COLON AND RECTAL CANCER

( By JASCAP )

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Treating rectal cancer

In most hospitals, a team of specialists will discuss the treatment that is best for you. This multidisciplinary team (MDT) will include a surgeon who specialises in bowel cancers, one or more oncologists (doctors who specialise in cancer treatments such as radiotherapy or chemotherapy) and a number of other health professionals.

How treatment is planned

Together, the MDT will be able to advise you on the best course of action and plan of treatment. They will take into account a number of factors, including your general health, age, the size of the cancer, where it is in the rectum, and whether it has begun to spread.

The stage is very important in determining treatment.

  • Surgery is the most common treatment. Most stage 1 rectal cancers can be treated successfully with surgery alone.
  • For stage 2 and stage 3 rectal cancers, radiotherapy or chemoradiotherapy (a combination of chemotherapy and radiotherapy) may be used in addition to surgery.
  • It‘s not often possible to cure stage 4 (advanced) rectal cancer but treatment can be given to control it.

Your doctors will have carried out various tests to help them plan your treatment. Although they will have a good idea about which treatments you need, they may not be able to tell you exactly until after an operation.

You will be asked to give your permission (consent) for the hospital staff to give you the treatment. It‘s important that you discuss with your doctor the treatments they recommend, and that you understand why a particular treatment has been suggested for you.

Treatment according to stage

Stage 1

Often, the cancer can be completely removed with surgery, and for most people it will never come back. People with stage 1 rectal cancer don‘t usually need to have any further treatment after their surgery, although very occasionally chemotherapy or radiotherapy may be given.

Stage 2

People with stage 2 rectal cancers are also usually treated with surgery. Radiotherapy, or a combination of radiotherapy and chemotherapy (chemoradiotherapy) may be given before surgery to shrink the cancer and make it easier to remove. Giving treatment before surgery is called neo-adjuvant therapy.

Chemoradiotherapy or chemotherapy on its own can be given after the operation if there is a risk that the cancer may come back in the future and treatment wasn‘t given before surgery.

Stage 3

People with stage 3 rectal cancers may be given radiotherapy or chemoradiotherapy before surgery to shrink the cancer and make it easier to remove. There is a greater risk that the cancer will come back after surgery, and chemotherapy is usually recommended unless neo-adjuvant treatment has been given.

Stage 4

Stage 4 (advanced) rectal cancer means that the cancer has spread from where it started in the bowel. It can spread into the area around the bowel, such as the abdomen, and this is known as local spread. If the cancer has spread to other parts of the body such as the liver or lungs, this is known as secondary, or metastatic, cancer.

It isn‘t usually possible to cure stage 4 rectal cancer, but treatment may be able to control it for some time. Treatment may also be used to reduce symptoms and give a good quality of life.

However, for some people in this situation, treatment will have little effect upon the cancer and they will have the side effects without many of the benefits.

The treatment that is most appropriate for you will depend on:

  • which part of your body the cancer has spread to
  • the treatment that you‘ve already had.

Chemotherapy is the most commonly used treatment for stage 4 rectal cancer. It may be given into a vein by injection or drip, or taken as tablets or capsules.

Surgery may sometimes be used, for example to remove a cancer that is blocking the bowel, or sometimes to remove secondary bowel cancers from the liver or lungs.

Radiotherapy may be used to shrink a cancer that is causing pain. This is known as palliative radiotherapy.

Monoclonal antibodies such as bevacizumab (Avastin®), cetuximab (Erbitux®) and panitumumab (Vectibix®) are sometimes used to control advanced rectal cancer for a time.

The benefits and disadvantages of treatment

Many people are frightened at the thought of having cancer treatments because of the side effects that may occur. Some people ask what will happen if they don‘t have any treatment.

Although the treatments can cause side effects, these can often be well controlled with medicines.

Treatment can be given for different reasons and the potential benefits will vary depending upon your particular situation.

Treatment decisions

If you have early-stage rectal cancer (stages 1, 2 and 3) and have been offered treatment that is intended to cure it, it may be easy to decide whether to accept the treatment. Your doctor will talk through your treatment and any other options with you.

However, if a cure is not possible and the treatment is being given to control the cancer for a period of time, it may be more difficult to decide whether to go ahead. Making decisions about treatment in these circumstances is always difficult.

You may need to discuss in detail with your doctor whether you wish to have treatment. If you choose not to, you can still be given supportive (palliative) care, which often involves medicines to control any symptoms.

You can ask for a second opinion if you feel it would be helpful.

Surgery for rectal cancer

Surgery is the most common type of treatment for rectal cancer and should be carried out by a surgeon who specialises in bowel surgery.

There are different types of rectal cancer surgery. Your doctor will discuss with you the most appropriate type of surgery, depending on the stage of your cancer and where it is in the rectum. You may be given radiotherapy or chemoradiotherapy before surgery to shrink the cancer and make it easier to remove.

Before your operation

Before your surgery the doctor and specialist nurses will explain the operation to you. They will tell you what to expect immediately after the surgery and in the few days following. This is a good opportunity to ask any questions about the operation.

You will probably be admitted to the ward the day before your operation, so that the doctors and nurses can do any further tests. To make sure that your bowel is completely empty, you‘ll be asked to follow a strict diet and take a medicine (laxative) to help empty your bowels the day before surgery. Your nurse or the doctor will explain this to you. You will be given antibiotics as an injection into a vein (intravenously) just before and after surgery to prevent infections.

