Medical Perspectives | Others

February 24, 2020



Gwen Y. Reyes-Amurao, M.D.

Manny was a 35-year-old fit young man who had always been known for his basketball and generally athletic abilities. In high school, he would always be named the Most Valuable Player in any tournament his team would join, and in all the basketball leagues he would play in for that matter. He was a fairly healthy eater with the occasional binging on his favorite fast food restaurant. He hated smoking and often enjoyed a drink or two during social gatherings. He had a high position at work and was doing quite well, marrying his college girlfriend and then having two wonderful kids. The past few months though, he noticed he was feeling more tired than usual but attributed it to his lack of exercise because of his busy schedule. He would also have crazy hours at work and would rarely have a decent meal or get enough sleep. One day while getting ready for work, he noticed that there was fresh blood in the toilet bowl after using it. He wasn’t really alarmed and figured it was just his hemorrhoids acting up again since he’d been eating a lot of spicy food lately. No other episodes followed until three months later when he noticed it again after using the bathroom. This time, there seemed to be more blood than usual. Alarmed, he immediately sought consult with a specialist, who later on requested for a colonoscopy to help determine where the bleeding was coming from. A suspicious looking lesion was seen during the procedure, and surgery was recommended thereafter. Biopsy of the mass was done, and Manny was diagnosed to have colon cancer.

 

Colon or colorectal cancer is the number one gastrointestinal cancer in the Philippines. According to Dr. Frederick Dy, president of the Philippine Society of Gastroenterology, there are over 3,000 new cases of colorectal cancer among Filipinos annually, with more than 2,000 of them dying due to its complications and its severity. In 2016, a global research revealed that the Philippines had the highest increase in mortality among the 37 countries surveyed. Find out more about this deadly disease and why more and more people are slowly succumbing to it.

 

What is colon cancer?

Colon cancer is a cancer of the large intestine, which is the terminal or end part of the digestive tract. Colon cancer can be collectively grouped with rectal carcinomas, more commonly known as colorectal cancers wherein the malignancy can be found within the colon or rectum. According to the American Cancer Society, most colorectal cancers begin as a growth called a polyp on the inner lining of the colon or rectum. Some types of polyps can become malignant after a few years, but not all of them do. Adenomatous polyps are those that can change into cancer, and are thus called a pre-cancerous polyps. Hyperplastic or inflammatory polyps are the more common type and are generally not pre-malignant. Other characteristics of the polyp, which can determine its likelihood to become malignant include size, quantity, and the presence of dysplasia wherein the cells may look abnormal but not yet completely cancerous.

 

How do I know if I have colon cancer?

Since these lesions often begin as small polyps, they may produce very few or no symptoms in the beginning. Once they are big enough to manifest signs and symptoms though, you may observe any or all of the following:

  • Change in bowel habits

In an article published by the Department of Science and Technology, Dr. Dennis Ngo, board director of the Philippine Society of Gastroenterologist, explains that some observable signs and symptoms may include stool frequency changes, or sudden change in stool size from big to small or the other way around. Other changes in stool consistency may include diarrhea or constipation, or tenesmus or pain when defecating.

  • Rectal bleeding described as mucopurulent or bloody stools

In the early stages, one can experience painless stools with blood or blood that is fresh or red (similar to that observed in hemorrhoids), which can later progress to dark red, and bloody stools, that may be covered with mucous.

  • Persistent abdominal discomfort like cramps, gas, pain or bloatedness
  • A feeling that your bowel is always full, or doesn’t empty completely
  • Unexplained weight loss, especially in the absence of dieting or exercising
  • Loss of appetite
  • Weakness, fatigue or a feeling of getting tired very easily

Aside from the symptoms mentioned above, later stages of colon cancer may cause frequency in urination, urgency or difficulty in urination when it has spread to other nearby tissues and organs such as the urinary bladder and the prostate. Pain in the waist area or sacrum can also be reported once it affects the lumbosacral plexus.

 

What causes colon cancer?

According to the Mayo Clinic, inherited gene mutations that increase the risk of colon cancer can be passed on through families. Common forms of inherited colon cancer syndromes include Hereditary Nonpolyposis Colorectal Cancer or HNPCC and Familial Adenomatous Polyposis or FAP. Those diagnosed with HNPCC or Lynch Syndrome often develop colon cancer before the age of 50, while FAP is a rare condition that predisposes a person to having thousands of polyps within the lining of the rectum or colon and often develop colon cancer before the age of 40. Since both are genetic, they can be detected through testing early on, especially in those with a strong family history of colon cancer. Although these inherited gene mutation increase one’s risk of having colon cancer, it does not make it inevitable. Research still suggests a strong association between diet, lifestyle and an increased risk for colon cancer. Other factors that can predispose a person to having this type of malignancy include:

  • Age of 50 years or older
  • Family history of colon cancer
  • Excessive smoking and/or alcohol intake
  • Obesity. An increase in adipose tissue or fat cells increases the risk of inflammatory conditions in the body and can lead to not only colon cancer, but any type of cancer for that matter
  • Diabetes and insulin resistance
  • Diet. A diet high in processed meats, high fat and low fiber diets are known to increase one’s risk of colorectal cancer.
  • Sedentary lifestyle
  • Personal history of polyps or colorectal cancer
  • Presence of chronic inflammatory conditions of the colon like ulcerative colitis and Crohn’s disease.

 

What do I do if there I observ any of the signs and symptoms?

