Colorectal Cancer

 

Surgical approach has been the main treatment modality for colorectal cancer with adjuvant chemotherapy and/or radiotherapy added for the disease of a later stage.  Concurrent Chemo-radio therapy prior to the surgery is sometimes an option to shrink the tumor for better surgical result, lower chance of recurrence, and higher survival rate.  Our extensive experience with targeted therapy has shown evidence pointing to benefit of targeted therapy for patients of certain colorectal recurrences.  Improved prognosis through multidisciplinary collaboration – a treatment model of the modern time – has placed colorectal cancer among its earlier success stories where the local relapse is reduced, rectum is reserved, quality of life improved, and, the survival increased.   

A total of 3,050 patients with newly diagnosed colorectal cancer were treated in our center between 1990 and 2011 - 1,684 men（55.2％）and 1,366 wemen（44.8％), with a median age of 60 years（19-92). More than half of these patients（57.3%）were in stage III or IV at diagnosis (please see table 1 below for related survival rates)   The increasing efforts in promoting cancer screeninng has not yet reflected much increase in early detection of colorectal cancer, which indicates a great need for further researches and improvements.

 

Table 1: Five-year AJCC Lung Cancer Survival by Stage in KFSYSCC 1990-2011

Stage	0	I	II	III	IV	Unclear	Total
# of patients	131	413	627	1,044	706	129	3,050
% of patients	4.3%	13.5%	20.6%	34.2%	23.2%	4.2%
5-year survival	94.1%	91.1%	82.2%	73.7%	10.9%		63.7%
10-year survival	84.3%	80.8%	67.7%	58.5%	4.8%		52.1%

Data source: KFSYSCC Annual Report 2011

 

Comparison of Survival Rates of Colorectal Cancer by genders 2006-2010:                                   

 KFSYSCC Rates vs. National Rates （%）

	KFSYSCC				Islandwide
	All patients		Male	Female		Male	Female
	1990-2011	2006-2010	2006-2010	2006-2010		2006-2010	2006-2010
1-year Survival	88.1	90.0	90.8	89.0		80.8	81.6
2-year Survival	78.2	80.0	79.8	80.2		69.5	71.3
3-year Survival	71.0	71.1	71.2	71.0		61.1	63.9
4-year Survival	66.0	65.5	66.5	64.4		55.3	59.0
5-year Survival	62.3	62.3	61.2	63.3		50.6	55.0

Data source: Health Promotion Administration, Ministry of Health and Welfare (2013)
                        KFSYSCC Annual Report 2011

 

Comparison of 5-year Survival Rates of Colorectal Cancer  2004-2009:                                   

 KFSYSCC Rates vs. National Rates （%）

Stage	KFSYSCC	Islandwide
I	90.8	82.5
II	85.0	75.2
III	71.8	59.1
IV	9.0	12.6

Data source: Health Promotion Administration, Ministry of Health and Welfare（2012）
                        KFSYSCC Annual Report 2011

 

Relative survival rate reported by SEER in the US vs. the KFSYSCC breast cancer survival rate  (2004-2010) 

	KFSYSCC			US SEER#
	All patients	Men	Women	A  patients	Men	Women
Survival rates	61.8	62.0	61.6	64.7	65.0	64.5

# SEER Cancer Statistics Review 1975-2011，relative survival rates
Data source: KFSYSCC Annual Report 2011

 

 

The diagnosis of colorectal cancer takes place either during an asymptomatic screening or a symptom related exam. The most frequently used screening is the fecal occult blood test (FOBT) which has been proven invaluable in the detection of colorectal cancer by years of clinical trials. According to three prospective studies, the use of FOBT has helped reduce the colorectal cancer mortality by 15-33% annually.   Three retrospective studies showed, aside from lowering the mortality rate, FOBT could also detect risks of colorectal cancer beforehand. In the event of suspicious screening result or any of the symptoms listed below, please seek medical help for further investigation. 

·         Changes in bowel movement such as diarrhea, constipation, or days of thin narrow stools

·         Feeling of incomplete stool and need of multiple bowel movements

·         Weight loss

·         Anemia

·         Intestinal bleeding or bloody stool

·         Abdominal pains

·         Weakness and fatigue

 

Having these symptoms does not necessarily mean you have colon cancer, but you need to tell doctor about it.  Bear in mind sometimes there may not be any symptoms at all.

