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Colorectal cancer

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Colorectal cancer


  


Introduction

Bowel cancer is a general term for cancer that begins in the large bowel. Depending on where the cancer starts, bowel cancer is sometimes called colon or rectal cancer.

Cancer can sometimes start in the small bowel (small intestine), but small bowel cancer is much rarer than large bowel cancer.

Bowel cancer is one of the most common types of cancer diagnosed in the UK, with around 40,000 new cases diagnosed every year.

About one in every 20 people in the UK will develop bowel cancer during their lifetime.

 

Signs and symptoms

The three main symptoms of bowel cancer are blood in the stools (faeces), changes in bowel habit (such as to more frequent, looser stools) and abdominal (tummy) pain. However, these symptoms are very common and most people with them do not have bowel cancer.

For example, blood in the stools is more often caused by haemorrhoids (piles), and a change in bowel habit or abdominal pain is usually due to something you have eaten.

As almost nine out of 10 people with bowel cancer are over 60 years old, these symptoms are more important as people get older. They are also more significant when they persist despite simple treatments.

Most people who are eventually diagnosed with bowel cancer have one of the following symptom combinations:



a persistent change in bowel habit causing them to go to the toilet more often and pass looser stools, usually together with blood on or in their stools



a persistent change in bowel habit without blood in their stools, but with abdominal pain



blood in the stools without other haemorrhoid symptoms such as soreness, discomfort, pain, itching or a lump hanging down outside the back passage



abdominal pain, discomfort or bloating always provoked by eating, sometimes resulting in a reduction in the amount of food eaten and weight loss



The symptoms of bowel cancer can be subtle and don’t necessarily make you feel ill.

 

When to seek medical advice

Try the bowel cancer symptom checker for advice on treatments you can try to see if your symptoms get better and when you should see your GP to discuss whether any tests are necessary.

Your doctor will probably carry out a simple examination of your tummy and bottom to make sure you have no lumps, and they may arrange a simple blood test to check for iron deficiency anaemia (as this can indicate whether there is any bleeding from your bowel that you haven’t been aware of).

In some cases, your doctor may decide it is best for you to have a simple test in hospital to make sure there is no serious cause for your symptoms.

Make sure you return to your doctor if your symptoms persist or keep coming back after stopping treatment, regardless of their severity or your age.

 

Who's at risk?

It's not known exactly what causes bowel cancer, but there are a number of things that can increase your risk. These include:



age – almost nine in 10 cases of bowel cancer occur in people aged 60 or over



diet – a diet high in red or processed meats and low in fibre can increase your risk



weight – bowel cancer is more common in people who are overweight or obese



exercise – being inactive increases the risk of getting bowel cancer



alcohol and smoking – a high alcohol intake and smoking may increase your chances of getting bowel cancer



family history – having a close relative (mother or father, brother or sister) who developed bowel cancer below 50 years of age puts you at a greater lifetime risk of developing the condition



Some people are also at an increased risk of bowel cancer because they have another condition that affects their bowel, such as severe ulcerative colitis or Crohn's disease over a long period of time.

 

Bowel cancer screening

To detect cases of bowel cancer sooner, the offers two types of bowel cancer screening to adults registered with a GP in England:



All men and women aged 60-74 are invited to carry out an FOB (faecal occult blood) test at home. They're sent the home test kit every two years through the post, until they reach the age of 74. The FOB test checks for the presence of blood in a stool sample, which could be an early sign of bowel cancer.



An additional one-off test called bowel scope screening is gradually being introduced in England. This is offered to men and women at the age of 55. As of March 2015, about two thirds of screening centres were beginning to offer this test to 55 year olds. It involves a doctor or nurse using a thin flexible instrument to look inside the lower part of the bowel and remove any small growths, called polyps, that could eventually turn into cancer.



Screening plays an important part in the fight against bowel cancer because it can help detect bowel cancer before it causes obvious symptoms, which increases the chances of surviving the condition.

 

Treatment and outlook

Bowel cancer can be treated using a combination of different treatments, depending on where the cancer is in your bowel and how far it has spread.

The main treatments are:



surgery to remove the cancerous section of bowel, this is the most effective way of curing bowel cancer and is all that many people need



chemotherapy – where medication is used to kill cancer cells 



radiotherapy – where radiation is used to kill cancer cells



biological treatments – a newer type of medication that increase the effectiveness of chemotherapy and prevent the cancer from spreading



As with most types of cancer, the chance of a complete cure depends on how far the cancer has advanced by the time it is diagnosed. If the cancer is confined to the bowel then surgery will usually be able to completely remove it.

