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2.

Treatment

Treatment options for patient with colorectal cancer have advanced greatly in recent years and it is very important to be well informed as there are probably several  options available to treat your cancer.

 

In the past all patients were treated in the same way - ‘one size fits all’ - and all patients with colorectal cancer received the same treatment. However new medicines that are available today are more personalised to the individual.

 

The planning and type of treatment you will receive depends on several criteria:

 

  • Your medical history and age

  • The clinical staging (Stage I - IV)  and Tumour Nodules Metastasis (TNM) classification, including the degree of penetration of the tumour through the wall of the colon and the presence, or absence, of lymph nodal involvement (see section on diagnosis)

  • The molecular profile of your tumour (for example presence or absence of mutations) (see section on diagnosis)

  • The high or low risk of cancer relapse (risk assessment)

 

Multidisciplinary Team (MDT)

Planning of treatment involves the input of a multidisciplinary team (MDT) of medical professionals. This usually implies a meeting of different specialists (oncologist, surgeon, pathologist, radiotherapist…).

These professionals will discuss your situation and it is called a multidisciplinary opinion or tumour board review.

After an MDT meeting, your treating clinician will propose a specific and personalised treatment plan for you and discuss it with you in detail.

The treatment will usually combine therapies that:

  • Act on the cancer locally - such as surgery or radiotherapy

  • Act on the cancer cells systemically (all over the body) such as chemotherapy and biologic targeted therapy

 

Curative or palliative treatment

Your clinician will explain that very early-stage malignancies can be treated with a clearly curative intention.

However in the case of cancers that have metastasised (spread beyond the original cancer site) treatment such as chemotherapy or targeted therapies cannot cure the cancer. Therapy may be helpful in shrinking the cancer, improving or completely eliminating distressing symptoms caused by the cancer for a period of time and helping you live longer. The use of chemotherapy in these situations is called palliative chemotherapy.

 

Benefits, risks and availability

All treatments have their benefits, their risks and their contraindications. It is recommended that you ask your doctors about the expected benefits and risks of every treatment in order to be informed about the consequences of the treatment.

For some patients several possibilities are available and the choice should be discussed according to the balance between benefits and risks.

Unfortunately not all treatment options/medicines are available in every country.

Talk

Before a treatment starts, talk with your doctor about the goal of any suggested (new) treatments. Talk about your chance of getting better.

Talk to your clinician about your interest in participating in a clinical trial and ask if she or he knows about one that may be a good match for you.

Treatment options

The extent of the treatment will depend on the stage of the cancer, on the characteristics of the tumour and on the risks for the patient.

 

Read more

What happens after?

It is not unusual for cancer patients to experience treatment-related symptoms after the treatment has been completed.

Read more

Treatment options

In this section we will briefly describe the main treatment options for colon and rectal cancer.

Please note that your treating clinician will advise you on the best approach to take. Treatments for colorectal cancer may include any one of the following or in some cases in different combinations.

 

  • Surgery

  • Chemotherapy

  • Biological (targeted) therapy

  • Radiation therapy

  • Clinical trials

  • Biosimilars

  • Treatment stop

 

 

There is often more than one treatment available but remember that the extent of the treatment will depend on the stage of the cancer, on the characteristics of the tumour and on the risks for you as a patient.

Overview of treatment of colon cancer by stage

Overview of treatment of rectal cancer by stage

 

SURGERY

 

Surgery is often the main treatment for earlier-stage colorectal cancers. The type of surgery carried out depends on the stage (extent) of the cancer, where it is, and the goal of the surgery.

 

 

Surgery for Colon Cancer

Local therapy: Polypectomy and local excision

Some early colorectal cancers (stage T0is and some early Stage 1 tumours) and most polyps can be removed during a colonoscopy. The procedure is called a polypectomy. It is usually done by passing a wire loop through the colonoscope to cut the polyp painlessly off the wall of the colon with an electric current.

 

A local excision is a slightly different procedure. Tools are used through the colonoscope to remove small cancer lesions on the inside lining of the colon along with a small amount of surrounding healthy tissue on the wall of colon.

Partial resection of the bowel with anastomosis

Tumours that cannot be removed with local therapies will need more extended surgery.

