What treatments are there?

Treatment for bowel cancer includes:

• surgery
• chemotherapy
• radiation therapy.

Most people will have surgery to remove the cancer from the colon or rectum. Some people receive a combination of two or more treatments. The treatment depends upon the size of the cancer and whether it has spread.

Your general health and your wishes are also important in the decision making. In some cases you may want to seek a second opinion. See also Questions to ask your doctor when you have cancer.

Surgery

Most bowel cancers need to be removed by surgery, which is usually done through the abdomen. Sometimes surgery will be carried out through your rectum as well. Usually the surgeon removes the cancer along with part of your bowel, and then re-joins the two ends of your bowel so it continues to work normally. This join is called an anastomosis. 

Sometimes, however, it will not be possible to do this. Instead, the surgeon will make an opening on your abdominal wall and join your bowel to the opening. This operation is called a colostomy if it is done in the large bowel, and an ileostomy if it is done in the small bowel.

Where the bowel is brought out through the abdomen wall is called a stoma. You need to wear a bag over the stoma to collect your bowel motions. Stomas are usually temporary and allow the bowel motions to be diverted away from the join so that it can heal. Another operation is done some months later to close the stoma and join up the bowel.

These days very few people with bowel cancer have a permanent stoma. If you have a colostomy, the nurses will manage your stoma bags initially and then work with you to teach you how to perform your own stoma care.

Ostomy bags and appliances are supplied free when you are at home if you are a New Zealand citizen. You may find it helpful to get in touch with someone else who has had a colostomy and talk to them about how they cope. Your local Ostomy Society or Cancer Society will be able to help.

As part of the operation the surgeon will also take out some lymph nodes to stage the cancer. You will usually stay in hospital for at least a week after your operation.

Side effects of surgery

An operation on your bowel is a major procedure and you may feel tired for weeks or even months. You may find that you will need to take 4 to 6 weeks off work and may require home help.

Staging

After the operation the laboratory will examine the tumour and surrounding tissue to assess the stage of the cancer and whether it has spread to the lymph glands or other organs such as the liver.  With this information the doctor will decide if further treatment is recommended.

Stage 0 or carcinoma in situ
This is the earliest form of cancer, found only in the innermost lining of the colon or rectum, usually as a polyp. Major surgery is unnecessary and most polyps can be removed at the time of colonoscopy (this is called polypectomy).

Stage I (sometimes called Dukes' A cancer)
This is also early cancer and is still confined to the wall of the bowel. Treatment is surgery to remove the cancer.

Stage II (sometimes called Dukes' B cancer)
Cancer has spread beyond the wall of the bowel but it has not gone to the lymph nodes. Treatment is surgery to remove the cancer. Occasionally chemotherapy is recommended and radiation therapy if the tumour is close to the edge of the resection.

Stage III (sometimes called Dukes' C cancer)
Cancer has spread to nearby lymph nodes, but has not spread to other parts of the body. Treatment is usually surgery to remove the cancer, sometimes combined with either chemotherapy or radiation therapy.

Stage IV
This means that cancer has spread to other parts of the body.  Treatment options include surgery, radiation therapy and chemotherapy.

Radiation therapy

Radiation therapy uses high-energy x-rays to destroy cancer cells.  Nowadays x-rays can be precisely targeted onto cancer sites in your body to minimise damage to surrounding tissue. Treatment is carefully planned to kill cancer cells while doing as little harm as possible to your normal body tissue.

Radiation therapy is commonly used in rectal cancer but rarely required in the treatment of colon cancer.  Radiation therapy is given either before the operation, to shrink the cancer down so the surgeon can remove it more easily, or afterwards to kill any remaining cancer cells.

Treatment is usually given every weekday for four to six weeks. Usually you can stay at home and go to the hospital every weekday. Each treatment only takes a few minutes under the machine, but sometimes you may be at the hospital for a few hours.

Blood tests and scans may be needed and you will probably also see your specialist once a week, which may mean staying longer that day. See also radiation therapy.

