Cancer Association of South Africa (CANSA)

Transcription

1 Cancer Assciatin f Suth Africa (CANSA) Fact Sheet n Clrectal Cancer Intrductin Clrectal cancer is cancer that ccurs in the cln and rectum. Smetimes it is called cln cancer, fr shrt. The cln is als knwn as the large intestine r large bwel. The rectum is the passageway that cnnects the cln t the anus. [Picture Credit: Anatmy Cln] Clrectal Cancer Cancers f the cln and rectum (clrectal cancer) start when the prcess f the nrmal replacement f lining cells ges awry. Mistakes in mucsal cell divisin ccur frequently. Fr reasns that are prly understd, smetimes mistakes ccur that escape ur editing systems. When this ccurs, these cells begin t divide independently f the nrmal checks and balances that cntrl grwth. As these abnrmal cells grw and divide, they can lead t grwths within the cln called plyps. Plyps vary in type, but many are precancerus tumurs that grw slwly ver the curse f years and d nt spread. As plyps grw, additinal genetic mutatins further destabilize the cells and can make the cells mre bizarre. When these precancerus tumurs change directin (grwing thrugh the tube rather than int the middle f it) and invade ther layers f the large intestine (such as the submucsa r muscular layer), the precancerus plyp has becme cancerus. In mst cases this prcess is slw, taking at least 8 t 10 years t develp frm thse early aberrant cells t a frank cancer. Incidence f Clrectal Cancer in Suth Africa Accrding t the Natinal Cancer Registry, the fllwing cases f clrectal cancer were histlgically diagnsed during 2013 (the mst recent frmal statistics available fr Suth Africa): Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] Nvember 2017 Page 1

2 Grup - Males 2013 Actual N f Cases Estimated Lifetime Risk Percentage f All Cancers All males :75 5,30% Asian males 113 1:49 13,63% Black males 518 1:197 4,81% Clured males 234 1:57 5,61% White males :30 5,15% Grup - Females 2013 Actual N f Cases Estimated Lifetime Risk Percentage f All Cancers All females :145 4,21% Asian females 77 1:84 7,41% Black females 426 1:388 2,73% Clured females 233 1:81 5,76% White females 805 1:49 5,07% The frequency f histlgically diagnsed cases f clrectal cancer in Suth Africa fr 2013 was as fllws (Natinal Cancer Registry, 2013): Grup - Males All males Asian males Black males Clured males White males Grup - Females All females Asian females Black females Clured females White females N.B. In the event that the ttals in any f the abve tables d nt tally, this may be the result f uncertainties as t the age, race r sex f the individual. The ttals fr all males and all females, hwever, always reflect the crrect ttals. Prescribed Minimum Benefits (PMB) Level f Care as per the Cuncil fr Medical Schemes Treatable clrectal cancer is a prescribed minimum benefit (PMB) cnditin under diagnsis treatment pair (DTP) cde 950C. Accrding t the PMB regulatin, treatable cancers are defined as fllws: The invlve nly the rgan f rigin, and have nt spread t adjacent rgans There is n evidence f distant metastatic spread They have nt, by means f cmpressin, infarctin, r ther means, brught abut irreversible and irreparable damage t the rgan within which they riginated (fr example brain stem cmpressin caused by a cerebral tumur) r anther vital rgan If pints (i) t (iii) d nt apply, there is a well demnstrated five-year survival rate f greater than 10%, fr the given therapy, fr the cnditin cncerned. Accrding t the PMB regulatins, schemes have t pay fr the diagnsis, treatment and care csts f treatable clrectal cancer, regardless f the medical scheme ptin. This wuld include diagnsis tests and fllw-up tests, cnsultatins with dctrs and ther Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] Nvember 2017 Page 2

3 health prfessinals, surgery, radilgy, chemtherapy, radiatin therapy as well as palliative care. Patients wh have metastatic clrectal cancer are als entitled t sme palliative care benefits. In these patients the cancer is nt treatable and death will be imminent. Other palliative measures might, therefre, be taken t make the patient cmfrtable. These shuld be reimbursed as PMB level f care under DTP cde 260S. (Cuncil fr Medical Schemes). Signs and Symptms f Clrectal Cancer Sign and Symptms f clrectal cancer include: A change in bwel habits, including diarrhea r cnstipatin r a change in the cnsistency f stls Rectal bleeding r bld in stls Persistent abdminal discmfrt, such as cramps, gas r pain A feeling that the bwel des nt empty cmpletely Weakness r fatigue Unexplained weight lss Many peple with clrectal cancer experience n symptms in the early stages f the disease. When appearing, symptms will likely vary, depending n the cancer's size and lcatin in the large intestine. (May Clinic) Risk Factrs fr Clrectal Cancer Risk factrs fr clrectal cancer include: Advancing age - natinal and internatinal data indicate that the risk f develping clrectal cancer increases with advancing age. Mst cases f clrectal cancer ccur in peple aged 50 r lder. Family r persnal histry A family histry f inherited clrectal cancer syndrmes, such as familial adenmatus plypsis (FAP) r hereditary nn-plypsis clrectal cancer (HNPCC r Lynch syndrme) A strng family histry f clrectal cancer r plyps. This usually means firstdegree relatives (parent, sibling, r child) wh develped these cnditins yunger than age 60 A persnal histry f clrectal cancer r plyps A persnal histry f chrnic inflammatry bwel disease (fr example, ulcerative clitis r Crhn's disease) (Natinal Institutes f Health, Clrectal Cancer (PDQ): Treatment; Btma, et al., 2012). Lifestyle Factrs that Cntribute t the Increased Risk fr Clrectal Cancer: Lifestyle factrs that cntribute t the increased risk f clrectal cancer include: Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] Nvember 2017 Page 3

