WHAT WE KNOW ABOUT CANCER OF THE COLLAR
More than 150,000 people in the United States find out that they have colon cancer each year. Despite the lack of very healthy cancer registries in Turkey, we estimate that approximately 30,000 people have been diagnosed with colorectal cancer proportionally. As Marmara University Faculty of Medicine Oncology Department, we aimed to give you information that may be important in this regard. This information includes the symptoms, diagnosis, treatment and causes of colon cancer and how to prevent it.
COLON AND RECTUM
The colon and rectum form the part of the digestive system called the “large intestine”. The upper part of the large intestines, approximately 150-180 cm, is called the “colon”, and the lower part of 15-17 cm is called the “rectum”.
After the food is digested in the stomach and small intestines, they come to the large intestines. Here, the water that has not been absorbed in the upper parts of the digestive system in the intestinal contents is also absorbed by the body, leaving the solid part called ‘stool’. The stool travels through the colon and rectum and is then expelled from the body through the anus.
WHAT IS CANCER?
Cancer is the uncontrolled excessive proliferation of cells in the body and their distribution to various parts of the body. There are more than 100 different types of cancer.
As in all other organs of the body, the colon and rectum are composed of different types of cell groups. Normally, cells reproduce only when the organism needs them. This ensures that the organism develops in a certain order and thus remains healthy.
If cells divide and multiply unnecessarily, a tissue mass is formed in that area. This extra mass is called ‘tumor (ur)’. These masses can be benign (benign) or malignant (malignant).
Benign tumors are not cancer. They do not spread to neighboring tissues and other organs of the body. Bening tumors can usually be removed from the body. Rarely, they can be harmful.
Polyp is a benign tumor. It can occur in the wall of the colon or rectum. These polyps in the colon and rectum should be removed because they may turn into cancer in the future. If a polyp is detected in a person, there is a high probability that a new polyp will form. Therefore, these people should be checked regularly.
Malignant tumors are called cancer. These tumors can spread to neighboring tissues and organs and damage them. Cancer cells can break off from the cancerous tissue and enter the blood or lymphatic pathways. This is how cancer spreads and tumors form in other parts of the body. The spread and spread of cancer is called “metastasis”.
Tumors can occur in any part of the colon and rectum. Cancer cells usually spread out of the colon and rectum through lymph (fluid). Colon and rectal cancers can spread to the liver, lungs, brain, kidneys and bladder.
When cancer spreads to another part of the body, they form a tumor of the same type as where it spread in that area and are called by the same name. For example, intestinal cancers are made up of colorectal cancer cells, the tumor that forms in the liver when it spreads to the liver. This condition is called “metastatic colorectal cancer” or “colorectal cancer that has metastasized to the liver”. It is not called “liver cancer”.
EARLY DIAGNOSIS
The earlier the cancer is diagnosed and treated, the better the results. This is especially important for colorectal cancers. The best results from the treatment are obtained if it is done before the disease spreads. By following the recommendations below, people can achieve early detection of colorectal cancers.
Request a “rectal examination” during regular check-ups. In this examination, the doctor wears a gel-coated glove to provide lubrication and examines the rectum with his finger and detects abnormalities in the rectum.
From the age of 50, have the “occult blood in stool” test done once a year. This test allows us to detect blood that may be found hidden in the stool. It can be done in a doctor’s office or a laboratory by placing a very small amount of stool in a plastic container. This test helps us to detect the amount of bleeding that we cannot see caused by colorectal cancers. In addition, there are other reasons that can lead to this type of occult bleeding. A positive test does not always indicate cancer.
From the age of 50, have a “sigmoidoscopy” examination every 3-5 years. This examination is to see the rectum and the lower part of the colon by entering through the anus with the help of a lighted tube pipe. With the help of this light tube, the doctor can see polyps, tumors and other abnormalities in this part of the intestines.
People who are at higher risk for colon and rectum cancer may need to have these tests more frequently or to have additional tests, upon the doctor’s recommendation.
SYMPTOMS
Colorectal cancers can show a variety of symptoms. Colorectal cancer should be suspected if the following symptoms are observed.
