CD-ROM Today 1996 January/CD-ROM Today 1996 January.iso/dp/0175/01752.txt

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$Title{Colorectal Cancer:  Learn the Vital Facts, part I}
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colostomies Radiation therapy Anticancer Chemotherapy chemicals OSTOMY
DIGESTIVE system RECTAL GASTROINTESTINAL ENDOSCOPY Carcinoma intestines bowels
constipation chemical}
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Copyright (c) 1991-92,1993

Health Update

by Dr. Allan Bruckheim

Colorectal Cancer:  Learn the Vital Facts, part I


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A real need--the need to know

     Reading this booklet may be among the most important things you ever do
because it could help save YOUR life!
     The following information is about a type of cancer that may be
avoidable, if you do certain simple things--and don't do others.  Even though
such cancers cannot always be avoided, they frequently can be treated
successfully, if found EARLY.  But if they are allowed to grow, the death rate
from them usually is high--about 60 percent within five years after the cancer
is detected.
     We now know that approximately 80 percent of cancer cases are related to
the manner in which people live.  Some examples are:  the foods we eat, the
work from which we earn our living and whether we use tobacco.  Choose
correctly and long, healthy life may be yours.  The wrong choices lead to ill
health, disease and possibly dreaded cancer.
     Knowing which things to avoid or some that might be increased can help us
all take control over our lives and decrease the known chances for developing
cancer.  Admittedly, some are very difficult to control, such as where you
work, the purity of the water you drink and the air you breathe.  Others are
easier to manage--as easy as eating the right, "good for you" foods.
     There are no guarantees, of course, but it's worth the little effort and
time it will take to read this booklet. . . you never really know, it could
make the difference between life and death

Good news

     But there is good news.  Medical science now has reliable ways to detect
cancers of the colon and rectum early and the skills to treat them immediately
and effectively, permitting you to live a full, fruitful life, but you must
learn the principle of early detection to gain these benefits for yourself and
for those you care about.  If a cancer is found before it has time to do
serious damage, grow and spread to other areas, it can be treated more easily,
with less need for radical surgery, less pain, fewer drugs along with their
side effects and less time away from work.  Naturally, early detection will
require less money to be spent while combatting the condition.
     Estimates indicate that 30,000 lives a year could be saved if people
older than 40 would have an annual bowel exam.  Others declare that the
percentage of colorectal cancer patients who survive for five years after
their cancers are diagnosed could more than double--from 40 percent to about
85 percent--if diagnosis occurred earlier.  Earlier means before the cancer
has a chance to spread into nearby lymph nodes, or to travel to other sites in
our bodies.

A "hush-hush" condition

     Many people have no problem discussing very intimate subjects, yet even
in these days, when frank conversation is the rule, some still are reluctant
to talk about their colons and rectums.  They are parts of our digestive
system that remain hidden and covered, concealed from view and thought.
Strange isn't it, because every person has them!  Also, nobody wants to talk
about cancer, as if not talking about it could lessen its occurrence or
effects.  But, like many undesirable conditions, cancer breeds well in
secrecy.
     The American Cancer Society estimates that during 1987, 145,000 new cases
of cancer of the colon and/or rectum will be found in the United States. (All
subsequent figures are for people in the United States.)  Included in this
figure are:  102,000 colon cancers and 43,000 cancers of the rectum.  Such
cancers, often referred to as "colorectal cancers," are the third most common
cancer in this country.  Only skin and lung cancers occur more frequently.
Expected deaths in 1987 from colorectal cancers will climb to an estimated
60,000 (52,000 from colon and 8,000 from rectum cancers).  Only lung cancer is
expected to cause more deaths.  These are not statistics we can pass over
lightly!
     Colorectal cancer develops over a period of time, so detection of it is
possible long before symptoms appear.  Detecting small cancers and polyps
reduces the likelihood of major surgery, yet not nearly enough people even
consider being tested for colorectal cancers.  In 1986, American men and women
older than 40 were studied by the Gallup Poll organization as to how they felt
about detection of colorectal cancer.  Results of the study showed that only
about 24 percent of people in that age group have ever asked their physicians
to examine their colon or rectum.  When they did ask for an exam, more than
half of them did so only because there apparently was something wrong with
those parts of their bodies, meaning they could have been running just a bit
late in preventing a serious situation from developing.

What is cancer?

