Colon Cancer Guide: All You Need to Know

Is Colorectal Cancer Common?

Colorectal cancer is the third commonest cancer in both males and females above the age of 50. Overall, the lifetime risk of developing colorectal cancer is about 1 in 22 (4.5%) for men and 1 in 25 (4%) for women. Colorectal cancer is one of the preventable cancers. Appropriate screening can reduce the risk of colorectal cancer by 60 percent. In the following posts we aim to discuss a lot of common concerns regarding colon and rectal cancer so as to spread more awareness about it.

Can we detect Colon Cancer at an early stage?

Unfortunately, most colorectal cancers are “silent” tumors. They grow slowly and often do not produce symptoms until they reach a large size. Early cancers can only be detected by screening tests.

What are the symptoms and Risk factor of Colon cancer?

Symptoms of Colon Cancer are as follows:

• A recent change in bowel habits, such as diarrhea, constipation, or narrowing of the stool
• Bright red blood in the stool
• Cramping or abdominal (belly) pain
• Weakness and fatigue
• Unintended weight loss

While anyone can get colorectal cancer, it is most common among people over age 50. Risk factors for colorectal cancer include:

• A personal or family history of colorectal cancer or polyps
• A diet high in red meats and processed meats
• Inflammatory bowel disease (Crohn’s disease or ulcerative colitis)
• Inherited conditions such as familial adenomatous polyposis and hereditary non-polyposis colon cancer
• Obesity
• Smoking
• Physical inactivity
• Heavy alcohol use
• Diabetes

How does our Diet contributes in development of Colon Cancer?

Dietary fat from red and processed meats may contribute to development of colorectal cancer. A diet rich in vegetables, fruits, legumes is protective against cancer. Such a diet is rich in antioxidants also. It is important to prevent constipation by drinking lot of water and consuming high fibre diet. In general avoiding heavily processed foods and consuming minimally processed food such as dairy products and yogurt is also protective. That’s why we need tele travel nursing giftedhealthcare.

Is Colon Cancer more common among young individuals?

Colorectal cancer usually occurs above age 50. But increasing number of cases are being diagnosed at younger ages. Individuals with a strong family history need to be careful. There is most likely a genetic basis for development of cancer in younger age. Genetic tests that can predict risk of development of colorectal cancer are now available.

What are the stages of Colon cancer?

The stage of the cancer determines probability of cure and survival. Colorectal cancer broadly has three stages.

1. Localized: The cancer has not spread outside the colon or rectum.
2. Regional: The cancer has spread outside the colon or rectum to the surrounding structures.
3. Distant: The cancer has spread to distant parts of the body such as the liver, lungs, or distant lymph glands.

What is a Polyp and how many types of polyps are found?

A polyp is a small growth in the inner lining of the colon. Polyps are small growths that appear inside the lining of the colon (also known as colonic mucosa). Colon polyps are common with increasing age. Polyps usually do not cause any symptoms and usually detected during colonoscopy. While majority of polyps are innocuous, some polyps can progress to cancer over a period of 10-15 years. The whole idea of colon cancer screening is to detect polyps that can turn into cancer and remove them when they are small.

If you were told to have a polyp during colonoscopy, make sure what was the type. There are generally two types:

1. Hyperplastic which are innocuous and not of concern and
2. Adenomas which are pre-cancerous.

Polyps more than a cm in size are of more concern. The type and size of polyp(s) determines when you would need to repeat a colonoscopy.

What are high risk cancerous polyps?

Polyps are generally of two types. Hyperplastic which are not of concern, and adenomas which are pre-cancerous and should be removed during a colonoscopy. Adenomas which are larger than 1 cm and have features called dysplasia seen on microscopic examination are the ones that can progress to cancer. Individuals who have more than three adenoma type polyps also have a higher risk of developing cancer.

What is colorectal cancer screening and How is it Done?

Screening is the process of looking for cancer or pre-cancer in people who have no symptoms of the disease. Regular colorectal cancer screening is one of the most powerful weapons against colorectal cancer. Screening is done with two objectives:

(a) Find early colorectal cancer, when it is small and within the colon and easier to treat,

(b) Detect polyps in the colon, and remove them before they progress to cancer.