– Change in defecation habits,
– Diarrhea or constipation,
– Seeing blood smeared in stool or black stool like tar,
– Thinning of stool diameter,
– General stomach complaints (gas, bloating, pain or cramps),
– Frequent gas pains,
– The state of not completely emptying the intestines at the end of defecation ,
– Unexplained weight loss,
– Prolonged fatigue.
These symptoms may also be due to other reasons such as ulcers, intestinal inflammation, hemorrhoids. Your doctor will decide the cause of the symptoms. If these symptoms occur, you should consult your doctor. Because of these symptoms, your doctor may send you to another specialist doctor (such as a gastroenterologist).
DIAGNOSIS
In order to find the cause of the above-mentioned findings, your doctor will ask a number of questions about you and your family, conduct a detailed examination and request some tests. In addition to the tests mentioned earlier, your doctor may order the following additional tests.
Imaging of the intestinal system: It is the process of taking x-ray films after a solution containing barium is given to the patient through the anus (barium enema). Barium provides visualization of the colon and rectum, allowing the doctor to identify a tumor or other abnormality. Sometimes the doctor may need to dilate the bowel to see a small tumor. Therefore, air can be carefully introduced into the intestines throughout the test. This process is called “double contrast barium film”.
Colonoscopy: It is the examination of the entire colon using a lighted tube. This procedure is the same as with a bendable sigmoidoscope, but this time the light tube is longer.
If the doctor detects a polyp or an abnormal growth, he or she can remove it with the help of a sigmoidoscope or colonoscope. By sending this piece to the pathology doctor, it ensures that the piece is examined and cancer cells are investigated. The name of this procedure is “taking a biopsy”. Most of the polyps are benign. But the only way to detect this is to take a biopsy. If the pathologist (pathologist) detects cancer, the patient’s doctor wants to know the stage, size and extent of this cancer. The staging process helps the doctor determine whether the cancer has spread to other tissue and affected other organs. The decision about the treatment will be made according to these findings.
Staging is done by scanning these organs with X-rays, ultrasonography, and computed tomography, as colorectal cancer has mostly spread to the lungs and liver. Your doctor may order additional blood tests to determine liver functions, and a CEA (carcino embryogenic antigen) test may be requested. This test can be found in higher-than-normal amounts in the blood of people with colorectal cancer, especially when the disease has spread.
TREATMENT
The doctor will make a necessary treatment plan for each patient. Treatment of colorectal tumors depends on the extent of the disease, location, stage, general health of the patient, and other factors.
Most cancer patients want to know all about their disease and treatment options. Doctors are the best people to answer their questions. While talking about treatment options, the patient may ask his doctor about the studies (research) about the disease. These studies are called “clinical trials” and they are carried out to make cancer treatment better.
It helps patients to prepare a list of questions to ask before seeing the doctor. The patient can take notes, record what the doctor said and what was spoken. Some patients find it helpful to have a friend or family member with them during their consultation with the doctor.
Some
questions that the patient may want to ask the doctor before starting treatment are:
– What is the stage of the disease?
– What are my treatment options? Which one would you recommend for me? Why?
– Is there a clinical trial that might be suitable for me?
– What benefits do we expect from each treatment?
– What are the risks and possible side effects of each treatment?
– What can be done about side effects?
– What measures can I take on my own during treatment?
– What will be the possible cost of treatment?
The patient or a relative may naturally want to be informed about the effectiveness of the treatment. Sometimes they may ask for statistical information about whether the patient will recover completely or how long his life will be. It should be noted that these values are average values obtained from large patient groups. In particular, it would not be appropriate to use it as definitive data about a person’s prognosis. Because even two cancer patients are not the same. People ask the doctor about their chances of recovery and life. But doctors don’t always know what’s going to happen. When talking about the course of the cancer, doctors should use the term “remission” instead of “cure”. For this reason, doctors use the term “remission” because of the possibility of the disease coming back even though most patients have fully recovered.
There is much to learn about cancer and its treatment. Patients may not understand all of these at once. They should not hesitate to ask different questions to explain what they do not understand or to get more information.
METHODS OF TREATMENT
Colon cancer is usually treated with surgery, chemotherapy and/or radiation (radiation) therapy. Studies on new treatment approaches such as biological therapy are ongoing. One or a combination of these treatment modalities may be required for a patient.