Overall, between seven and eight in every 10 people with bowel cancer will live at least one year after diagnosis and more than half of those diagnosed will live at least another 10 years.

Every year, around 16,000 people die as a result of bowel cancer.

Clinical commissioning groups (CCGs) are  organisations that organise the delivery of services in England. They play a major role in achieving good health outcomes for the local population that they serve.

 

Signs and symptoms of bowel cancer

The three main symptoms of bowel cancer are blood in the stools (faeces), a change in bowel habit (such as to more frequent, looser stools) and abdominal (tummy) pain.

However, these symptoms are very common. Blood in the stools is usually caused by haemorrhoids (piles) and a change in bowel habit or abdominal pain is often due to something you have eaten.

In the UK, an estimated 7 million people have blood in the stools each year and even more people have temporary changes in bowel habit and abdominal pain.

Most people with these symptoms do not have bowel cancer.

As the vast majority of people with bowel cancer are over 60 years old, these symptoms are more important as people get older. They are also more significant when they persist in spite of simple treatments.

Most patients with bowel cancer present with one of the following symptom combinations:



a persistent change in bowel habit, causing them to go to the toilet more often and pass looser stools, usually together with blood on or in their stools



a persistent change in bowel habit without blood in their stools, but with abdominal pain



blood in the stools without other haemorrhoid symptoms such as soreness, discomfort, pain, itching or a lump hanging down outside the back passage



abdominal pain, discomfort or bloating always provoked by eating, sometimes resulting in a reduction in the amount of food eaten and weight loss



The symptoms of bowel cancer can be subtle and don’t necessarily make you feel ill.

 

When to seek medical advice

Try the bowel cancer symptom checker for advice on what treatments you can try to see if your symptoms get better and when you should see your GP to discuss whether any tests are necessary.

Your doctor you will probably perform a simple examination of your tummy and bottom to make sure you have no lumps and a simple blood test to check for iron deficiency anaemia (as this can indicate whether there is any bleeding from your bowel you haven’t been aware of).

In some cases, your doctor may decide it is best to have a simple test in hospital to make sure there is no serious cause for your symptoms.

Make sure you return to your doctor if your symptoms persist or keep coming back after stopping treatment, regardless of their severity or your age.

 

Bowel obstruction

In some cases, bowel cancer can stop digestive waste passing through the bowel. This is known as a bowel obstruction.

Symptoms of a bowel obstruction can include:



severe abdominal pain, which may initially come and go



not being able to pass stools when you go to the toilet



noticeable swelling or bloating of the tummy



vomiting



A bowel obstruction is a medical emergency. If you suspect your bowel is obstructed, you should see your GP quickly and if this isn’t possible go to the accident and emergency (A&E) department of your nearest hospital.

 

 

Causes of bowel cancer 

Cancer occurs when the cells in a certain area of your body divide and multiply too rapidly. This produces a lump of tissue known as a tumour.

Most cases of bowel cancer first develop inside clumps of cells on the inner lining of the bowel. These clumps are known as polyps. However, if you develop polyps, it does not necessarily mean you will get bowel cancer.

Exactly what causes cancer to develop inside the bowel is still unknown. However, research has shown several factors may make you more likely to develop it. These factors are outlined below.

 

Age

Your chances of developing bowel cancer increase as you get older. Almost nine out of 10 cases of bowel cancer in the UK are diagnosed in people over 60 years of age.

 

Family history

Having a family history of bowel cancer can increase your risk of developing the condition yourself, particularly if a close relative (mother, father, brother or sister) was diagnosed with bowel cancer below the age of 50.

If you are particularly concerned that your family's medical history may mean you are at an increased risk of developing bowel cancer, it may help to speak to your GP.

If necessary, your GP can refer you to a genetics specialist who can offer more advice about your level of risk and recommend any necessary tests to periodically check for the condition.

 

Diet

A large body of evidence suggests a diet high in red and processed meat can increase your risk of developing bowel cancer. For this reason, the Department of Health advises people who eat more than 90 grams (cooked weight) of red and processed meat a day to cut down to 70 grams.

There is also evidence suggesting that a diet high in fibre could help reduce your bowel cancer risk.

 

Smoking

People who smoke cigarettes are more likely to develop bowel cancer, other types of cancer and other serious conditions such as heart disease than people who do not smoke.

 

Alcohol

Drinking alcohol has been shown to be associated with an increased risk of bowel cancer, particularly if you regularly drink large amounts of it.

