More Rectal Cancer Patients Can Avoid Colostomy

Often, patients diagnosed with rectal cancer have to grapple with two unpleasant realities - a fear of having cancer, and a dread that surgery will inevitably mean a permanent colostomy. A permanent colostomy is performed if the surgeon cannot stitch the rectum back together and make normal bowel function possible. Instead, the surgeon makes an opening, or stoma, on the outside of the body for waste to pass through, where it is collected in a bag worn by the patient.

Until a few years ago, depending on the location and stage of their cancer, nearly one-third of patients with rectal cancer or large precancerous polyps did undergo permanent colostomies. Today, however, more patients than ever are eligible for rectal cancer surgery that spares the sphincter, the muscle that opens and closes the rectum, thus reducing the likelihood of permanent colostomy to one patient in 10 or fewer.

"That's important, because a lot of people have actually refused surgery for rectal cancer because they don't want to wear a bag permanently," says Bruce Brenner, MD, Assistant Professor of Surgical Oncology at the Medical College of Wisconsin. He and his Froedtert & Medical College colleagues routinely perform sphincter-sparing surgery, often aided by pre-surgery radiation to shrink the malignant tumor before it is removed.

In Wisconsin, colorectal cancer is the third most common cancer among men and the second most common cancer among women, according to the American Cancer Society (ACS), which also says that colorectal cancer can almost always be cured if it is detected early enough.

Making sphincter-sparing surgery available to more patients is critically important, Dr. Brenner says. "Now, we are able to preserve the sphincter even in some cases where tumors are located almost all the way down to the sphincter."

Surgeons, working together with Froedtert & Medical College radiation oncologists, are conducting clinical trials on the use of both chemotherapy and radiation before surgery to reduce the size of the tumor and decrease the likelihood of recurrence. In some cases, chemotherapy is also administered after the surgery.

"We're now finding that the combination of chemotherapy and radiation before surgery can reduce the likelihood of local recurrence to as few as 5% of patients," Dr. Brenner says.

Who's at Risk?
More than 90% of colorectal cancer occurs in men and women over 50 years of age. Some people under 50, however, are at greater risk if there is a family history of colorectal disease. At the Medical College, researchers are also studying hereditary links to cancer in adult patients age 50 or younger who have been recently diagnosed with colon or rectal cancer. According to Dr. Brenner, a study leader in the project that has received funding from the NIH, as many as one in five of the 11,000 US patients diagnosed annually with early-onset colorectal cancer may have a form of hereditary colon or rectal cancer.

David M. Ota, Chief of Surgical Oncology at the Medical College, has been actively involved in the Medical College research efforts, describing them in the October 2002 issue of the medical journal, Surgical Clinics of North America.

Diet and Screening Tests
For those over 50 with no known genetic risk, the chances of developing colorectal cancer are found to be diminished by eating a low fat, high fiber diet and by increasing physical activity. In addition, says the American Cancer Society, "Screening tests offer a powerful opportunity for prevention, early detection and successful treatment of colorectal cancer."

The ACS recommends these screening guidelines for all adults 50 and older:

• A fecal occult blood test annually, or
• A flexible sigmoidoscopy every five years, or
• A combination fecal occult blood test and sigmoidoscopy every five years, or
• A double-contrast barium enema every five years, or
• A colonoscopy every 10 years.

According to the American Cancer Society, only 45% of Wisconsin adults over 50 have had a sigmoidoscopy in the past five years, which is similar to the percentage ACS found nationally. Every year on average between 1996 and 2000, the ACS found that 3,193 Wisconsin people were diagnosed with colorectal cancer and 1,155 died of the disease annually.

Symptoms
The symptoms of colorectal cancer include:

• A change in bowel habits
• Diarrhea, constipation or a feeling that the bowel does not empty completely
• Blood, either bright red or very dark, in the stool
• Stools that are narrower than usual
• General abdominal discomfort, including frequent gas pains, bloating, fullness or cramps
• Weight loss with no known reason
• Constant fatigue
• Vomiting

Not all these symptoms necessarily mean cancer, Dr. Brenner says. Some of these symptoms can be present due to an intestinal blockage or other cause. And common colorectal conditions like hemorrhoids and diverticulosis (pouches in the intestinal wall that can trap food and cause discomfort) do not indicate cancer, he notes.

If cancer is detected, however, abdominal surgery is not inevitable if the disease is in an early stage. Some surgeries for rectal cancer can be performed without an abdominal incision, Dr. Brenner notes.

Through Medical College research efforts and clinical trials, patients diagnosed with colorectal cancer have more options than ever, with improving survival rates, Dr. Brenner says. "And," he reminds us, "fewer and fewer patients face a permanent colostomy."

Barbara Abel
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.