4 Lack f regular physical activity Being verweight including besity Lw fruit and vegetable intake A lw-fibre and high-fat and high sugar diet Red meat cnsumptin Cnsuming prcessed meats Alchl cnsumptin Tbacc use (Life is Beautiful; Department f Health and Human Services; American Cancer sciety) Lifestyle Factrs that Play an Imprtant Rle in Reducing the Risk fr Clrectal Cancer The fllwing are f imprtance: Fibre research suggests that fibre (fund mstly in fruit, vegetables and whle grain prducts and cereals) is likely t reduce the risk fr bwel cancer Fruit and vegetables the large Eurpean Prspective Investigatin int Cancer and Nutritin (EPIC) study has shwn that peple wh eat a lt f fruit and vegetables have a lwer risk fr clrectal cancer Meat eating a lt f red meat, particularly prcessed meat, increases ne s risk fr clrectal cancer Fish eating mre fish high in Omega-3 lwers ne s risk fr clrectal cancer Calcium calcium rich diets may lwer the risk f clrectal cancer Alchl alchl has been classified as a Grup 1 carcingen by the Internatinal Agency fr Research n Cancer (IARC) and shuld be avided t reduce the risk f clrectal cancer Tbacc - peple wh use tbacc prducts have an increased risk f clrectal cancer and cancer in general. Smking is a well-knwn cause f lung cancer, but sme f the cancer-causing substances in smke disslve int saliva and if swallwed, can cause digestive system cancers like clrectal cancer Prcessed meats (like sausages, lunchen meats inclusive f ham and even biltng) can increase the risk fr clrectal cancer based n the use f nitrate and nitrites Cking meats at very high temperatures (frying, briling, r grilling) creates chemicals that increase cancer risk, namely Hetercyclic Amines (HCAs) Bdy weight being verweight increases the risk f develping and dying frm clrectal cancer. Obesity raises the risk f clrectal cancer in bth men and wmen, but the link seems t be strnger in men Physical inactivity - increases the risk f develping clrectal cancer - increasing activity may help reduce the risk Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] Nvember 2017 Page 4

5 Radiatin therapy fr cancer - radiatin therapy directed at the abdmen t treat previus cancers may increase the risk f clrectal cancer (Life is Beautiful; May Clinic; American Cancer Sciety; Cancer Research UK). Reducing the Risk fr Clrectal Cancer Clrectal cancer has been strngly assciated with a Western lifestyle. Several studies have shwn that high intake f red and prcessed meats, highly refined grains and starches as well as sugars are all factrs related t an increased risk f clrectal cancer. Replacing these fdstuffs mainly with fatty fish and plant surces as the primary surce f prtein; unsaturated fats as the primary surce f fat; as well as unrefined grains, legumes and fruits as the primary surce f carbhydrates is likely t lwer risk f clrectal cancer. With respect t lifestyle, cmpelling evidence indicates that avidance f smking and heavy alchl use, preventin f weight gain and maintenance f a reasnable level f physical activity are assciated with markedly lwer risks f clrectal cancer. The rle f supplementatin in the frm f calcium, as well as mega-3 and the recently identified tctrienl family (as part f the bigger vitamin E grup) with significant ant-inflammatry characteristics are all likely t be at least mdestly beneficial. Medicatins such as aspirin and nn-steridal anti-inflammatry drugs are assciated with substantial reductins in clrectal cancer risk, thugh their utility is affected by assciated risks. Screening Tests fr Clrectal Cancer - there is nt enugh evidence t determine which screening methd is best. Individuals shuld discuss all pssibilities is with their dctr t determine which tests are mst apprpriate fr them n individual basis. Beginning at age 50, bth men and wmen shuld have a cln cancer screening test. Screening ptins fr patients with an average risk fr cln cancer: Clnscpy every 10 years Duble-cntrast barium enema every 5 years Faecal ccult bld test (FOBT) every year - if results are psitive, a clnscpy is needed Flexible sigmidscpy every 5-10 years, usually with stl testing fr faecal ccult bld dne every 1-3 years Virtual clnscpy (based n cmputerised 3-D imaging) every 5 years (Chan & Givannucci). Researchers als fund that eating mre fruits, vegetables, and legumes were assciated with a lwer risk f clrectal cancer (Makarem, et al., 2015). Screening fr Higher Risk Individuals Peple with familial risk factrs fr clrectal cancer may need earlier (befre age 50) r mre frequent testing. Genetic testing in suspected familial cases may identify candidates fr secndary preventin. Screening fr high risk individuals is mre likely t be dne using clnscpy. (MedlinePlus) Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] Nvember 2017 Page 5

