What treatments are there for bowel cancer?

Treatment for bowel cancer includes surgery, chemotherapy, radiation treatment, and monoclonal antibodies. Most people will have surgery, while some people receive a combination of treatments. Treatment choice depends on the size of the cancer, its location, and whether it has spread. Your general health and your wishes are also important in the decision making. In some cases you may want to seek a second opinion.

Your treatment team

You will be cared for by one or more of a team of health professionals including:

• your family doctor, who will often be the first person you see
• surgeons, who specialise in surgery
• medical oncologists, doctors who are responsible for chemotherapy and other aspects of cancer care
• radiation oncologists, doctors who specialise in the use of radiation treatment
• radiation therapists, people who prepare you and give you your radiation treatment
• oncology nurses and/or colorectal nurse specialists, who will help you through all stages of your cancer treatment
• stomal therapists, who will assist you if you have a stoma bag (colostomy or ileostomy)
• dietitians, who will recommend the most suitable foods to eat
• social workers, physiotherapists and occupational therapists, who will advise you on the support services that are available and help you get back to normal activities.

See also Questions to ask your doctor when you have cancer

Other tests

You may have the following tests before or after surgery:

• chest x-ray
• CT (computerised tomography) scans, MRI (magnetic resonance imaging) scans and ultrasound.

These procedures can examine parts of your body, such as the liver, chest and abdomen. Ask the medical staff if it is appropriate for your partner or friend to stay with you when the tests are carried out.

Surgery for bowel cancer

The type of operation you have will depend on:

• where the cancer is in the bowel
• the type and size of the cancer
• whether the cancer has spread.

How long you stay in hospital will depend on the type of operation you have.

Types of surgery

Surgery to remove part of the bowel is called a colectomy:

• left hemicolectomy - left side of the bowel is removed
• transverse colectomy - middle part of the bowel (transverse colon) is removed
• right hemicolectomy - right side of the bowel is removed
• sigmoid colectomy - sigmoid colon is removed
• total colectomy - large amount of colon removed.

After your surgeon removes the part of the bowel containing the tumour and the surrounding lymph nodes, the ends of the colon are joined back together. The place where they join is called an anastomosis.

Sometimes, to give the area time to heal, the surgeon makes a temporary colostomy or ileostomy higher up the bowel (see below). You will have the temporary stoma repaired in another operation several months later. This is called a stoma reversal. In the meantime, you will have a colostomy bag over the opening of the bowel.

If you have a total colectomy, your surgeon may not be able to join together the ends of the bowel that are left. You may need to have a permanent ileostomy or stoma.

Colostomy

If, for some reason, the bowel cannot be rejoined, the upper end can be brought out onto the skin of the abdominal wall. This is called a colostomy and the opening of the bowel is known as a stoma. A bag is worn over the stoma to collect the stool (bowel motions).

Sometimes a colostomy is only temporary and another operation to rejoin the bowel can be done a few months later.

If it is not possible to reverse the colostomy, the stoma is permanent. However, only a small number of people with cancer of the colon will need a permanent colostomy.

Ileostomy

Some people need to have an operation called an ileostomy, in which the end of the small bowel (ileum), or a loop of ileum, is brought out onto the right side of the abdominal wall. As with a colostomy, stools are then collected in a bag worn over the stoma.

Surgery for rectal cancer

You may have radiation treatment or chemo-radiation to shrink a tumour before surgery, to make it easier to remove.

Total mesenteric excision (TME)

During most surgery for rectal cancer, the surgeon removes the tumour and some surrounding rectal tissue. They also remove the fatty tissue around the bowel and a sheet of body tissue called the mesentery. This lowers the risk of the cancer coming back. For cancers in the upper part of the rectum, your surgeon will remove the part of the rectum containing the tumour (a 'low anterior resection').

If your tumour is in the middle part of the rectum, your surgeon may remove most of the rectum and attach the colon to the anus (a 'colo-anal-anastomosis').

Sometimes the surgeon can make a small pouch by folding back a short section of colon, or by enlarging a section of colon. This small pouch then works as the rectum did before surgery. During this operation you will probably have a temporary colostomy or ileostomy made. You have the temporary ileostomy for some months while the bowel heals. You then have a second operation to close the stoma opening.

If the cancer is in the lower part of your rectum, your surgeon will not be able to leave enough of the rectum behind for it to work properly, so they will remove your anus and rectum completely. This is called an 'abdoperineal resection' (AP resection). Then the surgeon will make a permanent colostomy opening on your abdomen. After this type of surgery you have two wounds - a wound on your abdomen and a second wound around the anus, where it has been closed.

