Colorectal Cancer (Bowel Cancer)
The Colorectal Cancer Team are based at Russells Hall Hospital.
The MDT Lead Clinician is Mr Waterland
The Lead Clinical Nurse Specialist is Colleen Fernando on 01384456111 Ext 2286
The Multi-Disciplinary Team (MDT) takes place weekly on a Monday 12.45
Types of Colorectal cancer
Colorectal cancer is cancer of the following:
Colon (Large Bowel)
Rectum (Back passage)
Colorectal cancer is the third most common cancer in the UK after breast and lung cancer, with approximately 41,265 new cases diagnosed in 2014 in the UK (Cancer Research UK). Occurrence of colorectal cancer is strongly related to age, with almost three-quarters of cases occurring in people aged 65 years or over. Colorectal cancer is the second most common cause of cancer death in the UK after lung cancer (Cancer Research UK,2014).
People with a strong family history of colorectal cancer affecting people below 40 years of age have an increased risk of developing the disease. People with some long-standing inflammatory diseases of the bowel, such as Crohn’s disease or ulcerative colitis, may also have an increased risk of developing colorectal cancer. People who have a rare genetic condition known as familial adenomatous polyposis (FAP) or adenomatous polyposis coli, in which benign tumours called polyps are found in the lining of the colon, have an increased risk of developing bowel cancer. There are many different kinds of cancer. Colorectal cancer is cancer of the colon (large bowel) and rectum (back passage).
Symptoms
Not all symptoms are related to cancer. There are other illnesses that can cause these symptoms that are not cancer. It is important to speak with your GP or clinician team if you are concerned.
A change in bowel habit – symptoms can include going to the toilet more often and looser motions, perhaps alternating with periods of constipation. You may see dark blood in the motion or pass mucus.
Bleeding – rectal bleeding that persists. The most common sign is blood in or on the stools.
Other symptoms – other signs are unexplained weight loss, tiredness or breathlessness without obvious reason (usually due to anaemia from loss of blood). Some people feel a lump in the tummy.
Investigations for colon and rectal cancer
Your clinical team will discuss with you the most appropriate investigations you will require. You may not require all the following investigations.
Blood tests
Your consultant will request routine blood tests such as:
- Haemoglobin (Hb) or a full blood count (FBC) to check for anaemia and any other problems.
- Urea and electrolytes (U&E) to check how well your kidneys are working.
- Carcinoembryonic antigen (CEA) which can give an indication of active bowel cancer and is used for diagnosis together with other diagnostic tests.
Barium enema
This is an examination using barium to outline the whole bowel which then shows up on X-rays. It will be carried out in the hospital X-ray department. It is important that the bowel is empty for the test so that a clear picture can be seen. Therefore, we will give you a preparation to take the day before your test to empty your bowel. You will need to drink plenty of fluids when you take this. On the day of your barium enema, you will not be able to eat anything until after the test has been completed. The X-ray department will send you an instruction sheet with more information about this.
For the test, a small tube is placed in the anus and liquid barium and some air are put into your bowel through this tube. It is important to keep the liquid barium and air in the bowel until all the X-rays have been taken. The barium outlines the bowel and X-rays are taken to show up any abnormal areas. For a couple of days after the test, you may notice that your stools are white. This is the barium coming out of your body and is nothing to worry about.
Sigmoidoscopy
This test allows the doctor to look at the inside of the rectum and lower part of the large bowel. It is usually carried out in the hospital outpatient department or gastrointestinal unit (GI unit). For the test, you will need to lie curled up on your left side and then the doctor will gently pass a tube into your back passage. A small hand pump is attached to the tube so that air can be pumped into the bowel. A light on the inside of the tube helps the doctor to see any abnormalities. If necessary, the doctor can take a small sample of tissue (called a biopsy) for examination using a microscope to check for cancer cells. The biopsy should not hurt.
Colonoscopy
If your consultant wants to look inside the whole length of the large bowel, they may suggest you have a colonoscopy. This will usually be carried out in the GI unit.
For this test, the bowel has to be completely empty which means taking a preparation similar to that used for a barium enema. We will give you this and the instructions of how and when to take it. Just before the test, we may give you a sedative into a vein to help you relax. We will discuss this with you. You will need to lie on your side. The doctor will gently pass a flexible tube into your back passage which can pass around the curves of the bowel. A light on the inside of the tube helps the doctor to see any abnormal areas and allows photographs and samples (biopsies) to be taken of the inside of your large bowel.
As you may be sedated for the procedure, it is important to adhere to the following guidance:
- You will need to arrange for a responsible adult to take you home afterwards, either by car or taxi. You will not be able to go home on public transport.
- Someone should stay with you overnight.
- You cannot, by law, be in charge of a motor vehicle or moving machinery for 24 hours afterwards.
The medication (Midazolam) we give some patients before a colonoscopy relaxes and makes you comfortable. However, it may affect your memory for up to 24 hours afterwards. You may not remember information given to you by the doctor, but we will give you a report to take home. The effect of the sedation (Midazolam) may be prolonged by other medication you are taking. We will discuss this with you when you come for the procedure.
CT scan or CT colonogram
A CT scan is a type of X-ray that uses a scanner to take a series of detailed images of your body. This includes looking at the structures of your body including internal organs, blood vessels and bones. The scan gives information about tumours that helps the doctor plan your treatment. For the CT scan, you usually need to arrive before the scan time. This is because you may need to drink some special fluid before to highlight your bowel on the scan pictures. If you are having a CT colonogram, we will send you the fluid before the scan. You will need to drink this over several days along with some mild laxatives as your bowel will need to be clear for the scan. When you come for a CT scan, you will usually need to have an injection of contrast dye into a vein in your arm. This highlights the blood vessels and certain organs on the pictures.
