Anal Cancer Treatment Information

ANAL CANCER TREATMENT INFORMATION

What is Colo-rectum?

A cancer originating in the colon, or rectum, makes up this group. The colon and rectum are continuous, but the differing treatments for cancers arising in different parts of the intestinal tract makes it useful to distinguish them by location. The colon is also known as the "large intestine," and starts where the small intestine ends, in the area of the lower right portion of the abdomen. The area where the small intestine becomes the colon is called the"cecum," and the fingerlike "appendix" is located nearby. The colon is shaped like an arch. The right leg of the arch is called the "ascending colon," and runs up the right side of the abdomen, bending under the liver. The arching portion is the "transverse colon," and it runs under the pancreas and stomach, ending under the spleen. The left portion of the arch is the "descending colon" running down the left side of the abdomen. The descending colon connects to the "sigmoid colon," which is shaped like an "S," and moves toward the center of the pelvis. The sigmoid colon joins the "rectum" at the "recto-sigmoid" junction; the rectum is about 7 inches long. The rectum becomes the"anal canal" at the "ano-rectal" junction, this canal is about 2 inches long and terminates as the "anus," where bowel movements actually leave the body. Since the lining cells inside the colon and rectum are similar, and produce mucous, the cancers that arise in this part of the digestive system are also similar, and considered together. However, the cells lining the inside of the anal canal are different, so different cancers arise there, and this is a separate topic.

The colo-rectum has a rich blood supply ; this is needed to absorb nutrients from the bowel and get them into the bloodstream. The "mesenteric" arteries arteries are large branches off of the body's main artery (the "aorta"), and provide fresh blood with oxygen and nutrients to the bowel. If that blood supply is cut off, the bowel will become "infarcted" (shut off from fresh blood), painful, and ultimately die ("necrosis"). This will allow the bacteria normally within the bowel, which solidify stool, to escape into the sterile abdomen causing infection ("peritonitis"). The bowel can become infarcted from a blood clot in the mesenteric blood vessels, becoming twisted upon itself ("torsion"), telescoping in upon itself ("volvulus"), or by a growing tumor. Blood is drained from the bowel by the "mesenteric" veins, which send that blood through the liver ("portal vein") to extract and process digested fats, proteins and sugars. The processed blood is then returned to the heart by the large vein draining the liver ("inferior vena cava"). The point is that infection or cancer cells can travel from the bowel up into the liver, and from there through the regular bloodstream to other areas . If a cancer spreads ("metastasizes") via the bloodstream, it is called "hematogenous metastasis." Initially, single cancer cells traveling in the bloodstream will "seed" other areas ("micrometastasis"), and eventually (if unchecked) grow into large tumors there.

The bowel also has within it a series of "patches" of clumps of White Blood Cells, called "Peyer's Patches." These are called "lymphoid tissue," much like the tonsils in the throat, and help fight infection in the bowel. The bowel has an inner lining of specialized cells (see below) called the "mucosa," but it's walls are made of "muscle layers." These muscle layers allow the bowel to move ("peristalsis") so digesting food is passed through. Just underneath the delicate mucosal inner lining, but before the muscle layers, is an area of loose connective tissue called the "submucosa." Within the submucosa exists a network of "lymph channels," which collect the "tissue fluid" that has migrated out from the blood vessels, to bathe and nourish each cell. These lymph channels drain to pea-sized "lymph nodes" around the bowel, which are filled with White Blood Cells. The purpose of the lymph nodes is to filter and purify the blood, trapping germs and cancer cells. When lymph nodes are invaded by infection or cancer, they swell ("lymphadenopathy") . Normal "lymph fluid" is eventually returned back into the blood stream, after purification by the lymph nodes. The importance of this is that the lymph system can act as a conduit for spread of infections or cancer ("lymphogenous metastasis"). Commonly, but not always, the local lymph nodes are involved before more distant sites.

What is Colo-Rectal Cancer?

