Rectal Cancer – What it is, Symptoms and Treatments that many are unaware of. Also, the rectum is the last part of the large intestine. It starts at the end of the final segment of your colon and ends when it reaches the short, narrow passage that leads to your anus. Cancer within the rectum ( Rectal Cancer ) and cancer within the colon (colon cancer ) are often referred to as “colorectal cancer”.
Although colon and rectal cancer are similar in many ways, their treatments are quite different. This is mainly because the rectum is in a tight space, barely separated from other organs and structures in the pelvic cavity. As a result, the complete surgical removal of rectal cancer is challenging and highly complex.
Additional treatment is often needed before or after surgery — or both — to reduce the chance that the cancer will return. In the past, long-term survival was uncommon for people with rectal cancer, even after extensive treatment. Thanks to treatment advances over the past 30 years, rectal cancer can now, in many cases, be cured.
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Causes of Rectal Cancer: Rectal Cancer
But when a cell’s DNA is damaged and becomes cancerous, the cells continue to divide — even when new cells aren’t needed. As the cells accumulate, they form a tumor.
Over time, cancer cells can grow to invade and destroy normal tissue nearby. And cancer cells can travel to other parts of the body. Inherited gene mutations that increase the risk of colon and rectal cancer. In some families, genetic mutations passed from parents to children increase the risk of rectal cancer .
These mutations are only involved in a small percentage of rectal cancer . Some genes linked to rectal cancer increase an individual’s risk of developing the disease, but do not make it inevitable.
Genetic Syndromes: Two well-defined Genetic Syndromes of Rectal Cancer are: Hereditary Nonpolyposis Rectal Cancer (HNPCC) . HNPCC, also called Lynch syndrome, increases the risk of colon cancer and other cancers. People with HNPCC tend to develop colon cancer
Familial adenomatous polyposis (FAP). FAP is a rare disorder that causes you to develop thousands of polyps in the lining of your colon and rectum. People with untreated FAP have a much higher risk of developing colon or rectal cancer before age 40.
FAP, HNPCC and other, rare inherited Rectal Cancer syndromes can be detected through genetic testing. If you are concerned about your family’s history of colon cancer , speak to your doctor about whether your family history suggests that you are at risk for these conditions.
Symptoms of Rectal Cancer: The main common symptoms include:
- A change in your bowel habits, such as diarrhea, constipation, or more frequent bowel movements
- Dark or red blood in the stool
- mucus in feces
- narrow stools
- Abdominal pain
- Painful bowel movements
- Iron deficiency anemia
- A feeling that your bowels are not emptying completely
- unexplained weight loss
- Weakness or fatigue
When to See a Doctor: Make an appointment with your doctor if you have symptoms suggesting rectal cancer, particularly blood in your stool orunexplained weight loss.
Rectal Cancer Risk Factors: The characteristics and lifestyle factors that increase the risk of rectal cancer are the same ones that increase the risk of colon cancer. They include:
- Older age. The vast majority of people diagnosed with colon and rectal cancer are over 50 years old. Rectal cancer can occur in younger people, but it occurs much less frequently.
- African-American descent. People of African descent born in the United States have a higher risk of rectal cancer than people of European descent.
- A personal history of Rectal Cancer or Polyps. If you’ve had rectal cancer, colon cancer, or adenomatous polyps, you have a higher risk of rectal cancer in the future.
- Inflammatory bowel disease. Chronic inflammatory diseases of the colon and rectum, such as ulcerative colitis and Crohn’s disease, increase the risk of rectal cancer .
- Inherited syndromes that increase the risk of rectal cancer. Genetic syndromes passed down through generations of your family can increase your risk of rectal cancer . These syndromes include FAP and HNPCC.
- Family history of Rectal Cancer. You are more likely to develop rectal cancer if you have a parent, sibling or child with the disease. If more than one family member has cancer of the cervix or cancer of the rectum, your risk is even higher.
- Dietary factors. Rectal cancer can be associated with a diet low in vegetables and high in red meat, particularly when the meat is charred or well prepared.
- A sedentary lifestyle. If you are inactive, you are more likely to develop Rectal Cancer . Getting regular physical activity can reduce your risk of colon cancer.
- Diabetes. People with poorly controlled type 2 diabetes and insulin resistance may have an increased risk of rectal cancer .
- Obesity. People who are obese have an increased risk of rectal cancer and an increased risk of dying from colon or rectal cancer when compared to people considered to be of normal weight.