A surgeon will remove a part of the colon, also called a partial resection or hemicolectomy, removing the cancer and a small amount of healthy tissue around it. The two ends of the remaining colon are sewn or stapled back together – this is called anastomosis.

Depending on the location of the tumour these resections can be done in different ways:

  • If the tumour is located in the right side of the colon-the ascending colon-this is called
    a right hemicolectomy

  • If the tumour is located in the left side of the colon-the descending colon-this is called
    a left hemicolectomy

  • If the tumour is located in the sigmoid colon-this is called a sigmoid resection

  • Right and left hemicolectomies are sometimes extended to the transverse colon and
    are then called extended (right or left) hemicolectomy.

 

Lymph nodes and blood vessels

In addition the surgeon will also explore of the invasion of lymph nodes and blood vessels.

At least 12 nearby lymph nodes are also removed to perform accurate staging.

Surgery: How is it done?

Abdominal surgery can be done in 2 ways:

  • Laparotomy: The surgery is done through a single long incision (cut) in the abdomen

  • Laparoscopy: The surgery is done through many smaller incisions and with special tools. A laparoscope is a long, thin lighted tube with a small camera and light on the end that lets the surgeon see inside the abdomen. It's put into one of the small cuts, and long, thin instruments are put in through the others to remove part of the colon and lymph nodes

 

Because the incisions are smaller in a laparoscopic-assisted hemicolectomy than in an open colectomy, this procedure is minimally invasive. Patients often recover faster and may be able to leave the hospital sooner than they would after an open colectomy. But this type of surgery requires special expertise, and it might not be the best approach for everyone.

 

You should discuss the type of surgery with your surgeon.

Surgery for Rectal Cancer

Surgery is usually the main treatment for rectal cancer often in combination with chemotherapy and radiotherapy. Again the type of surgery used depends on the stage (extent) of the cancer, where it is and the goal of the surgery.

Local therapy: Polypectomy and local excision

Some early rectal cancers (stage T0is and some early Stage I tumours) and most polyps can be removed during a colonoscopy. The procedure is called a polypectomy. It is usually done by passing a wire loop through the colonoscope to cut the polyp painless off the wall of the rectum with an electric current.

 

A local excision is a slightly different procedure. Tools are used through the colonoscope to remove small cancer lesions on the inside lining of the colon along with a small amount of surrounding healthy tissue on the wall of the rectum.

 

Transanal Excision (TAE)

This procedure can be used to remove some early Stage I rectal cancers that are relatively small and not too far from the anus.

Today, experienced colorectal cancer surgeons can often perform surgery through the anus and remove only the rectal tumors and small amounts of surrounding tissue while leaving the anus and sphincter intact.

This transanal resection is done with instruments that are put into the rectum through the anus.

Transanal endoscopic microsurgery (TEM)

This procedure can be used for early Stage I cancers that are located higher in the rectum and cannot be reached using the standard transanal resection.

Guided by a video monitor, the surgeon utilises special equipment, up through the anal canal to remove the tumour and lymph nodes.

Because both TAE and TEM do not involve cutting open the abdomen the healing time is much shorter.

Low anterior resection (LAR)

Some Stage I rectal cancers and most Stage II or III cancers in the upper part of the rectum (close to where it connects with the colon) can be removed by low anterior resection (LAR). During the operation the part of the rectum containing the tumour is removed with the surrounding lymph nodes. The colon is then attached to the remaining part of the rectum.

In selected patients the surgeon needs to create a connection between the colon and the wall of the abdomen so the colon has time to heal before stools pass again. The edges of the colon are then stitched to the skin of the abdominal wall to form an opening called an ostomy or stoma

The stool can then pass through this opening in your abdomen. There are  different types of colostomies based on where they are located on the colon.

  • Temporary or permanent stoma?
    The stoma is usually temporary meaning that - when the tumour is resected and the colon has had time to heal - a second operation is performed to join the two ends of the colon together (anastomosis) and to close the stoma.
    The stoma may be permanent in some patients (e.g. those with very low position of a tumour in the rectum).

  • Proctectomy with colo-anal anastomosis
    Some Stage I and most Stage II and III rectal cancers in the middle and lower third of the rectum, require removing the entire rectum (called a proctectomy). All the lymph nodes near the rectum also have to be removed. The colon is then connected to the anus (called a colo-anal anastomosis) so that the patient will pass the stool in the usual way.