6 Testing fr bld in the stl (faeces) When a health care prvider tests stl with a faecal ccult bld test they are ften lking fr the presence f micrscpic bld in the faeces, which may be a sign f a grwth, inflammatin r bleeding in the digestive system. Causes f Bld in Stl Bld may appear in the stl in ne r mre f the fllwing cnditins: Benign (nn-cancerus) r malignant (cancerus) grwths r plyps f the cln Haemrrhids (swllen bld vessels near the anus and lwer rectum that can rupture, causing bleeding) Anal fissures (splits r cracks in the lining f the anal pening) Intestinal infectins that cause inflammatin Ulcers Ulcerative clitis Crhn's disease Diverticular disease, caused by utpuchings f the wall f the large intestine Abnrmalities f the bld vessels in the large intestine Gastrintestinal bleeding may be micrscpic (invisible t the eye) r may be easily seen as red bld r black tar-like bwel mvements, called melaena stls indicating digested bld. A Faecal Occult Bld Test - The faecal ccult bld test requires the cllectin f 3 small stl samples. Usually the samples are a bit f stl cllected n the end f an applicatr. The stl samples shuld be taken ne day apart, because clrectal cancers may bleed frm time t time, rather than cnsistently. Stl samples are cllected in a clean cntainer and evaluated by detecting clur changes n a test card, r by sending the samples, in a special cntainer and envelpe, directly t a labratry fr analysis. Preparatin befre a Faecal Occult Bld Test - The faecal ccult bld test results are largely affected by hw ne prepares fr the test, s it is imprtant t fllw the instructins carefully. Stl samples shuld NOT be cllected frm individuals: with haemrrhids during r within 3 days either side f a menstrual perid As certain fds can alter the test results, a special diet is ften recmmended fr 48 t 72 hurs befre the test. The fllwing fds shuld be avided during that time: Beets Brccli Spanspek (als cantalupe, cantelupe, cantalup, mushmeln, muskmeln, rckmeln, sweet meln, Persian meln) Carrts Cauliflwer Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] Nvember 2017 Page 6

7 Cucumbers Fish Grapefruit Hrseradish Mushrms Pultry Radishes Red meat (especially rare prepared) Turnips Vitamin C-enriched fds r beverages (WebMD; Natinal Bwel Cancer Screening Prgramme). What the Faecal Occult Bld Test Results Mean As small amunts f bld nrmally appear in the stl, tests fr ccult bld are designed t detect larger quantities f bld. A psitive faecal ccult bld test means that bld has been fund in the stl. The dctr will have t determine the surce f the bleeding, either by ding a clnscpy, r by ding an examinatin t determine if the bleeding is cming frm the stmach r small intestine. A negative test result means that n bld was fund in the stl sample during the testing perid. Regular screening afterwards is recmmended. (WebMD; Natinal Bwel Cancer Screening Prgramme). Care and supprt nce diagnsed t prevent further cmplicatins and recurrence f cancer Steps need t be taken t prevent cancer recurrence, usually as metachrnus tumurs. This generally invlves annual surveillance with clnscpy after surgical remval f the initial cancer if sme part f the cln remains. Hwever, sme familial cases may invlve ther mdalities, such as cyclxygenase inhibitrs, as an adjunct after the initial peratin. Clse fllw-up with a cmpetent health care prvider, such as a gastrenterlgist, is necessary t help prevent recurrence (Carethers, 2010). After treatment has finished, the patient may be required t have regular check-ups. These might include a physical examinatin, bld tests including Carcinembrynic Antigen (CEA) measurement, a scan, r a clnscpy. Check-ups may cntinue fr several years. At first it may be every few mnths. But if all is well it will gradually becme less frequent. If wrried, r upn nticing any new symptms between appintments, patients are advised cntact their dctr immediately and nt t wait until the next appintment. (Cancer Research UK). Stma Care Being diagnsed with cancer and having treatment takes time t cme t terms with. It can als be difficult t cpe with the physical effects f treatment. If a patient had a clstmy r ilestmy peratin as part f treatment, the end f the bwel is brught ut int an pening Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] Nvember 2017 Page 7

8 n the abdmen. The pening is referred t as a stma. Sme peple have a temprary clstmy (an artificial pening int the cln) made during their treatment fr bwel cancer. The clstmy is clsed a few mnths later when the bwel has fully healed. [Picture Credit: Ilestmy] [Picture Credit: Clstmy] Sme peple have a permanent clstmy r ilestmy (artificial pening int the ilium r small bwel). It can take a while t get used t dealing with a stma. There is a lt f advice and supprt available in the frm f a specially trained nurse referred t as a stma nurse. (Cancer Research UK). Basic Care f a Clstmy r Ilestmy The clstmy bag is designed t stick nt the abdmen where it cllects the faeces and flatus frm the stma. It is waterprf s ne can wear it while shwering r bathing. Mst clstmy bags have several special features including a filter. This filter wrks by releasing wind s the bag des nt inflate (which is called ballning ). The filter als has a dedrising actin t make sure that there is n smell, which is ne f the things that peple wrry abut the mst. Emptying and Changing a Stma Bag It is gd t establish a rutine fr changing a stma bag. Keep this rutine as simple as pssible. As the stma is mre active at certain times f the day, like shrtly after meals, bags shuld be changed at time when it is relatively inactive, like first thing in the mrning. Stma bag needs t be changed regularly usually between ne and three times a day depending n the amunt f faeces. If using a drainable bag, it is recmmended t empty the bag befre remving it. Then seal the bag inside a dispsal bag and place in the dustbin. D nt flush it dwn the tilet, as it will cause a blckage. Taking Care f the Skin Arund the Stma is very imprtant Adhesive plate - The adhesive plate must fit snugly arund the stma. If the hle in the adhesive plate is larger than the stma, the skin will becme expsed t the harmful effects f the faeces and becme irritated. Als, if the adhesive plate is cut t small, it may cause damage t the stma. Check regularly t ensure the adhesive plate has a snug fit arund the stma. Watch ut fr irritants - Leakage n t the skin, excessive remval f the adhesive plate and harsh skin cleansers can all cause irritatin f the skin. Bleeding - It is cmmn t experience a small amunt f bleeding arund the stma when cleaning Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] Nvember 2017 Page 8