If you are having a CT colonogram, the doctor will pass a very small flexible tube into your back passage to gently pump air into your colon. The air is important as it inflates the bowel slightly, opening any folds which might hide any polyps or growths.
The scanner itself looks like a large Polo mint as it has a hole in the middle. During the scan, you will lie on a table that moves through the hole. You will be in the scanner room for several minutes and many pictures are generated. A doctor (known as a radiologist) will look at these afterwards. The interpreting of the pictures takes a while so the report will be sent to your specialist later.
MRI scan
Magnetic resonance imaging (MRI) is often used as well as CT scans when looking at rectal tumours. It uses strong magnetic fields and radio waves to see inside the body, rather than X-rays. Due to the strong magnetic fields used, we will send you a questionnaire beforehand to make sure that there are no circumstances preventing you from having an MRI scan. The scan takes several minutes and during the test you will need to lie very still. The scanner makes a lot of noise so we will give you headphones to wear. We usually play music through these so you can bring along your favourite CD, if you want.
Anal/rectal ultrasound
This is an examination using high frequency sound waves to create images of tissue layers beneath the surface of the anal canal or the rectum. It uses a smooth probe the size of a finger which is placed in the anus or rectum.
This procedure can be performed for patients who have rectal cancer who are unable to have a MRI scan. It allows very good visualisation of the tissue. It is a safe procedure, and no radiation is used. The examination is performed by a consultant who has special training in ultrasound.
What is an anal/rectal ultrasound (USS) used for?
This test is used to map out anal fistulas before surgery. An Anal Fistula is a small tunnel that develops between the end of the bowel and the skin near the anus (where poo leaves the body). They’re usually the result of an infection near the anus causing a collection of pus (abscess) in the nearby tissue. When the pus drains away, it can leave a small channel. A USS is also used to look for abnormal areas or cancer, infections around the anus area and tears, scarring or injuries in the sphincter muscle in the anus. It provides additional information about rectal polyps and rectal cancer.
How do I prepare for the ultrasound?
Your bowel will need to be clear so we will send you an enema in the post with your appointment. You will need to use this at home before you come to the hospital for the procedure. When you arrive in the GI unit, a nurse will complete your assessment documents with you, including your medical history and current medications. The consultant will explain the procedure to you, answer any questions you have and obtain your written consent. Feel free to ask questions if something is not clear to you.
What happens after an ultrasound?
We will give you instructions to follow at home. Usually there are no restrictions on activity.
Abbreviations
These are some of the medical words and terms you may come across during your appointments.
Analgesia
Pain relief.
Anastomosis
The joining together of two ends of healthy bowel after diseased bowel has been cut out (resected) by the surgeon.
Chemotherapy
Drug therapy used to attack cancer cells.
Electrolytes
Salts in the blood e.g., sodium, potassium and calcium.
Enema
A liquid introduced into the rectum to encourage the passing of motions.
Faeces
The waste matter eliminated from the anus (other names – stools, motions).
Oncologist
A doctor who specialises in cancer care using drugs and radiotherapy.
Pathology
The study of the cause of the disease.
Stoma
An artificial opening made by surgery of part of the intestine onto the abdominal surface which allows stool to exit the body.
Tumour
An abnormal growth which may be benign (non-cancerous) or malignant (cancerous).
Diagnosis
What happens after I have had all my tests and investigations?
The findings of your tests and any biopsies will be discussed in a colorectal cancer multidisciplinary team (MDT) meeting by your consultant. After this, we will create a treatment plan for you. Sometimes as a result of discussions in the MDT meeting, you may need to have more investigations. If this is the case, your consultant or specialist nurse will contact you to discuss this.
Staging the disease
Your treatment will depend on the stage of disease at time of diagnosis. In order to stage the disease, the specialists use the findings from the tests and biopsies. They look at the characteristics of the tumour, whether the cancer has spread and if so, where it has spread to.
There are two standard systems used to stage bowel disease. These are the dukes’ staging system and the Tumour, Node and Metastasis (TNM) staging system
Staging
information from the TNM staging report can be used to give a number stage between 1 and 4.
- Stage 1 – the cancer hasn’t spread outside the bowel wall
- Stage 2 – the cancer has grown into or through the outer layer of the bowel wall
- Stage 3 – the cancer has spread to nearby lymph nodes
- Stage 4 – the cancer has spread to other parts of the body
The TNM staging system
This more detailed staging system describes the size of the primary tumour (T), whether any lymph nodes contain cancer cells (N), and whether the cancer has spread to another part of the body (M).
T stage Extent of cancer
T1 Tumour is only in the inner layer of the bowel
T2 Tumour has grown into the muscle layer of the bowel wall
T3 Tumour has grown into the outer lining of the bowel wall
T4 Tumour has grown through the outer lining of the bowel wall. It may have grown into another part of the bowel, or other nearby organs or structures. Or it may have broken through the membrane covering the outside of the bowel (the peritoneum)
N stage Extent of cancer
N0 There are no lymph nodes containing cancer cells
N1 One to three lymph nodes close to the bowel contain cancer cells
N2 There are cancer cells in four or more nearby lymph nodes
M stage Extent of cancer
M0 Cancer has not spread to other organs
M1 Cancer has spread to other parts of the body
The role of the colorectal cancer multidisciplinary team
NHS guidelines state that “everyone diagnosed with colorectal cancer should be under the care of a multidisciplinary team”. This is a team of health professionals who work together to discuss your case and how best to manage your treatment, the benefits of treatments available and the most appropriate types of treatment to meet your individual needs.