 

Obesity

Being overweight or obese is linked to an increased risk of bowel cancer, particularly in men.

If you are overweight or obese, losing weight may help lower your chances of developing the condition.

 

Inactivity

People who are physically inactive have a higher risk of developing bowel cancer.

You can help reduce your risk of bowel and other cancers by being physically active every day.

 

Digestive disorders

Some conditions affecting the bowel may put you at a higher risk of developing bowel cancer. For example, bowel cancer is more common in people who have had severe Crohn’s disease or ulcerative colitis for many years.

If you have one of these conditions, you will usually have regular check-ups to look for signs of bowel cancer from about 10 years after your symptoms first develop.

Check-ups will involve examining your bowel with a colonoscope – a long, narrow flexible tube containing a small camera – that is inserted into your rectum. The frequency of the colonoscopy examinations will increase the longer you live with the condition, and will also depend on factors such as how severe your ulcerative colitis is and if you have a family history of bowel cancer.

 

 Genetic conditions 

There are two rare inherited conditions that can lead to bowel cancer. They are:



familial adenomatous polyposis (FAP) – a condition that triggers the growth of non-cancerous polyps inside the bowel



hereditary non-polyposis colorectal cancer (HNPCC), also known as Lynch syndrome – an inherited gene fault (mutation) that increases your bowel cancer risk



Although the polyps caused by FAP are non-cancerous, there is a high risk that, over time, at least one will turn cancerous. Most people with FAP will have bowel cancer by the time they are 50 years of age.

As people with FAP have such a high risk of getting bowel cancer, they are often advised by their doctor to have their large bowel removed by surgery before they reach the age of 25. Families affected can find support and advice from FAP registries such as the FAP registry provided by St Mark’s Hospital, London.

Removing the bowel as a precautionary measure is also usually recommended in people with HNPCC because the risk of developing bowel cancer is so high.

 

 Diagnosing bowel cancer 

When you first see your GP they will ask about your symptoms and whether you have a family history of bowel cancer.

They will then usually carry out a simple examination of your abdomen (tummy) and your bottom – known as a digital rectal examination (DRE). 

This is a useful way of checking whether there are any lumps in your tummy or back passage. The tests can be uncomfortable and most people find an examination of the back passage a little embarrassing but they take less than a minute.

If your symptoms suggest you may have bowel cancer, or the diagnosis is uncertain, you will be referred to your local hospital initially for a simple examination called a flexible sigmoidoscopy

 

 Flexible sigmoidoscopy 

A flexible sigmoidoscopy is an examination of your rectum and some of your large bowel using a device called a sigmoidoscope. A sigmoidoscope is a long, thin flexible tube attached to a very small camera and light that is inserted into your rectum and up into your bowel.

The camera relays images to a monitor and can also be used to take biopsies (where a small tissue sample is removed for further analysis).

It is better for your lower bowel to be as empty as possible when sigmoidoscopy is performed, so you may be asked to carry out an enema (a simple procedure to flush your bowels) at home beforehand. This should be used at least two hours before you leave home for your appointment.

A sigmoidoscopy can feel uncomfortable but only takes a few minutes and most people go home straight after the examination.

 

 More detailed tests 

Most people with bowel cancer can be diagnosed by flexible sigmoidoscopy. However, some cancers can only be diagnosed by a more extensive examination of the colon. The two tests used for this are colonoscopy and computerised tomography (CT) colonography.

These tests are described in more detail below.

Colonoscopy

A colonoscopy is an examination of your entire large bowel using a device called a colonoscope, which is like a sigmoidoscope but a bit longer.

Your bowel needs to be empty when a colonoscopy is performed, so you will be advised to eat a special diet for a few days beforehand and take a laxative (medication to help empty your bowel) on the morning of the examination.

You will be given a sedative to help you relax during the test, after which the doctor will insert the colonoscope into your rectum and move it along the length of your large bowel. This is not usually painful, but can feel uncomfortable.

The camera relays images to a monitor, which allows the doctor to check for any abnormal areas within the rectum or bowel that could be the result of cancer. As with a sigmoidoscopy, a biopsy may also be performed during the test.

A colonoscopy usually takes about one hour to complete, and most people can go home once they have recovered from the effects of the sedative.

After the procedure, you will probably feel drowsy for a while so you will need to arrange for someone to accompany you home and it is best for elderly people to have someone with them for 24 hours after the test. You will be advised not to drive for 24 hours.

