NEWS of the Leader of the Opposition, Dr Peter Phillips’s, stage three colon cancer diagnosis shocked the island last week with many people questioning the form of cancer and one’s chances of survival.
Dr Phillips has subsequently affirmed his faith in the Jamaican health system and is set to undergo further treatment to overcome the dreaded disease.
The Jamaica Observer, however, consulted with three medical doctors who gave insight on the disease and explained its manifestation, progression, and approaches for treatment.
None of these doctors are part of Dr Phillips’s medical team nor are they aware of any details of his medical history or management, past or present, other than that which is already in the public domain.
For the purpose of this article, the information presented are general facts related to colon cancer and intended for educational purposes only.
According to Dr Andre Williams, oncologist at Teshuva Wellness in St James, a mass or tumour can form in the colon if the process for regulating the shedding and regrowth of the lining of the colon is not coordinated, thus making it too thick.
“The colon [or large bowel] is the main exit pipe for waste leaving the body, in the form of stool. The lining of the pipe is regularly shed and must be replaced. If the process for regulating the shedding and regrowth is not coordinated, the lining can become too thick. If this continues unchecked, a mass or tumour can form,” Dr Williams said.
Dr Abdulra’uf Waziri from Nigeria further stated that stage three colon cancer ensues from the cancer spreading through the underlying mucosa of the colon affected and has spread to the underlying lymph nodes, but not to the distant sites of the body.
“This means there is no metastasis yet. The treatment involves surgery to remove the tumour followed by chemotherapy and radiation. In such stages, there is approximately a five-year survival rate,” Dr Waziri said.
He added: “Even the stage three is divided into three. There’s A, B and C. In 3A the tumour has grown to, or through the muscular layers of the colon and is found in nearby lymph nodes. It has not spread to the distant nodes or organs. In 3B the tumour has grown through the deepest layers of the colon, and penetrates the visceral peritoneum [layer that covers the abdomen] or invades other organs or structures, and is found in one to three lymph nodes, or the tumour is not grown through the outer layers of the colon wall, but is found in four or more nearby lymph nodes. Finally in stage 3C, the tumour has grown past the muscular layers of the colon and cancer is found in four or more nearby lymph nodes. However, there’s no metastasis to other organs like the lungs or the liver.”
Similarly Dr Dilip Dan, professor and head of surgery at The University of the West Indies, St Augustine, told the Sunday Observer that colon cancer is a malignant lesion that starts on the inner lining of the colon and progresses by growing through the wall of the colon, then spreads via the lymphatics to the lymph nodes and then to the liver, lungs, and other organs – distant metastasis.
“The rate of growth and spread can vary depending on the aggressiveness of the tumour. Rectal cancer is somewhat different, and carries a different work-up, treatment and prognosis,” he said, while also pointing out that in the case of colon cancer stages one and two are limited to the wall of the colon, stage three has spread to the lymph nodes and stage four has spread to outside of the region of the colon to include liver, lungs and other organs.
But how serious is this disease at stage three?
“Stage three is a later disease. It clearly does not have as good a prognosis as stages one or two, and requires further therapy with chemo to improve the prognosis. However, this does not necessarily spell doom and gloom. With treatment, and good follow-up, the five-year survival exceeds 40 per cent and can go up to 83 per cent.
Further, as it relates to symptoms, Dr Williams said common symptoms of colon cancer include abdominal pain, constipation (if the colon becomes blocked) and blood in the stool. However, the oncologist explained that depending on the location within the colon, colon cancer can be discovered in a patient who has had none of these symptoms.
Likewise, Dr Dan said while many patients present with symptoms like change in bowel habits (constipation, diarrhoea frequency ), symptoms of anaemia or bleeding and weight loss, many are asymptomatic (symptom-less) and this is the bigger challenge.
Dr Dan said: “Often times when symptoms do occur the cancer has already spread [metastasised]. Hence it is best to identify tumours early through screening.”
To test for colon cancer, Dr Dan said if a patient has symptoms and colon cancer is suspected, he or she should have a colonoscopy.
“This allows the identification of the tumour and biopsy, which will confirm the type of cancer and give an idea of aggressiveness based on further testing. It is recommended that screening takes place so that lesions can be identified early in asymptomatic persons. All patients by the age of 45 should start screening. This may include yearly stool testing for blood, colonoscopy every five to 10 years or a sigmoidoscopy and barium enema every five years. If there is a close family member with colon cancer, the first degree relatives should be tested 10 years younger than the patient was at diagnosis or at 45 if the patient is older than 55. If there is a confirmed genetic syndrome, testing is done even earlier and this will depend on the type of genetic syndrome,” Dr Dan said.
In relation to testing, Dr Williams said, “A very basic test would be a stool sample to check for blood in the stool. More specific tests would include imaging studies (such as a CT scan or barium enema), or a colonoscopy (inserting a video camera into the colon to directly visualise the lining).”
Should the colonoscopy return positive, Dr Dan said once the cancer is identified and confirmed on biopsy the patient should be staged and apart from the clinical examination, a CT scan of the chest, abdomen, and pelvis is required.
In addition, Dr Dan said blood work is required, one test being a CEA (carcinoembryonic antigen). He advised that staging is important as it determines the treatment and the prognosis, while in most cases, the CEA can be used to monitor the treatment progress.