The colorectal cancer multidisciplinary team meetings are held on Monday lunchtimes (except for bank holidays). Your case will be discussed when all your investigations have been completed and a treatment plan will be created for you. The consultant who will be in charge of your treatment and your specialist nurse will discuss this treatment plan with you either by telephone or in the outpatient department. This may be a different consultant to the person you saw in the first instance.
The consultant’s secretary or your specialist nurse will contact you by telephone with the time for this appointment.
What is Colorectal/Bowel cancer?
The tissues and organs of the body are made up of tiny building blocks called cells. These cells repair and reproduce themselves continually as they age and become damaged. Sometimes during this process, normal cells become abnormal and as they continue to reproduce (divide) they develop into a tumour. Tumours can either be cancerous (malignant) or non-cancerous (benign).
In a benign tumour, the cells do not spread to other parts of the body. However, if they continue to grow, they may cause a problem by putting pressure on the surrounding organs or causing a blockage, for example, in the bowel.
A malignant tumour consists of cancer cells that have the ability to spread away from the original site. If the tumour is left untreated, it may invade and destroy the surrounding tissue. If cells break away from the original cancer (the primary one), they can spread to other organs of the body through the bloodstream. When these cells reach a new site, they may continue to grow and form a new tumour. This is known as a secondary cancer or metastasis.
Following all your investigations your doctor or Clinical nurse specialist will discuss a diagnosis with you. In this appointment the consultant or clinical nurse specialist will discuss the findings from your investigations with you and outline what options are available. Please click on the treatments tab to find out what options may be available.
Treatment for colorectal/Bowel cancer
Surgery
Your doctor may have explained that you have a cancer or possible cancer of the colon and the treatment for this is surgery.
This section aims to provide information to help you understand more about your proposed operation. We hope you find it useful and that it will help you understand the care you will receive.
What happens while I am waiting for my operation?
While you are waiting to come in for your operation, it is important that you try to prepare yourself physically. It is a good idea to:
- Try and eat a well-balanced diet, unless you have been
instructed to eat a special diet by your doctor.
- Do gentle exercise such as walking.
- Get plenty of fresh air.
- If you are a smoker, cutting down or preferably stopping smoking will help your recovery, reduce the risk of complications from the anaesthetic and reduce problems with healing. If you would like help with stopping smoking, please contact your GP
What happens at the pre-assessment clinic?
We will give or send you an appointment to come to the pre-assessment unit.
Who will I see at the pre-assessment clinic?
- Pre-assessment nurse
- Colorectal nurse specialist
- You may also see an anaesthetist
The pre-assessment nurse will:
- Assess your general fitness for surgery and anaesthetic.
- Discuss your health and write down your medical history.
- Ask you about your current medication including all prescribed and any other medication that you have purchased and take regularly. This will include tablets, inhalers, creams and eye drops. Please bring a list with you.
- Carry out tests which will include measuring your blood pressure, pulse, weight, height, blood tests, an ECG (a heart tracing test) and a swab for MRSA.
Your consultant may arrange for the anaesthetist to see you. The anaesthetist may need to do some other tests before your operation, to assess how safe a general anaesthetic is for you. The anaesthetist will also discuss the type of anaesthetic you need for your operation, and the type of pain relief you will have after your operation.
You may need to stop some of your regular medication before surgery, but the pre-assessment nurse will advise you if this is needed.
If your surgery involves or may involve having a stoma, your specialist nurse will mark this area on your skin.
What is the enhanced recovery programme?
When you come to hospital for your operation, you will be taking part in an enhanced recovery programme. This programme of care aims to help you recover quickly and safely. This information on what is involved in the programme, what you can expect from us and what we expect from you. The programme is different from traditional care and is based on the best available research evidence to improve and speed up your recovery after your operation.
During your hospital stay, we will give you daily goals which you will be encouraged to achieve as you can play an active part in your recovery. A team of doctors, nurses and other healthcare professionals will be monitoring your progress and will support you in reaching your goals.
If there is anything you are unsure about, please ask a member of the team responsible for your care.
What happens before I come into hospital?
You will be involved in planning your care and recovery from the time that we see you for your pre-admission assessment. This is an opportunity for you to tell us all about your individual needs and circumstances. It is important that you tell us as early as possible if you, or any of your family members, have any concerns about your ability to manage daily activities when you leave hospital after your operation. You should also let us know if any of your social circumstances change while you are in hospital.
We have a team of healthcare professionals who can help to organise any support you might need when you leave hospital. These include occupational therapists, physiotherapists, social workers and the discharge planning team.
How do I prepare for my operation?
Please bring in comfortable, loose-fitting clothes for during your stay in hospital as we will encourage you to dress in day clothes after your operation.
Bowel preparation
Before you come into hospital for your operation, we may ask you to take a bowel preparation. This is to make sure your bowels are empty for the operation. If you need to take this, your consultant or specialist nurse (key worker) will tell you. You will need to take this preparation at home before you come to hospital for your operation. The instructions on when to start will be enclosed with the bowel preparation. If you do not need to take a laxative bowel preparation, you may need to use a phosphate enema at 6pm the day before surgery and 6am the day of your surgery. An enema is a medication that you put in your back passage to clear the lower end of your bowels.
Your consultant or specialist nurse (key worker) will let you know if you have to do this.
Eating and drinking
Three days before your operation, you will need to start eating a low residue diet. Your specialist nurse/key worker will explain this to you and give you an information sheet.
If you are able to eat the day before surgery, it is a good idea to have a small meal the evening before the operation.