Sometimes the patient may need a short-term, temporary ileostomy (where the end of the ileum, the last part of the small intestine, is connected to a hole in the abdominal skin) while the bowel heals. A second operation is then done to reconnect the intestines and close the ileostomy opening.

Abdominoperineal resection (APR)

 

This type of surgery can be used to treat some Stage 1 cancers and many Stage II or cancers in the lower part of the rectum when the tumour is growing into the sphincter muscle (the muscle that keeps the anus closed and prevents stool leakage) or the nearby muscles that help control urine flow.

This operation is more invasive than a low anterior resection because the anus is removed a permanent colostomy is created to allow stool to leave the body.

Risk factors and side effects of surgery

 

  • Risk factors: Some risks are common for every surgical intervention performed under general anaesthesia. These complications are unusual and include deep vein thrombosis, heart or breathing problems, bleeding, infection or reaction to the anaesthesia. These can be prevented by thorough medical evaluation before surgery.

 

  • Side effects: A side effect is a secondary, typically undesirable one from a drug or medical treatment. These effects are unplanned and can cause physical or emotional reactions. Not all side effects will occur.
     

After a surgical intervention on the colon it can be quite normal to experience problems of intestinal motility. These can include colicky pain, diarrhoea, constipation and nausea.

There might be other side effects so always ask your treatment team for a complete list and mention side effects if they bother you as there are ways to help you feel better.

CHEMOTHERAPY

 

Chemotherapy or “chemo” includes drugs that disrupt the life cycle of the cancer cells and their aim is to kill or at least harm the tumour cells.

The types of chemotherapy differ in the way they work. Some kill cancer cells by damaging their DNA whilst others interfere with cell parts that make new cells so that no new cells are made.

Chemotherapy drugs used to treat colorectal cancer may be administered differently. They can be administered orally, by mouth (oral chemotherapy) or injected into a vein (intravenous chemotherapy).

Intravenous Chemotherapy

 

Chemotherapy will mostly be administered through a vein intravenously (IV) and therefore once in the bloodstream it can travel throughout your body to treat cancer.  But it can also be given orally, in pill form.

Chemotherapy is given in cycles of treatment days followed by days of rest. Depending on which drugs are used the cycles may vary (common cycles are 14 to 21 days).

  • Safe intravenous access
     

To make these treatments easier you might have a medical device called a catheter or port attached to your hand.

Sometimes the team may suggest using a bigger catheter. This goes into a large vein.

Your doctor may put this type of catheter completely under the skin. If so, it is connected to a small plastic or metal disc called a port. The entire device is called an Implantable Venous Access System.

Ports can remain in place for weeks, months, or years. Your team can use a port to reduce the number of needle punctures, give treatments that last longer than 1 day (the needle can stay in the port for several days), give more than 1 treatment or medication at a time and do blood tests and chemotherapy the same day.

Oral Chemotherapy

Oral chemotherapy is a drug taken in tablet, capsule or sometimes a liquid form. It has the same benefits and risks as chemotherapy given by infusion. As you can take oral chemo at home you don’t need to go to a hospital or clinic for every treatment. It is very important to take your pills just like your doctor or nurse tells you to.

 

Chemotherapy Treatment Lines

Neo-adjuvant and adjuvant chemotherapy

It is possible that you will receive chemotherapy prior (neo-adjuvant) and after surgery (adjuvant) depending on the stage of your tumour.

The aim of neo-adjuvant treatment is to shrink a tumour so it can be fully removed during surgery. The aim of treatment in an adjuvant setting is to prevent the cancer from recurring.

You can explain this type of treatment by comparing it with weeding.

Weeds grow in the garden. They must be removed. However, for various reasons, weeds often grow

back probably because they were not removed completely and part of their roots stayed in the soil.

The left-over roots allow them to grow again. That’s why we use weed killers.

Let us go back to the tumour full of cancer cells. You ‘remove’ the tumour during surgery (weeding)

but to prevent that cancer cells growing again you need an extra treatment -chemo and/or radiotherapy

(weed killers).

Next treatment lines

The initial treatment is referred to as first-line treatment or first-line therapy. It is usually what worked best in clinical trials for patients with the same type and stage of cancer.