Types of rectal cancer surgery

Local resection, transanal resection or transanal endoscopic microsurgery

Very early-stage rectal cancers can sometimes be removed using an operation known as a local resection or a transanal resection. Using an endoscope, similar to the one used to take a biopsy, the surgeon removes only the cancer from the wall of the rectum. This operation is sometimes called transanal endoscopic microsurgery (TEM). If the cancer is close to the anus, the surgeon may be able to operate without the need for an endoscope. A pathologist will examine the cells of the cancer and if

it‘s then found to be high-grade your surgeon may recommend that you have a second operation. This is done to remove more of the rectum to make sure that no cancer cells have been left behind.

Total mesorectal excision

Total mesorectal excision (TME) is an operation commonly used to remove a rectal cancer. It involves careful removal of the whole of the rectum as well as the fatty tissue that surrounds it, which contains the lymph nodes. This operation takes from 3–5 hours. Research has shown that a TME is better than other types of surgery at reducing the risk of the cancer coming back.

Depending upon the position of the cancer in the rectum, its size, and how far it is from the anus, your surgeon will do the TME operation by using either an anterior resection or an abdomino-perineal resection.

Anterior resection

An anterior resection is usually used for cancers in the upper and middle parts of the rectum (close to the colon). During the surgery, the piece of bowel that contains the cancer is removed and the two ends are then joined together. The join is known as an anastomosis.

The lymph nodes near the bowel are also removed, because this is usually the first place the cancer spreads to. After this operation you‘ll have a wound that goes in a straight line from just below your breast bone (sternum) to just above your pelvis.

If for some reason the bowel can‘t be rejoined, the upper end can be brought out onto the skin of the abdominal wall. This is known as a colostomy and the opening of the bowel is known as a stoma. A bag is worn over the stoma to collect the stool (bowel motions).

Sometimes a colostomy is only temporary and another operation to rejoin the bowel can be done a few months later. The operation to rejoin the bowel is known as stoma reversal. We can send you information about this.

If it isn‘t possible to reverse the colostomy, the stoma is permanent. Having radiotherapy or chemoradiation before surgery can help to reduce the chance of needing a permanent colostomy.

Abdomino-perineal resection

An abdomino-perineal resection is usually used for cancers in the lower end of the rectum. This operation will result in a permanent colostomy because the whole rectum and anus are removed. After the surgery there will be two wounds – an abdominal wound and a second wound where the anus has been surgically closed.

Surgery for advanced rectal cancer

If the cancer is too large to be removed and is pressing on the bowel causing it to narrow, it may be possible to insert a thin metal tube (a stent) into the bowel to keep it open. The stent is inserted using a colonoscope. You‘ll be given a mild sedative to help you relax and you may have a short stay in hospital.

Surgery may sometimes be used to remove the cancer when it has spread to another part of the body, such as the liver or lungs. Sometimes chemotherapy may be given before or after the surgery.

You may find JASCAP booklets on Secondary Cancer in the Liver and Secondary Cancer in the Lungs helpful.

After your operation for rectal cancer

How quickly you recover from your operation will depend on your age and health, and the type of surgery you‘ve had. Your doctor and specialist nurse can give you an idea about what to expect.

In the hospital

Getting moving

After your operation you‘ll be encouraged to start moving around as soon as possible. This is an essential part of your recovery. Even if you have to stay in bed, it‘s important to do regular leg movements and deep-breathing exercises. A physiotherapist or nurse will explain the exercises to you.

As you won‘t be moving around as much as usual, you may be at risk of blood clots forming. To prevent this you will be asked to wear special stockings, and may be given an anti-clotting drug called heparin.

Drips and diet

When you go back to the ward, you will have a drip (infusion) which gives you fluids through a thin tube (cannula) inserted into a vein in your hand or arm. This will be taken out once you are able to eat and drink normally again.

You may also have a thin tube that passes down your nose into your stomach (nasogastric or NG tube). This allows any fluids to be removed from your stomach so that you don‘t feel sick. It‘s normally taken out within a few days.

As an anaesthetic slows down the movement of the bowel, it‘s important that you don‘t start drinking until the bowel is working normally again. You will probably be ready to start taking sips of water within a few days. This will be increased gradually over a couple of days until you are able to eat a light diet.

Drains

Often, a small tube (catheter) is put into your bladder, and your urine is drained through this into a collecting bag. This is usually taken out after a couple of days.

You may also have a drainage tube in your wound, to drain any extra fluid and make sure that the wound heals properly. A drain isn‘t always needed.

Pain

After your operation, you‘ll probably have some pain or discomfort for a few days.

There are several different types of painkillers that can be given to you at regular

intervals or when you need them. You may be given painkillers into a vein in your arm through a pump. The pump can be set to give you a controlled amount of painkiller, or you may be able to control this yourself by pressing a button. This is called patient controlled analgesia (PCA).

Always let your doctor or nurse know if you have any pain or discomfort. The painkillers or their dose can be changed to suit your needs. Some people may continue to have some pain after they go home. Let your doctor or nurse know if you think you might need painkillers to take home with you.