A key aspect of the enhanced recovery programme is that you will be given carbohydrate drinks to have before surgery. The benefit of these drinks is that they will give you the much-needed energy you need to help you to recover. We will give you the drinks at your pre-admission appointment. You will need to drink one at 6pm and one at 10pm on the day before surgery, and one at 6am on the day of your surgery.
What if I am having a stoma?
If you have been told that you may need to have a stoma (ileostomy or colostomy), you will meet one of the colorectal/stoma care nurses for support and information before your operation. They will give you a pre-operation information pack. This is a step-by-step guide for patients to practise stoma care before their operation.
After your operation, the colorectal/stoma care team and the ward nurses will help you to adapt to life with a stoma.
What happens when I come for my operation?
On the morning of your operation, you will need to come to the Admissions Lounge at Russells Hall Hospital. Here a nurse will complete your admission paperwork. Your surgeon will discuss the operation details with you and the possible complications.
The nurse will check that you understand the details of the operation. If you want to go ahead with the surgery, we will ask you to give your written consent. The anaesthetist and your specialist nurse/key worker or one of the team will also come and see you. If you are having a stoma your specialist nurse will place a mark on your skin. When the operating theatre is available for you to have your operation, a nurse will take you to the arrivals lounge. You will need to change into a theatre gown and elasticated stockings to help prevent blood clots. We will then take you into the anaesthetic room.
What happens during the operation?
You will have already been given information about your operation by your consultant and specialist nurse. Surgery can be performed by two different techniques, known as laparotomy (open surgery) or laparoscopic (keyhole surgery):
Laparotomy (open surgery) is a traditional surgical procedure
involving a large cut up and down through the abdominal (tummy) wall.
Laparoscopic is an alternative to open surgery. It is also known as keyhole surgery.
In keyhole surgery, the part of your bowel that contains cancer will be removed but this will not involve a large cut in your abdomen. Instead, the surgeon makes four small cuts of five to 10 millimetres in length, in your abdomen. Small plastic tubes are inserted through these holes and surgical instruments can be passed through these tubes into your abdomen. These include a telescope and camera which allow the surgeon to see inside.
A harmless gas will be pumped into your abdomen to make the process possible. The surgeon removes the section of bowel through a separate cut about five to seven centimetres in length. Not every patient can have laparoscopic surgery. Previous surgery, on the abdomen in particular, may mean this approach is not possible. Also, in a number of cases, there is a possibility that during the operation the keyhole surgery may need to be converted to open surgery. Your consultant surgeon will discuss this with you before your operation.
For both types of surgery, during the operation the piece of colon that contains the cancer is removed along with lymph nodes near the bowel (see figure 1). These can be analysed to see if the cancer has spread.
Figure 1 – the digestive system from the oesophagus (food pipe) to the anus
If the parts of the bowel that have been cut cannot be joined back together, the surgeon will bring out one end of the bowel through an opening in the abdominal wall. The end of the bowel is called a stoma.
This can either be a colostomy where the end of the large bowel (colon) is brought out or an ileostomy where the end of the small bowel (ileum) is brought out. A bag is put over the stoma to collect the stools that usually pass
through the bowel and out of the body through the rectum and anus (back passage). We will train you how to change these bags yourself.
Sometimes the stoma is only temporary and a few months later you can have another operation to re join the bowel. If such an operation is not possible, the stoma will be permanent.
It is natural to be concerned that you will not be able to carry on with your day-to-day activities and that others will notice you are wearing a stoma bag. However, modern stoma equipment is discreet and secure, and there is no reason why you should not be able to do the activities you enjoyed before, including sporting and sexual activities.
Adjusting to life with a stoma can be challenging but most people become accustomed to it over time. You will see a specialist stoma nurse after having a stoma. Specialist stoma nurses can offer support and advice to help you adapt to life with a stoma.
What are the possible risks?
As with all surgery, this operation carries some risks and complications. It is important that we tell you about these risks so that you have the information you need to make a decision about the operation.
General anaesthetic
A general anaesthetic can cause serious problems such as an allergic reaction but these are very rare. If you have any worries about this, you can discuss them at your meeting before your operation (pre-assessment appointment) or with the anaesthetist before your operation.
Blood clot
A deep vein thrombosis (DVT) is a blood clot in a vein that usually causes symptoms of red, painful and swollen legs. The risks of a DVT are greater after any surgery. Although not a problem themselves, a DVT can move through the bloodstream and travel to the lungs. This is known as a pulmonary embolism (PE) and is a very serious condition which affects your breathing.
To limit the risk of a DVT, you will be given an injection once a day after you have your operation when you are in hospital, to thin your blood. This is given through a small needle under the skin, usually into your ‘tummy area’. When you are discharged, you will need to have the injections in your tummy for a month. We will teach you to give your injection or arrange for a district nurse to give injection.
If you are able to wear them, you will also be given some elasticated stockings that are specific to your calf and thigh measurements.
Nursing staff will advise you on how to use and care for these. Starting to walk and getting moving is one of the best ways to stop blood clots from forming.
Bleeding
As with all operations, there is a small risk of heavy bleeding. This may need to be treated with iron tablets or a blood transfusion. A blood transfusion, in rare cases, can cause transfusion reactions or Infection. If you would not accept a blood transfusion, please let your doctors know.
Infection
There is always a risk that an infection will develop after an operation. These are not usually serious and can be treated with antibiotics.
Nerve damage
The piece of bowel being operated on is very close to the bladder and the nerves responsible for sexual function. These may get damaged during the operation. Bladder function may also be disturbed.
Men may have problems with erection or ejaculation. In women, sexual response may be affected and there may be discomfort during sex.