     Cancer is not one disease.  There are more than 100 different kinds of
"cancer."  Yet, they all have this in common:  an abnormal growth of cells
that use up our bodies' reserves rather than building or repairing vital
tissues.
     Healthy cells, that usually make up all the body's tissues, normally
grow, divide and replace themselves in an orderly, self-controlled manner.
Sometimes those normal cells lose their ability to limit and direct their
growth. . . then they may grow wildly and form tumors.
     Tumors can be of two types:  benign or malignant.  Benign tumors do not
often spread and seldom are a threat to life.  Frequently, these can be
removed by surgery, and usually do not return.
     Malignant tumors are cancerous.  They can invade and destroy other nearby
tissues and organs.  Cancers also can metastasize, or spread, to other,
sometimes distant, parts of the body and continue to grow.  Many scientists
currently believe most cancers are caused in two steps by two kinds of agents.
Those are "initiators" and "promoters."
     "Initiators" start the damage to a cell that can lead to cancer. . . that
could be cigarette smoke, X-rays and some chemicals.  "Promoters" often do not
cause cancer alone.  They change cells already damaged by an initiator from
normal to cancerous.  Some studies have shown that alcohol promotes the
development of cancers in the mouth, throat and probably in the liver,
especially when combined with an initiator such as tobacco.
     Cancer afflicts humans and probably all other animals.  It can arise in
any organ or tissue in the body.  It is second only to diseases of the heart
and blood vessels as the major killer of Americans.
     Another of cancer's characteristics is its appearance when viewed through
a microscope.  Its individual cells vary in size and shape, and the orderly
pattern displayed by normal tissue is replaced by disorganization that may be
so complete that no recognizable structures remain.  Such loss of normal
appearance is called "anaplasia."  Some cancers grow very slowly and destroy
neighboring tissue, others are more aggressive and spread rapidly to distant
areas of the body.  In either case they are a serious threat to life and
longevity.

What are the colon and rectum?

     Your colon and rectum are a part of your digestive tract (see diagram),
or gastrointestinal system.  The main function of the digestive tract is to
extract the essential nutrients, fluids and electrolytes from foods and
liquids that have been ingested.  Another part of the tract's function is to
dispose of wastes from the digestive process.
     The final part of the digestive tract is called the colon.  It also is
referred to as the large bowel.  It starts with the cecum, a pouch that
receives liquid material from the small intestine.  The colon extends from the
cecum to the rectum in an inverted U shape.  It is made up of four parts:  the
ascending, transverse, descending and sigmoid sections.
     The ascending colon extends from the cecum upward along the right side of
the abdomen.  At a point just under the ribs, this tubelike organ turns left
and crosses the upper portion of the abdomen.  That section is called the
transverse colon.  The descending section extends downward along the left side
of the abdomen to the pelvic region.  There it meets the S-like sigmoid
portion of the colon.  The sigmoid colon is connected to the rectum.  The
rectum is the final eight to 10 inches of the colon.  The anus is located at
the end of the rectum.

Symptoms

     Symptoms of colorectal cancers depend greatly on the location and
function of the part of the intestine where the disease develops.  The most
frequent symptom is a change in bowel habits such as being constipated or
having diarrhea.  Other symptoms include a change in the size of your stools,
discomfort or pain in your abdomen, unexpected weight loss, unexplainable and
lingering tiredness, frequent gas pains, and/or blood in your stools (it may
be black or bright red).
     Such symptoms do not necessarily mean you have cancer.  They could be
caused by other conditions such as ulcers or an inflamed colon.  It is equally
important to remember that early cancer may have no symptoms at all, and a
routine but regular examination will be the best prevention.  Whatever, the
case, however, should any of the above symptoms last for up to two weeks, see
your doctor as soon as possible.  That's when the principle of "early
diagnosis:  can be made to work in your favor.

Who's most likely to develop it?

