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Options – Cancer What Now
What Now?

Your Colorectal Cancer Treatment & Recovery Online Resource in Alberta

Answers, insights & inspiration

Step 2: Choosing Treatment Options

What are my Options?

Rectal cancer therapy is very complex. Everyone’s cancer diagnosis is different. Treatment decisions are made based on your health, body, cancer stage and your wishes. For stage 0-3 the main goal of therapy is to “cure” the cancer, for stage 4 it may not be possible to cure the cancer and the goal will be be to control the cancer for as long as possible. 

There are 3 main types of therapy

Surgery

Uses surgical operations to remove cancerous tissues or organs from the body. Most patients require surgery to remove the cancer.

Learn more

  • Learn more about Surgery Click here or here

 

Radiation

Radiation therapy uses high-energy rays or particles to destroy cancer cells. Radiation is administered from Linear Accelerators (Linac) which electronically creates high energy X-rays that are delivered to the patient. In rectal cancer, the Linac is targeted to deliver treatment to specific parts of your pelvis and delivers radiation accurately to a carefully to a defined area. The radiation can be targeted to the tumor, the sugical tumor bed, and or the lymph nodes associated with the rectum. The X-rays pass through the body, depositing radiation dose that can damage both normal cells and cancer cells that they pass through. Radiation preferentially kills the cancer cells, because they lack the ability to repair the radiation damage. Normal cells can repair the radiation damage,  but their damage is still seen through radiation side effects which heal over time. Radiation related side effects only occur in areas of the body where the radiation was delivered (ie. the pelvis)

Learn more

  • To learn more about radiation click here

Chemotherapy

Chemotherapy uses medications (drugs) delivered in the form of pills or IV. The medications travel through the blood to all parts of the body and attack both normal and cancer cells. Chemotherapy preferentially kills cancer cells which lack the ability to process the cancer medications. Normal cells are also damaged by cancer medications, which causes the side effects that patients experience, but normal cells will eventuall heal themselves. Chemotherapy related side effects can occur throughout the body.

Learn more:

  • To learn more about chemotherapy click here

Do I need Surgery?

Surgery is the main therapy for all stages of rectal cancer. There are many possible surgical procedures for rectal cancer. Most patients will require some type of surgery to cure their cancer.

Learn more

  • To watch a video about TME surgery click here

Local Excision or TEMS

Is a limited surgery removing only a small section of the bowel wall. This can be used to remove small < 3cm, early cancers that have not penetrated deep into the rectal wall (Stage T1). Only a few patients are eligible for this therapy as most tumors are too large or deep to treat with this technique

Learn more

  • To learn more about TEMS click here 

Total Meso-rectal excision (TME)

Is the most common therapy for rectal cancer. This surgery involves removal of the complete rectum and surrounding tissues, this is a much larger surgical procedure.

TME can be performed using 2 techniques

  1. Low anterior resection (LAR) – this usually has an abdominal scar and temporary ostomy.
  2. Abdominoperineal resection (APR) – this technique is usually for ‘low’ rectal tumors near the anal sphincter and results in a scar in your perineum and abdomen. This procedure results in a permanent ostomy.

Learn more

  • To learn more about TME Surgery click here

Exenteration

Is a radical surgery which may involve removing some or most of the organs of the pelvis bladder, Female (Uterus, Vagina) Male ( Prostate, Seminal vesicles), rectum, and anus. This is a rarely used procedure and is only considered when the cancer is invading outside of the rectum into surrounding organs. 

Learn more

  • To learn more about Pelvic exenteration click here

Will I have an Ostomy Bag?

An ostomy (or Bag) is a surgically created opening connecting an internal organ to the surface of the body. An ostomy may be temporary (6 – 12 Months) or permanent. Most patients with rectal cancer surgery will require and ostomy depending of the factors below it may only be temporary. 

Why you may need a permanent ostomy:

  • low rectal tumors within 5 cm from the anus
  • tumors invading the anal sphincter
  • narrow pelvis and large tumors
  • invasion of nearby structures
  • perforation or scarring of the bowel
  • prior pelvic surgery or radiation

 Most patients can live normal healthy active lives after having a colostomy even if it is permanent.

Learn more:

Do I need radiation or chemotherapy?

Modern surgical techniques are excellent at removing all visible cancer cells. When a patient hears “we got it all” it means that all the cancer that was visible was removed. The tip of a pencil can hide 1 million cancer cells. Unfortunately microscopic cancer cells are not visible or detectable using any blood tests or scans. These invisible cancer cells can hide for many years and can begin to grow again.  Radiation or chemotherapy can help eliminate these microscopic cells reducing the risk of cancer returning. These treatments can be done before or after surgery depending on your cancer. By performing the treatments before surgery we can shrink your cancer making it easier to remove, reduce the toxicity of therapy and improve how effective they are at killing cancer cells. Radiation or chemotherapy can be done after surgery to eliminate any remaining cells reducing the risk that the cancer will return. 