Going home

Depending on the type of operation you‘ve had, you‘ll probably be ready to go home between 3–10 days after surgery. If you think that you might have problems when you go home (for example, if you live alone or have several flights of stairs to climb), let your nurse or the social worker know when you are admitted to the ward. They can then arrange help before you leave hospital.

You‘ll be given an appointment to attend an outpatient clinic for your post-operative check-up. At the appointment your doctor will be able to discuss with you whether you need to have any further treatment, such as chemotherapy.

Some people take longer than others to recover from their operation. If you have any problems, you may find it helpful to talk to someone who is not directly involved with your illness. See our useful organisations section for more information about who can help.

Our cancer support specialists can talk to you, and tell you how to contact a counselor or local cancer support group.

Enhanced Recovery Programmes (ERP)

Some hospitals follow an Enhanced Recovery Programme that can help to reduce complications following surgery and speed up your recovery. The programme involves careful planning before your operation so that you are properly prepared and any arrangements that are needed for you to go home are already in place.

You‘ll also be encouraged to take high-protein and high-calorie supplements before and after your surgery, and to start moving around as soon as possible, sometimes on the day of the operation. After you have gone home you‘ll be regularly reviewed to make sure that you are recovering well.

Diet after bowel surgery

After any bowel operation, you may notice that certain foods upset the normal working of your bowel, or your colostomy if you have one. High-fibre foods, such as fruit and vegetables, may give you loose stools and make you pass them more often than normal. Depending on the type of surgery you‘ve had, you may have diarrhoea.

Tell your doctor or nurse if this happens, as they can give you medicine to help.

It‘s important to drink plenty of fluids if you have diarrhoea. This is often a temporary reaction, and after a while you may find that the same foods don‘t have any effect.

There are no set rules about the types of food to avoid and each person needs to

experiment for themselves. Some foods that disagree with one person may be fine for another.

You may also find that your bowel produces more wind than before, and this can sometimes build up in the abdomen and cause pain. Drinking peppermint water or taking charcoal tablets can help to reduce this. Your doctor can prescribe these for you, or you can get them from your chemist.

It can sometimes take months for your bowel movements to get back to normal after surgery, and you‘ll probably need to find out which foods are right for you by trial and error. Some people may find that their bowel is always more active than before their surgery, and that they have to eat carefully to control their bowel movements.

If you continue to have problems, it‘s important to talk to a dietitian at the hospital, as they can give you specialist advice for your individual situation.

You may find JASCAP booklet on Diet and Cancer helpful.

Sex life after bowel surgery

Once you have recovered from the operation, there is usually no medical reason why you shouldn‘t have a normal sex life again. However, you may find that you feel self- conscious about the change in your body‘s appearance, especially if you now have a colostomy. This may stop you from wanting to make love.

Talking about your feelings may help lessen your anxieties. Try not to feel embarrassed talking to your nurse or doctor about what is troubling you. They can refer you for specialist counselling if you think that would be helpful.

Sometimes the operation can cause damage to the nerves that go to the sexual organs. If this occurs, a man may not be able to have or maintain an erection, and may have problems with orgasm and ejaculation. Women may also find that their sexual function or response is affected. This may improve over time, but sometimes it is permanent. There are treatments available, such as sildenafil (Viagra®) that can help men achieve erections. It‘s important to discuss this with your doctor as soon as you notice a problem, as treatment can often be more effective if started sooner.

We may find JASCAP booklet on Sexuality and Cancer helpful.

If you have any problems, your doctor or specialist nurse will be able to discuss them with you in more detail.

Living with a stoma

Some people with cancer of the rectum will need to have a colostomy. In this operation, the bowel is brought to the outside of the body through the abdominal wall. The opening is called a stoma.

This can be daunting at first. Learning to look after a stoma takes time and patience and no-one expects you to be able to cope straight away. Like anything new, it will get easier with time and practice.

Stoma care nurse

In most hospitals there are specially trained nurses called stoma care nurses (or colorectal nurses) who you will usually meet before your operation. They will show you how to look after your stoma and help you cope with any problems.

Before your operation, the nurse or doctor will carefully plan the position of your stoma so that your bag stays in place, whether you are sitting, standing or moving around.

For the first few days after your operation, the nurse will look after your colostomy for you and make sure that the bag is emptied and changed as often as necessary. At first your stoma will be slightly swollen and it can take several weeks before it settles down to its normal size.

As soon as you are feeling well enough, the nurse will show you how to clean your stoma and change the bags. There are several different types of bag or appliance available and the nurse will help you choose a suitable one.

Talking to people who have a stoma

You may find it helpful to talk to someone who has already learned to live with a stoma. Your nurse or doctor can often arrange for a volunteer to visit you and talk to you about the more practical and personal aspects, or you can contact the Colostomy Association.

This advice, coming from personal experience, can be invaluable, particularly in the first few months after your operation..

Looking after a stoma

When the nurse is showing you how to look after your stoma, it may help for a close relative or partner to be with you, in case you have any difficulties when you get home.

Before you leave hospital, your nurse will make sure that you have a good supply of stoma bags. Make sure that you have plenty of bags and cleaning materials to hand before you start to change or empty your bag. It‘s a good idea to keep everything you need in one place, so that you don‘t have to start searching for things at the last minute. Make sure that you allow yourself plenty of time and privacy, so that you can work at your own pace without any interruptions.