Surgery is the most common form of treatment for colon cancer. The type of surgery varies depending on the location and size of the disease. In most of the patients, a method in the form of partial colectomy is applied. In this operation, the surgeon removes the cancerous part of the large intestine and some healthy tissue around it. Surgery is often the only treatment needed for early-stage bowel cancer.
Usually removing the lymph nodes around the tumor also helps with the stage of the cancer. Pathologists examine these lymph nodes under a microscope and determine whether they are infected with cancer. If the cancer has spread to these lymph nodes, it is likely to have spread to other parts of the body, requiring further treatment.
In most cases, surgeons ligate the intact portions of the large intestine after removing the tumorous portion. This part of the surgical procedure is called “anastomosis”. If the healthy parts of the large intestines cannot be connected to each other, the surgeon applies a procedure called “colostomy” and connects the intestines here by opening a hole in the abdominal wall that allows the contents of the large intestine to be ejected. The patient attaches a bag to this hole and allows stool to accumulate in this bag. The colostomy can be temporary or permanent.
Temporary colostomy; It is used temporarily for the healing of the lower part of the intestine after the surgical procedure. Then, with a second operation, the surgeon connects the intact intestines and closes the colostomy. Intestinal functions of the patients return to normal.
Permanent colostomy; may be necessary if the cancer is in the rectum. A small number of patients with cancer in the lower part of the colon may require a permanent colostomy. About 15% of patients require a permanent colostomy.
Although it takes time to adapt to a colostomy, most patients can return to their normal lives. A nurse or an experienced colostomy care professional teaches patients about colostomy care and ways to resume normal activities.
Some questions the patient may want to ask their doctor before surgery:
– What type of surgery will it be?
– What happens next? Will I have pain? How will you help me?
– Will a colostomy be needed? Will it be temporary or permanent?
– How long will I be in the hospital?
– Will I have a special diet? Who will give me the diet?
– When can I return to my regular job?
– Will additional treatment be required?
Chemotherapy is the use of drugs that kill cancer cells. Chemotherapy is sometimes given after the surgical procedure to prevent the spread of the disease. This additional treatment is called “adjuvant chemotherapy”. Chemotherapy is given to prevent the formation of new tumors or to eliminate the complaints caused by tumors that are not completely removed. The doctor may use a single drug or a combination of several drugs.
Chemotherapy is given only by nurses with special training. The number of chemotherapy is expressed as a cure (such as the 1st cycle, the 2nd cycle) and usually the same drugs are given by repeating every 21 or 28 days. Chemotherapy is most often given in the form of intravenous fluids in outpatient centers or as an oral pill. Sometimes, depending on the general condition of the patient, the drugs given or the way the drugs are given, patients may need to receive their treatment in the hospital. After each cure, patients are checked in the medical oncology outpatient clinic. In these controls, patients are examined, their complaints are listened to, the side effects of drugs are questioned, and some blood tests are requested to investigate whether they cause any harm to other organs in the body. Before each cycle, blood count should be done and this count should be shown to authorized nurses giving chemotherapy. The characteristics of the tumor in the pathology report determine whether a patient will receive chemotherapy after surgery and, if so, how many cures he will receive. However, the age and general condition of the patient also play an important role in making these decisions.
Chemotherapy is a “systemic treatment”, meaning that drugs enter the blood stream and are distributed throughout the body.
In clinical studies, researchers try to find ways to apply chemotherapy drugs only to the area to be treated. For colon cancer that has spread to the liver, drugs can be given directly to the liver through the blood vessels (This treatment is called “intrahepatic chemotherapy”). Generally, a person can receive chemotherapy drugs in the hospital, doctor’s office, or at home. This depends on which drugs are given and the general condition of the patient. A short hospital stay may be necessary.
Patients may ask the following questions about chemotherapy:
– What is the goal of treatment?
– What medications will I take? What will they do (for what use)?
– Will there be side effects of the drugs? What can I do in this situation?
– How long will the treatment take?
Radiation therapy (called radiation therapy or radiotherapy) is based on the principle that high-energy rays damage cancer cells and prevent them from growing. Like surgery, radiation therapy is a regional treatment. It only affects cancerous cells in the treated area. Radiotherapy can sometimes be used to shrink the tumor before surgery to make it easier to remove. It is more commonly used to destroy cancerous cells remaining in the area after surgery. It can also be used to relieve pain or other symptoms that occur in tumors that cannot be removed by surgery. Radiotherapy can usually be given as an outpatient in the hospital or in the clinic for 5 days a week, for several weeks.
