CPD: Bowel cancer

We continue our series on cancer, with an explanation of symptoms and treatments of bowel cancer, which is curable if caught early.

Bowel Cancer – also known as colon and colorectal cancer – is the second most common cancer (after lung cancer) that kills people in the UK, causing more deaths every year than breast and cervical cancer put together.

Annually, more than 38,000 people are diagnosed with bowel cancer and more than 16,000 will die of the disease. It is the third leading cause of cancer-related deaths in the Western world. However, it is one of the most preventable cancers and one of the most curable if it is caught early enough.

This year more than one in five diagnoses – more than 7,000 – will be in people of working age. Occupational health nurses could play an important role in helping to save lives from this common cancer, and could help people who have had it get back to work.

With better awareness of how to prevent bowel cancer – and acting on that awareness, better uptake of screening programmes and surveillance of at-risk groups, and better knowledge of symptoms – most people could be diagnosed at an earlier, curable stage or avoid contracting bowel cancer in the first place.

What is bowel cancer?

Almost all bowel cancers occur in the large bowel where mutations in the cells lining the gut can turn into polyps (wart-like growths) called adenomas or flat lesions. Polyps are common in the population and most will not turn into cancer.

Who is at risk?

During their lifetime, one in 18 men and one in 20 women will be diagnosed with bowel cancer. It affects one in 10 families.

Genetic surveillance should be offered to families with two or more close blood relatives affected or one young person aged 45 or under at diagnosis – screening should be available 10 to 15 years before the age at which the youngest member was diagnosed with bowel cancer.

Genetic surveillance should also be available to people with inherited conditions like familial adenomatous polyposis (FAP) or non-polyposis colorectal cancer (HNPCC).

Hospital surveillance should be advised for sufferers of ulcerative colitis or Crohn’s disease with a history of more than eight years, and for people with a history of bowel cancer or polyp removal.

Most bowel cancers are sporadic – and it appears to be a Western lifestyle disease. It is thought that people who are sedentary, those with diets that are high in cured and red meats, smokers, heavy drinkers and the obese are at increased risk, but there is still not much known about the direct causes of the disease.

How to avoid bowel cancer

The American Institute for Cancer Research calls this common disease one of the most preventable cancers. New research reveals that 4,600 bowel cancers a year could be avoided in the UK if people could be persuaded to adopt lifestyle changes that include brisk walking for just 30 minutes a day or other forms of moderate activity that makes the heart beat slightly faster and makes people breathe more deeply.

The World Cancer Research Fund scientists state that the evidence on alcohol as a causal agent for bowel cancer is convincing for men and probable in women.

The link with red meat and processed meats is also convincing, beneficial effects of vegetables are likely but there is conflicting evidence on the value of fibre in the diet as a protective measure against bowel cancer.

Screening

Screening is recognised as the best way to prevent bowel cancer or to stop this common cancer in its development at an early stage when it is still curable.

The European Colorectal Cancer Quality Assurance in Screening Guidelines recommend screening by Faecal Occult Blood test (FOBt) and colonoscopy, and the UK’s NHS Bowel Cancer Screening Programme, which began in 2006, is now recognised as one of the best organised programmes in the world, although it is not completely implemented across the country in all age groups.

In the UK, FOBt kits are sent from central hubs direct to the public. These test for hidden blood in faeces and the results are quickly communicated back to the public without the direct involvement of GP practices.

In England, Wales and Northern Ireland, men and women aged between 60 and 69 are in the process of being sent FOBt kits every two years, with the upper age range gradually being extended to 74. In Scotland the programme is available to those aged from 50 to 74 – this age reduction is possible because two-thirds of the Scottish population have already been invited to participate in pilot screening programmes. As the scheme is gradually being rolled out across the UK, not everyone in the age ranges will yet have received kits.

The current status of the programme can be checked in each area via NHS websites such as www.cancerscreening.nhs.uk/bowel for England. There is a free GP information pack. Freephone numbers are available in each country for the public – 0800 707 60 60 (England), 0800 0121 833 (Scotland), 0800 294 3370 (Wales) and 0800 015 2514 (Ireland).

How the NHS screening programme works

Home testing kits sent through the post invite people to smear a small sample of stool onto a piece of treated card and return the card in a hygienically sealed, prepaid envelope. The results are quickly sent to their home address.

Only two out of every 100 people tested are likely to have a positive result. A positive FOBt does not mean they have cancer, but it does trigger the offer of a further test, which should be a colonoscopy. One in 10 colonoscopies in the screening programme is currently finding a cancer, which is usually at an earlier, more curable stage, and four in 10 find polyps or other abnormalities.