A direct look into the colon by a colonoscopy is the best screening test. This is recommended once every 10 years after the age of 45. Other screening tests rely on detection of occult blood in stool. The stool occult blood test should be done once a year after age 45. Small polyps do not bleed and hence the stool occult blood test is not very reliable. Virtual colonoscopy, colon capsule and a stool DNA test are other methods for colorectal cancer screening.

Colonoscopy

Is colonoscopy best screening tool?

It have been proven time and again that a colonoscopy done once every 10 years after the age of 45 is the most effective way to detect early cancers as well as colon polyps and remove them before they turn cancerous. Screening colonoscopy has been recommended by most major medical societies across the world as the recommended test for prevention of colorectal cancer.

People are apprehensive of the invasive nature of the test. It needs bowel cleansing with a special solution a day prior to the procedure. Actual procedure takes 10-15 minutes, but one needs to take a day off from work since the procedure is done under sedation. There is fear of bowel perforation, bleeding or infection but these events are extremely rare for screening colonoscopies with the risk being 1 in 5000 procedures.

Colonoscopy can cost between 3000 to 4500 dirhams. One needs to do it once in 10 years. That is about 1 dirham per day for preventing colon cancer.

Is colonoscopy painful?

It is absolutely not painful. It needs bowel cleansing a day prior to the procedure with a special laxative solution. This can cause diarrhea and discomfort. The actual procedure is done under intravenous sedation and except for mild bloating and discomfort, there is no pain during or after the procedure. A person can go to work on the next day.

Virtual Colonoscopy

Using CT scan, and special software, a 3-dimensional view of the inside of the colon can be reconstructed and this helps doctors look for polyps or cancer. This test is useful in people who do not want to have a traditional colonoscopy. This test does not require sedation but bowel preparation is necessary. If polyps are detected, then a traditional colonoscopy is needed to remove these polyps.

What is FIT test?

The FIT (Fecal Immunochemical test) is a better way to detect occult (hidden) blood in stool compared to the traditional fecal occult blood test (FOBT). Cancers and large precancerous polyps in the colon tend to bleed a little and this minute amounts of blood can be detected by the FIT test that is done on a sample of stool. It is recommended to have a FIT test every year after the age of 45. If FIT is positive, one needs a colonoscopy.

What is Colon Capsule?

It is now possible to swallow a small capsule with an integrated camera that passes to the colon and captures thousands of images and helps detect polyps and cancers in the colon. Bowel cleansing is needed similar to a conventional colonoscopy, but no sedation is needed and there is no discomfort associated with the procedure. If a polyp is detected during the capsule procedure, a colonoscopy is needed to remove the polyp.

What is Stool DNA Test?

A stool DNA test looks for certain abnormal sections of DNA from cancer or polyp cells. Colorectal cancer or polyp cells often have DNA mutations (changes) in certain genes. Cells with these mutations often get into the stool, where tests may be able to detect them. Cologuard, the only test currently available, tests for both DNA changes and blood in the stool. The stool DNA test is recommended once in three years.

What is Genetic testing for Colon Cancer?

Doctors may look for specific gene changes in the cancer cells that might affect how the cancer is best treated. Some common genes that are tested for in colon cancer biopsy samples are KRAS, NRAS  and BRAF genes. Depending on the genetic mutations, targeted anti-cancer drugs can be selected to treat patients. Another set of genes MSI and MMR predisposes patients to other cancers such as uterine and ovarian cancer in females, apart from colon cancer.

If Polyps are found when one have to repeat colonoscopy?

Individuals who are detected to have 1-2 polyps less than 1 cm in size need to repeat colonoscopy after 5 years. Individuals with 3-4 polyps or any polyp greater than 1 cm in size need to repeat colonoscopy after 3 years. Individuals with five or more polyps should repeat colonoscopy after one year.

What is the Treatment of colon cancer?

Surgery to remove the affected part of the colon/rectum is the main treatment for cancer localized to the colon/rectum. For cancer that has spread to lymph glands outside the colon or to distant organs, chemotherapy is required. Radiation therapy is usually required in rectal cancers prior to or after surgery. Treatment decisions are best taken by a multidisciplinary team consisting of the surgeon, oncologist and the radiation specialist.

What is the rate of survival in colon cancer?

With advances in treatment, 70 percent of patients are expected to survive 5 years or longer. For localized colorectal cancer (cancer within the colon), the survival can be as high as 90 percent. For advanced cancer (cancer that has spread to distant organs), the survival drops to 15 percent. This emphasizes the need for early diagnosis of colorectal cancer and hence the universal adoption of colorectal cancer screening techniques. Apart from the stage, the patient’s age, presence of other illnesses and response to cancer treatment are also important determinants of survival.