In a small number of people it may not be possible to pass the colonoscope completely around the bowel and it is then necessary to have CT colonography.

For more information about what a colonoscopy involves, watch this video: what happens during a colonoscopy?

CT colonography

CT colonography, also known as a 'virtual colonoscopy', involves using a computerised tomography (CT) scanner to produce three-dimensional images of the large bowel and rectum.

During the procedure, gas is used to inflate the bowel using a thin, flexible tube placed in your rectum. CT scans are then taken from a number of different angles.

As with a colonoscopy, you may need to have a special diet for a few days and take a laxative before the test to ensure your bowels are empty when the test is carried out.

This test can help identify potentially cancerous areas in people who are not suitable for a colonoscopy due to other medical reasons. A CT colonography is a less invasive test than a colonoscopy, but you may still need to have colonoscopy or flexible sigmoidoscopy at a later stage so any abnormal areas can be removed or biopsied.

 

 

 Further tests 

If a diagnosis of bowel cancer is confirmed, further testing is usually carried out to check if the cancer has spread from the bowel to other parts of the body and to help decide on the most effective treatment for you.

These tests can include:



a CT scan of your abdomen and chest to check if the rest of your bowel is healthy and whether the cancer has spread to the liver or lungs.



a magnetic resonance imaging (MRI) scan is also done for people with a cancer in the rectum to provide a detailed image of the surrounding organs



 

 Staging and grading 

Once the above examinations and tests have been completed, it should be possible to determine the stage and grade of your cancer. Staging refers to how far your cancer has advanced. Grading relates to how aggressive and likely to spread your cancer is.

This is important as it helps your treatment team choose the best way of curing or controlling the cancer.

A number of different staging systems are used by doctors. A simplified version of one of the common systems used is outlined below.



Stage 1 – the cancer is still contained within the lining of the bowel or rectum



Stage 2 – the cancer has spread beyond the layer of muscle surrounding the bowel and may have penetrated the surface covering the bowel or nearby organs



Stage 3 – the cancer has spread into nearby lymph nodes



Stage 4 – the cancer has spread beyond the bowel into another part of the body, such as the liver



There are three grades of bowel cancer:



Grade 1 is a cancer that grows slowly and has a low chance of spreading beyond the bowel



Grade 2 is a cancer that grows moderately and has a medium chance of spreading beyond the bowel



Grade 3 is a cancer that grows rapidly and has a high chance of spreading beyond the bowel



If you are not sure what stage or grade of cancer you have, ask your doctor.

 

 Treating bowel cancer  

Surgery is usually the main treatment for bowel cancer, and may be combined with chemotherapy, radiotherapy or biological treatments, depending on your particular case.

The treatments recommended for you will depend on which part of your bowel is affected and how far the cancer has spread, but surgery is usually the main treatment.

If it's detected early enough, treatment can cure bowel cancer and stop it coming back. Unfortunately, however, a complete cure is not always possible and there is sometimes a risk that the cancer could recur at a later stage.

In more advanced cases that cannot be removed completely by surgery, a cure is highly unlikely. However, symptoms can be controlled and the spread of the cancer can be slowed using a combination of surgery, chemotherapy, radiotherapy and biological treatments where appropriate.

 

 Your treatment team 

If you are diagnosed with bowel cancer, you will be cared for by a multidisciplinary team – including a specialist cancer surgeon, an oncologist (a radiotherapy and chemotherapy specialist), a radiologist and a specialist nurse.  

When deciding what treatment is best for you, your care team will consider the type and size of the cancer, your general health, whether the cancer has spread to other parts of your body and how aggressive the cancer is.

 

 


 Surgery for colon cance r  hide



If colon cancer is at a very early stage, it may be possible to remove just a small piece of the lining of the colon wall. This is known as local excision.

If the cancer spreads into muscles surrounding the colon, it will usually be necessary to remove an entire section of your colon. Removing some of the colon is known as a colectomy.

There are two ways a colectomy can be performed:



an open colectomy – where the surgeon makes a large incision in your abdomen and removes a section of your colon



a laparoscopic (‘keyhole') colectomy – where the surgeon makes a number of small incisions in your abdomen and uses special instruments guided by a camera to remove a section of colon



During surgery, nearby lymph nodes are also removed. It is usual to join the ends of the bowel together after bowel cancer surgery, but very occasionally this is not possible and a stoma (see below) is needed.

Both open and laparoscopic colectomies are thought to be equally effective in removing cancer and have similar risks of complications. Laparoscopic colectomies, however, have the advantage of a faster recovery time and less post-operative pain and this is becoming the routine way of doing most of these operations.