Keyhole bowel surgery

For small bowel cancer the surgeon can use keyhole surgery (laparoscopic resection). The surgeon makes several small cuts in your abdomen instead of making one large cut. The surgeon passes a long tube called a laparoscope and other instruments through these cuts, and can then look through the laparoscope to do the operation.

The surgeon then removes the tumour through as small a cut as possible. This type of surgery takes longer than a traditional open operation. However, the stay in hospital may be shorter.

If the cancer blocks the bowel

Usually, your surgery for colorectal cancer would be planned in advance, after your tests have found the cancer. But sometimes the cancer completely blocks the bowel ('bowel obstruction') and in this situation you need an operation straight away. The surgeon may put a tube called a stent into the bowel during an endoscopy.

The stent holds the bowel open so that it can work normally again. You may have immediate surgery to remove the cancer from the bowel or a stoma may be formed to relieve the obstruction.

Side effects of surgery

An operation on your bowel is a major procedure and you may feel tired for weeks or even months afterwards. You may find that you will need to take 4 to 6 weeks off work and will be unable to lift heavy objects.

Talk to your doctors and nurses about what you can expect. You may find it helpful to talk to a dietitian about what to eat. There are medications available to help manage changes in your bowel habits after bowel surgery.

Managing your stoma

If you have a stoma, the stomal therapists (specialist nurses) will manage your stoma bags initially, and then work with you to teach you how to do this yourself. Ostomy bags and appliances are supplied free when you are at home if you are a New Zealand citizen. You may find it helpful to get in touch with someone else who has had a stoma and talk to them about how they cope. Your stomal therapists, local Ostomy Society or Cancer Society will be able to help.

Staging the cancer

After the operation the laboratory will examine the tumour and surrounding tissue to assess the stage (size and extent) of the cancer and whether it has spread to the lymph nodes or other organs such as the liver.  With this information the doctor will decide if further treatment is recommended.

Stage 0 or carcinoma in situ
This is the earliest form of cancer, found only in the inner lining of the colon or rectum, usually as a polyp. Major surgery is unnecessary and most polyps can be removed at the time of colonoscopy (a 'polypectomy').

Stage I (sometimes called Dukes' A cancer)
This is also early cancer and is still confined to the inner lining of the bowel. Treatment is surgery to remove the cancer.

Stage II (sometimes called Dukes' B cancer)
Cancer has spread through the wall of the bowel, but it has not gone to the lymph nodes. Treatment is surgery to remove the cancer. Occasionally chemotherapy and radiation treatment are recommended.

Stage III (sometimes called Dukes' C cancer)
Cancer has spread to nearby lymph nodes and/or through the bowel wall, but has not spread to other parts of the body. Treatment is surgery to remove the cancer, which is usually followed by chemotherapy and/or radiation treatment.

Stage IV
This means that cancer has spread to other parts of the body. Treatment options may include surgery and chemotherapy and/or radiation treatment and monoclonal antibodies.

Chemotherapy

Chemotherapy is the treatment of cancer using anti-cancer (cytotoxic) drugs. The aim is to destroy cancer cells while doing as little harm as possible to normal cells. Usually, treatment is given in cycles, spread over weeks or months.

Chemotherapy is given by injection or drip into a vein, or via a portable infusion pump worn on the body to deliver the drugs continuously into the veins. Some chemotherapy drugs are given as tablets or capsules. Chemotherapy is usually given as an outpatient. Also see chemotherapy

Side effects of chemotherapy

Side effects of chemotherapy are usually temporary and go away soon after treatment. People may manage to continue with their normal life at home and work throughout their chemotherapy.

Problems may include:

• infections - the drugs can lower your ability to fight infections
• sore mouth
• diarrhoea (this may be severe; contact your treatment team immediately)
• constipation
• feeling sick or vomiting
• tiredness
• loss of appetite or taste changes
• weight loss
• redness, numbness, pain and peeling of hands or feet (sometimes called hand and foot syndrome)
• hair loss is an uncommon problem for people being treated for bowel cancer
• women may find their periods become less regular or stop altogether
• women may have hot flushes, a dry vagina, mood swings or other symptoms of menopause
• women may have vaginal itch, burning or infections.

If fever develops (if your temperature is 38 degrees or over) or you feel unwell, even with a normal temperature, do not wait to see what happens - take action quickly. Contact your cancer doctor or nurse and follow the advice given.

You and your partner should use a contraceptive during treatment because the drugs can cause birth defects or miscarriage.

Also see chemotherapy side effects

Radiation treatment

Radiation treatment is the use of high-energy radiation to destroy cancer cells or prevent them from reproducing. Radiation treatment only affects the part of the body at which the beam(s) is aimed, so is very localised.

Radiation treatment is commonly used in rectal cancer. It is given most commonly before the operation to shrink the cancer so that the surgeon can remove it more easily.