     In Western industrialized countries, colorectal cancers attack both men
and women, blacks and whites.  Colorectal cancer is particularly common in the
United States and Canada, the United Kingdom, Australia, New Zealand and other
highly industrialized nations.
     Contrastingly, it occurs infrequently in India, Colombia, Senegal and
other areas that are economically poorly developed.  So it appears that the
environment and eating habits have a great deal to do with who is most likely
to develop such cancers.
     The conditions occurs most often in people older than 40.  The risk
becomes even greater at 50 and doubles with each decade, reaching a peak at
age 75.  Also, it is particularly frequent in people who have a personal or
family history of colorectal cancer, cancer in other parts of the body, in
people with a history of polyps in the colon or rectum and those with
inflammatory bowel diseases (such as ulcerative colitis).
     Nearly all colorectal cancers develop from polyps, especially adenomas.
Most polyps in the colon do not become cancerous, but their presence--or a
history of polyps--points to increased risk.  The greater the number and size
of polyps in the colon, the greater the risk.  Approximately 5 percent of
patients who have a single diagnosed colon cancer develop another somewhere
else in the colon.  More black male and female Americans develop, and die
from, cancer--including colorectal cancer--than do their white counterparts,
according to statistics covering a 30-year time span.

Screening for colorectal cancer

     Examining people with no symptoms to detect cancer is known as screening.
Several techniques have been studied to develop effective screening methods
for colorectal cancer.  One of the simplest, safest and cheapest is to test
for occult (hidden) blood in the stool.  The most reliable of these tests
usually require a laboratory, but home tests have a real role in the detection
of cancer.  While not as reliable as those performed in clinical laboratories,
any test for blood that aids in early diagnosis must be considered valuable.
     Large-scale public screening programs have been suggested by some
researchers.  They state that such tests could uncover asymptomatic (showing
no symptoms) bowel cancer and point out that examinations for occult blood in
a test group doubled the detection of colorectal cancer.  Others argue that
because compliance by the public would be low, and test results are not always
correct, wide-scale screening would not be worth the money and effort
required.

Asymptomatic patients

     A doctor may suspect that a patient could have colorectal cancer even
though he/she is asymptomatic.  Asymptomatic patients could be those without
rectal bleeding, etc., but who have anemia or in whom unsuspected findings
were discovered during examination.  Patients with past histories of adenoma,
colorectal cancer, ulcerative colitis or family histories of cancer
particularly will need frequent checkups.  It may surprise you to learn that
65 percent of cancers of the colon or rectum are within reach of an examining
finger or can be detected by a simple sigmoidoscopic examination.

Diagnosis

     A physical examination from your doctor is the only way to be positive
that you do not have colorectal cancer.  To check the rectal area, your
physician will insert a gloved, lubricated finger into it and gently feel for
anything abnormal
     The doctor may decide to do a "procto" (an exam which allows him/her to
actually look into the rectum).  To do that a proctoscope (small, short,
rigid, hollow, lighted instrument) is inserted into the rectum.  To examine
the sigmoid portion of your colon, a sigmoidoscope (a small, hollow, lighted
instrument) may be inserted into the anus.  There may be need for further
tests.
     Perhaps your doctor will want you to have a series of "lower GI"
X-rays--taken after a thick solution of barium flows into the bowel through an
enema tube.  The barium allows an outline of the large intestine to show on
the X-ray pictures.  On occasion, air is pumped into the colon during a
barium-enema to provide better photographs of any small tumors that may be
present.  That is called an air-contrast barium enema.  Results from such
X-ray photographs may reveal tumors that were not found during other tests.
     Nowadays, however, you are more likely to undergo an exam using a
colonoscope.  Colonoscopes allow a physician to visually examine the entire
colon through a long, small, flexible, hollow, lighted fiberoptic instrument.
Colonoscopes permit identification of colorectal cancers at an earlier stage
than is possible with X-rays or other external examination techniques.  The
instrument also allows the doctor to remove precancerous polyps or other
suspicious growths in the colon during the examination.  Such growths must go
through a laboratory process called biopsy for definite determination of
whether they are malignant or benign.
     It was this procedure, on a routine examination, that led to the
discovery of President Reagan's cancer and its successful removal.
Additionally, the use of the colonoscopy often can replace what formerly was
known as "exploratory surgery" (surgically opening the body to find what is
causing a problem), thereby saving pain, anxiety, inconvenience, time and
money.

Treatment

     If a malignant tumor is found, your doctor will want to start a treatment
plan for you.  The plan will be designed to fit the type and extent of both
your cancer and your individual needs.