Some people with a colostomy avoid wearing a bag by flushing out (or irrigating) their colostomy about once a day, although this method doesn‘t suit everyone. Your stoma nurse will be able to discuss this with you in more detail.

Stoma supplies

There are different ways of getting stoma supplies when you are at home. You can get all your supplies from your chemist. Sometimes it‘s better to get them direct from a specialised supply company. These may also offer a cutting and delivery service. The Colostomy Association has details of companies. The supplies are free, but

you‘ll need a prescription from your GP. If you are aged between 16 and 60, make sure that your doctor signs the form saying that you‘re entitled to free prescriptions.

Home support

Once you are at home you can phone the stoma nurse if you have any problems. Your GP may also arrange for a district nurse to visit you for a few days when you first leave hospital. They can make sure that you are coping at home, and sort out any problems you may have with your stoma.

Having a colostomy is a big change in your life. Many people find that they are embarrassed by the stoma, and that it affects the way that they feel about their body. Embarrassment about a stoma can also affect relationships and some people are uncomfortable about their partner seeing it. These feelings are a natural part of coming to terms with the changes that a stoma causes, and usually decrease gradually over time.

Chemotherapy for rectal cancer

Chemotherapy is the use of special anti-cancer (cytotoxic) drugs to destroy cancer cells.

Chemotherapy may be given after surgery. Its aim is to get rid of any remaining cancer cells and reduce the chance of the cancer coming back in the future. This is called adjuvant chemotherapy.

Chemotherapy is sometimes given before an operation. This is known as neo- adjuvant chemotherapy. The aim of the treatment is to reduce the size of the cancer, to make it easier to remove during surgery. This may make it possible to avoid having a permanent colostomy.

Sometimes the chemotherapy is given in combination with radiotherapy – this is known as chemoradiotherapy.

If the cancer is advanced (stage 4), chemotherapy may be used to reduce symptoms.

Chemotherapy for early-stage rectal cancer (stages 1, 2 and 3)

Chemotherapy usually isn‘t needed for stage 1 rectal cancers that haven‘t begun to grow through the muscle wall and aren‘t affecting the lymph nodes (Dukes A).

In the treatment of stage 2 rectal cancer (Dukes B), the risk of the cancer coming back is low so chemotherapy may not be needed. However, after surgery the cancer will be examined carefully under the microscope, and your doctor may recommend that you have chemotherapy if cancer cells are found in the blood or lymph vessels very close to the cancer.

You may also be offered chemotherapy as part of a clinical trial. Your cancer specialist will discuss whether chemotherapy will be of any benefit to you if you have stage 2 rectal cancer.

People with stage 3 rectal cancer (Dukes C) are usually offered chemotherapy. The chemotherapy can be used in combination with radiotherapy or on its own. You may be offered chemotherapy as part of a clinical trial.

Drugs used to treat early-stage rectal cancer

The main drugs used to treat early-stage rectal cancer are:

  • 5-fluorouracil (5FU), which is often given with the vitamin folinic acid (leucovorin) to make it more effective
  • Capecitabine (Xeloda®), which is a tablet form of 5FU
  • Oxaliplatin (Eloxatin®), which may also be used if the cancer has spread to the lymph nodes close to the rectum (stage 3 or Dukes C).

Your specialist will discuss your particular course of treatment.

Pros and cons of chemotherapy for early-stage rectal cancer

There are various benefits and risks of having chemotherapy and your doctor can discuss these with you.

Chemotherapy can reduce the chance of the cancer coming back and increase your chance of being cured, but it doesn‘t guarantee this. It can also sometimes cause side effects that may be unpleasant. To help decide whether adjuvant chemotherapy may be appropriate in your case, your specialist will take into account the risk of any cancer cells being left behind, the likelihood that the chemotherapy will get rid of them, and the possible side effects of the treatment.

If the risk of the cancer coming back is low, the chemotherapy may only slightly reduce the chance of the cancer returning. However, if the risk of the cancer coming back is high, the benefit of chemotherapy may be greater. It‘s important to discuss with your doctor the possible risks and benefits of chemotherapy in your particular situation.

Chemotherapy for advanced rectal cancer (stage 4)

Chemotherapy may also be given when the cancer has spread to another part of the body. Many people have no further problems after their original treatment for cancer of the rectum, but unfortunately in some people the cancer comes back or spreads to other parts of the body. This is called secondary, advanced or metastatic cancer.

Sometimes, when the cancer is first diagnosed, it may already have spread beyond the rectum. The most common place for it to spread to is the liver. The next most common place is the lungs.

Although secondary cancer of the rectum can‘t usually be cured, treatment with chemotherapy may be recommended by your doctor. The aim of the chemotherapy is to shrink the cancer and reduce symptoms. This can sometimes help to prolong life.

Chemotherapy may be given to shrink cancers before they are removed from the liver or, more rarely, the lungs. Sometimes drugs called monoclonal antibodies are given in combination with chemotherapy.

In recent years, improvements in surgical techniques and drug treatment have meant that an increasing number of people with liver secondaries are able to have surgery to remove their cancers – this can sometimes lead to a permanent cure.

Your doctor or specialist nurse can discuss this with you further.

