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Questions to Ask if You Have Been Diagnosed
"Will I die from my colon and rectal cancer?"
No one can say what will happen to you as an individual. Your physician will be able to tell you whether your cancer has a high risk of shortening your life, but will not be able to predict the future. The prognosis will be based on the stage of the disease, and this can only be determined once the tumor is removed. People with very bad cancers do survive - even bad cancers are not always fatal.
Colon cancers can be dangerous in several ways:
- They can regrow in the colon. Even after a segment of the colon is removed, the area where the bowel is put back together is at increased risk to develop recurrence. This is called a 'local recurrence'.
- New colon cancers can arise in the colon. Unless the entire colon was removed, any cancer in one area of the colon is a sign that the rest of the colon is at an increased risk for developing cancer. This, however, can generally be watched closely and a careful follow up regimen will be recommended to make sure that no new cancers develop, or if they do develop, they are identified at a very early state.
- Colon cancers can leave the colon and grow in other parts of the body. The growth in another part of the body is called a 'metastasis.' A metastasis from colon cancer is a worrisome finding, but not universally fatal. In fact, metastases are increasingly being successfully removed. If they cannot be removed, new and increasingly effective chemotherapy agents are available to control the disease.
When a physician talks about danger or risks associated with a given cancer, they talk about the risks of local recurrence, or the risk of metastases, or more commonly, both. Individual colon cancers are characterized by type, size, location, grade, and the characteristics of the colon cancer itself.
"What kind of cancer do I have?"
By far, the most common cancer is adenocarcinoma. There are other unusual types of tumor that occur in the colon. Certainly the questions that you might ask your physician are all appropriate for these types of cancers. They are extremely rare and constitute less than 1% of colon cancers.
The adenocarcinoma evolves through different phases. As mentioned earlier, it is thought that all of these cancers are preceded by a benign, noncancerous growth in the colon, which is called a polyp. As this polyp enlarges, some of the cells in the polyp become cancerous and start to grow through the bowel wall. When the cancers are in the lining or mucosa of the bowel, but have not yet started to grow through the bowel wall, this is called an 'in situ' carcinoma. In situ carcinomas do not have the capacity to spread to other areas and, therefore, when they are removed, one can expect a 100% cure.
As the tumor grows more deeply through the bowel wall, the chances of spread to lymph nodes in the area and to other areas of the body increase. Invasive cancers have developed the ability to break through the wall of the bowel. They, therefore, have the capacity to grow in other parts of the body. They pose a significant threat to long-term health.
"Where is my cancer located?"
Your physician will describe the cancer as located in the right colon, the transverse colon, the descending colon, the sigmoid, or the rectum. The location is not particularly significant to the curability of the tumor. Rectal tumors are at increased risk to require a colostomy, but the risk of colostomy is very small in most practices today.
The significance of the cancer location is more in the symptoms after removal and the ability of your surgeon to remove the tumor and still preserve intestinal continuity in order to avoid a colostomy. Cancer of the rectum requires removal of a portion or all of the rectum. This compromised the storage function of the rectum and causes increased frequency and urgency of bowel movements. Because this are is located deep in the abdomen, many physicians are not comfortable trying to put the bowel back together and automatically tell the patients a colostomy will be necessary. Alternatively they may tell the patients there is a high risk of a colostomy. An experienced surgeon can predict with great accuracy the chances that a colostomy will be necessary. You should ask for a surgeon that can tell you before the surgery whether he will use a colostomy.
In an effort to save the rectum, many surgeons are recommending preoperative radiation therapy. This is a common technique and if your surgeon has had good experience with this technique, you should follow those recommendations. Different surgeons have different approaches to rectal tumors and you want to follow a course that your surgeon has found successful.
"Should the size of the cancer be meaningful to me?"
The size of the cancer will be measured upon x-rays or when the endoscopist looks at the mass through the colonoscope. In general, the larger the cancer, the deeper the potential for growth into the bowel wall. The increased size is also associated with an increased risk of spread to regional lymph nodes or to distant sites. However, in and of itself, the size of the cancer is not meaningful and, therefore, is not of great concern. What is of concern is how deeply the tumor goes through the bowel wall. Physicians will stage the cancer and there are typically four stages.
- Stage I: The tumor is limited to the bowel wall and has not grown through the bowel wall.
- Stage II: The tumor has grown through the bowel wall.
- Stage III: The tumor has spread to regional lymph nodes.
- Stage IV: The tumor has spread to other areas of the body.
Furthermore, the physicians have developed a staging system called "TNM."
- 'T' refers to the depth of invasion through the bowel wall.
- 'N' refers to how many lymph nodes have been involved with the tumor.
- 'M' refers to spread to other areas of the body.
On the surface of it, this may seem somewhat complex, but it has allowed physicians to more clearly compare results from different countries and different practices. It is this comparison that allows us to more carefully evaluate techniques and their value in certain situations. The only way that the TNM classification, and therefore the stage of the tumor, can be accurately determined is by removing the entire tumor and lymph nodes. If the tumor is locally removed without lymph nodes, the TNM classification can be estimated but cannot be accurately reported.
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