About the Author
KATHLEEN OGLE, MD, author of the Foreword, is the medical oncologist at Hennepin County Medical Center in Minneapolis, Minnesota. She lives in Minneapolis.
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Positive Options for Colorectal CancerSelf-Help and Treatment
By Carol Ann Larson
Hunter House Inc., PublishersCopyright © 2005 Carol Larson
All right reserved.
Chapter OneFacing the Unknown
You probably know very little about your colon. Who does? It's like using the plumbing in your house: We rely on it daily, yet most of us don't really know how it works.
Here are the basics: The colon is the large intestine or large bowel (see Figure 1 on page 6). It is approximately three inches in diameter and five feet long. Its job is to absorb water and work like a trash compactor, forming waste matter that can be eliminated through the anus. The beginning of the colon lies just past the ileum. It snakes its way up the right side of the lower abdomen, across, and down the left side, to the sigmoid colon, and then it joins the rectum.
What Is Colorectal Cancer?
Rectal cancers are found in the last six inches of the digestive tract, and colon cancers occur above the rectum, but both rectal and colon cancers are commonly called colorectal cancers. Colorectal cancers develop slowly over the years and most of them begin as polyps, flat or grapelike growths that can be detected using either a colonoscope or a sigmoidoscope. Not all polyps are malignant (cancerous). Colorectal cancer canbe easily treated in its early stage. If discovered early enough, minor malignancies can be eliminated during certain tests without further surgery. That's the good news.
The bad news is that a person with colorectal cancer may not have any of the common symptoms, or the signs may be so subtle they go unnoticed. Symptoms can masquerade as other problems, such as ulcers or gastric (stomach) upsets. The only way to be sure is to undergo screening for colorectal cancer.
The symptoms of colorectal cancer are varied and are easily missed. You may or may not have bleeding, or there may be only traces of blood in your stools. The feeling of general stomach discomfort may be minor.
Symptoms may be related to how far the disease has progressed and the area where the cancer is located. Abdominal cramping and loss of weight, for instance, might be a product of cancer on the right side of the colon (that is, in the portion of the colon on the right side of the torso, also called the ascending colon), while problems with constipation and diarrhea might indicate cancer on the left side (also called the descending colon, because the contents of the colon are descending toward the rectum and anus). A sense of rectal fullness or a change in the appearance of the stools may signify rectal cancer.
You should not ignore any of the following symptoms:
* any significant change in bowel habits, such as persistent diarrhea or constipation * a narrowing of the stools * bleeding * abdominal pain that is unexplained * bloating * fatigue
Paying Attention to Symptoms
When a person is facing an unknown disease, any fear they feel becomes magnified by silence. Some people are so convinced that cancer is a death sentence that they become fatalistic and believe there is nothing they can do. With increasing anxiety, they avoid seeking treatment as long as possible. Other people who experience rectal bleeding attribute it to hemorrhoids. If the bleeding stops, they nervously assume there was no problem and might assume there is no need for further investigation, hoping the problem will go away. These attitudes can just add to the stress level in the long run. Denial can be deadly if it prevents you from getting help.
In my case, the awareness of danger began like a faint siren, hardly noticeable but demanding attention. I was fifty-eight and wondering why I'd been having minor spotting of blood from my rectum for almost a month. The week before a vacation is always grueling, and my job as a high-school teacher in an alternative program was not an easy one, but as much as I tried to tell myself that the physical symptoms, such as spotting, were just "natural," some ancient wisdom inside of me was telling me this was not the case. The blood was bright red, and didn't that mean it wasn't dangerous? Still, I knew it was something I hadn't experienced before, and finally I could make no more excuses.
On my way to a party, I stopped to see a doctor at an urgent-care facility. When he examined me, my worst fears were confirmed. His direct eye contact signaled he was serious about what he was going to say and that there was not going to be an easy fix.
"Any kind of unexplained bleeding is a red flag," he said. "You need to call your doctor right away Monday morning and schedule a colonoscopy. Don't let them lose any time getting you in."
I was stunned. Everything in my life changed. I felt that I had suddenly come up against a barrier and was being directed urgently into unfamiliar territory. It felt like a flashing yellow signal was declaring:
DETOUR You may have colorectal cancer. Proceed cautiously. Your life may be in danger.
At that moment, without a map, I became sick with fear more than anything else. I felt frustrated and alone, unsure about what I should do. I'd never questioned it before, but now I became aware of my mortality. I knew my health was at risk, and I knew I wanted to survive. I had to face the fact that I might have colorectal cancer, a disease I knew nothing about.
