In Pennsylvania this year, we can expect over 8,000 new cases. In our community hospital practice, we see an average of two new patients a week with colon cancer. Only lung cancer takes a greater toll.

Being told you have cancer of the colon is a frightening experience, especially if you are unaware of the many recent improvements that have been made in cancer treatment. Often people are shocked at hearing the word "cancer" and may not hear anything else the doctor says. Most people, upon learning that they have cancer, are frightened. They are afraid of changes in personal relationships, job loss, surgery, pain, and death. These are normal feelings.

The best way to deal with this fear is to know what to expect. By understanding the illness and your treatment plan, you can start feeling in control of your life. This booklet has been written for those patients who have been diagnosed with colon cancer. Hopefully, it will help explain more about this illness and its treatment.

What Is Colon Cancer?
Cancer is a disease of the body's cells. The different tissues and organs inside our bodies are made of billions of tiny cells. These cells are so small that they can only be seen with a microscope. There are many different kinds of cells - some are muscle cells, some are skin cells, some are blood cells, some are cells that make up the colon.

As worn-out old cells die, they must be replaced. New cells are formed as healthy cells divide in two. This keeps the body in good repair. Sometimes, normal cells lose their ability to stop dividing. They divide too rapidly and grow without any order. These abnormal cells crowd out and destroy normal cells that the body needs. Too much tissue is produced and tumors begin to form. There are two kinds of tumors.

Benign (bee NINE) tumors are not cancer. The cells of a benign tumor can crowd out healthy cells, but they can not spread to other parts of the body. They are seldom a threat to life. Often, benign tumors can be removed by surgery.

Malignant (mah LIG nunt) tumors are cancer. Like a benign tumor, they can take over healthy cells, but they can also spread to other parts of the body. The cancer cells can separate from the tumor and travel through the bloodstream to other parts of the body. There they divide and grow and start new tumors made of malignant cells. However, cancer is not contagious. You can not give it to someone else.

There are more than 100 different types of cancer which can affect any part of the body. Colon cancer is a disease in which cancer cells are found in the tissues of the colon or rectum.

What Are The Symptoms?
Unfortunately, when colon cancer develops, there are usually few , if any, warning symptoms. In some cases, patients in our practice have had no warning signals or symptoms at all. It is really a silent disease. That is the biggest problem. The cancer can be in your colon for years before you notice any symptoms such as a change in bowel habits, rectal bleeding, abdominal pain, stools that are narrower than usual, or unexplained weight loss.

What Causes Colon Cancer?
The cause is not fully understood. Doctors can seldom explain why an individual develops colon cancer. In most cases, colon cancer is triggered by a complex interaction of several different factors. But, regardless of the cause, we have learned that cancer of the colon first develops as a small non-cancerous growth, or polyp. Normally the walls of the colon are smooth. For reasons not yet fully understood, some people develop these little "mushroom-like" growths on the inner surface of the intestinal wall. These polyps can occur anywhere in the colon. There are no symptoms. As time goes on, these small polyps may become larger and larger. Eventually, an uncontrolled growth of malignant cells may occur within a polyp. Left untreated this cancer can penetrate surrounding tissues and spread to other organs.

Certain factors may increase your risk of developing colon cancer. Your chance of developing colon cancer increases with age. Although young adults are occasionally affected, most colon cancer occurs in people after the age of 40. Contrary to some popular beliefs, both men and women are equally affected. Recently, scientists have identified a specific genetic mutation that may contribute to the risk of colon cancer. So, heredity is an important risk factor. Other factors such as insufficient fiber (roughage) in our diet may play a role in the formation of colon polyps and subsequent colon cancer.

How Is It Diagnosed?

If tissue that is not normal is found, the doctor will need to cut out a small piece and look at it under the microscope to see if there are any cancer cells. This is called a biopsy. Biopsies are usually painlessly done during a sigmoidoscopy or colonoscopy, in a doctor's office.