The cells lining the inner colon and rectum are called "columnar epithelial cells," and also "goblet cells" which secrete mucous to help keep the stool soft. These cells invaginate (fold upon themselves) to form glands, and the type of cancer which most commonly arises from glands is called "adenocarcinoma." As with all cells in the body, the production of new cells lining the intestine is under tight control from the "genes" within each cell, which are themselves composed of the basic genetic material "DNA." In the growing child, the cells divide quickly to form the enlarging intestines, but in the adult cells are only produced to replace those that die of injury or lost to old age. Colon cancer, like any cancer, starts in a single cell . This cell loses control of it's division and then starts to reproduce in a haphazard, uncontrolled manner to form a "tumor." A tumor merely means a swelling, it can be caused by most anything and is not necessarily cancer. A "benign" tumor, also called a "polyp" within the intestines, only grows within it's local area; it cannot go to other areas of the body and so is not cancer. In contrast, a "malignant" tumor is capable of spreading to any area of the body, it is cancer. This process of spread is called "metastasis." Sometimes previously benign tumors can become malignant over time, this process is called "malignant degeneration" and happens in some polyps. Most polyps, however, will never become cancerous. If cancer does arise and is not effectively treated, the will ultimately spread to other crucial body areas and kill the patient. Advanced colon cancer most often kills by causing anemia, debility, infection, and organ failure. This is why it is critical to diagnose and treat any cancer as early as possible, when the chances for successful treatment are highest.

How common is Colo-rectal Cancer?

Colo-rectal cancer is the third most most lethal cancer in the United States, after lung and breast cancer, with 156,000 new cases and 60,000 deaths in 1996 . Of these deaths, 52,000 are from colon cancer and 8,000 are from rectal cancer. Over their lifetimes, 5% of Americans will develop a colo-rectal cancer at some point. The disease is rare (3% of cases) in those under 40 years old. Men are effected slightly more often than women. The disease is more common in the Western World than in Asia. However, if an Asian person moves to the United States, there chance for getting colon cancer increases. In the United States, the highest risk areas are in the Northeast, and the lowest in the Southwest. The incidence of colo-rectal cancer has been going up over the past 3 decades, but the death rate peaked in 1985, owing to earlier detection and better treatments.

How and Where Does Colo-rectal Cancer Start?

It usually starts from a polyp, which is a protrusion of gut tissue which starts as being non- cancerous. These polyps are often screened for, and may be removed before becoming cancerous. If a polyp is less than 1 cm. across, it has only a 1% chance of being cancerous, but if it is larger than 2 cm. across, the chance of cancer rises to almost 50% . Polpys become much more common as we grow older, over 80% of people over 70 years old have at least one polyp. The risk for developing Colo-rectal cancer is increased with:

1) A high fat, low fiber diet. (The NCI noted 40 studies making this association). This is thought due these foods taking longer to pass through the colon, thus allowing more contact with cancer-inducing chemicals ("carcinogens") in these foods. In contrast, high fiber foods stimulate the colon to move food through quickly, and lessen the chance for polyps to form. Colo-rectal cancer is rare in societies that eat mostly fruits and vegetables, and the vitamins in these (especially vitamins A and E ) may be protective. This is a reason that colon cancer is rarer in the Far East where less dietary fat is consumed.
2) Family Predisposition Certain cancers, namely colo-rectal, breast, uterine and ovarian, tend to occur with alteration of the same genes, known as the "family cancer syndrome" genes. While not all people with these inherited genes get cancer, many do. Around 15% of new patients with colo-rectal cancer have close family members with disease.
3) Hereditary syndromes causing multiple polyps in the digestive tract. For example, 100% of Familial Polyposis patients will get colon cancer if the colon isn't removed. In this condition, there are thousands of polyps in the colon, and the more polyps, the greater the chances for a cancerous one to arise. Other rarer syndromes include "Turcot's," where there are associated brain tumors, and "Gardner's," with tumors in other glandular areas. The Peutz- Jeghers syndrome has lots of polyps throughout the intestinal tract, but they are the more benign type ("hamartomas") and the risk of cancer is low.
4) Age older than 40 years . Younger patients rarely develop this cancer, but if so it tends to be very aggressive. The average patient is 60 years old. This goes along with more polyp formation as we get older, and a greater risk that the polyps will be abnormal ("dysplastic") with age.
5) Inflammatory bowel disease, especially ulcerative colitis (less in Crohn's). The risk of developing colon cancer with ulcerative colitis is about 2% per year. In these conditions, there are many more new intestinal cells being produced to replace those lost through inflammation and infection. The more new cells formed, the greater chance that a cancerous one will arise.
6) Radiation Exposure to the abdomen or pelvis may trigger cancer, but usually not for 10 to 50 years after the exposure. The chance of developing cancer from medical X-rays is remote, estimated at about 6 cases per million X-ray procedures. Moreover, the type of cancer induced by radiation is more likely to be a muscle, bone or cartilage tumor ("sarcoma") than the much more common adenocarcinoma of the colo-rectum.
7) Chemical Exposure ("carcinogens") from foods or even from substances produced within our own bodies. It is thought that eating burnt foods, nitrites, and various artificial additives and preservatives may increase cancer risk, but it is hard to prove. The more fats a person eats, the more bile salts their gall bladder releases, and these have been shown to promote polyp growth. It is very hard to eat a pure, clean diet in America.
8) Possible link to depression, with decreased immune system response. Generally, digestive diseases have been considered by psychiatry to result from "anger turned inward." It is now known that normal people's immune systems are able to recognize and destroy tiny cancer cells before they can spread. In the diseased or depressed person, the immune system does not function efficiently and may allow cancer to start. The flip side is that a good positive attitude helps cancer patients live longer and better. Over 50% of cancers are in the rectum or lowest portion of the colon, the sigmoid. In the colon, 25% of cancers are in the ascending portion, 15% in the transverse portion, and 10% in the descending portion. There has been a shift toward the right colon in the past 2 decades.

