This hypothetical consultation about colon cancer is presented for purposes of general information. If you think you may have this condition, please see your doctor to discuss your individual case and the exams and treatments that are best for you.
Colon cancer, which includes cancer of the colon and cancer of the rectum, is the fourth most common cancer in both men and women in the United States. Over 90 percent of cases of colon cancer occur in individuals who are over 50 years of age, and the average colon cancer patient is in his or her mix-sixties when the cancer is discovered. In our example, the patient is a 65-year-old man who is referred to Colorectal Surgery at UC San Diego Health after undergoing a colonoscopy where a cancerous polyp was found.
Doctor: Hi, how are you?
Patient: I was sent to you because I had a colonoscopy and the gastroenterologist called me and said that the polyp was cancer, and so I came to see you.
Doctor Okay. Do you understand what that means and how we went about treating that colonoscopically and why you are seeing me for that?
Patient: I do not.
Doctor: Okay. So, we start screening patients for colonoscopy beginning at the age of 50, and the reason for that is to prevent the development of colon cancer. During the colonoscopy, if we encounter polyps, which are small growths in the colon, we remove them because they can, if left unchecked over many years, can become a cancer. In your case, having the colonoscopy has found the cancer in the polyp already, but we can’t simply treat it by removing the polyp using the colonoscope. We now need to treat it by removing that section of the colon that contains the cancer in it.
Patient: So what do you need to know about me?
Doctor: So, what I’d first like to know is, do you have any family history of colon cancer or rectal cancer?
Patient: No, but my mother had a bunch of polyps that they kept removing and I think I have a brother who has the same.
Doctor: Okay. Well, what we consider a significant family history for someone who is getting screened for colon cancer is someone who has a first-degree relative with colon cancer or someone who has a first-degree relative under the age of 60 who has had polyps found on colonoscopy. Barring that and other abnormalities such as certain genetic syndromes or inflammatory bowel disease, most people fall under the category of an average risk. How old was your brother when he had his polyps found?
Patient: He was 45.
Doctor: So you fit into a higher risk category. You and your children should probably get screened more often than the average person. But let’s get back to your cancer at this point. What questions do you have for me?
Patient: Well, I guess you think it ought to be operated on?
Doctor: Yes. So the primary treatment for colon cancer, which is what you’ve been diagnosed as having, is surgical removal. Once the cancer has been removed and all of the associated blood vessels and lymph nodes, then we can determine what the stage of the cancer is, and that determines what further treatment you may or may not need.
Patient: What exactly is involved in the surgery? Because you hear these horror stories of people that end up with ... what are they called?
Patient: Colostomies, yes.
Doctor: We rarely have to do colostomies in this day and age for patients such as yourself who are diagnosed electively, meaning in a non-emergency setting, with colon cancer. The other setting where we have to give people colostomies is when their tumor is located very low, in the last part of the colon called the rectum, and we have to take their sphincter and their anus. In your case, that does not apply. The operation takes somewhere between two and four hours, depending on the surgical method and how intricate the operation needs to be. After surgery you are in the hospital for somewhere between three and seven days, depending on the rate of your recovery. Before you can go home we want to make sure that you have good pain control with oral pain medications, that you are able to eat a normal diet without difficulty, and that you are moving your bowels fairly normally without much difficulty.
Patient: So, you’re going to take out a piece of my colon?
Doctor: Correct. Depending on where the cancer is located, and from your colonoscopy I can see that the cancer is located on the right side of the colon. The colon itself is somewhere between four and six feet in most people. When we do remove a section, called a segmental colectomy or a partial colectomy, we remove usually somewhere between six inches on either side, so a total of twelve inches of colon, and then we put the two ends of the bowel back together.
Patient: Will this change how I go to the bathroom?
Doctor: In the initial setting after surgery, most patients will experience looser stools, but most will return to their normal bowel function after six weeks.
Patient: Is this surgery done through a laparoscope or is it done through an incision?
Doctor: It can be done either way. It depends on the size of the tumor; it depends on how many previous operations you have had; sometimes it depends on the location of the tumor; and finally it can depend on patient preference. When we use a laparoscope, we make smaller incisions, and the operation sometimes takes a little longer than it would for a traditional open incision approach. The advantage of laparoscopy, we believe, is that patients are able to get up and move around more comfortably after surgery. A smaller incision translates into a little bit less pain, and we believe that you regain bowel function a little bit sooner than someone who has had a traditional open procedure. Patients are frequently able to go home a little earlier than someone who may have had the open procedure done. The reasons why we can’t perform laparoscopy in certain people may be that they have had multiple previous operations which would make it very difficult. If the tumor is very large, and we have to make a big incision to remove the tumor anyway, it doesn’t make sense to perform it laparoscopically. And finally, some people’s anatomy or body habitus prevents us from performing the laparoscopic procedure safely and so we do it using the traditional open technique.
Patient: So which technique are you recommending for me?