Researchers are investigating more effective ways of administering radiotherapy. For example, the benefits of pre- and post-surgical radiotherapy (sandwich technique) or the application of radiotherapy during surgery are being investigated. Doctors are also investigating the use of radiotherapy alone (without surgery) for rectal cancer that has not spread.
Some questions patients want to ask before radiation therapy:
– How will radiation (beam) be delivered?
– What is the aim and goal of this treatment?
– When will the treatment start and end?
– What should I do on my own during the treatment?
– What kind of side effects can occur?
– Is there a risk of infertility as a result of treatment?
Biological therapy is the act of activating the body’s defense system to help destroy cancer cells. In some patients, biologic therapy can be used in combination with chemotherapy or used as adjuvant therapy after surgery. New types of biological therapy have been used in clinical trials. Patients may need to stay in hospital to receive some types of biologic therapy.
SIDE EFFECTS OF THE TREATMENT
It is difficult to ensure that the administered chemotherapeutic drugs only affect cancer cells. Because healthy tissues are also damaged, treatment may cause unwanted side effects.
The side effects of cancer treatment can vary from person to person and from treatment to treatment. Doctors try to minimize these side effects. Therefore, the doctor should know very well the health problems that may occur during and after the treatment.
SURGERY
Surgical treatment and opened colostomy in colorectal cancer may cause temporary constipation and diarrhea in patients. Doctors may recommend diet or various medications to minimize these problems. The patient who has pain after the operation should definitely tell this to his doctor. Thus, the pain will be relieved with the drugs given by the doctor.
Physical activity should be restricted to allow the wound to heal after surgery. In patients with a colostomy, tenderness may occur in the skin around the colostomy. Doctors and nurses protect the area from this sensitivity and infection by informing the patient about the care and cleaning of the colostomy area.
CHEMOTHERAPY
Patients receiving chemotherapy should undergo a doctor’s control in the medical oncology outpatient clinic approximately one week after each chemotherapy. In this control, the patients are examined, their complaints are listened, the side effects of chemotherapy are evaluated and the dose of the drug is adjusted if necessary.
The side effects of chemotherapy vary according to the drug given. As a general rule, chemotherapy affects rapidly proliferating cells. Blood cells that provide coagulation during bleeding, make our defense against diseases and carry oxygen to the organs in our body are cells that multiply rapidly. These blood cells decrease in number about 1 week and 10 days after receiving chemotherapy, and therefore there may be rapid bruising or bleeding after minor procedures such as tooth brushing. Normally, since our defense system is strong when they enter our body, microbes that do not cause disease can easily cause us to catch febrile diseases as the cells that provide our defense after chemotherapy are reduced. During this period, you should avoid eating raw vegetables and fruits (such as salad) that we wash and eat for at least 10 days. During this period, you should also avoid being in crowded environments in order not to get germs from the people around.
Do not forget that this forbidden fruit and vegetables are not due to any effect on your disease, but to avoid possible microbes that may remain on the vegetable or fruit you eat, no matter how clean you wash them. Make sure your food is cooked within this time frame. If you have a fever above 38.50C, exceeding one hour, you should definitely contact your doctor. If you have a fever and your blood cells are found to be low in the blood count, you will need to be treated with antibiotics. This decrease in the number of your blood cells will go away on its own within a week to 10 days and the cells will reach their normal numbers.
Another group of rapidly proliferating cells are digestive system cells and hair root cells. For this reason, after chemotherapy, hair usually falls out after the first week. Loss of appetite, nausea, vomiting, diarrhea and mouth sores may develop in patients, almost all of these side effects can be controlled with medication. These side effects are short-lived, the complaints of the patients disappear before the next chemotherapy starts. The severity of these side effects of chemotherapy varies from patient to patient.
Long, persistent side effects are rare today with modern chemotherapy. However, some chemotherapy drugs can have negative effects on the heart, and in those who use such drugs, the doctor periodically asks for tests to see if your heart is affected. The chemotherapy drug doses and chemotherapy cycle numbers used today are not large enough to have a negative effect on the heart. Some cancer drugs kill egg cells by affecting the ovaries, so the ovaries cannot produce the female hormone estrogen and patients enter menopause. Menstruation may become infrequent or stop, and in this case, women cannot become pregnant. Especially over the age of 35-40, infertility caused by chemotherapy is permanent. In younger patients, periods that are interrupted during chemotherapy may return to normal after a while.