How can Colo-Rectal cancer be Prevented?

Increased intake of fiber and Vitamin A, and decreased fat in the diet, are thought protective against bowel cancers. For high risk patients, early detection with occult blood tests and periodic colonoscopy and polyp removal is appropriate. For the rare very high risk patient, who has a genetic disease with multiple polyps, prophylactic removal of the colon may be reasonable since almost 100% of these patients will get colon cancer if it isn't removed. Any prolonged rectal bleeding, whether bright and red or black and tarry must be promptly evaluated, and not just ignored as "hemorrhoids."

What are the Symptoms of Colo-rectal Cancer?

The most common symptom is blood in the stool . This is bright red with cancers of the rectum and sigmoid colon, but is usually thick, black, and "tarry" if the cancer is higher up in the digestive tract. This type thick tarry blood is called "melena," and is the result of the blood being partially digested. It is important to note that most blood found in the stool is not due to a cancer, but rather a benign condition such as ulcers, bleeding polyps, hemorrhoids or fissures in the anal canal. Nonetheless, persistant bleeding must never be ignored. With any prolonged slow bleeding, It is common to develop Iron-Deficiency anemia, manifested by weakness and paleness, and eventual shortness of breath. This bleeding may be so slow that the patient doesn't even realize it, yet comes to their doctor with anemia. Subsequent evaluation of this bleeding may prove a bowel cancer.

Changes in the stool are often seen. These are chronic diarrhea in many right-sided colon cancers, and pencil-thin stools in left sided or rectal cancer. A feeling of incomplete emptying of the rectum, called "tenesmus" is frequent with rectal cancer.Pain usually occurs only later in the disease, usually due to painful spasms of the intestine, and invasion of the cancer into nerves. If a cancer grows large enough, it can completely block the bowel, causing "bowel obstruction." Symptoms of total bowel obstruction include no appetite, no bowel movements, abdominal pain, bloating, vomiting. This is an emergency and must be treated with surgery. Every colo-rectal surgeon has had the experience of first detecting cancer at the time of this emergency surgery. Other common later ymptoms include abdominal masses as the tumor grows, weight loss, liver enlargement and bone pain with spread to those organs. Nearly all untreated colon cancer will eventually spread to the liver, since this follows the course of the draining (venous) blood from the colon . The liver provides an ideal spongy, blood-rich area for cancer "seeds" to implant and grow. Less than 10% of colon cancers spread to the brain, but a change in motor skills, judgement, memory or sensation is occasionally the first sign noted. Sometimes, the first sign is spread of the cancer to another body area, and the original tumor cannot even be found (but may have been from the digestive tract). This "cancer of unknown origin" is a well described clinical entity, and a different topic.

How is Colo-rectal cancer Detected and Evaluated?