Flexible sigmoidoscopy screening

New research published in The Lancet earlier this year (Atkin et al, 2010) has shown the huge potential for screening by flexible sigmoidoscopy, or (short colonoscopy) in the future.

A breakthrough in saving lives, Professor Wendy Atkin and colleagues found that a one-off screen by flexi-sig could reduce people’s chances of developing bowel cancer by one-third, prevent at least 5,000 people from being diagnosed with bowel cancer and at least 3,000 people from dying from the disease a year. This research will lead to changes in screening guidelines in years to come.

Symptoms and signs

Research has found that people have vague awareness of the symptoms of bowel cancer and symptoms advice, often widely available to professionals and the public, is not evidence-based.

It has also shown that, as most cancers have been developing for eight to 10 years before they are discovered, awareness of symptoms should not be over-promoted as the key to saving lives (Thompson et al, 2003).

Most people have bowel problems at some time in their lives but most symptoms/signs will not turn out to be cancer.

With rectal bleeding common in the population (affecting millions of people a year, especially younger people) and prolonged changes in bowel habit affecting many more millions, it can be difficult to diagnose this cancer.

There are, however, key symptoms and signs that should be investigated to exclude bowel cancer at any age:

  • Change of bowel habit and rectal bleeding: a combination of change of bowel habit which involves going to the toilet more often or trying to go without producing results, looser more-diarrhoea like stools with bleeding from the bottom. People with this symptom combination of bleeding and change of habit have a one-in-six chance of having bowel cancer and should usually be referred for hospital investigation at any age if these symptoms persist for more than four weeks.
  • Anaemia in men – and women after the menopause: people who are tired, pale, breathless, having difficulty walking or exercising should be tested for anaemia. Blood tests are cheap. Those people found to have lack of red blood cells should be investigated to exclude bowel cancer.

Other important signs and symptoms include:

  • Age – over-50s are more likely to develop bowel cancer and symptoms should be taken more seriously as people get older.
  • Family history – two or more close blood relatives or one young person under 45 affected.
  • Change of bowel habit that lasts more than four weeks and persists day after day without reverting to normal – the change involving more frequent visits to the toilet than normal and/or looser stools.
  • Bleeding from the bottom without any reason – no straining, piles, itching or soreness.
  • A palpable mass.
  • Severe colicky abdominal pain that begins suddenly and persists. Less severe sporadic pain is common in the population. People who have bowel cancer that causes pain will usually have other key symptoms too.

Investigation

People with symptoms (like bleeding) who visit their GP should be given an investigation of the rectum with a gloved finger and their stomach felt for any mass.

In hospitals how people are investigated depends on what is available in the hospital to which they are being referred.

Options include:

  • rigid sigmoidoscopy;
  • flexible sigmoidoscopy;
  • colonoscopy;
  • barium enema; and
  • virtual colonoscopy or CT.

Research from Portsmouth – led by consultant surgeon Mike Thompson and scientific researcher Karen Flashman (Thompson et al, 2000) – has proved that most symptomatic cancers can be found by a five-minute, safe and flexible sigmoidoscopy, which can examine the first 60cm to 70cm of the bowel, which is where two-thirds of bowel cancers occur.

The research introduction states: “A common clinical dilemma in a colorectal outpatient clinic is when to proceed to whole colonic imaging (WCI) by barium enema, colonoscopy or computed tomography (CT).

“This decision is usually based on the custom of the practitioner and fear of missing a cancer rather than a clear understanding of its real overall benefit to the patient.”

It concludes: “Patients with iron deficiency anaemia or a mass require whole colonic imaging. However, in patients with symptoms alone, flexible sigmoidoscopy detects 95% of cancers, and the diagnostic yield of WCI after FS is very low. Alternative management strategies need to be developed to avoid unnecessary investigations in this low-risk group.”

People who are concerned about having an endoscopic investigation by flexi-sig or colonoscopy can watch a very reassuring DVD – “Having a Colonoscopy” – a video of Lynn Faulds Wood’s latest colonoscopy at St George’s Hospital

Endoscopy Unit in South West London. The DVD is on YouTube or the charity’s website.

Treatment

Treatment depends on the staging of the cancer – with two types of staging currently used – either Dukes A, B, C, D system or TNM staging – TNM standing for Tumour, Node, Metastases – also with four stages:

Stage 1 – tumour only in the inner layer of the bowel – has a good cure rate – 90% at five years after surgery. Around 10% of patients are diagnosed at this stage.

Stage 2 – grown into the muscle layer of the bowel wall – around a quarter of patients are diagnosed at Stage 2 with the chances of surviving for five years almost 80%.

Stage 3 – grown into the outer lining of the bowel wall and lymph nodes/vascular system – almost 50% of patients will survive five years.