9 it n cause f alarm. If bleeding cmes frm inside the stma, a dctr is t be cntacted immediately. (Clplast). [Picture Credit: Clstmy Bag] Diagnsis f Clrectal Cancer On first visit the nclgist will ask abut the presence f symptms and whether there is a family histry f clrectal cancer A physical examinatin knwn as a digital rectal examinatin (DRE) is then cmmnly dne. A DRE invlves the placing a lubricated and glved finger int the anus, and then up int the rectum. A DRE is a useful way f checking whether there is a nticeable lump inside the rectum. This is fund in an estimated 40-80% f cases f clrectal cancer. A DRE is usually nt painful, but sme peple may find it uncmfrtable and even embarrassing. The patient may then be referred fr further examinatin - if the diagnsis uncertain r if symptms suggest clrectal cancer. Further examinatin Tw tests are cmmnly used t cnfirm a diagnsis f bwel cancer: Sigmidscpy - a device called a sigmidscpe is used, which is a thin, flexible tube attached t a small camera and light. The sigmidscpe is inserted int the rectum and then up int the large bwel, the camera relays images t a mnitr: this allws the dctr t check fr any abnrmal areas within the rectum r bwel that culd be the result f cancer A sigmidscpy can als be used t remve small samples f suspected cancerus tissue s they can be tested in the labratry; this is knwn as a bipsy A sigmidscpy is nt usually painful, but can feel uncmfrtable; mst peple g hme after the examinatin has been cmpleted [Picture Credit: Sigmidscpe] Clns cpy it is similar t a sigmid scpy except a lnger tube, called a clnscpe, is used t examine the entire large bwel [Picture Credit: Clnscpe] As the bwel needs t be empty when a clnscpy is perfrmed, the patient will be given a special diet t eat fr a few days befre the examinatin and a laxative (medicatin t help empty the bwel) n the mrning f the examinatin The patient will be given a sedative t relax, after which the dctr will insert the clnscpe int the rectum and mve it alng the length f the large bwel; the Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] Nvember 2017 Page 9

10 clnscpe can be used t btain a bipsy, remve plyps within the bwel, as well as relaying images f any abnrmal areas It usually takes abut ne hur t cmplete; althugh feeling drwsy mst peple can g hme nce they have recvered frm the effects f the sedative (NHS, UK). Staging f Clrectal Cancer Cancer staging is the prcess f determining the extent t which a cancer has develped by spreading. A staging system is a standardised way in which the cancer care team describes the extent f the cancer. The mst cmmnly used staging system fr clrectal cancer is that f the American Jint Cmmittee n Cancer (AJCC), smetimes als knwn as the TNM system. Older staging systems fr clrectal cancer, such as the Dukes and Astler-Cller systems, are mentined briefly belw fr cmparisn. The TNM system describes 3 key pieces f infrmatin: T describes hw far the main (primary) tumur has grwn int the wall f the intestine and whether it has grwn int nearby areas. N describes the extent f spread t nearby (reginal) lymph ndes. Lymph ndes are small bean-shaped cllectins f immune system cells that are imprtant in fighting infectins. M indicates whether the cancer has spread (metastasized) t ther rgans f the bdy. (Clrectal cancer can spread almst anywhere in the bdy, but the mst cmmn sites f spread are the liver and lungs.) Numbers r letters appear after T, N, and M t prvide mre details abut each f these factrs. The numbers 0 thrugh 4 indicate increasing severity. The letter X means cannt be assessed because the infrmatin is nt available. T categries fr clrectal cancer T categries f clrectal cancer describe the extent f spread thrugh the layers that frm the wall f the cln and rectum. These layers, frm the inner t the uter, include: The inner lining (mucsa) A thin muscle layer (muscularis mucsa) The fibrus tissue beneath this muscle layer (submucsa) A thick muscle layer (muscularis prpria) that cntracts t frce the cntents f the intestines alng The thin, utermst layers f cnnective tissue (subsersa and sersa) that cver mst f the cln but nt the rectum Tx: Tis: N descriptin f the tumur's extent is pssible because f incmplete infrmatin. The cancer is in the earliest stage (in situ). It invlves nly the mucsa. It has nt grwn beynd the muscularis mucsa (inner muscle layer). Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] Nvember 2017 Page 10

11 T1: The cancer has grwn thrugh the muscularis mucsa and extends int the submucsa. T2: The cancer has grwn thrugh the submucsa and extends int the muscularis prpria (thick uter muscle layer). T3: The cancer has grwn thrugh the muscularis prpria and int the utermst layers f the cln r rectum but nt thrugh them. It has nt reached any nearby rgans r tissues. T4a: The cancer has grwn thrugh the sersa (als knwn as the visceral peritneum), the utermst lining f the intestines. T4b: The cancer has grwn thrugh the wall f the cln r rectum and is attached t r invades int nearby tissues r rgans. N categries fr clrectal cancer N categries indicate whether r nt the cancer has spread t nearby lymph ndes and, if s, hw many lymph ndes are invlved. T get an accurate idea abut lymph nde invlvement, mst dctrs recmmend that at least 12 lymph ndes be remved during surgery and lked at under a micrscpe. Nx: N descriptin f lymph nde invlvement is pssible because f incmplete infrmatin. N0: N cancer in nearby lymph ndes. N1: Cancer cells are fund in r near 1 t 3 nearby lymph ndes N1a: Cancer cells are fund in 1 nearby lymph nde. N1b: Cancer cells are fund in 2 t 3 nearby lymph ndes. N1c: Small depsits f cancer cells are fund in areas f fat near lymph ndes, but nt in the lymph ndes themselves. N2: Cancer cells are fund in 4 r mre nearby lymph ndes N2a: Cancer cells are fund in 4 t 6 nearby lymph ndes. N2b: Cancer cells are fund in 7 r mre nearby lymph ndes. M categries fr clrectal cancer M categries indicate whether r nt the cancer has spread (metastasized) t distant rgans, such as the liver, lungs, r distant lymph ndes. M0: N distant spread is seen. M1a: The cancer has spread t 1 distant rgan r set f distant lymph ndes. M1b: The cancer has spread t mre than 1 distant rgan r set f distant lymph ndes, r it has spread t distant parts f the peritneum (the lining f the abdminal cavity). (American Cancer Sciety). Numeric Stages: Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] Nvember 2017 Page 11