Laparoscopic colectomies should be available in all hospitals carrying out bowel cancer surgery, although not all surgeons perform this type of surgery. Discuss your options with your surgeon to see if the laparoscopic method can be done.

 





Surgery for rectal cancer show



There are a number of different types of operation that can be carried out to treat rectal cancer, depending on how far the cancer has spread.

Some of the main techniques used are described below.

 

Local resection

If you have a very small, early stage rectal cancer, your surgeon may be able to remove it in an operation called a local resection (trans anal resection).

The surgeon puts an endoscope (a flexible tube with a light) in through your back passage and removes the cancer from the wall of the rectum.

 

Total mesenteric excision

In many cases, however, a local resection is not possible. Instead, a larger area of the rectum will need to be removed, along with a border of rectal tissue around it that is free of cancer cells and fatty tissue from around the bowel (known as the mesentery). This type of operation is known as total mesenteric excision (TME).

Removing the mesentery can help ensure all the cancerous cells are removed, which can lower the risk of the cancer recurring at a later stage.

Depending on exactly where in your rectum the cancer is located, one of two main TME operations may be carried out. These are outlined below.

Low anterior resection

Low anterior resection is a procedure used to treat cases where the cancer is in the upper section of your rectum.

The surgeon will make an incision in your abdomen and remove the upper section of your rectum, as well as some surrounding tissue to make sure any lymph glands containing cancer cells are also removed.

They will then attach your colon to the lowest part of your rectum or upper part of the anal canal. Sometimes, they turn the end of the colon into an internal pouch to replace the rectum. You will probably require a temporary stoma (see below) to give the joined section of bowel time to heal.

Abdominoperineal resection

Abdominoperineal resection is used to treat cases where the cancer is in the lowest section of your rectum. In this case, it will be necessary to remove the whole of your rectum and surrounding muscles to reduce the risk of the cancer re-growing in the same area.

This involves removing and closing the anus and removing its sphincter muscles too, so there is no option except to have a permanent stoma after the operation. Bowel cancer surgeons always do their best to avoid giving people permanent stomas wherever possible.

 





Stoma surgery show



Where a section of the bowel is removed and the remaining bowel joined, the surgeon may sometimes decide to divert your stool away from the join to allow it to heal. The stool is temporarily diverted by bringing a loop of bowel out through the abdominal wall and attaching to the skin – this is called a stoma. A bag is worn over the stoma to collect the stool.

Where the stoma is made from small bowel (ileum) it is called an ileostomy and where it is made from large bowel (colon) it is called a colostomy. 

A specialist nurse, known as a stoma care nurse, is usually available to advise you, prior to surgery, on the best site for a stoma. The nurse will take into account factors such as your body shape and lifestyle, although this may not be possible where surgery is performed in an emergency. During the first few days post surgery the stoma care nurse will advise on the care necessary to look after the stoma and the type of bag suitable.

Once the join in the bowel has safely healed, which can take several weeks, the stoma can be closed during further surgery. In some people, for various reasons, re-joining the bowel may not be possible or may lead to problems controlling bowel function and therefore the stoma may become permanent.

Before having surgery, the care team will advise whether it may be necessary to form an ileostomy or colostomy and the likelihood of this being temporary or permanent.

For anyone wishing to obtain further information about living with a stoma, there are patient support groups which provide support for patients who may have just had or are due to have, a stoma. You can obtain details through your stoma care nurse or visit them online for further information.

These include:



Ileostomy and Internal Pouch Support Group – this organisation provides a unique visiting service for anyone wishing to speak with someone who has been through similar surgery



The Colostomy Association



 





Side effects of surgery show



Bowel cancer operations carry many of the same risks as other major operations, including the risks of bleeding, infection, developing blood clots or heart or breathing problems. 

The operations all carry a number of risks specific to the procedure.

One risk is that the joined up section of bowel may not heal properly and may leak inside your abdomen. This is usually only a risk in the first few days after the operation.

Another risk is for people having rectal cancer surgery. The nerves controlling passing urine and sexual function are very close to the rectum, and sometimes an operation to remove a rectal cancer can damage these nerves.

After rectal cancer surgery most people need to go to the toilet to open their bowels more often than before, although it usually settles down within a few months of the operation.


 




Radiotherapy show



There are two main ways that radiotherapy can be used to treat bowel cancer. It can be given before surgery to shrink rectal cancers and increase the chances of complete removal, or used to control symptoms and slow the spread of cancer in advanced cases (called palliative radiotherapy).