It may be detected before symptoms with screening, or after symptoms cause the patient to seek medical care:

1) Screening: Has been shown to lower the death rate from this cancer, especially if polyps are detected, and removed with a "polypectomy." Patients at higher risk, such as having a family history of colon cancer, should get colonoscopy (where a doctor puts a tube up into the colon to examine it under light anesthesia) every 3 years after age 40. The regular-risk patients should get a yearly digital rectal exam and test for occult blood in the stool every year after age 40, along with their annual physical exam. "Occult blood" in the stool means quantities to small to be noted by the patient; a specially treated card ("guiac test") allows the doctor to smear a little stool on this card, and use a developer which turns the stool smear blue if blood is present. To be sure the test is "negative" (i.e. normal-- no blood present) several consecutive stool samples should be tested. If any test shows blood, the fuller evaluation (below) must be done.

2) Symptoms suggestive of colo-rectal cancer demand urgent evaluation:
a) Full physical examination, including digital rectal exam, with the doctor's gloved finger, can feel 80% ofrectal cancers. The doctor tests the retained stool on his examining glove for occult blood. This test also detects prostate enlargement in men. For women, it is appropriate to do a full pelvic exam, since gynecological cancers can cause bowel symptoms. Other things the doctor looks for in physical exam are enlarged glands ("lymph nodes") which can sometimes be felt on rectal exam, in the groin region or even in the arm-pit ("axilla"). Cancer tends to spread to these glands, and they enlarge. Note, however, just having gland enlargement does not prove cancer is causing it, as many infective or inflammatory processes can also cause enlargement. The physician also does a thourough abdominal exam to look for masses or organ swelling (especially in the liver) which may represent cancer spread, and listens for altered bowel sounds which may mean impending obstruction.
b) Procto-sigmoidoscopy for lower cancer, or full colonoscopy for higher cancers (such as in the ascending or transverse colon). This is basically putting a tube up through the anus and visualizing the rectum and colon, under a light anesthesia (demerol and valium). The bowel must obviously be cleaned out, or "prepped" with enemas prior to this procedure. If a polyps are seen, they can often be cut out using the scissors on the end of the colonoscope.
c) Barium enema, with "double-contrast" (both barium and air) can detect polyps. "Adenomatous" polyps, or "Hamartomatous" polyps are the most common type and are rarely cancerous, but ones with "Villous" or "Dysplastic" changes are pre-cancerous and must be totally removed ("polypectomy"). Polyps on "stalks" are called "pendunculated" and are the easiest to remove with clipping. They are also less likely to be cancerous compared to polyps which are ulcerated or flat ("sessile") or ulcerate into the bowel. An open surgical procedure is often needed to remove these types.
d)Trans-rectal Ultrasound uses sound waves to see how deeply the cancer penetrates the rectal wall and if lymph glands in the area are enlarged, which suggests (but doesn't prove) spread of cancer to them. Enlargement for lymph glands means they are bigger than 1 cm. (about 1/2 inch).
e) CT scan of the abdomen and pelvis is used to pre-plan radiation therapy and to see if there is apparent spread to other organs. It can also show whether enlarged lymph nodes are present in the abdomen or pelvis, and give an idea of how deeply a cancer penetrates into the intestinal wall. CT with contrast means injecting some "radio-opaque" material into an arm vein, this helps to highlight blood vessels around the tumor and make the scan easier to read. Insist upon "omnipaque" or equivalent contrast, which is more expensive but also more comfortable and less likely to cause an allergic reaction or kidney damage. A plain Chest X-ray is usually enough to obviate ("rule-out") any spread to the lungs. If it is suspicious then a CT scan of the chest will then be ordered, possibly in conjunction with a fine-needle sampling of a lung "spot" abnormality to prove or disprove cancer spread there. This procedure is done in the radiology department under local anesthesia, and is ~85% accurate for determining whether cancer has spread to the lung or not. The main risk from fine-needle sampling ("biopsy") is collapse of the lung, which will cause the patient marked shortness of breath. The risk of lung collapse approaches 20% depending upon how experienced the radiologist is. If the lung does collapse, a "chest tube" will need to be placed through a hole made in the chest wall, and suction applied to re-expand the lung. This usually only required an overnight hospital stay, afterwhich the chest-tube is removed. Fine Needle biopsy can also be done for a liver abnormality to "rule-out" cancer there. The main risk of this procedure is excessive bleeding from the liver, if this happens the patient may need emergency surgery to stem to bleeding. Magnetic Resonance Imaging ("MRI") uses magnetism instead of ionizing radiation and is excellent for showing enlarged lymph nodes and spread into the bowel wall. It can also be given with intravenous contrast ("gadolinium") to highlight the blood vessels and areas of tumor spread, which characteristically have some swelling ("edema") around them well shown by MRI. However, it is about three times as expensive as CT scan (~$1000) and isn't routine. Bone Scans or Brain CT scans are only gotten if there is suspected spread there. If a test will not change the intended therapy depending upon it's result, in general it will not help the patient and should not be ordered.
f) Other routine tests are blood tests ("CBC") for anemia and infection. The Iron-Deficiency anemia common in bowel cancers shows red blood cells with a small volume (low "MCV"), pale and washed-out appearing. Infection is shown on a CBC by an increase in the White Blood Cell count (>12,000). Also, we want a blood chemistry panel ("SMA") which tells sodium, potassium, glucose, cholesterol, liver and kidney function, and suggests if the cancer has gone to bone (by the "alkaline phosphatase" enzyme released from destroyed bone). In more advanced cancer, blood calcium may be high ("hypercalcemia"). There is a special blood test for bowel cancers, the Carcino-Embryonic Antigen ("CEA") which is produced by the cancer itself- this is called a "tumor marker" and is useful to detect recurrence after treatment (if it was elevated before the treatment and went down with the treatment). Unfortunately, it is not specific for bowel cancer and can be raised by other conditions . An Electrocardiogram ("EKG") is standard before any surgery, to see if there is recent heart damage. If major surgery is contemplated, we commonly get "clotting studies"(PT/PTT and bleeding time) to see how quickly the patient's blood clots. If the patient has been a long-time smoker or has asthma, "Lung Function Tests" may be gotten in the "pulmonology" laboratory to see how good their breathing is.
g) Biopsy, that is sampling a piece of the tumor, is the only way to absolutely make a diagnosis of colo-rectal cancer, or any other cancer for that matter. A piece of the tumor is sent to a "pathologist," a physician who specializes in diagnoses of disease from tissue samples. The pathologist examines the biopsy sample under the microscope and often uses special stains to help identify the tumor's origin. If cancer is detected, the pathologist will identify the type and specify the "grade," that is how aggressive and malignant the cancer looks. Grades are usually specified as I to III, with "I" being low grade (indolent) and "III" meaning high grade (very aggressive). Grade "II" is in between. The higher the grade, the less the cancer resembles it's normal tissue counterpart, (in this case the bowel lining cells) and the more likely it is to metastasize. It is not necessarily more resistant to local treatment, however. When a diagnosis of colo-rectal cancer is made, the next step is to assign the "stage."