Risk Factors

Your surgeon will discuss your individual case with radiation and chemotherapy specialists in a multidisciplinary tumor board. Your case will be reviewed by specialists who may need special tests to determine your risk factors. Your cancer specialist tries to estimate if you have a High or Low risk of the cancer coming back.

Low risk patients have a very good chance of being cured by surgery alone. If you have 2 or more risk factors you may need to talk to an Oncologist to see if radiation or chemotherapy is needed for you.

Important Risk factors

  • Large Tumor size                
  • Deep invasion of your Tumor (T3)
  • Low tumors near the anal sphincter
  • Malignant lymph nodes
  • Aggressive or High grade tumors
  • Invasion of small nerves or lymph nodes
  • Close margins
  • Special or unusual pathology

Common Pathways

There are 3 Main ways of sequencing radiation chemotherapy and surgery.

Path A

  • Most common
  • Radiation and Chemotherapy are given BEFORE Surgery 
  • Chemotherapy is given again AFTER surgery

Path B

  • Less common
  • Radiation and Chemotherapy are given AFTER Surgery

Path C

  • Rarely used
  • Radiation alone BEFORE Surgery
  • Chemotherapy AFTER Surgery

Palliative Therapy

In some patients the tumor is too large or advanced to be completely eradicated with Radiation, Chemotherapy, and Surgery. It is not possible to “cure” the cancer. It may still be possible to control the cancer and the treatment goals are to alleviate pain, improve quality and quantity of life. 

These therapies are very individualized to the patient depending on their health and types of symptoms

  • Radiation can help with pain, bleeding, and many other symptoms of cancer
  • Chemotherapy can help slow the growth of the cancer and increase survival
  • Surgery can potentially remove cancers from nearby organs, or clear blockages in the colon

What are the benefits of Radiation or Chemotherapy?

Radiation and Chemotherapy help reduces the risk of cancers coming back in the future (Local Control) and improve the chances of being alive in the future (Overall Survival). We cannot predict how any single patient will benefit from therapy but we know that therapy can reduce your “chances” of your cancer returning.

Benefits of Radiation BEFORE Surgery

  • Shrinkage of tumor (downstaging) before surgery can help to make the surgical resection easier
  • Reduces close or positive margins
  • Is better tolerated (less side effects) than if given after surgery
  • Reduces the risk that the cancer will come back in the future (local control)

Risk reductions

Surgery Alone

10%

 

Radiation & Surgery

5%

Relative reduction of 50% or absolute 5%

If 100 people had surgery and NEVER had any further treatment, approximately 10 people will have a recurrence of the cancer in their pelvis within 5 years.

If 100 people had surgery AND radiation, approximately 5 people will have a recurrence of cancer in their pelvis within 5 years.

Thus radiation reduces your chances of having a cancer recurrence by 5%. These are estimates and each patient’s risk will differ.

Benefits of Radiation AFTER Surgery

  • Helps to eliminate any microscopic cancer cells that may have been left behind after the surgery.
  • Reduces the risk that the cancer will come back in the future.

Risk reductions

Surgery Alone

10%

 

Radiation & Surgery

5%

Relative reduction of 50% or absolute 5%

If 100 people had surgery and NEVER had any further treatment, approximately 10 people will have a recurrence of the cancer in their pelvis within 5 years.

If 100 people had surgery AND radiation, approximately 5 people will have a recurrence of cancer in their pelvis within 5 years.

Thus radiation reduces your chances of having a cancer recurrence by 5%. These are estimates and each patient’s risk will differ.

Benefits of Chemotherapy

  • Having chemotherapy before or after surgery reduces the risk that the cancer will come back in the future
  • Chemotherapy increases yours chances of being alive and cancer free many years from now

Surgery Alone

65% alive

 

Surgery & Chemo

75% alive

10% absolute increase 

If 100 people had surgery and NEVER had any further treatment, 65 of those people will be alive in 5 years

  • 35 will have died due to cancer or some other cause.

If 100 people had surgery AND chemo, 75 of those people will be alive in 5 years, while

  • 25 will have died due to cancer or some other cause.

Thus chemotherapy improves your chances of being alive 5 years after treatment by 10%. Please note that these are estimates, and each patient’s individual risk will differ.

Myths and Truths

Myth: If I take radiation and chemotherapy I am cured

Truth: Many people believe that radiation or chemo will grant them perfect protection this is not true. These treatments reduce the “Chance” of having a cancer come back but are not perfect. Radiation or chemo can reduce the chance of cancer but it is never 0%

 

Myth: If I don’t take radiation and chemotherapy I will die

Truth: Even if you are a high risk patient there is still a chance that your cancer may not come back.

  1. 50% chance = Flipping a coin
  2. To most physicians >15% is considered high risk ~ this is about a 1/6 chance
  3. To most physicians < 5% is considered low risk ~ this is about a 1/20 chance
  4. To learn more about risks click here 

 

Truths

  • There are no Right or Wrong choices
  • Treatment has benefits and it has costs
    • Costs are measured in side effects, time and complications
  • You have to do what is you think is right for YOU