Radiotherapy given before surgery for rectal cancer can be performed in two ways:



external radiotherapy – where a machine is used to beam high-energy waves at your rectum to kill cancerous cells



internal radiotherapy (also known as brachytherapy) – where a radioactive tube is inserted into your anus and placed next to the cancer to shrink it



External radiotherapy is usually given daily, five days a week, with a break at the weekend. Depending on the size of your tumour, you may need one to five weeks of treatment. Each session of radiotherapy is short and will only last for 10-15 minutes.

Internal radiotherapy can usually be performed in one session before surgery is carried out a few weeks later.

Palliative radiotherapy is usually given in short, daily sessions, with a course ranging from two to three days to 10 days.

Short-term side effects of radiotherapy can include:



feeling sick



fatigue



diarrhoea



burning and irritation of the skin around the rectum and pelvis (this looks and feels like sunburn)



a frequent need to urinate



a burning sensation when passing urine



These side effects should pass once the course of radiotherapy has finished. Tell your care team if the side effects of treatment become particularly troublesome. Additional treatments are often available to help you cope better with the side effects.

Long-term side effects of radiotherapy can include:



a more frequent need to pass urine or stools



blood in your urine and stools



infertility



in men, erectile dysfunction



If you want to have children, it may be possible to store a sample of your sperm or eggs before treatment begins so they can be used in fertility treatments in the future.

 





Chemotherapy show



There are three ways chemotherapy can be used to treat bowel cancer. It can be given before surgery for rectal cancer in combination with radiotherapy to shrink a tumour, after surgery to reduce the risk of the cancer recurring, or to slow the spread of advanced bowel cancer and help control symptoms (palliative chemotherapy).

Chemotherapy for bowel cancer usually involves taking a combination of medications that kill cancer cells. They can be given as a tablet (oral chemotherapy), through a drip in your arm (intravenous chemotherapy), or as a combination of both. Treatment is given in courses (cycles) each two to three weeks long, depending on the stage or grade of your cancer.

A single session of intravenous chemotherapy can last from several hours to several days.

Most people having oral chemotherapy take tablets over the course of two weeks before having a break from treatment for another week.

A course of chemotherapy can last up to six months depending on how well you respond to the treatment. In some cases it can be given in smaller doses over longer periods of time (maintenance chemotherapy).

Side effects of chemotherapy can include:



fatigue



feeling sick



vomiting



diarrhoea



mouth ulcers



hair loss with certain treatment regimens, but this is generally uncommon in the treatment of bowel cancer       



a sensation of numbness, tingling or burning in your hands, feet and neck



These side effects should gradually pass once your treatment has finished.

It usually takes a few months for your hair to grow back if you experience hair loss.

Chemotherapy can also weaken your immune system, making you more vulnerable to infection. Inform your care team or GP as soon as possible if you experience possible signs of an infection, including a high temperature (fever) or a sudden feeling of being generally unwell.

Medications used in chemotherapy can cause temporary damage to men's sperm and women's eggs. This means that for women who become pregnant or for men who father a child, there is a risk to the unborn baby’s health. Therefore, it is recommended you use a reliable method of contraception while having chemotherapy treatment and for a period after your treatment has finished.

 





  Biological treatments   show



Biological treatments, including cetuximab, bevacizumab and panitumumab, are a newer type of medication also known as monoclonal antibodies.

Monoclonal antibodies are antibodies that have been genetically engineered in a laboratory. They target special proteins found on the surface of cancer cells, known as epidermal growth factor receptors (EGFR). As EGFRs help the cancer to grow, targeting these proteins can help shrink tumours and improve the effect and outcome of chemotherapy.

Biological treatments are therefore usually used in combination with chemotherapy when the cancer has spread beyond the bowel (metastatic bowel cancer).

These treatments are not available to everyone with bowel cancer. The National Institute for Health and Care Excellence (NICE) has determined specific criteria which need to be met before they can be prescribed.

Cetuximab is only available  when:



surgery to remove the cancer in the colon or rectum has been carried out or is possible



bowel cancer has spread to the liver and cannot be removed surgically



a person is fit enough to undergo surgery to remove the cancer from the liver if this becomes possible after treatment with cetuximab



Cetuximab, bevacizumab and panitumumab are available through a government scheme called Cancer Drugs Fund. All these medications are also available privately but are very expensive.







Clinical commissioning groups (CCGs) are organisations that organise the delivery of services in England. They play a major role in achieving good health outcomes for the local population that they serve.

