Colorectal cancer has cut short the lives of two dear brothers of mine. My brother-in-law is now battling this formidable foe. So, somehow, I feel a connection whenever I encounter patients with this third leading cause of cancer deaths in the Philippines.
Although classically, colorectal cancer may have signs and symptoms such as blood in the stools, narrower stools, change in bowel habits and general stomach discomfort, many patients, especially in the early stages, may be completely symptom-free.
Screening tests therefore for everyone 50 years or older are important. High-risk patients such as those with history of polyps in the colon or rectum, family history of colorectal cancer, and those fond of high-fat foods, should be screened earlier.
The good news about it though is that when detected early (Stage 0 or Stage 1), surgery?resection of the part of the big intestines where the tumor is?could be curative. Some don?t even require chemotherapy if the cancer is caught at a very early stage, and the tumor cells have not spread outside the intestinal or rectal walls.
When it has breached the intestinal boundaries but has not spread to the adjacent lymph nodes (Stage 2), or when it has infiltrated the adjacent nodes but not the surrounding tissues (Stage 3), chemotherapy and radiation may be offered after surgery to reduce the risk of a relapse. If initial diagnostic tests indicate stage 2 or 3 cancer, some centers consider giving chemotherapy and radiation before surgery.
When the tumor is quite big already and has spread to other parts of the body like the lungs and liver, available treatments may no longer significantly prolong survival. Many patients with advanced cancer may have tumors that are too extensive to resect or these patients may have other medical problems that render them unfit for surgery.
To improve their quality of lives and make them enjoy whatever remaining time they have, new techniques have been developed to tide them over this critical stage. Dr. Choy Nolasco, one of the country?s leading lady gastroenterologists, writes about these procedures in the December issue of the H&L (Health and Lifestyle) magazine.
Dr. Nolasco explains that previously, emergency surgical intervention was done on these patients with advanced cancers. However, this approach carries a high death and complication risk, especially in patients with big tumors already obstructing the big intestines. In addition, studies show that surgical resection of the primary tumor in patients with incurable disease no longer significantly improves their survival.
Nonsurgical methods of palliation in cases of intestinal obstruction and bleeding, therefore, is a good alternative to this group of patients whose cancers have spread extensively. Dr. Nolasco identifies these high surgical risk patients, such as older patients, those with severe cardiopulmonary disease (making them unfit for surgery) and those who refuse to undergo surgery.
Available modalities of nonsurgical palliation include chemotherapy, radiotherapy, endoscopic palliation, or a combination of these treatments.
The most commonly used endoscopic palliation techniques are endoscopic stenting and endoscopic laser ablation and recanalization.
Stenting is carried out through the anus and is generally well tolerated by patients with only conscious sedation or no anesthesia at all. It may be used as a definitive palliative measure or can be used as a ?bridge to surgery? to allow stabilization of the patient?s condition before surgery. More extensive surgery could be done at a later date as an elective procedure, when the patient stands a better chance of surviving the surgery.
Dr. Nolasco writes that stenting has an overall technical success rate of 92 percent and clinical success rate of 88 percent (defined as relief of obstructive symptoms within 96 hours). It is however not a harmless procedure. Complications of stenting include perforation, stent migration, and reobstruction. Bleeding and pain occur in rare instances.
Endoscopic laser treatment is another palliative procedure to control bleeding, relieve obstructive symptoms by tumor debulking, and to control excessive mucus discharge in patients with inoperable or advanced colorectal cancer. Although bleeding might be effectively controlled after the first session, obstructive symptoms may require more sessions to achieve complete relief. Multiple treatments over several weeks are often required.
Combined laser treatment and radiotherapy for advanced rectal cancer has also been tried to relieve the intestinal obstruction and prevent tumor extension beyond the bowel wall and nearby nodes. ?Used alone in patients presenting with obstruction, radiotherapy may produce edema during the first few days, which aggravates the obstruction,? Dr. Nolasco says.
The desired relief of obstruction with radiotherapy may take some time; hence, warranting the need for initial laser treatment. As palliative treatments, therefore, they may be complementary. Relapse rate has also been reduced with the combined laser treatment and radiotherapy for advanced rectal cancer.
Dr. Nolasco says that endoscopic palliation (stenting and laser ablation/recanalization) are easy to perform, relatively safe and with high success rate. They improve the quality of life of these patients with advanced colorectal cancers. However, there is no convincing data showing that they could prolong the lives of these terminal patients.
Well, these endoscopic palliative procedures may not add more months to the lives of patients with advanced cancers, but at least, they can add more life and meaning to their remaining few months.