Bowel Cancer

Bowel cancer is a general term for cancer that begins in the large bowel. Depending on where the cancer starts, bowel cancer is sometimes called colon or rectal cancer.

Bowel cancer is one of the most common type of cancers. Most people diagnosed with it are over the age of 60.

Symptoms of bowel cancer

The 3 main symptoms of bowel cancer are:

• Persistent blood in your stool – that happens for no obvious reason or is associated with a change in bowel habit
• A persistent change in your bowel habit – which is usually having to go to toilet more and your stool may also become more runny or watery
• Persistent lower abdominal (tummy) pain, bloating or discomfort – that’s always caused by eating and may be associated with loss of appetite or significant unintentional weight loss

Most people with these symptoms do not have bowel cancer. Other health problems can cause similar symptoms. For example:

• Blood in the stool when associated with pain or soreness is more often caused by piles (haemorrhoids)
• A change in bowel habit or abdominal pain is usually caused by something you’ve eaten
• A change in bowel habit to going less often, with harder stool, is not usually caused by any serious condition – it may be worth trying laxatives before seeing your doctor

These symptoms should be taken more seriously as you get older and when they persist despite simple treatments.

When to get medical advice

See a surgeon If you have 1 or more of the symptoms of bowel cancer and they have persisted for more than 4 weeks.

They may decide to:

• Examine your tummy and bottom to make sure you have no lumps
• Arrange for a simple blood test to check for iron deficiency anaemia – this can show whether there’s any bleeding from your bowel that you have not been aware of
• Arrange for you to have a simple test in hospital to make sure there’s no serious cause of your symptoms

Causes of bowel cancer

The exact cause of bowel cancer is not known, but there are a number of things that can increase your risk, including:

• Age – almost 9 in 10 people with bowel cancer are aged 60 or over
• Diet – a diet high in red or processed meats and low in fibre can increase your risk
• Weight – bowel cancer is more common in overweight or obese people
• Exercise – being inactive increases your risk of getting bowel cancer
• Alcohol – drinking alcohol might increase your risk of getting bowel cancer
• Smoking– smoking may increase your chances of getting bowel cancer
• Family history – having a close relative (mother or father, brother or sister) who developed bowel cancer under the age of 50 puts you at a greater lifetime risk of developing the condition; screening is offered to people in this situation, and you should discuss this with your doctor

Some people also have an increased risk of bowel cancer because they’ve had another condition, such as extensive ulcerative colitis or Crohn’s disease in the colon for more than 10 years.

Although there are some risks you cannot change, such as your age or family history, there are several ways you can lower your chances of developing the condition.

Bowel cancer screening

To detect cases of bowel cancer sooner, there are 2 common types of bowel cancer screening

• All men and women aged 60 to 74 are invited to carry out a FIT or FOB test.
• An additional test called bowel scope screening/ colonoscopy. It involves a doctor or nurse looking inside the lower part of the bowel using a camera on the end of a thin, flexible tube.

Taking part in bowel cancer screening reduces your chances of dying from bowel cancer. Removing any polyps – small growths that can develop on the inner lining of your bottom (rectum) – found in bowel scope screening can prevent cancer.

However, all screening involves a balance of potential harms, as well as benefits. It’s up to you to decide if you want to have it.

Treatment for bowel cancer

Bowel cancer can be treated using a combination of different treatments, depending on where the cancer is in your bowel and how far it has spread.

The main treatments are:

• Surgery – the cancerous section of bowel is removed; it’s the most effective way of curing bowel cancer and in many cases is all you need
• Chemotherapy – where medicine is used to kill cancer cells
• Radiotherapy – where radiation is used to kill cancer cells
• Targeted therapies – a newer group of medicines that increases the effectiveness of chemotherapy and prevents the cancer spreading

Keyhole surgery is being used more often, which allows surgery to be performed with less pain and a quicker recovery.

Treatment for bowel cancer will depend on which part of your bowel is affected and how far the cancer has spread.

Surgery is usually the main treatment for bowel cancer, and may be combined with chemotherapy, radiotherapy or biological treatments, depending on your particular case.

If it’s detected early enough, treatment can cure bowel cancer and stop it coming back.

Unfortunately, a complete cure is not always possible and there’s sometimes a risk that the cancer could come back at a later stage.

A cure is highly unlikely in more advanced cases that cannot be removed completely by surgery.

But symptoms can be controlled and the spread of the cancer can be slowed using a combination of treatments.

Your treatment team

If you’re diagnosed with bowel cancer, you’ll be cared for by a multidisciplinary team, including:

• A specialist cancer surgeon
• A radiotherapy and chemotherapy specialist (an oncologist)
• A radiologist

When deciding what treatment is best for you, your care team will consider the type and size of the cancer, your general health, whether the cancer has spread to other parts of your body, and how aggressive the cancer is.