12 (Picture Credit: Numeric Stages] Stage 0 -- Cancer is nly in the innermst lining f the cln r rectum. Stage I -- Cancer has grwn int the muscle layer f the cln r rectum. Stage II -- Cancer has grwn int r thrugh the utermst layer f the cln r rectum. Stage III -- Cancer has spread t ne r mre lymph ndes in the area. Stage IV -- Cancer has spread t ther parts f the bdy, such as the liver, lung, r bnes. (WebMD). Where Clrectal Cancer May Spread T Shuld clrectal cancer spread in the bdy, it may spread as indicated in the table belw: Cancer Type: Bladder Breast Cln Clrectal Lung Melanma Ovary Pancreas Prstate (Natinal Cancer Institute). Main Sites f Metastasis (Spread) Bne, liver, lung Bne, brain, liver, lung Liver, lung Liver, lung, peritneum (lining f abdmen) Adrenal gland, bne, brain, liver, ther lung Bne, brain, liver, lung, skin, muscle Liver, lung, peritneum (lining f abdmen) Liver lung, peritneum (lining f abdmen) Adrenal gland, bne, liver, lung Reducing the Risk fr Clrectal Cancer Get screened fr cln cancer - Peple with an average risk f cln cancer can cnsider screening beginning at age 50. But peple with an increased risk, such as thse with a family histry f cln cancer, shuld cnsider screening sner. African-Americans and American Indians may begin cln cancer screening at age 45. Several screening ptins exist each with its wn benefits and drawbacks. Talk abut yur ptins with yur dctr, and tgether yu can decide which tests are apprpriate fr yu. Optins may include: Annual faecal ccult bld testing Flexible sigmidscpy every five years Clnscpy every 10 years Virtual clnscpy (CT clngraphy) every five years Stl DNA testing thugh this is a new screening apprach and it's nt clear hw ften it shuld be repeated Mre frequent r earlier screening may be recmmended if yu're at increased risk f cln cancer. Discuss the benefits and risks f each screening ptin with yur dctr. Yu may decide ne r mre tests are apprpriate fr yu. Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] Nvember 2017 Page 12

13 Make lifestyle changes t reduce yur risk - Yu can take steps t reduce yur risk f cln cancer by making changes in yur everyday life. Take steps t: Eat a variety f fruits, vegetables and whle grains. Fruits, vegetables and whle grains cntain vitamins, minerals, fibre and antixidants, which may play a rle in lwering the risk fr cancer. Chse a variety f fruits and vegetables s as t get an array f vitamins and nutrients [Picture Credit: Fruit and Vegetables] Stp smking. Talk t a dctr abut ways t quit. Jin CANSA s e-kickbutt prgramme Limit alchl cnsumptin rather abstain frm cnsuming any alchl Exercise mst days f the week. Try t get at least 30 minutes f exercise n mst days. If inactive, start slwly and build up gradually t 30 minutes. Als, talk t a dctr befre starting any exercise prgram Maintain a healthy weight. If yu have a healthy weight, wrk t maintain that weight by cmbining a healthy diet with daily exercise. Reducing the risk fr cln cancer fr peple with a high risk - sme treatments, including medicatins and surgery, have been fund t reduce the risk fr precancerus plyps r cln cancer. Hwever, nt enugh evidence exists t recmmend these medicatins t peple wh have an average risk f cln cancer. Discuss the benefits and risks f these preventive treatments with a dctr: Aspirin. Sme evidence links a reduced risk f plyps and cln cancer t regular aspirin use. Hwever, studies f lw-dse aspirin r shrt-term use f aspirin haven't fund this t be true. It's likely that ne may be able t reduce the risk fr cln cancer by taking large dses f aspirin ver a lng perid f time. Using aspirin in this way carries a risk f side effects, such as gastrintestinal bleeding and ulcers Other pain relievers. Other pain relievers, such as ibuprfen (Advil, Mtrin, thers) and naprxen (Aleve, thers), have als been studied as a way t prevent cln cancer. Sme studies have fund these ther pain relievers may reduce the risk fr precancerus plyps and cln cancer. Side effects include ulcers and gastrintestinal bleeding. Sme f these ther pain relievers have been linked t an increased risk fr heart prblems Celecxib (Celebrex). Celecxib and ther drugs knwn as COX-2 inhibitrs prvide pain relief. Sme evidence suggests COX-2 drugs can reduce the risk fr precancerus plyps in peple wh've been diagnsed with these plyps in the past. But COX-2 drugs carry a risk f heart prblems, including heart attack. Tw COX-2 inhibitr drugs were remved frm the market because f these risks Surgery t prevent cancer. In cases f rare, inherited syndrmes such as familial adenmatus plypsis, r inflammatry bwel disease such as ulcerative clitis, the dctr may recmmend remval f yur entire cln and rectum in rder t prevent cancer frm ccurring (May Clinic). Treatment fr Clrectal Cancer Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] Nvember 2017 Page 13