The problem was that no one I knew talked about colorectal cancer, and that made it even more frightening to me. Relatives from both sides of my family had struggled with the disease, but I didn't know what they'd gone through because it was politely hushed up and avoided as a topic of conversation. I wanted to prepare myself for what I was going to have to endure. I needed more information.
I was referred to a gastroenterologist, a doctor who specializes in disorders of the digestive tract, and the following week I went in for a colonoscopy. The doctor found three polyps and removed them immediately. It was lucky for me that he did. The biopsy revealed that two of the polyps were malignant. Though I found out later that the cancer had spread to my lymph nodes, I would probably not be alive today if I had waited longer to go to a doctor.
* * *
Knowing the early warning signs of colorectal cancer can help a person catch the disease before it has gone too far, as the story below illustrates.
Jane was in her forties when she noticed subtle, gradual changes in her bowel habits. Like most women she knew, she questioned whether an irregularity was due to something she had eaten or to what is now termed irritable bowel syndrome. Those seemed like reasonable explanations to her. But in the back of her mind she wondered if it was something more. She knew colon cancer ran in her family. Her father had been diagnosed with colorectal cancer at the age of sixty-eight. So she kept watching.
Jane also knew from her experience as an oncology nurse that, tragically, many cancers are not caught in time. Many of her patients either discounted their symptoms due to ignorance or fear, or their physicians discounted them. Many went to their deaths consumed with regret for having lacked the courage to speak up or to seek a second opinion. Jane's awareness paid off. She had a moment of reckoning in the cramped quarters of a hospital employee restroom. She remembers, "I was consumed with pain, holding onto the walls for support, resorting to Lamaze breathing to have a bowel movement. All I could think about was 'What's wrong with this picture?' I couldn't deny it anymore. This was not normal." At her next OB/GYN physical, she mentioned her periodic difficulty having a bowel movement and the change in her stool's color, texture, and frequency. Since a younger sister had recently undergone gall bladder surgery, the physician ordered an ultrasound and blood work. Later, a reassuring phone call from the doctor's office announced that everything was "okay." Jane was told she was just "a little anemic." Her search for an accurate diagnosis would have ended there if Jane had not continued it. Physically, she was not convinced that everything was okay. She found a highly regarded general practitioner and asked for help. Without hesitation, the doctor recommended a colonoscopy, because of her symptoms and family history. That intervention changed her life. As Jane recalls, "The procedure was performed on April Fool's Day. When I was shown the pictures, I knew this was no joke, but something very serious. Following a colon resection for adenocarcinoma (a type of cancer), I received the encouraging news that I was lucky. The cancer had not spread through the intestinal wall or to my lymph nodes. I surrendered eight inches of colon and gained hope the length of a lifetime." It is possible that working in health care may have given Jane an edge in discovering her cancer in its early stages. But she believes that taking responsibility for knowing her body and reporting her concerns is what really made a difference to her survival. "We all have instincts," Jane says. "We just have to listen to and honor them with action."
Basic Screening Tests for Colorectal Cancer
The American Cancer Society has issued the following guidelines for men and women who are over fifty and not in a high-risk group for colorectal cancer:
* an annual fecal occult blood test, in combination with a sigmoidoscopy every five years * a barium enema every five years if a colonoscopy is not feasible * a colonoscopy every ten years
The screening guidelines for people who are in a high-risk group or increased-risk group are determined by the doctor and change depending on the circumstances. A person in a high-risk group is someone who has a family history, or known heredity, of colorectal cancer. A person in an increased-risk group has one close relative with colorectal cancer before the age of sixty or two close relatives with colorectal cancer at any age.
If there are no known problems, the general guidelines for screening people in high-risk or increased-risk groups are a colonoscopy every three to five years beginning at age forty.
Let's take a look at each of the four tests listed above:
The fecal occult blood test is a chemical (laboratory) test that can detect microscopic evidence of blood in the stool. Usually you take this test by bringing a kit home, obtaining a sample of your stool, and placing it on a treated card. The test is easy to take and relatively inexpensive, but some cancers and polyps may go undetected if they are not bleeding at the time of the test, and some foods or medications may affect the results. To get an accurate reading, your doctor will give you specific instructions on medicinal and dietary restrictions before you take this test.
In the future, colorectal cancers and precancerous tumors may be detected through a similar test that reveals abnormal DNA in stool samples.