Side-effects of radiation therapy

Radiation therapy is not painful but in some cases there are side effects. Usually these are temporary. It is important to discuss any side effects with your cancer treatment team who can advise you on how to manage these effects.

Side effects may include:

• not wanting to eat.
• nausea or vomiting.
• tiredness.
• diarrhoea.
• skin irritation.
• loss of pubic hair which may not grow back.

Women who are treated in the pelvic or abdominal area may find their ovaries are affected because it can be difficult to shield these organs from the radiation. Periods may stop during treatment, or for a few months afterwards.

Women may also have hot flushes, a dry vagina, or other symptoms of menopause. If your ovaries are permanently affected, you will not be able to have children. Difficult menopause symptoms can be controlled.

Men who are treated in the pelvic or abdominal area are less likely to have either temporary or permanent sexual problems because it is much easier to shield the testicles from the radiation.

Ask your doctor whether you are likely to have any problems.

If you are experiencing side-effects:

• rest if you feel tired.
• there is medication to treat nausea. Eating four or five small meals a day may help.
  stay near the hospital if travelling is tiring. Many hospitals can arrange hostel or other accommodation.
• keep your skin dry. Avoid using soaps on the lower abdomen where you are having radiation therapy.

For more information see radiation therapy side effects.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. Because anti-cancer drugs enter the bloodstream and circulate through the body, they can kill cancer cells which have spread to distant parts of the body.

Usually treatment is given in cycles, spread out over weeks or months. Treatment is given either as one dose or over a number of days. This is followed by a rest period of days or weeks with no treatment. The rest periods give your body a chance to recover from any side effects of the treatment. 

Chemotherapy is usually given as an outpatient so you may be able to live at home and just go to the hospital for each treatment.  Chemotherapy is sometimes given via a portable infusion pump worn on the body to deliver the drugs continuously. For more information see chemotherapy.

Side-effects of chemotherapy

Most people having chemotherapy for bowel cancer experience few or no side effects. Some people have temporary side effects which go away when the treatment ends or soon after.

Many people manage to continue with their normal life at home and work throughout their chemotherapy.

Problems may include:

• infections - the drugs can lower your ability to fight infections. If you are feverish and have a temperature of 38 degrees Celsius or more, phone your specialist, doctor, oncology district
• nurse or hospital immediately for advice.
• sore mouth.
• diarrhoea or constipation.
• feeling sick or actually vomiting. There are medicines to control these symptoms.
  not wanting to eat - try to eat small meals at frequent intervals.
• hair loss is an uncommon problem for people being treated for bowel cancer.
• some people may experience a low sex drive.
• some women's periods may become less regular or stop altogether.
• some women may have hot flushes, a dry vagina, mood swings or other symptoms of menopause.
  vaginal itch, burning or infections.
• you and your partner should use a contraceptive or natural family planning during treatment because the drugs can cause birth defects or miscarriage.

For more information see chemotherapy side effects.

Treatment for advanced cancer

If the cancer has recurred or spread, there are still many treatments that can be offered to extend survival and control symptoms:

• surgery to remove the cancer or to bypass any obstruction so that the bowel will continue to work normally.
• surgery to remove parts of other organs such as the liver, where the cancer may have spread.
• radiation therapy to shrink the cancer.
• chemotherapy to kill cancer cells present in other parts of the body.
• ablation therapy which includes radio frequency or alcohol ablation and cryotherapy (freezing treatment) for areas of cancer in the liver.
• stenting.
• nerve blocks for pain.

Chemotherapy can be used to control symptoms. Pain can be eased and many of the problems the cancer is causing can be controlled. In many cases advanced cancer does not require active treatment, especially if it is growing slowly.

Taking part in a clinical trial

Research into the causes of bowel cancer and into ways to prevent, detect and treat it, is continuing. Your doctor may suggest you consider taking part in a clinical trial.

Clinical trials are a vital part of the search to find better treatments for cancer. Doctors conduct clinical trials to test new or modified treatments and see if they are better than existing treatments.