Case Study: Rectal Bleeding

Blood in the stools or rectal bleeding is often an alarming thing to happen. It can happen at any age and is often sudden. It may be small in quantity in the form of few drops at time or it may be a large amount mixed with stools. It may be associated with pain while passing stools or can be absolutely painless. It often causes concern and scare, especially if it is large in amount.

Mark (name changed) was an otherwise healthy fifty-year-old gentleman who came to us with complaints of passing small quantity of fresh blood with stools for one week. He had no other complaints. He had similar blood in the stools 3 months ago and had shown to a doctor. He was told to have hemorrhoids (piles) and given some pills. He remained fine till the current episode of bleeding.

Blood in the stools is most commonly due to piles or hemorrhoids. The blood is usually in the form of drops of blood seen separate from the stools. Usually there is no pain. Hemorrhoids are common in those who have habitual constipation and strain a lot to pass stools. Minor bleeding from hemorrhoids can be treated with medicines. For recurrent bleeding and severe bleeding, surgery is required.

Another common cause of blood in the stools is anal fissure which is actually a sharp cut in the anal skin. This type is bleeding is usually associated with severe pain while passing stools unlike bleeding from piles which is painless. Anal fissure is usually treated with medicines and ointments.

A serious cause of bleeding in stools is inflammatory bowel disease also known as ulcerative colitis. This type of bleeding usually occurs for several days, blood is usually mixed with stools and stools itself are loose or soft. There is no pain while passing stools but there can be lower abdominal pain. The diagnosis of ulcerative colitis has to be confirmed on a biopsy from the colon. This is a chronic disease and needs treated with medications over several years.

The most alarming cause of blood in the stools is colon or rectal cancer. It can present with intermittent blood in the stools, usually painless. Person may have recent change in bowel habits especially development of constipation. Colon cancers can be effectively treated if diagnosed early.

A proper assessment of a patient with blood in the stools is essential. While hemorrhoids and anal fissure can be diagnosed by a simple rectal examination, it is often necessary to do a sigmoidoscopy to visualize the rectum and lower colon if other diseases such as colon cancer or ulcerative colitis are suspected. Flexible sigmoidoscopy is a very safe and simple procedure to perform and takes hardly 10 minutes to ascertain the exact cause of bleeding.

Mark finally underwent a sigmoidoscopy and found to have a small cancer in the lower part of the colon. He also had small hemorrhoids. Since the diagnosis was made quite early, Mark underwent a successful surgery for removal of the colon cancer.  

Some important points to remember:

• Any blood that is mixed with the stool should be investigated further
• Hemorrhoids bleeding is usually in the form of drops and blood is seen separately from stools.
• Presence of hemorrhoids does not mean that bleeding is necessarily from hemorrhoids. There can be other causes of bleeding that often go missed if proper investigations are not done.
• Any bleeding that occurs repeatedly should be investigated

Case Study: How Effective is Treatment for Colon Cancer?

A 70-year-old man had presented to a general practitioner for bleeding in stools. The person examined him in OPD and diagnosed him to have grade 4 hemorrhoids. He posted him for surgery but at the time of operation he realized that the patient has a tumor in the rectum. He abandoned the procedure and took biopsy from the growth.

The patient was diagnosed with a low carcinoma of the rectum. The plan of treatment changed completely. The patient had undergone different investigative tests like CT scan, MRI, PET scan to stage the disease and was advised to have a neoadjuvant treatment with chemotherapy and radiation to shrink the size of the tumor. The patient also had diabetes and hypertension in addition to chronic renal disease. The patient a course of therapy and then had the surgery done after 6 months. Laparoscopic surgery was done, and the patient responded excellently.

He still remains on my follow up with a continuous evaluation and monitoring of symptoms.

Colon and rectal cancers have a good outcome in the long run. They can be effectively treated by a multidisciplinary team of surgeon, medical oncologist and radiation oncologists. The long-term cure rates of colon cancer are very high. We have an aggressive approach to these group of malignancies. Early diagnosis remains the key. The biology of the tumor is another deciding factor. All patients should have complete access to state of art therapies available and aim to get a cure.