Surgery for colon cancer

If colon cancer is at a very early stage, it may be possible to remove just a small piece of the lining of the colon wall, known as local excision.

If the cancer spreads into muscles surrounding the colon, it’s usually necessary to remove an entire section of your colon, known as a colectomy.

There are 3 ways a colectomy can be performed:

• An open colectomy – where the surgeon makes a large cut (incision) in your abdomen and removes a section of your colon
• A laparoscopic (keyhole) colectomy – where the surgeon makes a number of small incisions in your abdomen and uses special instruments guided by a camera to remove a section of colon
• Robotic surgery – a type of keyhole surgery where the surgeon’s instruments guide the robot, which removes the cancer

During surgery, nearby lymph nodes are also removed. The ends of the bowel can be joined together after bowel cancer surgery, but very occasionally this is not possible and a stoma is needed.

Both open and laparoscopic colectomies are thought to be equally effective at removing cancer, and have similar risks of complications.

But laparoscopic or robotic colectomies have the advantage of a faster recovery time and less postoperative pain.

Laparoscopic surgery is now becoming the routine way of doing most of these operations.

Laparoscopic colectomies should be available in all hospitals that carry out bowel cancer surgery, although not all surgeons perform this type of surgery.

Discuss your options with your surgeon to see if this method can be used.

Surgery for rectal cancer

There are a number of different types of surgery for rectal cancer, depending on how far the cancer has spread.

Some operations are carried out through the bottom, with no need for abdominal incisions.

Local resection

If you have a very small early-stage rectal cancer, your surgeon may be able to remove it in an operation called a local resection (transanal, through the bottom resection).

The surgeon puts an endoscope in through your bottom and removes the cancer from the wall of the rectum.

Total mesenteric excision

In most cases, a local resection is not possible at the moment. Instead, a larger area of the rectum will need to be removed.

This area will include a border of rectal tissue free of cancer cells, as well as fatty tissue from around the bowel (the mesentery).

This type of operation is known as total mesenteric excision (TME).

Removing the mesentery can help ensure all the cancerous cells are removed, which can lower the risk of the cancer recurring at a later stage.

Depending on where in your rectum the cancer is located, 1 of 2 main types of TME operations may be carried out.

Anterior resection

Low anterior resection is a procedure used to treat cases where the cancer is away from the sphincters that control bowel action.

The surgeon will make an incision in your abdomen and remove part of your rectum, as well as some surrounding tissue to make sure any lymph glands containing cancer cells are also removed.

They then attach your colon to the lowest part of your rectum or upper part of the anal canal.

Sometimes they turn the end of the colon into an internal pouch to replace the rectum.

You’ll probably need a temporary stoma to give the joined section of bowel time to heal.

This will be closed at a second, less major, operation.

Abdominoperineal resection

Abdominoperineal resection is used to treat rectal cancer in the lowest section of your rectum.

It’s usually necessary to remove the whole of your rectum and surrounding muscles to reduce the risk of the cancer regrowing in the same area.

This involves removing and closing the anus and removing its sphincter muscles, so there’s no option except to have a permanent stoma after the operation.

Stoma surgery

Where a section of the bowel is removed and the remaining bowel joined, the surgeon may sometimes decide to divert your poo away from the join to allow it to heal.

Poo is temporarily diverted by bringing a loop of bowel out through the abdominal wall and attaching it to the skin – this is called a stoma. A bag is worn over the stoma to collect the poo.

When the stoma is made from the small bowel (ileum) it’s called an ileostomy, and when it’s made from the large bowel (colon) it’s called a colostomy. 

In the first few days after surgery, the stoma care nurse will advise on the care necessary to look after the stoma and the type of bag suitable.

Once the join in the bowel has safely healed, which can take several weeks, the stoma can be closed during further surgery.

For various reasons, in some people rejoining the bowel may not be possible – or may lead to problems controlling bowel function – and the stoma may become permanent.

Before having surgery, the care team will advise you about whether it may be necessary to form an ileostomy or colostomy, and the likelihood of this being temporary or permanent.

Side effects of surgery

Bowel cancer operations carry many of the same risks as other major operations, including:

• Bleeding
• Infection
• Developing blood clots; usually in the legs (deep vein thrombosis)
• Heart or breathing problems

The operations all carry a number of risks specific to the procedure.

One risk is that the joined-up section of bowel may not heal properly and leak inside your abdomen. This is usually only a risk in the first few days after the operation.

Another risk is for people having rectal cancer surgery. The nerves that control urination and sexual function are very close to the rectum, and sometimes surgery to remove a rectal cancer can damage these nerves.

After rectal cancer surgery, most people need to go to the toilet to open their bowels more often than before, although this usually settles down within a few months of the operation.

Occasionally, some people – particularly men – have other distressing symptoms, such as pain in the pelvic area and constipation alternating with frequent bowel motions.

Frequent bowel motions can lead to severe soreness around the anal canal.