14 Mst peple with early clrectal cancer have surgery. Surgery - In many peple with early bwel cancer the surgen is able t cut away all f the cancer withut any further treatment required. There are different types f surgery fr clrectal cancer. Which type f surgery is best will depend n where the cancer is, its type and size, and whether it has spread (metastesised) r nt. If the cancer is remved frm the bwel lining it is called a lcal resectin. If the cancer is larger, the surgen will remve the part f the bwel where the cancer is and jin the tw ends back tgether again. If the cancer has spread the lymph ndes nearby in the abdmen will als be remved. In the case f rectal cancer, the surgen will usually als remve the sheet f bdy tissue that cvers the bwel (the mesentery). T give the area time t heal, the surgen may want t make a temprary clstmy r ilestmy. This is an pening frm the bwel n t the surface f the abdmen called a stma. Waste matter is cllected int a special bag ver the pening. Such a persn will have t have anther peratin t repair the stma after a few mnths. If a large amunt f bwel r rectum has been remved, the surgen may have t make a permanent stma. He r she will discuss this with the patient befre the peratin. Mst peple dn t need a permanent clstmy r ilestmy. In the past few years surgens have been develping keyhle surgery t remve early stage bwel tumurs. This type f peratin is called a laparscpic resectin. (Cancer Research UK). Raditherapy - Raditherapy is nt ften used t treat cancer f the large bwel. It might be used befre r after surgery fr rectal cancer. Smetimes raditherapy and chemtherapy are given tgether fr rectal cancer. In the case f a large tumur, these treatments can shrink the tumur befre surgery. Raditherapy uses high energy rays t kill cancer cells. It is ften used t treat cancer that started in the rectum. It may be used befre r after surgery t lwer the risk f the cancer cming back after peratin. Befre surgery it can als shrink tumurs and make them easier t remve cmpletely. The patient usually has raditherapy at the same time as chemtherapy. Flururacil chemtherapy makes the cancer cells mre sensitive t radiatin. A mre recent treatment fr rectal cancer is high dse internal raditherapy befre surgery (called brachytherapy). A tube cntaining radiactive material is put int the rectum, and psitined clse t the tumur. It is left in place fr a predetermined perid f time. Raditherapy fr bwel cancer symptms - Raditherapy uses high energy rays t treat cancer. If the bwel cancer has already spread, the raditherapy treatment wn't cure it. The aim f the treatment is t slw the cancer grwth r shrink it. This relieves symptms such as pain in the pelvis r rectum. Raditherapy t relieve symptms is called palliative raditherapy. Raditherapy des nt hurt. The patient cannt feel the raditherapy and needs t lie very still fr the few minutes that the treatment lasts. Raditherapy des nt make the individual radiactive. It is perfectly safe t be with ther peple, including children, thrughut the curse f treatment. Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] Nvember 2017 Page 14

15 Shrt term side effects fr raditherapy usually cme n during the curse f treatment and carry n fr a week r tw after the curse has finished. The side effects might include diarrhea, nausea, tiredness, passing urine ften, r sre skin in the treatment area. The dctr will usually prescribe medicines t help with diarrhea and nausea. The patient may experience symptms f cystitis (a bladder infectin) and shuld try t drink plenty f liquids - many peple find that drinking cranberry juice helps. Lng term side effects f raditherapy ccur when the shrt term side effects ccur fr lng perids f time. These can start frm a few mnths t a cuple f years after finishing the curse f treatment. Lng term effects f raditherapy t the bwel include diarrhea, weight lss, bladder prblems, early menpause, lss f fertility, dryness and shrinkage f the vagina in wmen and difficulty in getting an erectin in men. (Cancer Research UK). Chemtherapy - Chemtherapy uses anti-cancer (cyttxic) drugs t destry cancer cells. It wrks by disrupting the grwth f cancer cells. As it circulates in the bld, it can reach cancer cells almst anywhere in the bdy and kill them. Chemtherapy may be given befre surgery fr rectal cancer. Chemtherapy is als given as a treatment fr clrectal cancer that has spread (metastasised). Chemtherapy may als be given after surgery - chemtherapy after surgery is called adjuvant chemtherapy. The specialist may recmmend that the persn has chemtherapy when he/she has recvered frm surgery if there is a risk that the cancer culd recur r spread in future r if cancer cells were fund in any f the lymph ndes during surgery. Different types f chemtherapy are used after surgery fr bwel cancer. Chemtherapy fr advanced bwel cancer - treatment with chemtherapy fr advanced bwel cancer is unlikely t cure the cancer but the chemtherapy can help the patient live lnger and may shrink the tumur. Other aims f the treatment are t slw the grwth f the cancer and cntrl symptms such as pain, lss f appetite and weight lss. The patient may have treatment as tablets r capsules t take at hme r may have treatment as liquids given int a vein. The dctr will take int accunt varius factrs when deciding which chemtherapy treatment is best. They will lk at which treatments have already been received and hw lng it tk fr the cancer t cme back. Chemtherapy with raditherapy fr rectal cancer sme specialists ften treat rectal cancer with raditherapy either befre r after surgery. Flururacil chemtherapy makes the cancer cells mre sensitive t the radiatin s the patient is likely t have chemtherapy at the same time as the raditherapy treatment. This treatment is called chemradiatin, chemraditherapy, r cncmitant chemtherapy and raditherapy. Receiving chemtherapy - chemtherapy may be given as a series f injectins int a vein befre raditherapy treatment, r thrugh a drip (an infusin), r as an infusin thrugh a pump that is wrn 24 hurs a day, r as capecitabine tablets. Side effects f chem-raditherapy - having chemtherapy and raditherapy tgether can make the side effects f the treatments wrse. The cmbined treatment may make ne feel very tired. The patient may als experience diarrhea, feel sick, have a lw resistance t infectin, need t pass urine mre ften and have sre skin in the treatment area. Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] Nvember 2017 Page 15