 

If you think you may have colon or colorectal cancer, the doctor will take a detailed history of your medical condition, perform physical exam, order lab tests, and assess your risk factor before a diagnosis and possible status of metastasis are reached.  The tests commonly done for possible colorectal cancer are:

·         FOBT – fecal occult blood test

·         Colonoscopy

·         Flexible sigmoidoscopy

·         Barium enema prep

·         Blood test (liver function, CEA level, and more)

·         Biopsy

·         Ultrasound, CT，MRI and chest x-ray

·         PET scan
 

Surgical resection remains the primary therapy for colorectal cancer.  For better prognosis, adjuvant chemotherapy or radiotherapy, or both are added for patients with lymph node involvement and for all stage III patients.

 

People gasp at the notion of getting artificial bowel opening, but there have been great breakthroughs thanks to advances in medical equipment and surgical technique that improved not only the treatment outcome, but also the preservation of rectum and quality of life.  Where a patient used to need a permanent artificial bowel opening, there is now options, such as sphincter preserving chemoradiotherapy and diverting colostomy, to preserve the anus while maintaining the normal bowel function.  About 90% of our colorectal cancer patients get to keep their rectum. 

The likelihood of recurrence for stage II and beyond is relatively high with more than 1/3 of the patients returning for local pelvic mets causing great discomfort for the patients and challenges for the physicians.   In cases where the tumors have invaded other organs and cannot be removed, a diverting colostomy is performed to relieve patient of the obstruction issues.  In summary, regardless of the size, site, symptoms, time extent of disease, as long as the tumor is not attached to any organs, it can be surgically removed when the patient’s physical condition can tolerate the surgery.  In cases of distant mets of the liver, lung, or bones, the removal of the tumor itself bears the benefit of prevention of tumor related bleeding, obstruction or puncture , which may lead to symptoms like anemia, abdominal fullness, or frequent bowel movement.  This means significant improvement in quality of life.    

Generally speaking, early detection and surgical removal of a tumor means a good chance for cure.  The same rule applies to colorectal cancer.  Our clinical data show that stage I colorectal cancer patients with the tumor mostly still inside the intestinal wall have a five-year overall survival rate of > 90%; stage II with tumor invasion to the intestinal epithelium, >70% , and stage III with local lymph node invasion, >60%.   A free margin also translates into curable and good prognosis for more than 50% of the patients.   Therefore, the key is regular complete physical for early detection.  Recurrent or metastatic colorectal cancer is most likely to take place during the first two years after the treatment.  After five years the possibility decreases to very low.  This means five-year survival doesn’t mean five years of survival. 

Aside from the surgical approach to remove as much of the tumor as possible, there has been targeted therapy available lately to shrink down the tumor size and its area of invasion, which may give some patients the chance of surgical removal and with it, longer survival.

 

Facing cancer

Facing cancer is a facing threat to one’s very existence.  The blow from cancer hits not just the physical being but often scars the mental and emotional presence, of the patient as well as the patient’s family.  The different phases of reactions, from shocking blank to angry denial, though normal and expected, but if not managed well, could add more pain and damage on top of the cancer itself.   Anxiety, sense of loss, fear of uncertainty, insomnia, guilt, depression, despair, and anger are among the commonly seen symptoms which require professional help as well as social support. 

 

Stress Screening

About 50% of cancer patients worldwide develop psychological symptoms but only 8 – 10 % would voice their concerns and seek help.  In our hospital, a Distress thermometer is offered to every patient upon their first visit to assess their distress level.  When necessary, the social psychotherapy team and the social works are asked to join the multidisciplinary team to help patient and the family cope with cancer and to safeguard the quality of life for patient.   There are also various cancer support groups and religious support organizations that will offer to accompany the patient in their walk with cancer and fight against cancer.

 

A letter to the family

Being there for the patient means the world to the patient.  Support and company from the family and relatives are a critical part in cancer care.   Listening to the patient and respecting the patient’s wishes bring positive energy.    When a member in the family gets cancer, the rest of the family are affected in many aspects: physical, psychological, financial, and emotional, to where the whole family system could collapse.  When providing the much deserved and much needed care to the patient, the family members must remember to also provide equal amount of care to one another and to oneself.   In the event of exhaustion or burn-out, remember to seek professional help.