Doctor: From viewing your CT scan, which appears to show the tumor to be small to medium size, and given that you are a fairly thin person, I think a laparoscopic approach would be a good operation technique for you.
Patient: When will I go back to work?
Doctor: Everybody is different. Most people return to work at about three weeks after surgery. It depends on how comfortable you feel with your ability to move around. A lot of what patients experience after surgery is fatigue, so they can’t put in a full day’s work, but many patients go back part-time and slowly regain their energy and strength and eventually return full time. There should be nothing that keeps you from getting up and moving around except for pain control and fatigue.
Patient: Are you going to cure me?
Doctor: It depends on the stage of your cancer. If it is a very early stage, Stage I or Stage II, that is generally cured by surgery and no further treatment is needed. If it is Stage III or Stage IV, surgery only removes a part of the tumor. Some of it may still remain in the body, so that you would need to be followed by a medical oncologist who will administer chemotherapy.
Patient: In those more advanced cancers, do people live?
Doctor: There are a percentage of patients who do well with chemotherapy in Stage III - where the tumor has gone outside of the bowel wall into the lymph nodes but has not spread to any other organs. The survival rate for Stage III cancer ranges somewhere between 40 and 60 percent, depending on features of the cancer and how responsive it is to the chemotherapy. The chemotherapy for colorectal cancer is well tolerated by patients. If the tumor is more advanced, meaning that it has spread to other organs, most commonly the liver or the lung, then the cure rate drops significantly, and the five-year survival is usually less than 5 percent. But in those instances we have in addition to chemotherapy new clinical trials and different ways in which we can treat those patients and prolong their survival longer than what would be expected from normal treatments.
Patient: Are there complications to the surgery?
Doctor: That’s a good question. The risks of surgery begin with infection, which can happen inside the abdomen or inside the wound. Inside the abdomen, I mean by an abscess, which would be treated by IV antibiotics. Sometimes it requires drainage by the radiologist. A more significant infection is what is called a “leak” and that means where the two ends of the bowels have been stapled together they don’t heal properly and the contents of the bowel is allowed to “leak” out into the abdominal cavity, which can make a patient very sick. Small leaks are treated by IV antibiotics, sometimes by drainage. Larger leaks may require a trip back to the operating room. The incidence of leak is less than 5 percent for all bowel surgery. The rates go up for patients who are significantly immunocompromised or those who are on steroids.
More superficial infections can involve just the wound itself, where the wound may get red or even contain a little bit of purulent material. That’s mainly treated by antibiotics and by opening the skin to let the infection out. That can prolong someone’s hospitalization by a few days, but generally does not deter from someone’s overall health and well-being. Wound infections happen anywhere from 15 to 30 percent of cases, mainly related to the fact that we are operating on the bowel, which is not a very clean organ to begin with.
Patient: Would the “leak,” as you call it, be less if you did the open procedure than the laparoscopic procedure?
Doctor: The leak rates are the same for both.
Patient: And what other complications are there, not that that wasn’t enough?
Doctor: There’s a small risk of bleeding. We generally do not have to do a blood transfusion for this type of operation, but many colon cancer patients are already anemic to begin. Because of the small blood loss associated with surgery some people may need transfusion because of the cumulative effect of the anemia and the surgery blood loss.
The other risks are mainly related to anesthesia and an operation, which include risks to the heart and the lungs, and there is an increased risk of pulmonary embolism in cancer patients. That’s why we ask you to get up and move quickly after surgery.
Patient: One always hears about small bowel obstructions with surgeries like this. Is that a problem with this?
Doctor: Small bowel obstructions occur in 20 percent of patients who have any kind of abdominal surgery. Whether it’s an appendectomy, a C-section, or a colon resection, your risk is the same. Small bowel obstructions are due to scar tissue that develops after the abdomen has been operated on, and in most patients it does not require anything more than hospitalization and bowel rest. In a small percentage of patients it may require an additional operation.
Patient: Are there other things that I should know before making a decision?
Doctor: After surgery, you need to be followed regularly by a medical oncologist for the next five to ten years because your risk of developing another colon cancer is higher than the average population because you’ve already had one. We recommend screening after the operation at one year. If that colonoscopy is normal, then it can be three to five years before your next colonoscopy. Yearly, you will require a chest x-ray, lab studies, and sometimes a CT scan to make sure we don’t see any evidence of cancer recurrence. Depending on your stage, the risk of cancer recurrence is very low at the early stages and slightly higher at the more advanced stages, and that is why it’s important to continue to follow up with your medical oncologist and with me so we can keep an eye on you.
Patient: Well, my sense is that I don’t really have any reasonable alternatives or choices because I would like to live, so I appreciate the things that you’ve told me and I look forward to getting started on this.
Doctor: Please don’t hesitate to call me if you have more questions.
Read more about Colorectal Surgery and UC San Diego Moores Cancer Center. Also see a hypothetical consultation on colonoscopy.