Other risks
If you have two parts of your bowel joined together by surgery, it is possible for the surgical join in your bowel to break down. If this happens, you may need to have more surgery. This may include having a stoma that may be temporary or permanent.
These complications may be temporary or permanent. You can discuss any problems or queries you may have with your colorectal nurse or surgeon.
What happens after my operation?
If you have had open surgery and suffer from other medical conditions that require closer monitoring, you will go to the Surgical High Dependency Unit, usually for a day or two. If you have had keyhole surgery, you will probably be taken to a ward, but this will be decided by your consultant and anaesthetist.
A few hours after your operation, you will be able to start having drinks. You may even be able to have something light to eat later that day, if you are not feeling sick. In addition to normal food, we will encourage you to have nutritional supplement drinks every day during your hospital stay. These are called Fortisip or Fortijuce and are provided in various flavours. It is important that you eat and drink early after your operation as the nutrients and vitamins from this will help your overall recovery.
Sickness
After an operation, some people may feel or occasionally be sick. Many things may contribute to this but the anaesthetic is designed to reduce the risk of sickness as much as possible.
If you do feel sick, it does not usually last long. We can give you anti-sickness medication through your drip to help you; therefore, if you feel sick, please tell a member of staff. It is important that we relieve your sickness so that you feel better and can eat and drink normally.
Pain control
Effective pain control after your operation is an essential part of the enhanced recovery programme. It will allow you to breathe deeply, start walking around, feel relaxed and sleep well, all of which are a very important part of your recovery process.
The pain control you receive will depend on the type of operation but usually involves a combination of:
- local anaesthetic that is given to you at the time of the operation
- painkillers given through your drip
- tablets or syrup taken by mouth
Please let a member of staff know if the pain control you are receiving is not enough. There are several extra things that we can do to make sure you are as comfortable as possible.
Tubes and drips
While you are having your operation, the doctor will put a tube (catheter) in your bladder so we can measure how much urine you are producing after your operation.
You may have a drip in your arm or neck to give you the fluids that you need.
Some people have a drain put into their abdomen to allow any bloody fluid from the operation to be drained away.
These will usually be removed after you have been reviewed by your specialist doctors.
Exercises
When you wake up from your operation, it is important to start doing deep breathing exercises as soon as possible. This can help to prevent a chest infection. The exercises are:
- Breathe in through your nose as deeply as you can, hold for three seconds, sniff inwards, then breathe out slowly through your mouth. Repeat these five more times.
- Breathe in deeply, support your abdomen, lean forward and cough strongly to clear any phlegm.
- Repeat this whole cycle a further three times.
In addition, to improve circulation, you should point your feet up and down and circle your ankles as often as possible (at least every
hour).
Getting out of bed and walking
The ward staff or physiotherapist will help you to get out of bed as soon as possible after your operation. This may be on the same day as your operation if you are well enough, probably about four hours after you arrive on the ward. You will spend two hours out of bed on the first occasion, and then at least six hours each day after this. This could be three hours in the morning and three in the afternoon, or three sets of two hours. We will encourage you to walk 20 metres, three to four times a day on the first day after surgery. This should increase to 60 metres, four to six times a day, from the second day. Being out of bed in a more upright position, and walking regularly, is good for your lungs and will help to prevent a chest infection. It is good for your circulation and helps prevent blood clots. It also improves other body functions such as bowel movement.
Preventing blood clots (deep vein thrombosis – DVT)
Whilst you are in hospital, we will give you a daily injection of a medication called enoxaparin. This helps to reduce the risk of blood clots occurring in the legs by thinning the blood. Some people may need to continue having these injections at home. If this applies to you, the ward staff will show you how do this before you leave hospital.
If you can wear them, we will also ask you to wear compression stockings to help prevent clots. Exercise plays a very important part in the prevention of clots. While you are awake, you should try to move your feet, legs, arms and hands for at least five minutes every hour. You should also move around regularly.
What do I need to look for when I get home?
It is unusual for serious problems to happen after this type of operation but if they do, it is important to treat them as early as possible. Therefore, it is important to know what to look out for. During the first two weeks after surgery, if you are worried about anything, please telephone the numbers listed towards the back of this booklet. If you cannot contact any of the people listed, ring your GP, or if necessary go to your nearest Emergency Department (A&E).
If you have any problems within three days of going home from hospital, please contact:
B5 Surgical Assessment Unit (SAU) on 01384 244359
Abdominal pain
It is quite common to suffer sudden abdominal pains during the first week after you have had part of your bowel taken out. The pains usually last for a few minutes and will decrease between spasms.
However, if you have severe pain that lasts for several hours, it is possible that you may have a leakage of fluid from the area where the bowel has been joined together. This can be serious although it is rare. If you get this, you may also have a fever (high temperature). Therefore, if you have severe pain lasting more than one or two hours, or have a fever and feel generally unwell within two weeks of your operation, contact one of the numbers listed in this booklet.
Bowel habits
Your bowel habits may change after you have part of your bowel removed. For example, your stools may become looser or you may get constipation. To help prevent this, make sure you eat regular meals at least three times a day, drink enough and take regular walks during the first two weeks after your operation.
If you are constipated for more than three days, you might be able to take a laxative. However, we suggest you contact us or your GP for advice first. If you are passing loose stools more than three times a day, for more than four days, please contact us or your GP for advice. If you have a stoma, your colorectal/stoma nurse specialist will discuss how to manage this with you, before you go home.
Blood clots
Blood clots are a possibility after any form of surgery and although these are rare, it is still important that you know what to look out for. If you develop pain, redness and/or swelling in either leg, you should contact the ward you were on after your operation, or your GP, immediately. Very rarely, blood clots can travel to the lungs and cause you to have chest pains and/or shortness of breath. This is an emergency and you should dial 999 and ask for an ambulance.