How well your treatment works often varies. A first-line treatment may not work, may start but then stop working, or may cause serious side effects. Your physician may then suggest a second-line treatment also called second-line therapy. It is a different treatment but it is likely to be effective.

There are factors that affect whether second-line therapy may work such as the stage of your colon cancer, if you experienced side effects during the previous treatment and of course your overall health.

If you need a second-line treatment this does not mean that you did not get the right treatment the first time or that there are no more treatments to try.

Third-line therapy or additional rounds of treatment

As well as the first-line therapy, the second-line treatment  may not work, may have had an effect but then stopped working or may cause serious side effects that need treatment discontinuation.

It is possible that your doctor will discuss with you the opportunity of a third-line therapy or additional rounds of treatment. Depending on the available drugs in your country you may be able to have another line of treatment.

Taking the time to review all possible options for care may help you feel more comfortable in making your decision about further treatment.

Cytotoxic Drugs

The mainstay of chemotherapy for colorectal cancer is treatment with cytotoxic drugs called fluoropyrimidines, given either as single therapy (called monotherapy) or in combination with other drugs (called combination therapy).

Single therapy

The fluoropyrimidines that are used are:

In combination chemotherapy fluoropyrimidines are combined with other chemotherapeutic drugs such as oxaliplatin or irinotecan.

Side Effects of Chemotherapy

Side effects of chemotherapy are frequent even if progress has been made in controlling them using adequate supportive measures. They will depend on the drug(s) administered, on the doses, length of treatment and on individual factors. If you suffered from other medical problems in the past some precautions should be taken and/or adaptation of the treatment should be made.

Listed below and in the table above are the side effects that are known to occur with one or several of the chemotherapy drugs currently used for colorectal cancer. The nature, frequency and severity of the side effects vary for every chemotherapy combination used. Some can be very serious while others can be unpleasant but not serious.

Most side effects appear shortly after treatment starts and will stop (several days) after treatment. Other side effects however are long-term or may stay permanently or appear years later.

The most frequent general side effects of chemotherapy are:

  • Decreased blood cell counts

         - Decrease in white blood cells (neutropenia) leading to higher risk of infection

         - Decrease in platelets (thrombocytopenia) leading to easy bruising and bleeding

         - Decrease in red blood cells (anemia) leading to fatigue

  • Fatigue which may be prolonged

  • Nausea or vomiting

  • Diarrhoea

  • Sore mouth or mouth ulcers

  • Hair loss

 

How Targeted Therapies Work

 

In contrast to cytotoxic chemotherapy, targeted therapy is cytostatic, it does not kill, but mainly blocks the rapid increase in the number of cancer cells by interfering with specific factors, for example growth factors and growth factor receptors.

 

Blocking growth factors and receptors

Growth factors are chemicals produced by the body that control cell growth. There are many different types of growth factors and they all work in different ways.

These growth factors are also present in normal tissues, but they are often changed (mutated) or over-expressed (too many) in tumours.

 

Growth factors work by binding to receptors on the cell surface.

These receptors, like antenna, pick up growth signals and send a

signal to the inside of the cell. This sets off a chain of complicated

chemical reactions that prompt the cells to grow and divide.

Cancer cells often have with too many of these receptors, can pick up too many growth signals, then ‘transmit’ the signals to the inside of the cell and end up growing and multiplying uncontrollably.

Targeted therapy drugs block growth signals either on the outside of the cell by blocking the antenna or on the inside of the cell or by blocking the signal pathway. This is called inhibition - the act of stopping or slowing down a process.

Either way, by blocking the signals the growth will be interfered with.

 

You can compare this mechanism with the underground (metro)…

Imagine that you need to take the metro to go from one place to another. It might be possible that the entrance to the station (receptor) is blocked, you cannot enter and you need to wait until the door opens. It might be possible that you can enter the station but that the carriage (wagon) is out of order (your path is blocked) again you need to wait and you cannot get to your location.

 

Types of growth factor

There are a number of different growth factors and receptors.

 

Examples are:

  • Epidermal growth factor (EGF) –  Epidermal growth factor receptor (EGFR) – Some people with colon cancer have abnormal changes in their genes that control the epidermal growth factor receptor. These changes may cause the cancer cells to have too many receptors or they may be too active thus causing new cancer cells to develop quickly.
     