- Smoke. People who smoke may have an increased risk of colon cancer .
- Alcohol. Regularly drinking more than three alcoholic drinks a week can increase your risk of rectal cancer .
- Radiation therapy for previous cancer. Radiation therapy targeted to the abdomen to treat previous cancers may increase the risk of rectal cancer .
Diagnosis of Rectal Cancer: Rectal cancer is often diagnosed when a doctor orders tests to find the cause of rectal bleeding or iron deficiency anemia. Colonoscopy is the most accurate of these tests. In a colonoscopy, a doctor uses a thin, flexible, lighted tube with a video camera at the end (a colonoscope) to see inside the colon and rectum.
Sometimes rectal cancer has no visible symptoms. People without symptoms can learn they have rectal cancer when they have a screening colonoscopy — that is, a colonoscopy recommended at age 50 for everyone at average risk of rectal cancer . It is usually possible to remove small tissue samples (biopsies) from suspicious areas during a colonoscopy. Laboratory analysis of this tissue helps define the diagnosis.
Rectal Cancer Stage: Once you are diagnosed with rectal cancer, the next step is to determine the extent of the cancer (stage). Staging helps guide decisions about the treatments that are best for you. The following blood tests and imaging studies are involved in performing rectal cancer:
- Complete blood count (CBC). This test reports the number of different types of cells in your blood. The CBC shows if your red blood cell count is low (anemia), which suggests that a tumor is causing blood loss. A high level of white blood cells is a sign of infection, which is a risk if a rectal tumor grows through the wall of the rectum.
- Carcinoembryonic antigen (CEA). Cancers sometimes produce substances called tumor markers that can be detected in the blood. One of these markers, carcinoembryonic antigen (CEA), can be higher than normal in people with rectal cancer . The CEA test is particularly useful for monitoring your response to treatment.
- Chemistry panel. This test measures a number of chemicals in the blood. Abnormal levels of some of these chemicals may suggest that the cancer has spread to the liver. Elevated levels of other chemicals can indicate problems with other organs, such as the kidneys.
- Computed tomography (computed tomography) of the chest. This imaging test helps determine whether the rectal cancer has spread to other organs, such as the liver and lungs.
- Magnetic resonance imaging (MRI) of the pelvis. An MRI provides a detailed picture of the muscles, organs, and other tissues that surround a tumor in the rectum. An MRI also shows lymph nodes near the rectum and different layers of tissue in the rectal wall.
Rectal Cancer Stages: Rectal cancers fall into one of five possible stages (Stage 0 through Stage 4). The stages, in a simplified way, are:
- Stage 0. Cancer cells on the surface of the rectal lining (mucosa), sometimes inside a polyp
- Stage I. Tumor that extends beneath the rectal mucosa, sometimes penetrating the rectal wall
- Stage II. Tumor that extends into or through the rectal wall, sometimes reaching and growing or adhering to tissues beside the rectum
- Phase III. Tumor invades lymph nodes alongside the rectum, as well as structures and tissues outside the rectal wall
- Stage IV. Tumor has spread to a distant organ or lymph nodes distant from the rectum
Implantation also involves analyzing a sample of tissue taken from the tumor (a biopsy) to determine the tumor’s classification. Low-quality tumors tend to grow and spread slowly. In contrast, high-grade tumors grow and spread quickly, so they may need more aggressive treatment.
Rectal Cancer Treatments: Rectal cancer often requires more than one type of treatment (modality), an approach known as multimodal therapy. In general, the treatment modalities used for rectal cancer are the same as those used to treat many other types of cancer. They are:
- Surgery to remove the tumor.
- Chemotherapy, usually consisting of two or more drugs that target cancer cells. In people with rectal cancer, chemotherapy is often used along with radiation therapy, either before or after surgery.
- Radiation therapy, which uses high-powered beams, such as X-rays, to kill cancer cells.
Surgery: Your surgical options depend on a number of factors, including:
- The stage and series of cancer
- The location of the tumor in the rectum
- the size of the tumor
- Your age
- your general health
- Your medical history
- Your preferences after learning about different procedures
Some of the commonly used procedures to treat rectal cancer are:
- Abdominoperineal Resection with Final Colostomy A: Abdominoperineal resection (APR) offers the best chance of cure for rectal tumors located extremely close to the anal sphincter. With cancer at this site, the surgeon has to remove both the tumor and the sphincter. Otherwise, it is not possible to take a margin of healthy tissue on all sides of the tumor – and clear or healthy margins reduce the risk of the cancer returning. After APR, it is no longer possible to pass stool through the anus. A final colostomy connects the end of the colon that was attached to the rectum before the PRA to a surgical opening (stoma) in the lower abdomen. The stool passes into a removable pouch placed over the stoma.