Wound care
Your wound will probably be slightly uncomfortable for the first one to two weeks. Please contact the ward you were on after your operation, or your GP, if your wound:
- Becomes hot, inflamed, swollen or very painful
- Has fluid coming out of it
Diet
A balanced, varied diet is recommended, and you should try to eat three or more times a day. You may need to change how much fibre you eat depending on whether you are constipated or have looser stools.
If you have a stoma, the stoma care nurses will give you specialist advice on what to eat. It is important that you eat the right foods that contain the protein, calories and nutrients to help your body to heal. If you are finding it difficult to eat, you may benefit from having three to four nutritional drinks a day. These include Fortisip and Fortijuce which can be prescribed by your GP, or Meritene Energis Shakes and Complan, which you can buy in chemists.
If your appetite does not improve after a few weeks, or if you are losing weight without trying, you may benefit from a consultation with a dietitian. Your consultant, GP or colorectal/stoma nurse specialist can refer you to a dietitian.
Exercise, hobbies and activities
We encourage you to be active as soon as you can after surgery. You should plan to exercise several times a day and gradually increase this each day after your operation.
Taking up your normal hobbies as soon as possible again after surgery will also help you to be active which will help you to heal. Just be careful – if your wound is pain free, you should be able to do most activities.
However, you should not lift anything heavy (Including shopping bags) for six weeks after your surgery.
Work
Many people are able to return to work within four weeks of their surgery. However, if your job involves heavy manual work, we advise that you take six weeks off after your operation. If you are not sure about when you should return to work, please ask your GP for advice.
Driving
Do not drive until you are confident that you can do so safely. We would advise that you wait at least six weeks. It is important that any pain has gone away enough for you to be able to perform an emergency stop and turn the wheel quickly in an emergency. You should also make sure that you can sit in your car, fasten the seatbelt, press all the pedals and turn your head without any discomfort.
Do not drive if you have any discomfort that may distract you. It is very important that you check with your insurance company as to when you can drive again after surgery.
Stoma care
The stoma nurses will give you a supply of the equipment needed to care for your stoma before you go home. The colorectal/stoma nurse responsible for your care will discuss with you when they will ring you and will arrange follow up.
They will also give you contact telephone numbers, and information and advice about your stoma.
What follow up care will I receive?
The part of your bowel that is taken out will be examined in our laboratory.
Your consultant surgeon will contact you to discuss these results. Your consultant will be able to tell you if any further treatment, such as chemotherapy, is advisable. If you need any more treatment, we will refer you to a medical oncologist who will discuss this with you. Some patients may already know that they need more treatment. In this case, an oncologist will give you your results and discuss your treatment plan with you. We will send you follow up appointments for at least five years after your surgery. During these appointments, you may have:
- a physical examination
- blood tests that will include checking your levels of CEA. These are proteins found on cancer cells, particularly those originating from colorectal cancers
- a colonoscopy – a test that allows your doctor to look at the inner lining of your large intestine
- CT scans
However, this will depend on your condition.
How will I feel after the operation?
Having surgery can be a stressful experience, physically and emotionally. In the first weeks at home, you may have some days when you feel quite low, and this is normal.
Most people feel overwhelmed when they are told that they have cancer. Many different emotions arise which can cause confusion and frequent changes in mood.
However, reactions differ from one person to another. These emotions are part of the process that people go through in coming to terms with their illness, and friends and family often experience similar emotions and need support and guidance too.
It is important to remember that there are people available to help you and your family. You may find it easier to talk to someone who is not directly involved with your illness and so you might find it helpful to talk to a counsellor. In Dudley, we have a Psychology Healthcare Department that we can refer patients to for expert psychological support.
You can also contact your colorectal specialist nurse/key worker to discuss any worries you may have. Your colorectal specialist nurse/key worker may carry out an assessment with you called a holistic needs assessment. This is designed to help us work with you to address your specific concerns and worries so that we can give you the support you need. You may want to get together with other people who are in or who have been in a similar position to yourself. For this reason, Cancer Support at The White House in Dudley is available for patients, relatives and carers for support, information, and relaxation therapies. Partners are also welcomed along for support, information, and relaxation too.
What other treatment options are there available?
Surgery is usually the first treatment for rectal cancer; however, this will depend on the stage of your disease. Your consultant will discuss your specific treatment plan with you.
Clinical trials
Depending on the outcome of the MDT meeting, we may ask you if you want to participate in a clinical trial before surgery. This will be explained firstly by your colorectal surgeon at your outpatient appointment and then in more detail by the appropriate oncologist (doctor specialising in cancer treatment).
Surgery
Your consultant will explain the surgical procedure to you with the aid of a diagram. You may be offered laparoscopic surgery, otherwise known as keyhole surgery. This type of surgery reduces discomfort after surgery, minimises scarring and reduces your hospital stay, although the risks are the same as that of open surgery.
Your specialist nurse will give you written information about it and will answer any queries or questions you may have.
After surgery
The part of the bowel containing the cancer will be examined by our Pathology Team. When the results are available, we will discuss in the next available MDT meeting whether further treatment is advisable. If this is the case, we will refer you to an oncologist who will discuss this treatment with you in more detail at an outpatient appointment.
In addition, you will have an appointment about four weeks after your surgery where your consultant surgeon will discuss your results with you.