  • Vascular endothelial growth factor (VEGF) – Vascular endothelial growth factor receptor (VEGFR) - controls blood vessel development. The  growth of new blood vessels is called angiogenesis. New blood vessels are constantly forming in the body to heal wounds and repair damaged tissues. In females angiogenesis also occurs during the monthly reproductive cycle. The body controls angiogenesis by balancing stimulatory (activators) and inhibitory (inhibitors) factors. Cancer cells need food and oxygen in blood in order to grow that is why the tumour sends chemical signals (such as VEGF  and its receptor) which in turn stimulates blood vessel growth and therefore allowing it to grow rapidly.

Types of targeted therapy

  • Monoclonal antibodies are mostly are administered intravenously

  • Small molecule inhibitors are usually taken orally, in a pill form

                   

These are either given as single therapy (called monotherapy) or in

combination with chemotherapy (called combination therapy).

RADIATION THERAPY

 

Radiotherapy is a possible treatment for rectal cancer and it is not usually used to treat bowel cancer.

It uses high-energy, highly focused rays to locally treat cancer. These rays will damage the DNA and kill the cancer cell.

 

How is radiotherapy given?

Radiotherapy can be used in several ways:

  • External beam radiation therapy (EBRT) is delivered from outside of the body by a machine. Each treatment lasts a few minutes and is performed as an outpatient procedure.

  • Internal radiotherapy involves positioning radioactive sources inside or near to the tumour.  The use of internal radiotherapy depends on the size of the cancer and where it is in the rectum. The main advantage of this treatment is that it can deliver a high dose of radiation directly to the cancer while limiting damage to surrounding tissues and organs. This treatment is also known as brachytherapy or contact radiotherapy and is not currently available at all cancer centres. You may have to travel to a specialist centre to receive this treatment.

  • Ablation refers to treatments that destroy small (less than 4 cm across) tumours without removing them. There are many different ablation techniques and ablation can be used to treat tumours in other places too.

  • Selective Internal Radiation Therapy (SIRT - also called radioembolisation) SIRT is a targeted treatment for liver tumours that delivers millions of tiny radioactive beads called SIR-Spheres microspheres directly to the liver tumours. Patients with advanced colorectal cancer often present with liver metastases.
     

You can read more about SIRT in this booklet: CLICK HERE

Indications

  • Before surgery (along with chemo) to help shrink a tumour and make it easier to remove. This is specifically needed in patients with rectal cancer according to the stage of the tumour and the location in proximity of the anus. The multidisciplinary review meeting can decide to perform a short course of radiation followed by surgery or for a long course of radiation (for example 5 weeks) in combination with continuous administration of chemotherapy to improve the effect of radiation

  • During surgery: right to the area where the tumour was, to kill any cancer cells that may be left behind. This is called intraoperative radiation therapy (IORT)

  • After surgery: radiation therapy may be used to try to kill any cancer cells that may have been left behind

  • To ease symptoms: for example, if advanced cancer is causing pain

  • Treatment of metastasis: as a treatment to relieve pain caused by cancer that has spread into the bone or brain
     

Side effects of radiation therapy

During radiotherapy side effects may occur in organs that are directly targeted but also in healthy organs that lie close to the region that needs to be irradiated and that cannot be avoided by the X-rays. Side effects are more intense when radiotherapy is administered together with chemotherapy. Use of radiotherapy in addition to surgery also increases the risk of surgical complications.

 

Strategies to maximally prevent and relieve post-radiation reactions are provided by the radiation oncologist.

 

CLINICAL TRIALS

 

A clinical trial is a test to measure the effectiveness and/or safety of a new product or medical procedure.

Clinical trials must follow an approved protocol or standard method of testing that covers everything from how patients are evaluated before entering the trial to how the product is used during the trial and how patient results are collected and measured. This is done to reduce as much as possible the potential effects of unrelated factors and determine as accurately as possible if the product is working as it is designed to work.

It is possible that you will be asked to participate in a clinical trial. Choosing to participate in a clinical study is an important personal decision.

If you’re interested in participating in a clinical study you should know as much as possible about the study and feel comfortable asking the research team questions about the study, the related procedures and any expenses.

You will need to sign a patient informed consent form. This document contains information of all aspects of the trial that are relevant to the your participation. Please read it carefully and remember that your willingness to participate in a particular trial is voluntarily and freely given.