A sigmoidoscopy is a visual examination of the lining of the lower colon and rectum (the last two feet of the intestine). The last part of the colon is S-shaped and is called the sigmoid colon. Using a thin, lighted tube called a flexible sigmoidoscope, the doctor will examine thirty inches of your lower colon and rectum. By pumping air into the tube, the doctor is also able to see the lining of the colon. The entire test takes less than ten minutes. The air pumped into the tube might cause some minor cramping, not unlike the feeling just before a bowel movement. You might find that deep breathing and relaxation exercises can help you relax to some degree (for one such exercise, see page 18). It can also be helpful to count out the seconds during the most uncomfortable part.
The preparation for a sigmoidoscopy is simpler and less uncomfortable than it is for a colonoscopy. Usually you are required to drink only clear liquids for twelve to twenty-four hours prior and to take two Fleet enemas two hours before the examination. The payoffs of such an exam far outweigh any discomfort you might experience. For people of average risk, the test will reveal up to 70 percent of all polyps in the colon. If anything looks suspicious, the doctor can remove some tissue, biopsy it, and send it to a lab for testing.
The double-contrast barium enema is an X-ray examination of the entire rectum and colon. In this test, barium, a chalklike substance that shows up white on X rays, is usually given as an enema to coat the bowel wall, helping doctors to detect abnormalities that might indicate the presence of colorectal cancer. While taking this test you may experience cramping, like the need to evacuate your bowel, but the test is safe and does not require sedation. The disadvantages of this test are that it detects problems with only a 50 to 80 percent accuracy rate and can only be used for diagnosis. If polyps are discovered, tissue samples must be removed through some other means. This type of test is commonly used as a substitute if a colonoscopy is not possible because of some other problem.
A colonoscopy is the gold standard of colorectal tests. The advantage of a colonoscopy is that it enables the doctor to see the entire colon by inserting a long, flexible tube linked to a video camera and a display unit. The test is usually done on an outpatient basis in a hospital and is performed while the patient is sedated. If a polyp is discovered, it can be painlessly removed right then and there. A sample is then sent to a lab to be examined under a microscope to determine if there is any malignancy. You should be able to get the test results within a few days.
Cleansing of the bowel before a colonoscopy is more involved and complete than it is for other tests. Doctors differ on the kind of preparation they want patients to do for a colonoscopy. Some want their patients to ingest an electrolyte-based solution that is mixed with a gallon of cold water, drinking an eight-ounce glass every ten minutes on the night before the test. One of the common names for this solution is "Go-Lytely," which is a misnomer if there ever was one. You can expect to be running to the bathroom quite often throughout the night before your colonoscopy, which is a good reason for replenishing your fluids the next day. Supposedly, if you drink the Go-Lytely cold, it will taste better. You may request an alternative two-glass version of sodium phosphate, which is much easier to endure, but some doctors prefer the Go-Lytely or something similar for a clearer picture.
Regardless, follow all directions and put discomfort behind you, so to speak, so you can check into the hospital the next morning with your colon fully cleansed. Since most colonoscopies are performed under sedation, the test is usually easier to take than the preparation. The anesthesia, generally injected into your arm, will relax you so that if you do experience some cramping, it will be minor. Since you are being sedated, you will need someone to drive you home after the test.
A colonoscopy is very safe, but there is a slight chance of tearing the bowel (one out of a thousand cases) or of excessive bleeding (three out of a thousand cases). It is also the most expensive of all the tests, so you need to check with your insurance company to see if it covers the procedure. (This is a good thing to do for any medical test.)
A virtual colonoscopy is a test that uses computer and radiology technology to simulate images of the complete colon on a screen without the use of an endoscope. (Endoscopy is the generic term for any procedure involving insertion of an instrument into an organ to view its interior, e.g., colonoscopy or sigmoidoscopy.) The accuracy of virtual colonoscopies has been good for larger polyps, but about 25 percent of polyps smaller than five millimeters in diameter may be missed. The test can only be used for diagnosis, and is especially useful if a colonoscopy is not possible. It requires the same bowel preparation as a regular colonoscopy. The gas pumped into the colon for the procedure can cause discomfort.
Excerpted from Positive Options for Colorectal Cancer by Carol Ann Larson Copyright © 2005 by Carol Larson. Excerpted by permission.
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Table of ContentsForeword
Chapter 1: Facing the Unknown
Chapter 2: Gathering Information
Chapter 3: Working with Medical Professionals
Chapter 4: Dealing with Your Feelings
Chapter 5: Making Decisions About Treatment
Chapter 6: Coping with Surgery
Chapter 7: The First Six Weeks After Surgery
Chapter 8: The Challenges of Chemotherapy
Chapter 9: Possible Complications After Treatment
Chapter 10: Lessons Learned