You can now check how your local CCG compares against others for bowel cancer survival (PDF, 900 Kb).




 

 


 Living with bowel cancer  

Bowel cancer can affect your daily life in different ways, depending on what stage it is at and what treatment you are having.

How people cope with their diagnosis and treatment varies from person to person. There are several forms of support available if you need it. Not all of them work for everybody, but one or more of them should help:



talk to your friends and family – they can be a powerful support system



communicate with other people in the same situation – for example, through bowel cancer support groups (see links below)



find out as much as possible about your condition



do not try to do too much or overexert yourself



make time for yourself



 

 


 Talk to others   hide



Your GP or nurse may be able to reassure you if you have questions, or you may find it helpful to talk to a trained counsellor, psychologist or specialist telephone helpline operator. Your GP surgery will have information on these.

Some people find it helpful to talk to others with bowel cancer at a local support group or through an internet chat room.

Beating Bowel Cancer offers support services to people with bowel cancer. For example, they run a nurse advisory line on 08450 719 301 that is available from 9am to 5:30pm on Monday to Thursday, and from 9am to 4pm on Fridays. You can email a nurse at nurse@beatingbowelcancer.org.

The organisation also runs a national patient-to-patient network for people affected by bowel cancer – and their relatives – called Bowel Cancer Voices.

 





  Your emotions   show



Having cancer can cause a range of emotions. These may include shock, anxiety, relief, sadness and depression.

Different people deal with serious problems in different ways. It is hard to predict how knowing you have cancer will affect you. However, you and your loved ones may find it helpful to know about the feelings that people diagnosed with cancer have reported.

 





  Recovering from surgery   show



Surgeons and anaesthetists have found that using an enhanced recovery programme after bowel cancer surgery helps patients recover more quickly.

Most hospitals now use this programme. It involves giving you more information before the operation about what to expect, avoiding giving you strong laxatives to clean the bowel before surgery, and in some cases giving you a sugary drink two hours before the operation to give you energy. 

During and after the operation, the anaesthetist controls the amount of IV fluid you need very carefully, and after the operation you will be given painkillers that allow you to get up and out of bed by the next day.

Most people will be able to eat a light diet the day after their operation.

To reduce the risk of deep vein thrombosis (blood clots in the legs), you may be given special compression stockings that help prevent blood clots, or a regular injection with a blood thinning medication called heparin until you are fully mobile.

A nurse or physiotherapist will help you get out of bed and regain your strength so you can go home within a few days.

With the enhanced recovery programme, most people are well enough to go home within a week of their operation. The timing depends on when you and the doctors and nurses looking after you agree you are well enough to go home.

You will be asked to return to hospital a few weeks after your treatment has finished so tests can be carried out to check for any remaining signs of cancer. You may also need routine check-ups for the next few years to look out for signs of the cancer recurring.

 





  Diet after bowel surgery   show



If you have had part of your colon removed, it is likely that your stools (faeces) will be looser because one of the functions of the colon is to absorb water from the stools. This may mean that you need to go to the toilet more often to pass loose stools.

You should inform your care team if this becomes a problem, because medication is available to help control it.

You may find some foods upset your bowels, particularly during the first few months after your operation.

Different foods can upset different people, but food and drink that is commonly known to cause problems include fruit and vegetables that are high in fibre, such as beans, cabbages, apples and bananas, and fizzy drinks, such as cola and beer.

You may find it useful to keep a food diary to record the effects of different foods on your bowel.

If you find that you are having continual problems with your bowels as a result of your diet, and/or you are finding it difficult to maintain a healthy diet, you should contact your care team. You may need to be referred to a dietitian for further advice.

 





  Living with a stoma   show



If you need a temporary or permanent stoma with an external bag or pouch, you may feel worried about how you look and how others will react to you.

Information and advice about living with a stoma (including stoma care, stoma products and ‘stoma-friendly’ diets) is available on the ileostomy and colostomy topics.

For anyone wishing to obtain further information about living with a stoma, there are patient support groups who provide support for people who may have had, or are due to have, a stoma. You can obtain details through your stoma care nurse or visit them online for further information.

These include:



Ileostomy and Internal Pouch Support Group – this organisation provides a unique visiting service for anyone wishing to speak with someone who has been through similar surgery



The Colostomy Association



 





  Sex and bowel cancer    show



Having cancer and its treatment may affect how you feel about relationships and sex. Although most people are able to enjoy a normal sex life after bowel cancer treatment, if you have stoma you may feel self-conscious or uncomfortable.