Clinical studies can take place in many locations, including hospitals, universities, doctors' offices, and community clinics. The location depends on who is conducting the study.

BIOSIMILARS

 

Biologic medicines have revolutionised patient treatment by offering new and effective medicines for acute and chronic conditions including neutropenia (lack of specific part of white blood cells) cancer and a wide range of other diseases. As the patent expires for individual originator medicines, biosimilar medicines can be introduced to provide additional options for patients.

 

Biosimilar medicines

 

These have been used across Europe for many years as treatments for growth hormone replacement, neutropenia and anemia (low hemoglobin) related to chronic kidney failure or cancer. Further biosimilar medicines for cancer treatment (including treatment for metastatic colorectal cancer) are in development or under review for approval as originator biological medicines come off patent.

 

What is a biologic medicine?

 

Biologic medicines are derived from living cells or organisms and consist of large, highly complex molecular entities which may be difficult to characterise. Due to the variability of the biological system and the manufacturing process, biologic medicines may show a certain degree of variation even between batches of the same product.

What is a biosimilar medicine?

A biosimilar medicine is a biologic medicine that is developed to be highly similar and clinically equivalent to an existing biologic medicine. A biosimilar contains a version of an active substance of an already approved biologic medicine which is referred to as the ‘reference medicine’ or ‘originator medicine’.

Similarity to the reference medicine in terms of quality, structural characteristics, biological activity, safety and efficacy must be established based on a comprehensive scientific comparability exercise such that they do not have any clinically meaningful differences from the reference medicine in terms of quality, safety and efficacy.

Biosimilar medicines are not the same as generic medicines which contain simpler chemical structures and are identical in terms of molecular structure to their reference drugs.

How are biosimilars medicine authorised for use in Europe?

Biosimilars are approved according to the same standards of pharmaceutical quality, safety and efficacy that apply to all biological medicines. The European Medicines Agency (EMA) is responsible for evaluating the majority of applications to market biosimilars in the European Union (EU). The resulting marketing authorisation, issued via a decision by the European Commission, is valid in all EU Member States.

The evidence acquired over ten years of clinical experience shows that biosimilars approved through EMA can be used as safely and effectively in all their approved indications as other biological medicines.

Ask your physician about the availability and usage of biosimilars in your treatment centre.

 

STOPPING TREATMENT

 

You, your caregivers and your doctor may decide that undergoing another new treatment is not the best choice. This may happen if your disease has reached an advanced stage. Another new active cancer treatment may have unpleasant or serious side effects and  the chance for success is small.

Making the decision to stop active cancer treatment can be very painful emotionally; it is a tough decision that requires some careful thought.

Choosing to stop active treatment for your cancer does not mean that you are giving up. Rather, it is an active choice to live your last days in the way you wish to live them.

This decision does not mean you will need to stop all treatments. In fact, switching the focus of treatment towards managing symptoms places a higher priority on making you as comfortable as possible.

Are there words that you find difficult to understand? Click here to see the dictionary of words we have chosen throughout the site explained.

 
 
 
 
 
 

What Happens After Treatment?

The day cancer treatment ends…… a new chapter begins…

 

Care for people with cancer does not end when active treatment does. After cancer treatment ends, you will continue to see your health care team and be looked after.

 

Treatment Follow-up

Follow-up begins with being informed. You can find information about your disease and its treatment in a Treatment Summary. This is a document that your hospital team should produce at the end of your treatment. It describes the treatment you have had and explains what to expect now treatment has finished. Knowing what happens next can help you adjust to your new life. This summary will include information about possible side effects or late effects of your treatment. Late effects are side effects that do not go away after a few months or side effects that develop months or years after treatment. Your Treatment Summary should be discussed with you and you should receive a copy.

 

A copy will also be sent to your General Practitioner.

 

Follow-up plan and care

 

You and your health care team will work together to develop a personalised follow-up care plan. This plan will serve as a guide for monitoring your health for the months and years that follow. Your care plan may include regular physical examinations and medical tests. This plan is usually based on medical guidelines for a specific diagnosis.

 

Your doctor will also consider your individual needs and preferences.

 

Participating in follow-up care helps many survivors feel in control as they transition back into their everyday lives.