16 Side effects f chemtherapy - it has sme general side effects like lwering the number f healthy bld cells. This can mean that the patient is mre likely t get infectins and may be mre tired than usual. The patient can als be prne t nsebleeds and ther bleeding prblems. Other side effects f bwel cancer chemtherapy may include: Nausea (feeling sick) and vmiting (being sick) Hair lss r thinning f hair Sme types f chemtherapy and bilgical therapy drugs can cause changes in the lining f the muth and make it very sre. Sme f these drugs can even cause muth ulcers. Inflammatin f the inside f the muth is called mucsitis. It can happen abut 5 t 10 days after cmmencement f treatment. It usually gradually clears up 3 t 4 weeks after the treatment ends. Bisphsphnates and hrmne therapies d nt usually cause a sre muth. Diarrhea Changes in the menstrual cycle Sre eyes the eyes may feel as if they have grit in them - ask a dctr r nurse fr eye drps (Cancer Research UK). Bilgical Therapy - bilgical therapies are drugs that help the bdy t cntrl the grwth f cancer cells. Sme bilgical therapies, knwn as mnclnal antibdies, can be used t treat cln r rectal cancer that has spread t anther part f the bdy. A cstly bilgical therapy called cetuximab (Erbitux) may be used fr sme peple with bwel cancer that has spread. This treatment is nly used if the cancer has a nrmal cpy f a gene called k-ras and has nly spread t the liver. It has been advcated fr use with chemtherapy fr newly diagnsed bwel cancers that has spread t the liver within the Natinal Health System (NHS) in the United Kingdm. (Cancer Research UK). Immuntherapy - Current immuntherapies fr clrectal cancer fall int seven brad categries: checkpint inhibitrs and immune mdulatrs, mnclnal antibdies, therapeutic vaccines, adptive cell therapy, nclytic virus therapy, adjuvant immuntherapies, and cytkines. Mst f these therapies are still in early-phase clinical testing (phase I and II) fr clrectal cancer, but their successful use in ther types f cancers suggests that they may ultimately prve useful fr clrectal cancer as well. Checkpint Inhibitrs and Immune Mdulatrs - a prmising avenue f clinical research in clrectal cancer is the use f immune checkpint inhibitrs. These treatments wrk by targeting mlecules that serve as checks and balances n immune respnses. By blcking these inhibitry mlecules r, alternatively, activating stimulatry mlecules, these treatments are designed t unleash r enhance preexisting anti-cancer immune respnses. Mnclnal Antibdies - mnclnal antibdies are mlecules, generated in the lab, that target specific antigens n tumurs. Several mnclnal antibdies are currently being tested in clinical trials. Cancer Vaccines - cancer vaccines are designed t elicit an immune respnse against tumur-specific r tumur-assciated antigens, encuraging the immune Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] Nvember 2017 Page 16

17 system t attack cancer cells bearing these antigens. Tumur antigens that have been targeted in clrectal cancer include carcinembrynic antigen (CEA), MUC1, and NY-ESO-1. Several clinical studies f cancer vaccines fr clrectal cancer are pen. Adptive Cell Therapy - in this apprach, immune cells are remved frm a patient, genetically mdified r treated with chemicals t enhance their activity, and then reintrduced int the patient with the gal f imprving the immune system s anticancer respnse. Onclytic Virus Therapies - nclytic virus therapy uses a mdified virus that can cause tumur cells t self-destruct and generate a greater immune respnse against the cancer. Adjuvant Immuntherapies - adjuvants are substances that are either used alne r cmbined with ther immuntherapies t bst the immune respnse. Sme adjuvant immuntherapies use ligands mlecules that bind t prteins such as receptrs t help cntrl the immune respnse. These ligands can be either stimulating (agnists) r blcking (antagnists). Cytkines - cytkines are messenger mlecules that help cntrl the grwth and activity f immune system cells. (Cancer Research Institute). Treatment fr Advanced Clrectal Cancer Advanced clrectal cancer means the cancer has spread t ther parts f the bdy frm where it started in the bwel (cln) r back passage (rectum). The cancer may be advanced when it is first diagnsed, r the cancer may recur sme time after riginal treatment. Once a bwel cancer has spread t anther part f the bdy it is unlikely t be curable. But treatment can ften keep the cancer under cntrl fr quite a lng time. The chice f treatment depends n the cancer type, the number f secndary cancers, the lcatin f the cancers and treatment previusly received. Chemtherapy and raditherapy can be used t shrink a cancer and cntrl symptms. Surgery can be used in sme situatins t treat advanced clrectal cancer. Specialised surgical treatments are smetimes used t destry bwel cancer that has spread t the liver (liver secndaries). These treatments include hepatic artery chememblisatin, radifrequency ablatin, crytherapy, micrwave ablatin and laser therapy. Newer types f bilgical therapy drugs, such as bevacizumab (Avastin) and cetuximab (Erbitux), are licensed fr advanced clrectal cancer. Deciding abut treatment - It can be difficult t decide which treatment t try, r whether t have treatment at all, when ne has an advanced cancer. It is imprtant t understand what any treatment might achieve. The patient s quality f life als need t cnsidered while having the treatment. It is imprtant fr the patient t discuss all situatins with a dctr r specialist nurse, a therapist r even a lved ne. (Cancer Research UK). Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] Nvember 2017 Page 17