Once you experience any of the specific or general signs and symptoms mentioned, it is best to seek medical attention as soon as possible. According to the National Cancer Institute, your doctor should perform a complete and thorough physical examination and history once you go for consult.  This allows you to be checked for general signs of health and disease or anything else that seems unusual. A rectal exam may also be needed wherein your rectum will be examined manually to detect any masses or abnormalities within that area. A history of the patient’s health and lifestyle habits, including past medical history, illnesses and treatments are of utmost importance.

Aside from these, your doctor will most likely request for diagnostic tests that can help confirm the presence of malignancy.

  • A series of x-rays of the lower gastrointestinal tract known as barium enema or lower GI series can help determine the presence of a mass or other lesions within the lower GI tract.
  • Colonoscopy. During this procedure, a long, flexible and slender tube attached to a camera and monitor is passed through the entire length of the colon and rectum to help visualize any polyps or lesions that may be causing the symptoms. Once suspicious lesions or areas are found, your doctor can take samples of tissues from the lesion itself and send them to pathology for analysis. Small polyps may also be removed during the procedure. Once large masses or tumors are detected, the specialist should take note of its specific location and other characteristics that can help determine if it is malignant or not.
  • Ultrasound or CT scans can help confirm the location, position and size of the tumor definitively. It can also help determine if the malignancy has spread to other nearby tissues or has metastasized to neighboring organs such as the liver and lymph nodes.
  • Blood tests are also very helpful in determining the presence of malignancy. A tumor marker known as the Carcinoembryonic Antigen or CEA is important since it is most often produced by colon cancer. It is also important later on when determining how effectively the patient is responding to treatment and help with prognosis later on.

 

What are the stages of colon cancer and why is it important?

Once the diagnosis of colon cancer has been confirmed, the stage or extent of malignancy should be immediately determined. The stage will help with prognosis and which treatment plan or treatment options will be best for the patient. The American Joint Committee on Cancer or AJCC recommends following the TNM system, which is based on 3 key categories: (1) the extent or size of the Tumor (T), (2) the spread to nearby lymph nodes (N) and (3) the spread or metastasis to distant sites such as the liver or lungs. T also refers to how far the cancer has grown into the wall of the color or rectum, and if the inner and outer layers of the colon have already been affected. According to the AJCC, beginning January of 2018, the pathologic or surgical stage based on the table (attached) shall be used since it is more likely to be accurate compared to the clinical staging, which is based on physical exam, biopsy and other diagnostic tests done before the surgery. Since this may be a bit complicated, your doctor or specialist would be the best person to explain which particular stage you may fall under and what it means for you in terms of prognosis and treatment.

 

What treatment options will my doctor discuss with me and how do I know which one is best?

The type of treatment your doctor recommends will depend largely on the stage of your cancer. Typically, treatment options include surgery, chemotherapy and radiation or radiotherapy.

Surgery is commonly advised based on several indications. When surgery for early-stage colon cancer is recommended, minimally invasive surgical procedures can be done during colonoscopy. If the cancer has grown into or through the colon, surgery may be performed to remove the part of your colon that contains the cancer, along with a margin of normal tissue on either side of the cancer. The healthy parts of the colon are then reconnected afterwards. When it’s not possible to reconnect the healthy portions of the colon or rectum, a colostomy bag may be placed in order to eliminate the stool into a bag. Lymph node removal may also be advised during the surgery itself.

In some cases, the location may be not ideal for surgery or the cancer may be too large such that if it is resected or removed, the function of the colon may be affected dramatically. In this case, the other modes of therapy may be considered.

Chemotherapy for colon cancer is usually given after surgery if the cancer is known to have spread to lymph nodes, or it can be done prior to surgery in order to decrease the size of the mass or tumor.

Radiation Therapy or Radiotherapy may be indicated before surgery to help decrease the size of the mass or to relieve symptoms of colon or rectal cancer. This may be done alone or in combination with chemotherapy.

 

Because cancer research has reached new levels in the past few years, new treatment options are now being considered. Procedures like hyperthermic intraperitoneal chemotherapy, targeted therapy using chemotherapeutic drugs and immunotherapy are now being used in certain parts of the world. Aside from this, palliative or supportive care is now being incorporated into treatment, to provide relief from pain and other symptoms of serious illness that comes along with colon cancer.

 

Can colon cancer be prevented?

According to the Philippine Society of Gastroenterologists, early detection is key in prevention. Individuals with an average risk of colon cancer should be screened by the age of 50 or sooner. Lifestyle changes can also reduce the risk of colon cancer especially in the absence of any inflammatory or genetic conditions that predisposes a person to this condition. Here are some important tips cited by the Mayo Clinic, which can help prevent colon cancer.

  • Eat a variety of fruits, vegetables and whole grains.  Studies show that their antioxidative properties and their high fiber content play a major role in cancer prevention.
  • Drink in moderation
  • Stop smoking
  • Exercise regularly with at least 30 minutes of exercise two to three times weekly
  • Maintain a healthy weight

In a study published in the Journal of the National Cancer Institute, diet, physical activity, obesity, aspirin use and family history have all been identified as modifiable factors that can increase risk of colon cancer and can increase the risk of fatal colon cancer dramatically. Other studies by the American Journal of Clinical Nutrition and the National Cancer Institute have also seen the important role of prebiotics and probiotics or symbiotic intervention in helping decrease the colorectal cancer biomarkers favorable, something which may be looked into and studied further in order to help decrease the number of deaths attributable to this deadly cancer.

 

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