Radiotherapy
This uses high energy X-rays to destroy cancer cells while doing as little harm as possible to normal cells. It is given to selected patients with rectal cancer before surgery to shrink the tumour and make it easier to remove. The treatment is carefully planned and monitored for each person, to ensure that normal cells suffer little or no long-term damage. Some patients (very few) may also benefit from radiotherapy after surgery if it is thought that there may be small amounts of cancer cells left behind.
Radiotherapy is given as an outpatient at The Deansley Centre at New Cross Hospital in Wolverhampton. You will need to go there every day for between five days to six weeks depending on the nature of your rectal tumour. We will discuss this with you beforehand. If you need radiotherapy, we will send you an appointment to go to the radiotherapy department for treatment planning to ensure that you receive carefully targeted treatment. On this visit, you will need to lie under a large machine called a CT simulator which takes a scan of the area to be treated. A small number of pinprick tattoo marks will be put onto your skin. These are used to accurately target the radiotherapy X-rays when your treatment starts.
At the beginning of your radiotherapy, you will be advised how to look after the skin in the area to be treated. Before each session of radiotherapy, the radiographer will position you carefully and comfortably as you have to be still whilst the treatment is given. The treatment only takes a few minutes. During this time, you will be left alone in the room but the radiographer will be watching you carefully from an adjoining room. The treatment is not painful.
Will I suffer from any side effects?
Radiotherapy to the bowel area can cause side effects such as diarrhoea, nausea and tiredness. If you do suffer from nausea, this is usually mild and anti-sickness drugs can normally control this effectively. If you do not feel like eating, you can replace meals with nutritious, high calorie drinks which are available on prescription or from most chemists. Diarrhoea can occur if radiotherapy irritates your bowel. This can be reduced by medication which your hospital doctor or GP can prescribe.
As radiotherapy can make you feel tired, try to get as much rest as you can to help you cope with the tiredness and the daily travelling. In addition, the skin in the area being treated may become red and sore. The nurses and radiographers will advise you how to look after your skin during your course of treatment. Finally, radiotherapy to the bowel can cause inflammation of the lining of the bladder (cystitis). This can make you feel as if you want to pass urine often and you may also feel a burning sensation when you pass urine. It will help to drink plenty of fluids to make the urine less concentrated and again, your hospital doctor or GP can prescribe medication to make you more comfortable. These side effects usually continue while you are having treatment and then disappear slowly once the course of treatment is over. Chemotherapy is often given as well as radiotherapy. If this is the case, your oncologist will discuss this with you.
Chemotherapy
The specialists trained extensively to use chemotherapy drugs are called medical oncologists.
Chemotherapy is the use of special anti-cancer drugs (known as cytotoxic drugs) to destroy cancer cells. They are usually given by injection into a vein in the back of the hand or into a Hickman Line.
This is a tube which avoids the need for needles and goes into a vein below the collar bone.
Nearly all chemotherapy is given as a day case procedure where you only have to be at hospital for the day.
The reasons for giving chemotherapy are as follows:
1) to shrink the tumour and make it easier to remove during surgery (which we call neo adjuvant chemotherapy)
2) to increase the chance of a cure after surgery (which we call adjuvant chemotherapy)
3) to treat advanced disease and prolong life (which we call palliative chemotherapy)
Neo adjuvant and adjuvant chemotherapy saves many lives and if appropriate to your care, may form part of your treatment plan. You may have just one drug or a combination of drugs. The main chemotherapy drug used to treat colorectal cancer is called 5-fluorouracil (or 5FU). It is usually given with the vitamin folic acid or with other chemotherapy drugs. It can be given as an infusion (drip) for 48 hours, daily or at weekly intervals initially. The dosage will depend on the condition being treated and whether or not other drugs are being given to you. Other drugs which may be used are irinotecan and oxaliplatin. Irinotecan kills the rapidly multiplying cells that make up a cancer. For patients receiving their first course of chemotherapy for colorectal cancer, it is usually given every two weeks and can also be used in conjunction with other anti-cancer drugs. Oxaliplatin is normally given with 5FU. It is a platinum-based chemotherapy drug given to treat metastatic colorectal cancer (cancer which has spread). It has also been recommended by the National Institute for Health and Care Excellence (NICE) to shrink secondary tumours in the liver and can lead to potentially curable surgery for some people. It can be given every two or three weeks as a course of treatment. The number of courses you have will depend on the type of cancer you have and how well it is responding to the drugs. However, the treatment is generally given for six to 24 doses over three months to a year.
You will need to have blood tests taken on the day of treatment and these, together with the state of your health, will determine whether you have the drugs on the day.
If the cancer starts to grow again, during or after the chemotherapy, you may be given a different type of chemotherapy drug. This is known as second line treatment.
Several research trials are being carried out to find the best type of chemotherapy for colorectal cancer. You may be asked if you want to take part in one of these trials using new chemotherapy drugs or new types of treatments.
Will I suffer from any side effects?
Some people experience very few side effects and even those who do suffer from them will only have these temporarily during treatment.
Some of the more common side effects include reduced resistance to infection, tiredness, hair loss, mouth ulcers, nausea and diarrhoea. However, nausea and diarrhoea can usually be well controlled with medicine. Some people also experience soreness and redness on the palms of their hands and soles of their feet.
You should talk to your medical oncologist about any side effects from the chemotherapy drugs.
What alternative treatments are there?
Self-expanding metal stents (SEMS) are metallic tubes used to hold open the bowel, if it is obstructed by a tumour, so that stools can pass through. They can provide rapid relief of distressing symptoms in people who cannot have surgery, or for those who have symptoms of bowel obstruction which need to be treated urgently. This treatment may be suggested before any detailed investigations are carried out. It can help stabilise a patient’s condition so that a longer term treatment plan can be created. SEMS are being increasingly used for people with a bowel obstruction as they are considered to be a safe and effective way of achieving relief in patients with advanced colorectal cancer.