Support and advice should be offered on how to cope with these symptoms until the bowel adapts to the loss of part of the back passage.

Radiotherapy

There are several ways radiotherapy can be used to treat bowel cancer:

• Before surgery – to shrink rectal cancers and increase the chances of complete removal
• Instead of surgery – to cure or stop the spread of early-stage rectal cancer, if you cannot have surgery
• As palliative radiotherapy – to control symptoms and slow the spread of cancer in advanced cases

Radiotherapy before surgery for rectal cancer can be given in 2 ways:

• External radiotherapy – a machine is used to beam high-energy waves at your rectum to kill cancerous cells
• Internal radiotherapy (brachytherapy) – a tube that releases a small amount of radiation is inserted into your bottom and placed next to the cancer to shrink it and kill the cancer cells

External radiotherapy is usually given daily, 5 days a week, with a break at the weekend.

Depending on the size of your tumour, you may need 1 to 5 weeks of treatment. Each session of radiotherapy is short and will only last for 10 to 15 minutes.

Internal radiotherapy may also involve several treatment sessions. If you’re also having surgery, this will usually be carried out a few weeks after your radiotherapy course finishes.

Palliative radiotherapy is usually given in short daily sessions, with a course ranging from 2 to 3 days, up to 10 days.

Short-term side effects of radiotherapy can include:

• Feeling sick
• Fatigue
• Diarrhoea
• Burning and irritation of the skin around the rectum and pelvis – this looks and feels like sunburn
• A frequent need to pee
• A burning sensation when peeing

These side effects should pass once the course of radiotherapy has finished.

Tell your care team if the side effects of treatment become particularly troublesome.

Additional treatments are often available to help you cope with the side effects.

Long-term side effects of radiotherapy can include:

• A more frequent need to pee and poo
• Blood in your pee and poo
• Infertility
• Erectile dysfunction

If you want to have children, it may be possible to store a sample of your sperm or eggs before treatment begins so they can be used in fertility treatments in the future.

Chemotherapy

There are 3 ways chemotherapy can be used to treat bowel cancer:

• Before surgery – used in combination with radiotherapy to shrink the tumour
• After surgery – to reduce the risk of the cancer recurring
• Palliative chemotherapy – to slow the spread of advanced bowel cancer and help control symptoms

Chemotherapy for bowel cancer usually involves taking a combination of medicines that kill cancer cells.

They can be given as a tablet (oral chemotherapy), through a drip in your arm (intravenous chemotherapy), or as a combination of both.

Treatment is given in courses (cycles) that are 2 to 3 weeks long each, depending on the stage or grade of your cancer.

A single session of intravenous chemotherapy can last from several hours to several days.

Most people having oral chemotherapy take tablets over the course of 2 weeks before having a break from treatment for 1 week.

A course of chemotherapy can last up to 6 months, depending on how well you respond to the treatment.

In some cases, it can be given in smaller doses over longer periods of time (maintenance chemotherapy).

Side effects of chemotherapy can include:

• Fatigue
• Feeling and being sick
• Diarrhoea
• Mouth ulcers
• Hair loss with certain treatment regimens, but this is generally uncommon in the treatment of bowel cancer       
• A sensation of numbness, tingling or burning in your hands, feet and neck

These side effects should gradually pass once your treatment has finished.

It usually takes a few months for your hair to grow back if you experience hair loss.

Chemotherapy can also weaken your immune system, making you more vulnerable to infection.

Inform your care team or doctor as soon as possible if you experience possible signs of an infection, including a high temperature (fever) or a sudden feeling of being generally unwell.

Medicines used in chemotherapy can cause temporary damage to men’s sperm and women’s eggs.

This means there’s a risk to the unborn baby’s health for women who become pregnant or men who father a child. 

It’s recommended that you use a reliable method of contraception while having chemotherapy treatment and for a period after your treatment has finished.

Targeted therapies

Targeted therapies are medicines designed to target 1 or more of the biological processes that bowel cancer uses to spread inside the body.

For example, cetuximab and panitumumab are medicines that target proteins called epidermal growth factor receptors (EGFRs), which are found on the surface of some cancer cells.

As EGFRs help the cancer grow, targeting these proteins can shrink tumours and improve the effect of chemotherapy.

Targeted therapies are sometimes used in combination with chemotherapy when the cancer has spread beyond the bowel (metastatic bowel cancer).

Living with bowel cancer

Bowel cancer can affect your daily life in different ways, depending on what stage it’s at and the treatment you’re having.

How people cope with their diagnosis and treatment varies from person to person. There are several forms of support available if you need it:

• Talk to your friends and family – they can be a powerful support system
• Communicate with other people in the same situation – for example, through bowel cancer support groups
• Find out as much as possible about your condition
• Do not try to do too much or overexert yourself
• Make time for yourself

You may also want advice on recovering from surgery, including diet and living with a stoma, and any financial concerns you have.