Less commonly, it is given after surgery to destroy any remaining cancer cells. Radiation is usually given daily for 5 days a week. It can continue for 6 to 7 weeks, depending on the size of the tumour, the kind of treatment being used and the dose required. Blood tests and scans may be needed, and you will see your doctor once a week.

See also radiation treatment

Side effects of radiation treatment

Although radiation treatment is not painful, there are side effects. Usually these are temporary. It is important to discuss any side effects with your cancer treatment team who can advise you on how to manage these effects.

Side effects may include:

• tiredness
• diarrhoea
• skin irritation
• not wanting to eat
• nausea or vomiting  
• loss of pubic hair.

Pre-menopausal women who are treated in the pelvic or abdominal area may find their ovaries are affected, because of the difficulty in shielding these organs from the radiation. These women might find their periods stop during treatment, or for a few months afterwards, and may not return.

Women may also have hot flushes, a dry vagina, or other symptoms of menopause. If a woman's ovaries are permanently affected, she will not be able to conceive children naturally.

Men who are treated in the pelvic or abdominal area are less likely to have sexual problems because it is much easier to shield the testicles from the radiation.

Also see radiation treatment side effects

Combined treatment before surgery for rectal cancer

Research has shown that for people at greater risk of rectal cancer recurrence, the combination of chemotherapy and radiation treatment before surgery is more effective at reducing the risk of cancer coming back, compared with radiation treatment alone.

This treatment would be for a 5-week period, usually followed by a 6-week break while the radiation treatment continues to work. After this break, surgery would take place. However, having chemotherapy and radiation treatment together increases the chance and severity of side effects, such as diarrhoea, feeling sick (nausea) and low blood counts.

Treatment for advanced cancer

If the cancer has spread, your doctor will discuss various treatments for specific problems caused by the cancer.

These may include:

• surgery to remove the cancer or to bypass any obstruction so that the bowel will continue to work normally
• surgery to remove the cancer in other parts of the body, such as the liver or lungs
• chemotherapy and radiation treatment which can shrink the cancer and control symptoms, such as pain and bleeding
• treatment with monoclonal antibodies (called this because they come from a single cell), which work by recognising the protein on the surface of the cancer cell and then locking onto it (like a key in a lock). They destroy the cancer by either:
  -triggering the body’s immune system to attack the cancer cell, causing the cell to kill itself, or
  -attaching a cancer drug or a radioactive substance to the antibody. This delivers them directly to the cancer cell because they target those specific cells (targeted therapy).
  -an example of a monoclonal antibody is bevacizumab (Avastin).
• ablation therapy, which includes radio frequency or alcohol ablation and cryotherapy (freezing treatment) for areas of cancer in the liver
• stenting to relieve bowel obstruction
• nerve blocks for pain.

Referral to palliative care services will be helpful for ongoing management and support. Contact your local Cancer Society for details of services within your area. In some cases, advanced cancer does not require immediate active treatment, especially if it is growing slowly.

Taking part in a clinical trial

Research into the causes of bowel cancer and into ways to prevent, detect and treat it, is continuing. Your doctor may suggest you consider taking part in a clinical trial. It is always your decision to take part in a clinical trial. If you do not wish to take part, your doctor will discuss the best current treatment for you.

After treatment

During your illness you will be monitored frequently. This usually involves regular CEA (carcinoembryonic antigen) blood tests and colonoscopy (procedure to inspect the bowel). After the completion of your treatment, you may need to have regular check-ups. Your doctor will decide how often you will need these check-ups as everyone is different. Check-ups will gradually become less frequent if you have no further problems.

Many people worry that any pain or illness is a sign that the cancer is coming back. This is usually not the case, but if you are worried about whether your bowel cancer is going to come back, ask your doctor what to expect. If your bowel cancer returns, you may need further treatment. It is important to report any new symptoms to your doctor.

Sexuality and bowel cancer

The anxiety and/or depression felt by some people after diagnosis or treatment can affect their sexual desire. Tiredness following an anaesthetic, major surgery, radiation treatment or chemotherapy will also reduce sexual desire. See also Cancer and sex.

Cancer support and ostomy societies

Cancer support groups offer mutual support and information to people with cancer and their families. It can help to talk with others who have gone through the same experience. Support groups can also offer many practical suggestions and ways of coping.

Ostomy societies provide support and practical advice to people with ostomies (stomas). Some societies may not be listed in the phone book, but your local Cancer Society centre will be able to put you in contact with a group in your area.

Related topics

See Bowel cancer and Bowel cancer diagnosis

See Cancer: getting support and Eating well when you have cancer

What does that term mean? See Cancer glossary

Original material provided by the Cancer Society, 2009. Reviewed by everybody, July 2010.