 

During follow-up care for cancer you will be seeing a health care provider for regular medical checkups. These checkups may include blood testing as well as other tests and procedures that look for any changes in your health or any problems that may occur due to your cancer treatment.

The visits are also a time to check for physical and emotional problems that may develop months or years after treatment ends. It is not unusual for you to experience treatment-related symptoms after the treatment has been completed.

 

Here are some examples:

  • Experiencing treatment-related symptoms: fatigue, skin problems, incontinence, and effects on sexuality and sex life

  • You may experience anxiety, sleeping difficulty or depression and may need psychological support

  • During and after treatment nutrition may become problematic due to reduced appetite, nausea and general malaise

  • Difficulties in concentrating and memory loss are not uncommon side effects of systemic chemotherapy

 

You can find information about these topics in the chapter on “SURVIVORSHIP

 

Goals of follow-up care and long-term implications

 

Checking for a recurrence

One goal of follow-up care is checking for a recurrence. Recurrent cancer is cancer that has come back after treatment. Cancer recurs because small areas of cancer cells may remain undetected in the body. These cells may increase in number until they show up on test results or cause signs or symptoms.

 

The chance that a cancer will recur depends on the stage you were originally diagnosed with. This will  also affect the most likely timing and location of a recurrence.

Unfortunately, it is impossible for doctors to predict who will experience a recurrence. However a physician familiar with your medical history can give you more personalized information about your risk of recurrence. He or she can also suggest ways to minimize this risk.

The follow-up protocol will include regularly timed office visits and investigations. The intensity depends on the staging of the cancer that was treated, and on the type of treatment given.

 

The fear of recurrence is very real and entirely normal.

 

In general follow-up visits may include a combination of the following investigations:

  • You will be asked questions on your general physical health and colorectal cancer-related symptoms (pain, stool pattern, …)

  • Physical examination

  • Laboratory test for carcinoembryonic antigen (CEA) level

  • Colonoscopy

  • Radiological investigations to detect progression or recurrence of the primary tumour, or the appearance of metastasis (ultrasound liver, X-ray lungs, CT scan abdomen (and chest), PET CT scan)

 

It is accepted that after treatment for colorectal cancer all patients should be followed up intensively. Should you present specific symptoms that raise concern for recurring disease appropriate additional laboratory or radiological investigations will be performed. However there is not one generally accepted follow-up protocol.

 

Talk to your physician to discuss your follow-up care plan.

Managing long-term and late side effects

 

Although most long-term survivors of colorectal cancer report a very good quality of life following their treatment several problems can still occur. It is very important to be informed.

Late side effects after surgery

 

Surgery (hemicolectomy) can lead to loose stools (even diarrhoea) but this usually improves over time; surgery can also lead to adhesions (formation of scar tissue between bowel loops and the inner lining of the abdominal wall or with other organs within the abdominal cavity). This can cause abdominal discomfort, bloating or pain.

Some patients can have bowel dysfunction: diarrhoea, constipation, bowel obstruction, pain.

It is important to ask for dietary counselling and  if needed, use of over-the-counter medications (e.g., fibre laxative, stool softeners, antidiarrheal).

 

Do not hesitate to talk to your surgeon to discuss the late side effects.

 

After chemotherapy and/or targeted therapy

 

Not all chemotherapy  or targeted medicines have the same late effects. A lot depends on the kind of medicines that you were treated with. The dosage and whether chemo or targeted therapy was combined with another type of treatment are also important.

 

Before starting treatment, ask your health care provider about the possible after-effects of all the medications you will receive.

 

Late effects of chemotherapy include:

  • Fatigue

  • Difficulty with focused thinking (sometimes called chemo brain)

  • Dietary problems (taste changes)

  • Heart problems

  • Kidney and urinary problems (incontinence)

  • Effects on sexuality and sex life

  • Skin problems (discolouration, nail changes,…)

  • Nerve problems such as numbness, painful sensations and tingling

  • Bone and joint problems

  • Muscle weakness

Long-term side effects

Other side effects called long-term side effects may develop months or even years after cancer treatment ends. Long-term and late effects can include physical and emotional changes, even the development of second cancers.

 

Your doctor can inform you about your risk of developing long-term side effects.

 

Key contacts

 

Do not forget to ask your hospital team to give you contact details of who to get in touch with if you have any concerns about your health or possible side effects of treatment.