18 Abut Clinical Trials Clinical trials are research studies that invlve peple. These studies test new ways t prevent, detect, diagnse, r treat diseases. Peple wh take part in cancer clinical trials have an pprtunity t cntribute t scientists knwledge abut cancer and t help in the develpment f imprved cancer treatments. They als receive state-f-the-art care frm cancer experts. Types f Clinical Trials Cancer clinical trials differ accrding t their primary purpse. They include the fllwing types: Treatment - these trials test the effectiveness f new treatments r new ways f using current treatments in peple wh have cancer. The treatments tested may include new drugs r new cmbinatins f currently used drugs, new surgery r radiatin therapy techniques, and vaccines r ther treatments that stimulate a persn s immune system t fight cancer. Cmbinatins f different treatment types may als be tested in these trials. Preventin - these trials test new interventins that may lwer the risk f develping certain types f cancer. Mst cancer preventin trials invlve healthy peple wh have nt had cancer; hwever, they ften nly include peple wh have a higher than average risk f develping a specific type f cancer. Sme cancer preventin trials invlve peple wh have had cancer in the past; these trials test interventins that may help prevent the return (recurrence) f the riginal cancer r reduce the chance f develping a new type f cancer. Screening - these trials test new ways f finding cancer early. When cancer is fund early, it may be easier t treat and there may be a better chance f lng-term survival. Cancer screening trials usually invlve peple wh d nt have any signs r symptms f cancer. Hwever, participatin in these trials is ften limited t peple wh have a higher than average risk f develping a certain type f cancer because they have a family histry f that type f cancer r they have a histry f expsure t cancer-causing substances (e.g., cigarette smke). Diagnstic - these trials study new tests r prcedures that may help identify, r diagnse, cancer mre accurately. Diagnstic trials usually invlve peple wh have sme signs r symptms f cancer. Quality f life r supprtive care - these trials fcus n the cmfrt and quality f life f cancer patients and cancer survivrs. New ways t decrease the number r severity f side effects f cancer r its treatment are ften studied in these trials. Hw a specific type f cancer r its treatment affects a persn s everyday life may als be studied. Where Clinical Trials are Cnducted Cancer clinical trials take place in cities and twns in dctrs ffices, cancer centres and ther medical centres, cmmunity hspitals and clinics. A single trial may take place at ne r tw specialised medical centres nly r at hundreds f ffices, hspitals, and centres. Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] Nvember 2017 Page 18

19 Each clinical trial is managed by a research team that can include dctrs, nurses, research assistants, data analysts, and ther specialists. The research team wrks clsely with ther health prfessinals, including ther dctrs and nurses, labratry technicians, pharmacists, dieticians, and scial wrkers, t prvide medical and supprtive care t peple wh take part in a clinical trial. Research Team The research team clsely mnitrs the health f peple taking part in the clinical trial and gives them specific instructins when necessary. T ensure the reliability f the trial s results, it is imprtant fr the participants t fllw the research team s instructins. The instructins may include keeping lgs r answering questinnaires. The research team may als seek t cntact the participants regularly after the trial ends t get updates n their health. Clinical Trial Prtcl Every clinical trial has a prtcl, r actin plan, that describes what will be dne in the trial, hw the trial will be cnducted, and why each part f the trial is necessary. The prtcl als includes guidelines fr wh can and cannt participate in the trial. These guidelines, called eligibility criteria, describe the characteristics that all interested peple must have befre they can take part in the trial. Eligibility criteria can include age, sex, medical histry, and current health status. Eligibility criteria fr cancer treatment trials ften include the type and stage f cancer, as well as the type(s) f cancer treatment already received. Enrlling peple wh have similar characteristics helps ensure that the utcme f a trial is due t the interventin being tested and nt t ther factrs. In this way, eligibility criteria help researchers btain the mst accurate and meaningful results pssible. Natinal and Internatinal Regulatins Natinal and internatinal regulatins and plicies have been develped t help ensure that research invlving peple is cnducted accrding t strict scientific and ethical principles. In these regulatins and plicies, peple wh participate in research are usually referred t as human subjects. Infrmed Cnsent Infrmed cnsent is a prcess thrugh which peple learn the imprtant facts abut a clinical trial t help them decide whether r nt t take part in it, and cntinue t learn new infrmatin abut the trial that helps them decide whether r nt t cntinue participating in it. During the first part f the infrmed cnsent prcess, peple are given detailed infrmatin abut a trial, including infrmatin abut the purpse f the trial, the tests and ther prcedures that will be required, and the pssible benefits and harms f taking part in the trial. Besides talking with a dctr r nurse, ptential trial participants are given a frm, called an infrmed cnsent frm, that prvides infrmatin abut the trial in writing. Peple wh agree t take part in the trial are asked t sign the frm. Hwever, signing this frm des nt mean that a persn must remain in the trial. Anyne can chse t leave a trial at any time either befre it starts r at any time during the trial r during the fllw-up perid. It is imprtant fr peple wh decide t leave a trial t get infrmatin frm the research team abut hw t leave the trial safely. Researched and Authred by Prf Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupatinal Health] Apprved by Ms Elize Jubert, Chief Executive Officer [BA Scial Wrk (cum laude); MA Scial Wrk] Nvember 2017 Page 19