Chemotherapy drugs are mostly given intravenously and they can damage the vein they are given over time, causing the vein to harden and become visible when viewed from the outside. You should inform your doctor immediately if redness, swelling and burning occur in the arm that you take the drug while you are receiving chemotherapy or the day after you take it.
If you need to use painkillers for any reason while receiving chemotherapy, consult your doctor. Because some painkillers can cause a decrease in the number or function of blood cells in the body. Apart from this, you can continue with your medicines that you use for your heart, lung and kidney disease and which are of vital importance during chemotherapy. It would be appropriate to show your doctor about these drugs that you have to use during your visits and ask if there is any harm.
BEAM THERAPY
Nausea, vomiting and diarrhea may occur in patients receiving radiation therapy to the abdominal region. Radiation therapy applied in colorectal cancers can cause hair loss in the pelvic region. This effect can be permanent or temporary. During treatment, the skin may become red, dry, tender and itchy. Patients should avoid tight clothing and prefer cotton clothing. Lotion or cream should never be applied to the skin without a doctor’s recommendation. During radiation therapy, patients feel very tired. This may continue, especially weeks after treatment. In this process, patients should rest as much as possible, but patients should not go away from their normal activities.
BIOLOGICAL THERAPY
Although the side effects of biological therapy are very diverse, a flu-like condition, chills, fever, weakness, nausea, vomiting, diarrhea and sometimes rashes may occur.
OTHER SIDE EFFECTS
Cancer can cause decreased appetite. Some patients experience an unpleasant taste in the mouth. Nausea, vomiting and mouth sores, which are mostly side effects of treatments, make it difficult for the patient to eat. But nutrition is very important. Meals must contain sufficient calories and protein. Thus, weight loss and tissue repair can be achieved.
Patients receiving treatment will feel more energetic and better if they eat regularly and adequately, and the side effects of drugs will be less common.
Sometimes colorectal cancer treatment can affect patients’ sex life. Temporary or permanent impotence may occur as a result of damage to some nerves and vessels during surgery due to treatment. Radiation therapy applied to the abdomen can also sometimes cause erectile dysfunction in men. Sexual problems may also occur in women who have undergone surgery for colorectal tumors. Radiation therapy may also cause temporary vaginal dryness and sensitivity. Doctors and nurses can make suggestions to overcome these problems.
It is okay to continue your sexual life as before during and after the treatment. Due to the mutagenic effects of chemotherapy on ovarian cells (serious abnormalities may occur in the baby), one of the birth control methods should be preferred to prevent pregnancy during the treatment. Most of the chemotherapy drugs given impair the functioning of the ovaries, but the degree of this effect varies from patient to patient.
The physical and mental problems you experience with the post-diagnosis treatment plan may affect your feelings such as fatigue, feeling of weakness, desire and excitement in your sexual life, due to illness or treatment. Such problems with your sexual life will pass over time, as will other problems you experience during this period and pass after treatment.
Patients with colostomy have special concerns about their sexual life. It may take time to get used to the colostomy before they are ready for sexual intercourse. Some patients may share this with a partner, friend, or therapist who understands their thoughts and feelings. Enterostomy specialists can help patients adjust to a colostomy in their sexual lives. He can take some precautions and make suggestions for the continuation of their sexual life.
Do not hesitate to tell the doctors and nurses in the chemotherapy unit that you are receiving treatment that you have concerns about your sexual life and that you would like help in this regard.
FOLLOW-UP
Regular follow-up of patients after colorectal cancer treatment is very important. The cancer may reappear in the same or adjacent area, or it may spread to another part of the body. Doctors will monitor their patients closely and if the cancer comes back, they will treat it again as soon as possible.
Follow-up includes physical examination, stool occult blood test, sigmoidoscopy, colonoscopy, chest X-ray, various blood tests, and CEA measurement. Sıklıkla ameliyattan önce hastaların CEA düzeyleri yüksektir ve ameliyatla tümör çıkarıldıktan sonra haftalar içinde normalleşir. Eğer CEA düzeyleri tekrar yükselmeye başlarsa, bu kanser geri geliyor anlamına gelebilir. Bu arada diğer testlerde yapılmalıdır. Çünkü bu yükselme kanser dışında diğer nedenlerle de olabilir.