The anus is the last portion of the bowel, and an amazing organ for preserving human dignity. It can tell the difference between solid, liquid, and gas, releasing each at the proper time. Common problems in this area include itching and hemorrhoids, but rarely cancer may develop in the anal canal. There are actually four types of tissue in the anal canal, which can give rise to different cancers.

If someone develops anal cancer, it is critical to get prompt diagnosis and proper treatment. Getting the best treatment can make the difference between having an "sphincter sparing" operation, where the anus is preserved, or having to wear a colostomy bag to drain stool from the abdomen. Moreover, proper treatment can make the difference between life and death. Understanding your options will give you the peace-of-mind of knowing you've done everything possible to ensure a successful outcome for yourself or a loved one.

CancerAnswers's material explains, in plain English, the definition, types, risk factors, frequency, symptoms, evaluation, historical and latest effective treatments for anal cancer. We describe surgery, radiation and chemotherapy along with "anal sparing" procedures. We cover expected side-effects and results. While we don't promise a cure, we tell you everything you must know to help make the right choices today in dealing with an anal cancer problem.

This is just an excerpt of CancerAnswers's report on Anal Cancer. Much more, including latest treatment, can be sent to you by mail when you order the complete Anal Cancer transcript at a nominal cost. Thank you for using CancerAnswers as your information resource.