- Anal Colon Anastomosis: This sphincter-saving procedure may be an option for rectal cancer surgery if the tumor is at least 0.39 inches (1 centimeter) above the top of the anal sphincter. The surgeon removes the entire rectum and enough surrounding tissue to obtain clear margins. Then the remaining end of the colon can be molded into a pouch that is connected to the colon. Alternatively, the end of the colon can be connected directly to the anus.
- Low Anterior Resection: This procedure, which also leaves the anus intact, can be performed when the tumor is located in the upper part of the rectum. The surgeon removes the tumor and a margin of healthy tissue around it, leaving the lower part of the rectum. The end of the colon is then attached to the remaining section of the rectum.
- Excision: Local Local excision removes the rectal tumor, along with a margin of healthy tissue and the section of rectal wall below the tumor. This technique is usually reserved for early, small stage 1 rectal cancer, after a biopsy shows that the tumor is unlikely to spread or recur. Unlike the other procedures listed, local excision does not include lymph node removal. Instead, the excised tissue is examined in a laboratory to ensure that the tumor does not have features that suggest more advanced cancer than expected. If any of these features are present, a standard operation may be required.
- More Extensive Surgery: People with rectal cancer associated with Crohn’s disease , ulcerative colitis, or a genetic predisposition to Rectal Cancer often need more extensive surgery than the procedures described here. Chemotherapy is also needed before or after surgery.
Combination Therapy: The standard treatment for stage II and stage III rectal cancer is typically a combination of chemotherapy and radiation (chemoradiotherapy) given before surgery (preoperatively). This approach is also an option for treating certain stage I rectal cancers that have a high risk of recurrence. The benefits of preoperative chemoradiotherapy include:
- Increased response to radiation because of the effect of chemotherapy on cancer cells
- Reduced tumor size
- Lowered the stage of cancer in some cases
- Increased chance that surgery will leave the anal area intact (sphincter-sparing surgery)
- Lower risk of cancer recurrence
The usual period between preoperative chemoradiotherapy and surgery is about six weeks. After surgery, most people also have additional chemotherapy to destroy any remaining cancer cells.
Stage IV Rectal Cancer: Some of the treatments used for stage II and III rectal cancers may also be appropriate for stage IV cancer. By definition, however, stage IV rectal cancer has spread (metastasized) to a different part of the body, usually the liver.
In some cases, a metastatic tumor can appear in the liver when the primary tumor is still mostly confined to the rectum and nearby lymph nodes. If this happens, your doctor may recommend surgery to remove both the primary tumor and the liver tumor at once.
In other cases, the primary tumor may spread to organs close to the rectum, such as the uterus and ovaries, before liver metastases appear. Complex surgery and reconstruction of pelvic structures may also be possible in these cases.
Drugs for Rectal IV Cancer: Chemotherapy can prolong the lives of people with stage IV rectal cancer, as can radiation therapy in some cases. Any treatment can be given after surgery, while chemotherapy is mostly used before surgery. Chemotherapy or radiation can be used to relieve symptoms in cases where the cancer is too extensive for surgery.
People with stage IV rectal cancer can receive one of the three latest FDA-approved drugs in addition to cancer chemotherapy. These drugs, called biologics, characterize carcinogenic characteristics that allow tumors to grow. The addition of a biologic drug to standard chemotherapy has been found to improve treatment response in certain cases of Rectal Cancer . Therapy that includes biologics is called targeted therapy.
FDA-approved biologics used with chemotherapy in the first-line treatment of Stage 4 Rectal Cancer are:
- Bevacizumab (Avastin)
- Cetuximab (Erbitux)
- Panitumumab (Vectibix)
Supportive (Palliative) Care: Palliative care is focused on providing relief from pain and other symptoms of a serious illness. Palliative care specialists work with you, your family and your other doctors to provide an extra layer of support that complements your ongoing care. An example of palliative care might be surgery to relieve a blockage in the rectum to improve your symptoms.
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Palliative care is provided by a team of specially trained doctors, nurses and other professionals. Palliative care teams aim to improve the quality of life for people with cancer and their families. This form of care is offered alongside curative or other treatments you may be receiving.