Kolorektal kanserle ilgili kontrollerin yapılması sırasında hastalar diğer kanser tipleri açısından da kontrol edilmek isteyebilirler. Kalın bağırsak kanseri olan kadınlarda meme, yumurtalık ve rahim ağzı kanserlerinin gelişme riski artmıştır. Erkeklerde ise prostat kanserinde artış görülür.
Kanser tedavisi gören hastaların az bir kısmında yıllar sonra da yan etkiler görülebilir. Hastalar olabilecek bu yan etkiler konusunda da doktorlarıyla konuşmak isteyebilirler. Böylece hastalar düzenli kontrollere devam ederler ve herhangi bir problem ortaya çıkar çıkmaz doktora haber verirler.
NEDENLER VE KORUNMA
Kolorektal kanser en sık kanserlerden biridir. Kolorektal kanser oluşumu tek bir sebebe bağlanamaz. Çeşitli faktörler kolorektal kanser oluşumunda rol oynayabilir. Kanser bulaşıcı değildir. Bazı insanların kolorektal kanser olma riski diğerlerinden daha fazladır. Aşağıdaki durumlarda risk artmıştır:
Polipler: Çoğu (hemen hemen hepsi) kolorektal kanser, bağırsak poliplerinden gelişir. Polip selim bir oluşumdur fakat bazen kansere dönüşebilir. Poliplerin alınması kanser oluşumunu önlemede en önemli yoldur.
Yaş: 50 yaşın üstü kolorektal kanser riskinin arttığı yaş grubudur.
Aile öyküsü: Yakın akrabalarda bağırsak kanseri bulunması kanser oluşum riskini artırır. Hatta bazı tip kolon kanserleri ailesel geçiş gösterir.
Familial polipozis: Bu kalıtsal hastalık kalın bağırsaklarda yüzlerce polip oluşumu ile kendini gösterir. Zamanla bu polipler kansere dönüşebilirler. Tedavi edilmemiş “familial polipozis”li hastalar mutlaka bir süre sonra kanser olurlar.
Diyet: Diyetlerinde yüksek yağ, düşük meyve ve sebze ve düşük posalı gıdalar alanlarda kolorektal kanser görülme riski daha fazladır.
Ülseratif kolit: Bu hastalık bağırsağın iltihabi bir hastalığıdır. Bu hastalarda diğer insanlara göre bağırsak kanseri olma riski daha fazladır.
Araştırmacılar bazı faktörlerin de kanser oluşumunu arttırdığını düşünmektedirler. Örneğin şehir yaşamının kanser oluşumunu arttırdığı düşünülmektedir. Siyah ırkta kolon kanseri, beyaz ırkta da rektum kanseri görülme sıklığı fazladır.
İnsanlar bağırsak kanseri olma risklerini azaltabilirler. Örneğin bağırsaklarında polip saptanan birisi doktoru ile görüşerek onun alınmasını sağlayabilir. Yeme alışkanlıklarını değiştirip daha az yağlı yiyecekler yiyebilirler. Fazla yağlı yiyecekler; et, yumurta, kurutulmuş yiyecekler, yemeklerde ve salatalarda kullanılan yağlardır. İnsanlar yiyeceklerindeki posa miktarını artırabilirler. Posalı yiyecekler; kepekli ekmek ve tahıllardır. Bu konuda diyet uzmanları size yardımcı olabilir.
Sonuç olarak özellikle 50 yaş üzeri insanların bağırsak kanseri konusunda risk durumlarını doktorları ile görüşüp, onların uygun göreceği kontrolleri yaptırmalarında yarar vardır.
Bağırsak kanserleri konusundan daha fazla bilgiyi aşağıdaki telefon, fax ve e-mail adresleri ile ilgili internet sitelerinden edinebilirsiniz.
Bu kitapçık ABD Ulusal Kanser Enstitüsü tarafından yayınlanan “What You Need To Know About Cancer of the Colon and Rectum” adlı kitapçık esas alınarak hazırlanmıştır.