Staging

     The first step in treatment often is to find out the "stage" of the
cancer.  Colorectal cancer is classified, or staged, by direct observation of
the tumor, either during microscopic examination of tumor cells (pathologic
staging) or during surgery.  Staging tests show whether the disease has spread
from its starting point to other parts of the body and will help your doctor
plan the best treatment.
     Physicians often order X-rays or other visual exams (scans) of the chest,
liver, kidneys and bladder.  Blood tests are used to measure certain
substances that may increase in the liver or the blood of those having such
cancers.  The same types of blood tests sometimes are used later to determine
how well a patient is responding to treatment.
     Duke's pathologic staging system, developed years ago, separates
colorectal cancers into three groups--Stage A:  tumors that are found only in
the wall of the bowel and do not extend into surrounding muscle; Stage B:
those that have penetrated into the muscle; and Stage C:  cancer that has
spread into lymph nodes.  The system has been modified to include more
distinct phases that can occur in stages B and C.  Some physicians have added
a stage D.  And as our knowledge has increased, other systems of staging the
extent of the cancer have been developed and are used by some physicians.

Plan

     Following staging, your physician will develop a treatment plan to fit
your medical history, general health, as well as the location and type or
cancer involved.  But before that treatment commences, you may want (and your
health insurance company may require) a second doctor's opinion and review of
your diagnosis and treatment plan.  If so, you may wish to take advantage of
some of the resources listed in the back of this booklet.
     No matter how many different opinions one obtains, there are only three
basic colorectal cancer treatment methods.  They are:  surgery, radiation
therapy (includes X-ray, radio, cobalt and/or irradiation therapy) and drug
therapy (chemotherapy).  Decisions regarding the use of just one of the above,
two or all of them will depend on your unique treatment needs.  You may be
referred to other physicians for specific treatment in one, or all, of those
three different specialties.

Surgery

     The above notwithstanding, the standard treatment for colorectal cancer
is surgery.  Therefore, it usually is not a question of if you need surgery,
but what type.  The size of the cancer and where it is located determines, to
a great extent, the type of surgery required.  Hopefully, your surgeon may
have to remove only a small portion of the bowel that contains the cancer.
(See diagram on Page 5.) Following that, yet during that same operation, it is
possible that the remaining healthy sections can be rejoined.  Such surgical
procedures (another term for what commonly is called an operation) are named
bowel resection.  Frequently, resections are required if a cancer is in the
right-hand side of a colon (ascending), or in the trans verse colon.  In such
cases, it often is advisable to remove nearby lymph nodes that help drain the
areas because they are among the most typical area to which colorectal cancers
spread.  The lymph system carries vital fluid throughout the body, much like
the blood system carries blood.  The lymph system also can carry cancer cells
in its fluid as it flows from one part of the body to others.  When lymph
nodes are removed there is less chance for a cancer to spread.
     When a cancer blocks the bowel an operation known as a colostomy may be
required.  Colostomies either are temporary or permanent.  Approximately 95
percent of colorectal cancer patients require only a temporary colostomy.  In
both temporary and permanent colostomies, a surgeon removes the cancerous part
of the bowel and creates an opening (called a "stoma") in the abdomen through
which wastes are routed out of the body.  A colostomy makes waste removal
possible without the necessity of it passing through the lower colon and
rectum
     Temporary colostomies are performed to allow the lower colon and rectum
to rest and heal.  Following the healing process, a second operation is
performed to close the stoma, at which time the body can resume normal
digestive and elimination functions.
     When a cancer occurs in the lower rectum, usually the entire rectum will
have to be removed.  In such cases, a permanent colostomy is needed.  After
such an operation, a bag, called an appliance, is attached to the stoma to
collect waste.  You must wear the colostomy appliance continually.  Luckily,
it does not show under everyday clothing, and a therapist can teach you how to
take care of your stoma and appliance with very little adjustment in your
everyday mode of living.
     Fortunately, advances in surgical techniques and medical care have made
extensive surgery possible for people previously considered too old or infirm
for it.  So there is new hope for all, and many more can be helped.

Radiation therapy

     Radiation therapy utilizes high-energy rays to stop cancerous cells from
growing and spreading.  It can be used prior to, or following, surgery, to
shrink a tumor, or to destroy cancer cells that might not have been removed
during an operation.  It also may relieve pain caused by some cancers.  Your
physician will define a radiation therapy schedule for you, if you need it,
based on your condition's exact requirements.
     Usually you will not have to be hospitalized while receiving radiation
therapy.  Your treatments will be administered by radiation therapists located
in private offices, clinics or hospitals.  Until recently, radiation therapy
was not used extensively in treating colorectal cancer.  However, advanced
research indicates that when radiation is used before an operation, it may be
possible to stop the growth of a large number of cancer cells.  That action
reduces the risk of recurrence and metastasis.