Our organization, JASCAP has further information about Secondary cancer in the liver and Secondary Cancer in the Lungs.

Drugs used to treat advanced colon cancer

The most commonly used chemotherapy drugs for advanced rectal cancer are:

  • 5-fluorouracil (5FU), which is usually given with the vitamin folinic acid
  • Capecitabine (Xeloda®) tablets
  • Teqafur with uracil (Uftoral®) tablets, which are usually given with the vitamin folinic acid
  • Oxaliplatin (Eloxatin®)
  • Irinotecan (Campto®)
  • Mitomycin

Several research trials are being carried out to test new drugs for advanced rectal cancer, and to help find the best way of using the current drugs (those mentioned above). You may be asked if you‘d like to take part in a research trial using new chemotherapy drugs or new types of treatments.

If the cancer starts to grow again during or after the chemotherapy, you may be given a different type of chemotherapy (known as second-line treatment). Sometimes a third course of chemotherapy (third-line treatment) is also given.

Benefits and disadvantages of chemotherapy for advanced rectal cancer

There are various benefits and disadvantages of chemotherapy for advanced rectal cancer, and it‘s important to discuss these with your cancer specialist.

It isn‘t possible to predict whether the chemotherapy will work for a particular person, but if they are fairly fit the treatment is more likely to be effective. It‘s also less likely to have side effects than in someone who is unwell when they start treatment.

You don‘t have to have chemotherapy treatment unless you want it. If you choose not to, you‘ll still be given treatment to help control any symptoms that the cancer causes. This is known as supportive or palliative care. Palliative care can also be given alongside chemotherapy if needed.

Your doctor will consider a number of things before asking you to make a decision about particular treatments. This will include where the secondary cancer is, your general health, and any chemotherapy treatment you‘ve had in the past.

If you have advanced cancer, there are many difficult issues to deal with and you may find it helpful to read JASCAP booklet on Coping with advanced cancer.

JASCAP booklets on Controlling cancer pain and Controlling the symptoms of cancer explain ways that pain and symptoms can be relieved. They also give information on the support that is available from health professionals and other sources.

How chemotherapy is given

Many people having chemotherapy for rectal cancer will be given capsules or tablets. These are swallowed with water. Some people are given their chemotherapy drugs by injection into a vein (intravenously).

The drugs may be given through a fine tube in the back of your hand or arm (cannula), a plastic line, called a central line in your chest; or through a thin tube inserted into a vein in the crook of your arm (a PICC line).

Position of a central line

The PICC line is threaded through the vein until the end is near your heart

Sometimes chemotherapy can be given continuously through a small portable pump, which is attached to your central or PICC line. A controlled amount of the drug can be given into the bloodstream over a period of time. This means that you can go home with the pump, and spend less time in hospital. Some people whose cancer has spread to the liver may be given chemotherapy into an artery that goes directly into the liver.

Intravenous chemotherapy is usually given as a session of treatment. A session may last from a few hours to several days. If you have treatment for a few hours, this may be repeated each week for several months. This chemotherapy is usually given as an outpatient.

If your treatment lasts a few days you‘ll usually have a rest period of a few weeks before the next session. This allows your body to recover from the side effects of the treatment.

The chemotherapy session and the rest period make up a cycle of treatment. You may need to stay in hospital for your treatment, but it can also often be given to you as an outpatient. Your specialist will discuss this with you.

The number of cycles you have depends on the stage of the cancer and how well it‘s responding to the drugs.

Contraception during chemotherapy

It is not advisable to become pregnant or father a child while taking any of the chemotherapy drugs used to treat rectal cancer, as they may harm the developing baby. It‘s important to use effective contraception during your treatment and for a year afterwards. You can discuss this with your doctor or specialist nurse. Condoms should be used during sex within the first 48 hours after chemotherapy to protect your partner from any of the drug that may be present in semen or vaginal fluid.

Our Chemotherapy booklet discusses the treatment in more detail.

Side effects of chemotherapy for rectal cancer

Chemotherapy can sometimes cause unpleasant side effects. These will vary depending on which chemotherapy drugs you are given. Your doctor or nurse will tell you what problems to expect from your treatment. Common side effects include:

  • lowered resistance to infection
  • bruising or bleeding
  • anaemia (low number of red blood cells)
  • tiredness
  • feeling sick
  • diarrhea
  • sore mouth
  • hair loss
  • soreness of hands and feet
  • numbness or tingling.

Although side effects may be hard to bear at the time, they will gradually disappear once your treatment is over. For some people this can take some months.

Most people have some side effects from chemotherapy. But if your cancer is causing symptoms it can also make you feel better by relieving them.

There are many things that can be done to help reduce and control side effects so let the staff looking after you know if you are having problems.

Lowered resistance to infection (neutropenia)

While the drugs are acting on the cancer cells in your body, they may also temporarily reduce the number of normal white blood cells. This is called neutropenia. When these cells are reduced you are more likely to get an infection. While your level of white blood cells is low, it‘s important to avoid crowded places, where you may come into contact with infection, and to avoid anyone who already has an infection, such as a cold or flu.

Contact your doctor or the hospital straight away if you have any signs of infection, such as a high temperature (above 38°C or 100.5°F), or if you suddenly feel unwell (even with a normal temperature). During chemotherapy your blood will be tested regularly and, if necessary, you will be given antibiotics to treat any infection.