With regards to age as a predisposing factor, Dr Dan highlighted that there is an increasing incidence of colon cancer with age and it used to be considered a disease of the elderly, however, now there is no age limit.
“…We are seeing sporadic colon cancer in patients in their 20s. Other risk factors include obesity, high-fat low-fibre diet, race – with higher incidence in Afro-Caribbean individuals – alcohol, diabetes, smoking. There is also a familial predisposition and inherited syndromes that place family members at high risk for developing colon cancer,” he said.
On the matter of age, Dr Williams, asserted that the prognosis or survival rate of colon cancer is primarily impacted by the stage.
“Earlier stages have a higher chance of survival, and the likelihood of long-term survival decreases with increasing stage. Several other parameters will also affect prognosis, including age, prior medical illnesses, and features specific to the tumour itself,” he said.
Furthermore, the treatment regime of colon cancer is dependent on the stage. According to Dr Dan, if the cancer is at stage one, two or three, treatment is primarily surgery with resection of a section of colon and the lymph node basin. Additionally, Dr Dan said for stage three patients and some stage two patients, chemotherapy is required.
In respect of the nature of the surgery, Dr Dan said it can be performed in the traditional open way, laparoscopic and even robotic. But, for patients with stage four disease, treatment is primarily chemotherapy and in many cases palliative care.
“Surgery is only used in stage four if there is obstruction or bleeding. There is a subset of stage four patients who may, if they have limited metastases, be considered for surgery to resect the primary tumour and the metastases. Rectal cancer is treated differently and may require radiation as part of the care,” he said.
As it pertains to the need for a colostomy, Dr Dan said, for colon cancer, once the surgery is being done electively there is usually no need to have a colostomy. However in the event of emergency obstruction, or perforation or major haemorrhage, Dr Dan said one may require a colostomy. He further explained that for rectal cancer, one may require a colostomy either as a temporary or permanent diversion if the tumour is very low.
Dr Williams shared similar points regarding the treatment of colon cancer dependent on the stages. He added that localised colon cancer is treated first with surgery to remove the mass as well as the healthy portions of the colon on either side of the mass.
“They (surgeons) also remove several lymph nodes for testing. All the removed specimens are sent to the lab for testing, to confirm a diagnosis of cancer. Provided that the diagnosis of cancer is confirmed, both in the mass and in the lymph nodes, the cancer will be classified as stage three disease. Stage three disease automatically prompts a recommendation of additional treatment with chemotherapy. Chemotherapy is used to destroy any remaining cancer that would not be visible to the naked eye during surgery,” Dr Williams said.
The chances of survival with colon cancer is also dependent on the stage of the cancer.
Dr Dan said: “Stage one and two colon cancer patients can expect a five-year survival of greater than 90 per cent, and hence can be potentially cured of the disease. Stage three, 40 to 83 per cent and stage four is less than 15 per cent five-year survival. The five-year survival is the reference used to compare the expected survival in a similar group of persons without the disease. Rectal cancer in general carries a lower prognosis than colon cancer.”
Dr Williams said, “Based on the staging system, one can see that colon cancer is easier to treat in the earlier stages (stages one and two), when the disease is limited to the colon itself. These early stages can be treated quite successfully with surgery only, though some situations require additional chemotherapy treatment as an added precaution.”
But will one’s body work normally following chemotherapy for colon cancer?
“Once the tumour is resected and the joining performed [anastomosis], once there are no complications, bowel function returns in a couple days and a regular diet is given. Recovery is faster with laparoscopic versus open surgery. One may experience loose stools early on but this will regularise with time. Chemotherapy has its own set of risks and these will be explained by the oncologists. Usually the course of chemo required for stage three disease is six to nine months and these can be given intravenously and oral,” Dr Dan explained.
Regarding bodily function after chemotherapy, Dr Williams said,”Several factors will impact how well the body functions after surgery/chemotherapy. Patient-related factors include age, the absence of other medical illnesses, and nutritional status. Treatment-related factors include the type of surgery required, and potential side effects of the chemotherapy medications.”
Meanwhile, following treatment, patients have to be followed closely to ensure they remain in good health.
“…The patients have to be followed up to identify new tumours or recurrence. This will take the form of history and physical, blood tests, CT scans and colonoscopy. There are guidelines for the follow- up and patients are generally followed very closely for the first five years and continue to be followed for life. Family members must also be screened,” Dr Dan said.
Dr Williams gave similar advice, stating that the patient has to be carefully evaluated throughout the course of chemotherapy treatment, which includes repeating blood tests and imaging studies at the end of all treatments, to determine if there is any remaining cancer in the body.
Regarding lifestyle changes, Dr Williams said it depends entirely on the patient-related and treatment related factors prior to the diagnosis, however, Dr Dan said changes will likely include following a healthy diet plan, with exercise, avoiding alcohol and smoking and understanding your body so that you can detect changes early.
Despite treatment and care, there is always a risk of cancer returning and with colon cancer Dr Dan said patients are at an increased risk for developing a second or third cancer of the colon.
“The risk of recurrence is related to the stage of the tumour and the aggressiveness as well. Hence the reason to continue the follow-up for life.,” Dr Dan said.
Dr Williams, however, maintained that the interventions made by the surgical and oncology teams help to reduce this risk and the successfully treated patient, would then have regular check-ups, to rule out any recurrence of the cancer.
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