Although they are considered to be convenient and safe, several complications have been reported. The complications depend on where the stent is located in the bowel and include stent obstruction and movement, perforation (damage) of the colon and/or rectum, impacted stools, bleeding, abdominal pain and the constant feeling of wanting to pass stools. However, complications are usually minor in the majority of people and if treated, usually only last about 48 hours. Stenting carries a mortality rate (rate of deaths) of around two per cent. However, it should be remembered that this is a lower risk than the 20 per cent mortality rate associated with emergency surgery.
Complementary therapies
Complementary therapies are natural therapies which can be used with conventional medical and nursing treatments. However, they should not replace traditional care.
Complementary therapies include a number of different treatment kinds such as counselling, acupuncture, aromatherapy, homeopathy, meditation, visualisation, healing, relaxation, massage, osteopathy, reflexology, hypnosis and dietary treatments. The aim of these therapies is to relieve physical symptoms and help emotional reactions, including stress and anxiety, and therefore enhance wellbeing. Frequent symptoms that complementary therapies aim to improve are flatulence (passing wind), sleep disorders, tiredness, worry and pain. In every instance, it is recommended that you use a suitably qualified practitioner to give you the complementary therapies. We strongly advise you to speak to your consultant before starting a course of therapy, to ensure that it will not interfere with your other treatments.
White House Cancer Support in Dudley provides a wide range of complementary therapies for both patients and their family and carers. They have specific knowledge and expertise about cancer related issues (see section ‘Where can I find out more?’ for contact details). Your specialist nurse/key worker will be happy to give you their contact details.
What treatment will I have if I have advanced colorectal cancer?
Advanced colorectal cancer means the cancer has spread from where it started in the bowel or back passage to other parts of the body such as the liver or lungs. Your cancer may be advanced when it is first diagnosed, or it may come back some time after you are first treated. Once a bowel cancer has spread to another part of the body, it is unlikely to be curable. However, treatment can often keep it under control for quite a long time. The choice of treatment depends on the cancer type, the number of secondary cancers and where they are, and the treatment you have already had. Surgery can be used in some situations to treat advanced colorectal cancer and often results in a stoma (for example, a colostomy). Chemotherapy can sometimes be used to shrink a cancer and control symptoms.
Money and financial support
Some people may experience financial problems due to their illness or operation. If this is the case, support may be available. Advice can be provided by the Citizens Advice Bureau or Macmillan Cancer Support (see section ‘Where can I find out more?’ for contact details).
Alternatively, you may want to discuss this with your colorectal specialist nurse.
Prescriptions
People with cancer in England can have free prescriptions. If you live in England and need prescriptions for things that are related to cancer or its effects, you can apply for an exemption certificate by collecting form FP92A from your GP surgery or oncology clinic.
Follow up care
You will have follow up appointments for up to five years. This will often include a physical examination, blood tests including for the carcinoembryonic antigen (CEA), visualisation of the colon (colonoscopy) and CT scans. Your consultant will let you know when you need to have these tests. Throughout the follow up period, you can contact the colorectal clinical nurse specialists on 01384 244286. If we are not in, please leave a message on our 24-hour private answering machine and we will get back to you.
Colorectal/stoma care specialist nurses
01384 244286 (8.30am to 6pm, Monday to Thursday, 8.30am to 5pm on Fridays). If we are not available, please leave a message on the answerphone and we will get back to you.
or
Ward B4 (west wing)
01384 244126 (out of hours and weekends)
Ask to speak to the nurse in charge. If the nursing staff cannot answer your questions, they will suggest alternative contacts.
Important information
If you have had keyhole (laparoscopic) surgery and have any problems within three days of going home from hospital,
please contact:
B5 Surgical Assessment Unit (SAU) on 01384 244359
Russells Hall Hospital switchboard number: 01384 456111
Bowel Cancer Uk
020 7940 1760
admin@bowelcanceruk.org.uk
Benefits Advice
http://www.dudley.gov.uk/resident/care-health/dudley-socialservices/
paying-for-care/benefits-advice/
White House Cancer Support
10 Ednam Road
Dudley
West Midlands
DY1 1JX
01384 231232
Fax: 01384 459975
info@support4cancer.org.uk
www.support4cancer.org.uk
Cancer Research UK
PO Box 1561
Oxford
OX4 9GZ
0300 123 1022
www.cancerresearchuk.org
Citizens Advice Bureau
www.citizensadvice.org.uk
24
Citizens Advice Bureau – Dudley Branch
0344 411 1444
Email: dudleybureau@dudleycabx.org
Colon Cancer Concern
www.canceractive.com
Colostomy Association
Enterprise House
95 London Street
Reading
RG1 4QA
0800 328 4257
www.colostomyassociation.org.uk
Crohn’s and Colitis UK
45 Grosvenor House
St. Albans
Hertfordshire
AL1 3AW
0300 222 5700
www.crohnsandcolitis.org.uk
Ileostomy and Internal Pouch Support Group
Danehurst Court
35-37 West Street
Rochford
Essex
SS4 1BE
0800 018 4724
www.iasupport.org
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Ileostomy Association Stourbridge Branch
Contact the Secretary
01562 755630
Stourbridge.iasupport.org
Email: stourbridge@iasupport.org
Macmillan Cancer Support
89 Albert Embankment
London
SE1 7UQ
0808 808 00 00 (Monday to Friday, 9am to 8pm)www.macmillan.org.uk
www.dgft.nhs.uk (Our services: L for Living with and beyond cancer)