Bruising or bleeding

Chemotherapy can reduce the production of platelets (which help the blood to clot). Let your doctor know if you have any unexplained bruising or bleeding, such as nosebleeds, blood spots or rashes on the skin, or bleeding gums.

Anaemia (low number of red blood cells)

While having treatment with chemotherapy you may become anaemic. This may make you feel tired and breathless.

Tiredness

You‘re likely to find that you become very tired and have to take things much more slowly. Just do as much as you feel like and try not to overdo it. JASCAP has a booklet on Coping with fatigue, which you may find helpful.

Feeling sick

Some of the drugs may make you feel sick (nauseated) and possibly be sick (vomit). There are anti-sickness drugs (anti-emetics) to prevent or reduce nausea and vomiting. Your doctor will prescribe these for you. Let your doctor or nurse know if your anti-sickness drugs are not helping, as there are several different types you can take.

Diarrhoea

Some of the chemotherapy drugs used to treat bowel cancer can cause diarrhoea.

This often starts several days after the treatment. If you‘re taking chemotherapy tablets or capsules at home, it‘s important that you let your doctor or nurse know if you have diarrhoea. Your treatment may need to be stopped.

If you have diarrhoea your doctor can give you medicine to reduce this and slow down the bowel. You may also be able to help control it by eating a low-fibre diet. Our booklet on Diet and Cancer has useful advice on this.

If you‘ve had a colostomy, it may be more difficult to cope with diarrhoea caused by the chemotherapy. Your stoma nurse or cancer specialist can give you advice and support. Some people find that they need to make sure they are close to a toilet during the course of their treatment and for a while afterwards. This can be frustrating, but usually improves gradually a few weeks after the treatment has ended. If the diarrhoea continues after this time it‘s important to talk to your cancer specialist or stoma nurse, so that they can help you find ways of overcoming the diarrhoea.

Sore mouth

You may find that you get a sore mouth and mouth ulcers while having chemotherapy. Keeping your mouth clean with regular mouthwashes is important. Your nurse will show you how to use these properly. If a sore mouth makes eating difficult, you can try replacing meals with nutritious drinks — our fact-sheet on Mouth Care during Chemotherapy has some useful tips on coping with a sore mouth.

Hair loss

Ask your doctor if the drugs you are taking are likely to make your hair fall out. Most drugs used to treat colon cancer do not, but some may make your hair thin. If your hair does fall out, it will start to grow back again once your treatment is over. We have more information about coping with hair loss.

Soreness of hands and feet

If 5FU or capecitabine are given over a long period of time or are given continuously through a pump, soreness and redness of your palms and the soles of your feet can

occur. This is known as hand/foot syndrome or palmar-plantar syndrome. Vitamin B6 may be prescribed to help reduce this side effect and non-perfumed moisturising creams can often help to relieve the symptoms. If the symptoms are severe your doctor may reduce the dose of the chemotherapy or give you a short break from it.

Numbness or tingling

Oxaliplatin can affect the nerve endings and cause numbness, burning or tingling in the hands, feet, neck or throat (known as peripheral neuropathy). You may also find it hard to do up buttons etc. The numbness or tingling may not happen with the first treatment. If it occurs, it should gradually disappear once the treatment has finished. Sometimes in the first few days after oxaliplatin is given, these side effects can be triggered by anything cold, such as cold drinks or washing water, but often they only last a few minutes.

Our Chemotherapy booklet discusses the treatment in more detail and has tips for coping with the side effects.

Radiotherapy for rectal cancer

Radiotherapy treats cancer by using high-energy rays to destroy the cancer cells, while doing as little harm as possible to normal cells. Radiotherapy is often given in combination with chemotherapy, which is called chemoradiotherapy. The chemotherapy makes the cancer cells more sensitive to radiotherapy.

Radiotherapy doesn‘t make you radioactive and it‘s perfectly safe for you to be with other people, including children, throughout your treatment.

Radiotherapy for early-stage rectal cancer

Radiotherapy may be given before surgery to shrink a cancer and make it easier to remove. It also reduces the chance of the cancer coming back.

A short course of radiotherapy consisting of five treatments may be given over a week, just before the surgery.

If the cancer is large, a long course of radiotherapy may be given, lasting for up to six weeks. This is usually given with chemotherapy (chemoradiotherapy), which can help make the radiotherapy more effective. Following the course of radiotherapy you‘ll have to wait up to six weeks for the side effects to settle down before you can have the operation.

If radiotherapy was not given before surgery, you may have it afterwards if:

  • the cancer was difficult to remove
  • some cancer cells may be left behind
  • the cancer had spread through the bowel wall or into nearby lymph nodes.

This type of radiotherapy may be given as treatment every weekday for 4–5 weeks.

Radiotherapy for secondary rectal cancer

If a rectal cancer has spread or come back after initial treatment (particularly in the pelvic area), radiotherapy may be used to shrink the cancer. It also relieves symptoms such as pain.

How radiotherapy is given

Radiotherapy for rectal cancer is usually given as an outpatient in the radiotherapy department as a series of short daily treatments. The radiotherapy is given using equipment similar to a large x-ray machine and is known as external radiotherapy. The treatments are usually given each weekday with a rest at the weekend. How the treatment is given varies, depending on what is considered to be most effective for your situation. The course may last for just one week or a few weeks.

