Professor R J (Bill) Heald considers some questions frequently asked by patients.
Please note that these are general answers applying to Hampshire Hospitals NHS Foundation Trust’s Basingstoke and North Hampshire Hospital practice. If you have questions or concerns about your specific diagnosis and treatment, you should talk to your specialist nurse.
Firstly, remember that every available option has both ‘pros’ and ‘cons’, but it is your body and your future, and you have the final say.
Take heart: correct decisions before surgery, and recent advances in surgical technique mean that more cures are possible with bowel cancer than with all the other internal cancers added together.
A few weeks delay will do no harm – the right decision and, if you are unhappy, a second opinion from another specialist is really worthwhile.
Q1. Do I really need to have a permanent colostomy?
Your surgeon will always write down the height of your tumour above the bottom of the anal canal – so it is reasonable to ask him what this height is, as it makes a major difference to your future.
- Around 2 – 3 centimetres. Cancers with their lower edge this low down will almost always require abdomino-perineal excision and permanent colostomy, with the exception of some rather uncommon tumours that can sometimes be completely controlled with chemoradiotherapy.
- 4 – 6 centimetres. Some specialists will be prepared to perform an operation that preserves the anal canal and restores colorectal continuity or even joins a colon “pouch” on to the anal canal itself, thus restoring relatively normal anal function. In these cases where a permanent colostomy is being suggested, a second opinion is a really sensible course of action, which should give no offence to the surgeon concerned.
- 7 – 12 centimetres. Tumours this far into the rectum will almost always be suitable for a restorative procedure (which allows the bowel to be joined together) which requires at the most a temporary protective colostomy or ileostomy. This should ultimately lead to relatively normal bowel function after the primary treatment has been concluded and the stoma closed. Again, if a permanent colostomy is recommended a second opinion is appropriate.
- 12 – 15 centimetres and above. These cancers are in general more simple to understand and manage: removal and re-joining is generally possible.
In modern multi-disciplinary team management, the MRI examination can help your surgeon and the other relevant specialists to decide what is optimal management and choice of operation for you.
The Pelican-funded MERCURY study provided a clarification that MRI should be available in all cases of rectal cancer (see the articles in the British Medical Journal of October 2006). The Clinical Services Journal, Improving management of bowel cancer has more information about the use of MRI in bowel cancer management in the UK today.
Q2. Should I have radiotherapy and/or chemotherapy before my operation?
- In large studies using radiotherapy a decreased incidence of locally recurrent disease is reported. In specialised centres with good MRI assessment, however, the risk of such recurrence without radiotherapy can be as low as 5% (1 in 20). In this case few people would accept the disadvantages of radiotherapy, for what would amount to little more than a 1 in 40 chance of benefit.
- In general most surgeons with a long experience of colorectal cancer will prefer to avoid radiotherapy except where the extent and spread of the tumour locally within the pelvis presents a significant risk of leaving some tumour behind. The principal argument for giving radiotherapy is:
- It reduces the incidence of locally-recurrent disease- some idea of what the chance of cure is without such treatment would be relevant to the enquiring patient considering this question.
- The decision as to whether a tumour is sufficiently advanced to merit pre-operative radio and chemotherapy is made in part by physical examination and in part on the examination by specialist MRI.
- It is our opinion that every patient who is able to do so should have a specialised MRI to assist in this.
- The principal reasons why a patient might decline radiotherapy are cases when:
- There is a good chance of cure by surgery alone.
- Sexual sterility is almost inevitable, and the risk of impotence increased by radiotherapy.
- If a restorative operation without a permanent colostomy is planned/contemplated the bowel function may be made much more frequent and “irritable” by the previous radiotherapy. Some patients may even become incontinent.
- When the patient is cured of rectal cancer, there is an increased risk of other malignancies within the radiated area after many years.
Q3. If the surgeon gives me a temporary ileostomy or colostomy whilst my “low join” heals securely, how long will I need to keep this?
- In general it is possible to close the ‘stoma’ (temporary ileostomy or colostomy) with a relatively small operation, which can be performed under general or sometimes local anaesthesia around 6 weeks after the main operation.
- If it has been decided to give chemotherapy after the operation, then there is frequently a problem in timing of the closure, and whether it is best to get this safely out of the way before the chemotherapy starts.
- Some specialists, which include the Basingstoke team, would favour the closure of the stoma before the chemotherapy starts. However, there is some evidence that the early start of the chemotherapy may improve its effectiveness, so some confusion for the patient may arise from differing opinions.
- In some cases it is possible that the temporary stoma must be retained for perhaps 6 months or more because the postoperative chemotherapy treatment might interfere with healing of closure.
Q4. What quality of bowel function and other pelvic functions can I expect after my rectal cancer surgery?
- Most patients, often after a period of time during which frequent and sometimes urgent visits to the toilet are necessary, do achieve a normal lifestyle without significant impairment of any of the pelvic functions.
- There is always some technical risk of damage to the nervous system within the pelvis but at least ¾ of those patients who have normal sexual function before surgery will achieve normal erection afterwards, though temporary impairment is not uncommon.
- If both radiotherapy and a “low join” have been combined then some bowel frequency and urgency may become a persistent nuisance, and a few patients will even have actual accidents.
- In a very small number of cases the function may be such that the patient will prefer to be given a colostomy which is easier to manage than the severely incontinent anus. This is not an operation of similar magnitude to the main procedure.
- Happily however, such requests are extremely rare and most people achieve a normal lifestyle or at least an acceptable increase in the number of daily visits.
Q5. Do I need to have chemotherapy AFTER my operation?
- Current common practice tends to recommend a course of chemotherapy in individual cases if the pathology report suggests that the lymph glands examined in the removed tissue were involved, or if there are implications that some cancer cells might be left behind. In some individual cases chemotherapy has been found to be clearly beneficial, but in rectal cancer the benefit is marginal and, if side-effects are severe, it may be perfectly sensible to stop the treatment.
Q6. Should I have my operation by “keyhole surgery” (laparoscopy)?
- This is a complex question, which depends upon the particular skills of the individual surgeon. The advantages are a lesser scar on the abdomen and a somewhat quicker recovery. The disadvantages are that certain bowel cancers really require the extra access afforded by the incision, in particular some of the low rectal tumours. It is best to be guided by the surgeon in whom you place your trust.
Q7. So I do have to have a colostomy?
- For the very lowest cancers (below 3-4cm) this may be inevitable. You should not forget that there are alternatives to “the bag”- the irrigation method is worth considering. To read more about one patient’s experience with irrigation, see Richard’s Allardyce’s story.
Q8. I have read about tumours disappearing altogether after chemo-radiotherapy. Could this happen to me, and how can I benefit from it?
- This is rather new in the UK, and is a complex subject. However we believe that an MRI scan should be performed before, and several weeks after, chemo-radiotherapy. If this and the clinical assessment by the surgeon shows a marked reduction in size, and if all your symptoms have disappeared, then there may be an argument for delaying the surgery. Ask if a highly satisfactory response to the treatment is reported.
- Pelican, in collaboration with the Royal Marsden Hospital, is currently conducting a study of such patients as a small number of tumours may indeed regress completely, so that surgery becomes unnecessary. For further information see Pelican’s Deferral of Surgery Study information page.