Anticancer medications

     Chemotherapy is the term used when cancer patients are treated with
anticancer drugs.  Chemotherapy usually is given when there are indications
that a cancer has spread to other parts of the body, or when that danger seems
probable.  Chemotherapy, as with all anticancer treatments, works best
early--before the cancer has had a chance to grow much.
     Various chemicals are used as medications in chemotherapy and there are
different ways of administering them.  Some are given orally some are more
potent when administered by injection into a vein, artery or muscle.
     Frequently, chemotherapy is given in cycles:  a period of treatment,
followed by a period with none, then another treatment period, a period with
none.  No matter how you receive chemotherapy, the medicines travel through
your bloodstream to nearly every area of your body, assisting it to halt the
growth and division of cancer cells.  Many of the medicines can be given to
you as an outpatient.  With others, you may have to be hospitalized for a few
days so that your doctors can watch what effects the drugs produce.  After
that initial stay, usually you will be able to receive your medications at the
hospital but on an outpatient basis.
     A large amount of research is being done to study the use of anticancer
drugs alone--or along with radiation--shortly after surgery in efforts to
reduce the chance of recurrence.  Many current chemotherapy research studies,
particularly those involving patients with advanced colorectal cancer, use
several drugs in combination.
     Some of the most frequently administered are:  5-fluorouracil,
vincristine, methyl CCNU, methotrexate and DTIC.  Of course, other drugs are
in use in research that, hopefully, soon will increase chemotherapy's
abilities to help control cancer.
     Immunotherapy, the use of the body's own immune system to treat cancer,
also is being studied with what appears to be encouraging results.  The
National Large Bowel Cancer Project has underwritten a number of preclinical
studies to develop new medical ways to treat colorectal cancers--particularly
those in the large bowel.  These are undertaken in hope of discovering new,
innovative and, importantly, more effective methods to help cancer patients.

Treatments may have side effects

     Because any cancer can spread rapidly and with life-threatening results,
drugs used against them must be extraordinarily powerful.  Because of that, it
is almost impossible to limit the effects of chemotherapy to the point that
only cancerous cells are destroyed.  Nearby normal cells often are damaged
along with those containing cancer.
     With that in mind, you will understand why chemotherapy patients often
experience unpleasant side effects as their disease is being fought by the
medications.  Chemotherapy affects the cancer cells and other rapidly growing
ones such as hair cells and some cells that form the tissue lining the
digestive tract.  That can result in such side effects as hair loss, nausea
and vomiting.  Periods of radiation therapy may produce unusual tiredness and
skin reactions surrounding the area of treatment.  Additionally, loss of
appetite that many cancer patients experience can be a serious side effect.
     But cancer patients need to consume a balanced diet.  Research has proved
that patients who eat well are much more able to withstand various therapies
and their side effects.  Eating well also helps patients prevent serious
weight loss.  Physicians consider nutrition a necessary part of a treatment
plan.  Particularly important is having enough protein in one's diet to build
and repair organs, muscles, skin and hair.  Cancer patients often find it
easier to eat frequent, smaller meals throughout the day rather than the usual
three large meals.
     Your physician, along with dietitians and nurses, can provide expert
advice on what side effects you may experience and how best to deal with them.
They also can recommend advisable diet planning to help you keep your strength
and weight.
     When your treatments are completed, you should continue to have medical
examinations regularly so that your physician can monitor your progress.
Should physical rehabilitation be needed, your doctor may be relied upon to
offer you good counsel and direction.  Your local hospital may be quite
helpful with information, and other community organizations are prepared to
give you many kinds of help.
     The social service department at your hospital can advise about local
organizations that offer help for cancer patients and their families.  The
assistance offered may include financial aid, transportation to and from the
hospital for medical care and homemaker services. (Here again, a careful study
of some of the names and addresses of helpful organizations included in this
booklet may get you off to the living start you need.)

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The material contained here is "FOR INFORMATION ONLY" and should not replace
the counsel and advice of your personal physician.  Promptly consulting your
doctor is the best path to a quick and successful resolution of any medical
problem.