Your doctor will discuss your treatment with you beforehand, including how it will be given and how long it will last.

Planning your treatment

To make sure that your radiotherapy is as effective as possible, it has to be carefully planned. Planning ensures the radiotherapy rays are aimed precisely at the cancer and cause the least possible damage to the surrounding healthy tissues. The treatment is planned by a specialist doctor known as a clinical oncologist. Planning is very important and may take a few visits.

Marks may be drawn on your skin to help the radiographer, who gives you your treatment, to position you accurately and to show where the rays are to be directed. These marks must stay visible throughout your treatment, but they can be washed off once it‘s over. At the start of your radiotherapy you‘ll be told how to look after the skin in the area to be treated.

What happens in your treatment sessions

Before each session of radiotherapy, you‘ll be carefully positioned on the couch, either sitting or lying. The radiographer will make sure that you are comfortable.

During your treatment, which only takes a few minutes, you‘ll be left alone in the room, but you can talk to the radiographer who will watch you from another room.

Radiotherapy isn‘t painful but you do have to be still for a few minutes during treatment.

Positioning the radiotherapy machine

Side effects of radiotherapy for rectal cancer

Radiotherapy to the bowel area can cause side effects such as diarrhoea, feeling sick (nausea) and tiredness. It can also cause more specific side effects, such as inflammation of the bowel or bladder lining. These side effects can be mild or more troublesome, depending on the strength of the radiotherapy dose and the length of your treatment, but they tend to get worse as the treatment goes on.

The side effects will usually continue until a week or so after the treatment has finished, and then will gradually start to get better. Your clinical oncologist will tell you what to expect, and you can ask your radiographer for advice if side effects are becoming a problem for you.

Feeling sick

Some people may feel sick (nauseated) but this is usually mild, and anti-sickness drugs (anti-emetics) can usually control this effectively. If you don‘t feel like eating, you can replace meals with nutritious, high-calorie drinks. These are available from most chemists and can also be prescribed by your GP.

Diarrhoea

Radiotherapy may irritate the bowel and cause diarrhoea. Your doctor can prescribe drugs to reduce this. Our section on diet gives helpful hints on coping with problems such as nausea and diarrhoea.

Tiredness

As radiotherapy can make you feel tired, try to get as much rest as you can, especially if you have to travel a long way for treatment.

Skin reaction

The skin in the area that is treated may become red and sore. Many people find this is mild, but for others, the skin can become very sore and painful. The nurses and radiographers can advise you on how to look after your skin during treatment. If your skin gets very sore, soothing creams can be prescribed.

Inflammation of the bladder lining (cystitis)

Radiotherapy to the rectum may cause inflammation of the lining of the bladder. This can make you feel as though you want to pass urine often. You may also feel a burning sensation when you pass urine. It helps to drink plenty of water and other fluids to make your urine less concentrated. Your doctor can prescribe medicine to make passing urine more comfortable.

These side effects generally continue for several weeks and then disappear gradually once the course of treatment is over. It‘s important to let your doctor know if they continue.

Possible long-term side effects of radiotherpy

In some people, the bowel or bladder may be permanently affected by the radiotherapy. If this happens, the increased bowel motions and diarrhoea may continue, or you may need to pass urine more often than before. The blood vessels in the bowel and bladder can become more fragile after radiotherapy treatment and this can make blood appear in the urine or in bowel movements.

It can take months or years before these side effects develop. If you notice any bleeding, it‘s important to let your doctor know so that you can have tests and appropriate treatment.

Infertility and impotence

Radiotherapy to the pelvic area is very likely to cause infertility in men and women. Men may find that they become impotent due to the effect of the radiotherapy on the nerves in the pelvic area. Women may find that sensations during sex are different.

These effects can be distressing and it‘s important to discuss them with your doctor or specialist nurse, who can help you to find ways of dealing with them.

Our booklet on Sexuality and Cancer has advice on coping with impotence.

Our Radiotherapy booklet discusses the treatment and its side effects in more detail.

Chemoradiotherapy for rectal cancer

Chemoradiotherapy is a combination of chemotherapy and radiotherapy. It‘s sometimes known as chemoradiation and may be given in the treatment of rectal cancer before surgery to help shrink the cancer, or after surgery to reduce the risk of the cancer coming back.

The chemotherapy drugs can make the cancer cells more sensitive to radiotherapy, so a combination of treatment may be more effective than having either chemotherapy or radiotherapy alone.

The chemotherapy drug that is most commonly used is fluorouracil (5FU), which may be given as a series of injections before the radiotherapy or as a drip (infusion). The chemotherapy can also be given as tablets called capecitabine.

Giving chemotherapy and radiotherapy together can make the side effects of the treatment worse. Your doctor or specialist nurse can give you more information about chemoradiotherapy and the possible side effects.

Biological therapies (targeted therapies) for rectal cancer

Biological therapies use substances that occur naturally in the body to destroy cancer cells. There are several different types of biological therapies. The main ones used to treat rectal cancer are monoclonal antibodies called cetuximab (Erbitux®) and panitumumab (Vectibix®).