Many people all over the world have taken part in clinical trials that have resulted in improvements to cancer treatment. However the decision to take part in a clinical trial is always yours.

If your doctor asks you to take part in a clinical trial, make sure you fully understand the reasons for the trial and what it means for your treatment.

Before deciding whether or not to join the trial, you may wish to ask your doctor:

• what treatments are being tested and why?
• what tests are involved?
• what are the possible risks or side effects?
• how long will the trial last?
• will I need to go into hospital for treatment?
• what will I do if any problems occur while I am in the trial?

If you decide to join a randomised clinical trial, you will be given either the best existing treatment or a promising new treatment. You will be chosen at random to receive one treatment or the other, but either treatment will be appropriate for your condition.

If you join a clinical trial, you have the right to withdraw at any time. Doing so will not jeopardise your treatment for cancer.

It is always your decision to take part in a clinical trial. If you do not wish to take part, your doctor will discuss the best current treatment for you.

After treatment

During your illness you will be monitored frequently. After the completion of your treatment, you may need to have regular checkups. Your doctor will decide how often you will need these checkups as everyone is different. Checkups will gradually become less frequent, if you have no further problems. 

 If the disease relapses, you may need further treatment. It is important to report any new symptoms to your doctor without delay. The treatment used for the relapse is often different from the first treatment.

Many people worry that any pain or illness is a sign that the cancer is coming back. This is usually not the case but if you are worried about whether the cancer is going to come back, ask your doctor what to expect. You may feel less worried if you know exactly what to look for and what you do not have to worry about.

Most side effects from the treatment you have had will go fairly soon, although some will last for a couple of months and some may be with you forever. You might feel worried or depressed when your treatment is over and have time to realise what has happened to you.

Because you will see your doctors less often it can feel as though no one is looking after you. You may find it helpful to continue in or join a cancer support group to help you through the months ahead.

Sexuality and bowel cancer

The anxiety and/or depression felt by some people after diagnosis or treatment can affect their sexual desire. Tiredness following an anaesthetic, major surgery, radiation therapy or chemotherapy will also reduce sexual desire.

However, once your wound has healed and you feel well enough you should be able to return to your normal lifestyle and a normal sex life, even if you are wearing a colostomy bag.  Sometimes the operation permanently affects your sexual ability and/or ability to have children. This can happen if the nerves going to the sexual organs are damaged in the operation. If you are male this means you could find it difficult to have an erection and ejaculate.

However there are practical ways to help overcome impotence. Physical devices such as vacuum pumps and constriction rings can help you achieve and maintain an erection. 

Drug treatments such as injections given straight into the penis to achieve an erection work for many men. Viagra is another option to discuss with your doctor, although men who take nitrate-based medicine for heart problems cannot use this drug. 

 In women the vagina can become narrower or scarred. Ask your specialist if this is likely to happen to you. If it does, talk to your doctor, nurse, or stoma therapist about what can be done. 

 You may also feel worried about how a colostomy will affect your personal relationships. You may feel sexually unattractive. Or you may just not feel like having sex for a while. Sex may seem more difficult. If this happens to you, take things slowly. Try touching and cuddling as a start to sexual recovery.

If sexual problems continue, talk about your worries with your partner. He or she probably needs to talk about it too. Talking often helps, as does the passage of time.

Many couples find that the experience of cancer brings them closer together. Many single people who have had cancer have gone on to find love and happiness in new sexual relationships. You will find that you can get back to your normal sex life eventually.

If you or your partner continue to have problems it may be helpful to have some sexual counselling - ask your specialist, GP or your local Cancer Society if there are counsellors in your area who specialise in sexual counselling. There may also be a specialist impotence advisory service in your area where you can discuss treatment options. See also Cancer and sex.

Related topics

What is bowel cancer? See Bowel cancer

How is bowel cancer diagnosed? See Bowel cancer diagnosis

What support services are available? See Cancer: getting support

What does that term mean? See Cancer glossary

Original material provided by the Cancer Society, 2002. Reviewed by everybody, January 2005.