has become the standard of care for colorectal cancer.

 

What is laparoscopic surgery?

Laparoscopy is a type of surgery in which operation is performed using tiny incisions (3mm to 12mm) over skin with the help of a camera and delicate instruments. This type of surgery can be used to perform surgery in the thorax, abdomen, and pelvis. Other names for laparoscopic Surgery are Minimal Invasive Surgery, Keyhole surgery, or band-aid surgery. 

 

Why do we need Laparoscopic Surgery?

Cancer surgeries involve resection of multiple organs to achieve complete removal of disease. This requires good tissue exposure, for which extensive incisions need to be taken over the body cavity. Due to prolonged surgery, the interior of our body is exposed to the environment for a long time during surgery, leading to an increased risk of infections. Keyhole/ Laparoscopic Surgery provides very good vision due to recent advances in lens and camera systems that we use and which can be inserted in the body cavity through less than 1 cm incisions. 

 

What are the advantages of laparoscopy in cancer surgery?

 

Advantages for Surgeons:

 

Perfect vision.

Minute details of surgery visible.

High precision surgery can be carried out due to camera magnification.

 

Advantages for the patient:

Less Blood loss.

Reduced rate of infection.

It decreased postoperative pain.

Early discharge from hospital.

Early resumption of the regular day-to-day activity.

Less incidence of postoperative incisional hernia

 

Does it requires different expertise/experience apart from conventional cancer surgery training?

Yes. It requires extensive skill-based training after receiving conventional cancer surgery training. Not every surgeon is comfortable with advanced laparoscopic surgery. It requires dedicated extra hours of commitment and willingness to improve surgical skills using fine laparoscopic instruments. Remember, “NOT ALL SURGEONS ARE CANCER SURGEONS AND NOT ALL CANCER SURGEONS ARE LAPAROSCOPIC SURGEONS” It takes years of training and experience in all three aspects- CANCER, SURGERY, and LAPAROSCOPY.

 

What are the costs involved?

 

At face value, Laparoscopic Surgery might seem to be slightly costly compared to open surgery. However, when other costs are taken into accounts, such as increased hospital stay, more pain killers, more number of surgical site dressings, and increased cost of antibiotics ( if there is an infection, which is more likely in open surgery), then the cost of laparoscopic surgery is actually less or similar compared to open surgery. Not to forget the decreased pain in a postoperative period, which makes every pennyworth.

 

For more information on Laparoscopic cancer surgery, visit- https://laparoscopiccancersurgery.blogspot.com/2021/04/laparoscopiccancer-surgery-1.html

 

What happens after surgery?

 

After a few days of postoperative period depending upon the final histopathology, the disease stage will be decided. Depending upon the stage and other clinical factors, an accredited Tumor board will decide upon further treatment, i.e., Chemotherapy/Radiotherapy/Targeted therapy.

 

How do I follow up after the treatment?

 

You need to follow up after three months of treatment completion with your cancer surgeon. After that, every 3-6 months for the 1^st two years and then 6-12 months for the next three years and after that annually. At every visit, a complete history taking and physical examination will be done. A few blood tests and Ultrasound abdomen/Pelvis or CECT/ PET CECT may be advised.

 

For a more detailed discussion or queries on colorectal cancer treatment/ Laparoscopic Cancer Surgery, mail drarvindlapsurgeon@gmail.com/drajeetramantiwari@gmail.com

Contact: Mob/Whatsapp: 9833984333/9818826423