These drugs can be used to treat some cases of rectal cancer that have spread outside of the bowel (stage 4, advanced or metastatic cancer).

How monoclonal antibodies work

Monoclonal antibodies are drugs that recognise and lock onto specific proteins (receptors) that are present in particular cancer cells. Because of this they are often called targeted therapies, because they =target‘ the cancer cells.

Some cancer cells have proteins known as epidermal growth factor receptors (EGFRs). When other proteins in the body known as growth factors attach to these receptors, the cancer cell is stimulated to grow and divide.

The monoclonal antibodies cetuximab (Erbitux®) and panitumumab (Vectibix®) lock onto the EGFR, stopping growth factors from attaching, and so may prevent the cancer cell from growing and dividing.

How the drugs are given

Cetuximab is usually given in combination with the chemotherapy drug irinotecan, although it can be used on its own. It‘s given as a drip (infusion) into a vein.

Panitumumab is also given as an infusion into a vein and usually in combination with chemotherapy.

When monoclonal antibodies are used

Not all rectal cancers respond to cetuximab or panitumumab. Before having either drug your doctors will test the cancer cells for a gene called KRAS. Knowing if the KRAS gene is normal or mutated can help the doctors decide whether cetuximab or panitumumab will be appropriate for you.

The National Institute for Health and Clinical Excellence (NICE), which advises doctors about treatment, has recommended the use of cetuximab in combination with chemotherapy for some people who have advanced (metastatic) rectal cancer that has spread to the liver. Treatment with the combination of cetuximab and chemotherapy may make it possible to remove the secondary cancers in the liver using surgery.

The NICE guidance doesn‘t recommend cetuximab for everyone in this situation and your cancer specialist can discuss with you whether cetuximab is recommended for you. Currently, NICE doesn‘t recommend panitumumab.

Another monoclonal antibody called bevacizumab (Avastin®) , which works in a slightly different way, can also be used to treat advanced cancers of the rectum that have not been controlled by other chemotherapy combinations. Bevacizumab works by preventing the cancer from developing a new blood supply, and so starves the cancer of oxygen and nutrients.

Drugs that interfere with blood vessel growth in this way are called angiogenesis inhibitors or anti-angiogenics. NICE doesn‘t currently recommend bevacizumab and as a result it may not be possible to get it on the NHS.

Side effects of monoclonal antibodies

Some people can have an allergic reaction to monoclonal antibodies. This can make you have a flu-like reaction, a drop in blood pressure or feel sick. Other possible side effects include skin rashes and tiredness. With some monoclonal antibodies, the first dose is given slowly, over a number of hours. You may be given some other drugs first to make a reaction less likely.

Research - clinical trials for rectal cancer

Cancer research trials are carried out to try to find new and better treatments for cancer. Trials that are carried out on patients are known as clinical trials.

Clinical trials may be carried out to:

  • test new treatments, such as new chemotherapy drugs, gene therapy or cancer vaccines
  • look at new combinations of existing treatments, or change the way they are given, to make them more effective or reduce side effects
  • compare the effectiveness of drugs used to control symptoms
  • find out how cancer treatments work
  • see which treatments are the most cost-effective.

Trials are the only reliable way to find out if a different operation, type of chemotherapy, radiotherapy, or other treatment is better than what is already available.

Taking part in a trial

You may be asked to take part in a treatment research trial. There can be many benefits in doing this. Trials help to improve knowledge about cancer and develop new treatments. You will also be carefully monitored during and after the study. Usually, several hospitals around the country take part in these trials.

It‘s important to bear in mind that some treatments which look promising at first are often later found not to be as good as existing treatments, or to have side effects that outweigh the benefits.

If you decide not to take part in a trial, your decision will be respected and you do not have to give a reason. If you do decide to take part, you are allowed to withdraw from the trial at any time.

In either case, there will be no change in the way that you are treated by the hospital staff and you will be offered the standard treatment for your situation.

Blood and tumour samples

Many blood and tumour samples may be taken to help make the right diagnosis. You may be asked for your permission to use some of your samples for research into cancer. If you‘re taking part in a trial you may also be asked to give other samples which can be frozen and stored for future use, when new research techniques become available. These samples will have your name removed so you can‘t be identified.

The research may be carried out at the hospital where you are treated, or at another one. This type of research takes a long time, and it may be many years before the results are known.

The samples will be used to increase knowledge about the causes of cancer and its treatment. This research will hopefully improve the outlook for future patients.

Our booklet on Clinical Trials describes the process in more detail.

Follow-up after treatment for rectal cancer

After your treatment has finished, you‘ll have regular check-ups and blood tests, and possibly scans (CT, MRI or ultrasound), x-rays and sometimes colonoscopies. These may continue for several years, but will become less and less frequent.

If you have any problems or notice any new symptoms between your appointments, let your doctor know as soon as possible.

At the present time a lot of research is being carried out to find the best way of following up people who have had rectal cancer. The pattern of timing of hospital visits and tests and the amount of follow-up done by GPs varies considerably.

Many people find that they get very anxious before their appointments. This is natural and it may help to get support from family, friends or one of the organisations listed during this time.

For people whose treatment is over apart from regular check-ups, JASCAP booklets on Recovery and Life after Cancer Treatment give useful advice on how to keep healthy and adjust to life after cancer.

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