Pilodidal Sinus: Traditional Treatment or the Latest for a Painless Recovery

A young girl presented with a swelling on the lower back with severe pain . On examination she had a pilonidal abscess. She was admitted in emergency and drainage of the abscess was done. There was a large wound after the surgery. It took around 2 months of regular dressing to heal it. One year later she had a recurrent abscess. This burst on its own. The doctor then advised her surgery to remove the sinus. There was a sutured wound after Third surgery. It developed a seroma and a olorcollection. This was drained and pressure dressing was applied. Slowly it resolved. Patient is on a continuous follow up to remove the hair in the area to prevent another recurrence on cialis treatment.

This is one of the usual stories of a pilonidal sinus. Sometimes you would realise the patient had 6-7 radical surgeries.

Is there another way out. Endoscopic treatment of the Pilonidal sinus (EpSIT) is on e such techniques. It uses a camera to eliminate the root cause of the evil. The ingrowing hair in the area. It minimizes the trauma because of the surgery. It is a day care procedure. The pain is minimal. There are higher chances of recurrence, but those remain in open surgery too. The concept of radical surgeries is being questioned. The amount of trauma for a simplistic problem is being challenged.

What can be done or at-least attempted in a minimally invasive manner should become the front line of treatment. The radical procedures should be reserved for more complicated or recurrent cases.

Young women need a personalized care with best cosmetic results. EpSIT is  being  offered as a laser or minimally invasive alternative for treatment of pilonidal sinus by our colorectal surgeon Dr Ritu Khare in Dubai, Sharjah and AbuDhabi.

She has practiced all methods from traditional drainage; Karyadakis Flap, laser and EpSIT and can counsel what would be considered as the best option for a particular patient.

Understanding Surgery: A One-on-One with Dr. Ritu Khare

What are some recent groundbreaking laparoscopic surgical techniques for cancer patients?

It is an exciting phase. The first barrier has been breached. Patients’ understand how keyhole or laparoscopic surgery can benefit them. For cancers, the results of laparoscopic surgery are comparable or even better than open surgery. Patient acceptance and tolerance is better and post-operative recovery is faster. The survival of cancer patients’ has further improved with advances in adjuvant therapies. Minimally invasive surgery is by far the most important advance in the surgical field and is applicable In all sub-specialties. From a simple condition like repair of abdominal hernia or removal of the gallbladder to the most complex biliary and pancreatic surgeries; these can all be done by small holes in the abdominal wall. But it takes years of training and skills to get the correct combination.

What makes surgeries of the breast interesting to you?

“Women are women at the core. The breast is one part of the body which signifies feminism. Even after years, there is a strong element of inhibition in women to be able to openly express discomfort, pain, or something abnormal. This inherent issue leads to a delay in diagnosis of breast cancer, which if detected early is imminently curable. Being a female in this surgical field, it has been a privilege to have been able to break this barrier. It is overwhelming to see a large number of women seeking an opinion and eventually getting diagnosed. The presence of a female surgeon is required at the grassroots level. Breast cancer is increasing at an alarming rate and despite so much hype, we still have millions who need awareness and attention. It is an honor to be at a pedestal where one can directly offer valuable service, perform surgeries, and help save someone every single day.”

What are your favorite and challenging aspects about your job as a female surgeon?

“Being a surgeon gives you ‘power’ and the humility to accompany with it. You can only try your best to save or cure the patient. Many a times you succeed and there are times you don’t. The challenges are that you need to abide by the principles and ethics. Do not advise an un-indicated surgery. Always consider as if the patient was your ‘kin’ and try to do your best. Always remember ‘The patient trusts you and has put his faith in you.’ The other challenge is to deal with prejudice. A patient comes to you because you are a female surgeon; you diagnose a breast or a colon cancer and then the same patient gets operated by a male colleague, assuming him to be more capable. If a doctor is capable to diagnose, she is capable to treat as well. We need to keep our craft, training, and skill set updated. There is no scope of complacency. There is no scope for error. The patient also has to understand and respect the years of hard work before discriminating on the basis of gender.”

Dr. Ritu Khare,
Consultant Surgeon, Laparoscopic, Bariatric, and Breast Surgeon

A surgeon par excellence, Dr. Ritu Khare is a Consultant Surgeon practicing in the UAE for the last 15 years. She specializes in advanced laparoscopic surgery, gastrointestinal surgery, bariatric surgery, and breast diseases. Here she highlights some exciting aspects about her field.