Talking about how you feel with your partner may help you both to support each other. Or you may feel you’d like to talk to someone else about your feelings. Your doctor or nurse will be able to help.

 





  Financial concerns   show



A diagnosis of cancer can cause money problems because you are unable to work or someone you are close to has to stop working to look after you. There is financial support available for carers and for you if you have to stay off work for a while or have to stop work because of your sickness. 

Free prescriptions

People being treated for cancer are entitled to apply for an exemption certificate giving free prescriptions for all medication, including medication to treat unrelated conditions.

The certificate is valid for five years and you can apply for a certificate by speaking to your GP or cancer specialist.

 





  Dealing with dying    show



If you are told there is nothing more that can be done to treat your bowel cancer, your GP will still provide you with support and pain relief. This is called palliative care. Support is also available for your family and friends.

 

  Preventing bowel cancer   

There are some things that increase your risk of bowel cancer that you can't change, such as your family history or your age.

However, there are several ways you can lower your chances of developing the condition.

  Diet  

Research suggests that making changes to your diet can help reduce your risk of bowel cancer.

It may help to prevent bowel cancer if you eat:



less cured and processed meat such as bacon, sausages and ham



less red meat (see below) and more fish



more fibre from cereals, beans, fruit and vegetables



The Department of Health advises people who eat more than 90 grams (cooked weight) of red and processed meat a day to cut down to 70 grams to help reduce their bowel cancer risk. 

 

  Exercise  

There is strong evidence to suggest regular exercise can lower the risk of developing bowel and other cancers.

It is recommended adults exercise for at least 150 minutes (2 hours and 30 minutes) of moderate-intensity aerobic activity (such as cycling or fast walking) every week.

 

  Healthy weight  

Being overweight or obese increases your chances of developing bowel cancer, so you should try to maintain a healthy weight if you want to lower your risk

Changes to your diet and an increase in physical activities will help keep your weight under control.

 

  Stop Smoking  

If you smoke, stopping can reduce your risk of developing bowel and other cancers.

The free Smoking Helpline can offer advice and encouragement to help you quit smoking. Call 0300 123 1044 or visit the  Smokefree website.

Your GP or pharmacist can also provide help, support and advice if you want to give up smoking.

 

  Cut down on alcohol  

Drinking alcohol has been linked to an increased risk of developing bowel cancer, so you may be able to reduce your risk by cutting down on the amount of alcohol you drink.

The current recommendations concerning alcohol are:



men should not regularly drink more than 3-4 units of alcohol a day



women should not regularly drink more than 2-3 units a day



if you've had a heavy drinking session, avoid alcohol for 48 hours



 

  Bowel cancer screening  

Although screening cannot stop you getting bowel cancer, it can allow the condition to be detected at an earlier stage, when it is much easier to treat.

As well as making lifestyle changes to reduce your risk of bowel cancer and keeping an eye out for possible symptoms of bowel cancer, participating in bowel cancer screening when it is offered can help reduce your chances of dying from bowel cancer.

In England, bowel cancer screening is currently offered to everyone aged 60 to 74 who is registered with a GP.

 

  Screening for bowel cancer  

Bowel cancer is the fourth most common cancer in the UK. If it's detected at an early stage, before symptoms appear, it's easier to treat and there's a better chance of surviving it.

To detect cases of bowel cancer sooner, the offers two types of bowel cancer screening to adults registered with a GP in England:



All men and women aged 60-74 are invited to carry out an FOB (faecal occult blood) test at home. They're sent the home test kit every two years through the post, until they reach the age of 74. The FOB test checks for the presence of blood in a stool sample, which could be an early sign of bowel cancer. If you are 75 or over, you can ask for this test by calling the freephone helpline on 0800 707 60 60.



An additional one-off test called bowel scope screening is gradually being introduced in England. This is offered to men and women at the age of 55. As of March 2015, about two thirds of screening centres were beginning to offer this test to 55 year olds. It involves a doctor or nurse using a thin flexible instrument to look inside the lower part of the bowel and remove any small growths, called polyps, that could eventually turn into cancer.



Taking part in bowel cancer screening reduces your chances of dying from bowel cancer, and removing polyps in bowel scope screening can prevent cancer. However, all screening involves a balance of potential harms, as well as benefits. It's up to you to decide if you want to have it.

To help you decide, read our pages on bowel cancer screening, which will explain what the two tests involve, what the different possible results mean, and the potential risks for you to weigh up.
Colorectal cancer