Stage 4 – grown into other parts of the bowel and usually liver but may also reach the small bowel/peritoneum/lungs – survival after liver surgery now approaching 50% with the best surgeons, otherwise survival chances low.

Today B2 and some T2 patients would be offered chemotherapy and most T3 and T4.

Bowel cancer has long been known as “the surgical disease” with well-trained surgeons often able to avoid stomas and other complications.

The National Bowel Cancer Audit, organised by the Association of Coloproctology of Great Britain and Ireland, now includes most hospital trusts and it reveals the differences between hospitals in outcomes.

Bowel cancer diagnosed in the earlier stages can be curable. However, when it is detected at later stages (when distant metastases are present) it is less likely to be curable. Surgery remains the primary treatment while chemotherapy and/or radiotherapy may be recommended depending on the individual patient’s staging and other medical factors.

Increasingly bowel cancer patients are being offered laparoscopic surgery and “enhanced recovery” – a technique which means shorter stays in hospital, less trauma on the body and the ability to return to work more quickly.

Working after having bowel cancer

Cancer is expensive for families. People diagnosed with bowel cancer may need to return to work as quickly as possible. However, timing of the return and support is important to help the patient and colleagues to adjust to any physiological, practical and emotional difficulties.

Most people diagnosed with bowel cancer will be offered further treatment involving at least four months away from the workplace – part-time return to work will depend on the individual’s ability to cope with the treatment and the type of work they do, together with the will or need to work.

Patients diagnosed with early stage cancers can return to work more quickly as they are unlikely to be undergoing further treatment. Those with more advanced cancers will be offered chemo-therapy and other trials or follow-up regimes.

Case study

Practice nurse Toni Millard, diagnosed at 39 with a C2 bowel cancer at the end of last year, found she sailed through the first three to four chemotherapy sessions.

She said: “It took about three hours in the hospital then I would go home with a vacuum pump. Then chemo 5 and lethargy and weakness kicked in.

“I would feel awful after each session. I’ve worked nights, been up with sick children – there’s no comparison. The chemo zapped me completely.”

Toni had a further eight sessions every two weeks to endure. “The side effects were also bad – diarrhoea and horrific pins and needles in my fingers and feet. I’ve finished the chemo but I still have residual pins and needles – they’re lessening now but still with me.

“When the chemo stops, you go from intense care, seeing the doctor every other week – and then it all ends. You’re pleased to be away from the chemo but you can feel quite vulnerable.”

Nine months after her operation, Toni is still not back at work.

Conclusion

Survival is directly related to detection and the type of cancer involved. Survival rates for early stage detection are about five times that of late stage cancers.

Lynn’s Bowel Cancer Campaign is campaigning for better training of GPs in relevant signs and symptoms, more specialist endoscopy nurses to help to speed up the screening and diagnostic programme, thus save lives by catching this common cancer earlier – and reductions in the screening age to 55 as soon as is practicable and proven in pilots.

It is hoped the Scottish screening experience from 50 will help to illuminate the best age to commence screening without risking detriment to otherwise healthy people. Lynn’s Bowel CancerCampaign has also helped to fund the Portsmouth Hospitals’ Bowel Cancer Database, which is now probably the country’s best database on signs and symptoms.

Occupational health nurses and professionals can help to save lives by judicious awareness-raising in the workplace with evidence-based materials from authoritative sources; by promoting screening in the relevant age groups; by encouraging at-risk groups to receive appropriate surveillance; by promoting healthy eating and activity such as walking clubs; by supporting people diagnosed with bowel cancer and their families to return to physical and economic health.

Lynn Faulds Wood is a former presenter of BBC’s Watchdog. She survived advanced bowel cancer and is founder of Lynn’s Bowel Cancer Campaign.

References

Cancer Research UK: Bowel cancer key facts 2010-09-03.

World Cancer Research Fund

Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre random control trial, Atkin et al The Lancet, Vol 375 issue 9726 p1624-1633 8th May 2010.

Identifying and managing patients at low risk of bowel cancer in general practice, Thompson MR, Health I, Ellis BG, Swarbrick ET, Faulds Wood L, Atkin WS, BMJ 2003; 327: 263-265.

Rectal bleeding in general and hospital practice; “The tip of the iceberg” Thompson JA Pond CL Ellis BG Beach A, Thompson MR, Colorect Dis 2000; 2; 288-293.

Cancer Research UK Cancer help tests.

Flexible sigmoidoscopy and whole colonic imaging in the diagnosis of cancer in patients with colorectal symptoms, Thompson MR, Flashman KG, Wooldrage K, Rogers PA, Senapati A, O’Leary and Atkin W. British Journal of Surgery 2008; 95: 1140-1146.

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