When colon cancer is found, your prognosis (chance of recovery) and choice of treatment depend on the stage of your cancer (whether it is just in the inner lining of your colon or if it has spread to other places) and your general state of health.

Stages of Colon Cancer
The colon is much like a hollow pipe made of three basic layers - a smooth inner lining, a wall of muscle and connective tissue, and an outer protective covering.

As mentioned, colon cancer initially starts in a polyp on the inner lining of the colon. This polyp may then turn cancerous. Like other types of cancer, this cancer can invade and destroy normal tissues. As the cancer grows, it penetrates the muscular wall and eventually breaks through the outer protective covering. Then it has the opportunity to spread to the lymph nodes. (Lymph nodes are small, bean-shaped structures that are found throughout the body. They produce and store cells that fight infection.) In time , the cancer cells will migrate to the liver and other organs.

Once cancer of the colon is found, more tests may be needed to find out if cancer cells have spread to other parts of the body. Your doctor needs to know the stage of your disease to plan treatment. The Dukes system, developed many years ago, is widely used to classify colon cancer into several stages:

There are treatments for all patients with cancer of the colon. The primary goal of therapy is to cure. We see many patients in our practice who have been cured of colon cancer years before. If cure is not possible, treatment is often still possible to achieve long term control of the illness and to manage the symptoms associated with cancer.

Three kinds of treatments are available:

• surgery - taking out the cancer.
• radiation therapy - using high-energy x-rays to kill cancer cells.
• chemotherapy - using special drugs to kill cancer cells.

Surgery

Surgery is the most common treatment for all stages of cancer of the colon. Surgery is an operation. The goal of surgery is to remove the part of the colon affected by cancer. Most patients express a fear that they will have to "wear a bag" (colostomy) after colon cancer surgery. In fact, most patients do not need a colostomy pouch after surgery.

Of course, surgery requires hospitalization and general anesthesia. After making an abdominal incision, the surgeon takes out the cancer and a small amount of healthy tissue around it. The healthy parts of the colon are then sewn together (anastomosis) with stitches or metal staples. This is much like repairing a garden hose by removing the bad section and splicing the good ends back together. The surgeon may also take out lymph nodes near the intestine and look at them under the microscope to see if they contain cancer.

Sometimes the colon cannot be sewn back together. Then, the surgeon makes an opening (stoma) on the outside of the abdomen for waste to pass out of the body, a colostomy. Sometimes, a colostomy is only needed until the colon has healed, and then it can be reversed. However, in about 15% of cases the cancer is located very close to the end of the rectum. In this case, the surgeon must take out the entire rectum to remove all of the cancer. Then, the colostomy is permanent.

If you have a colostomy, you will need to wear a special bag to collect body wastes. This special bag, which sticks to the skin around the stoma with a special glue, can be thrown away after it is used. This bag does not show under clothing, and most people take care of these bags themselves.

Radiation Therapy

Radiation therapy uses high-energy x-rays to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external radiation therapy) or from putting materials that contain radiation through thin plastic tubes (internal radiation therapy) in the intestine area for a short time. Radiation can be used alone or in addition to surgery and/or chemotherapy. To protect healthy cells, special lead shields are often used. The person who gets radiation treatment is not radioactive during or after treatment. None of the treatment can hurt those around you. Although radiation treatment is painless, it can cause side effects such as tiredness, diarrhea, skin rash, and nausea.

Chemotherapy

Chemotherapy uses special drugs to kill cancer cells. Chemotherapy may be taken by pill, or it may be put into the body by a needle in a vein. Chemotherapy is called a systemic treatment because the drug enters the bloodstream, travels through the body, and can kill cancer cells outside the colon.

If your doctor removes all the cancer that can be seen at the time of the operation, you may still be given chemotherapy after surgery to kill any cancer cells that may be left behind. Chemotherapy given after an operation to a person who has no remaining cancer cells that can be seen is called preventative, or adjuvant chemotherapy.

Treatment By Stage

Treatments for cancer of the colon depend on the stage of your disease, your age, and your general health. Your doctor will recommend treatment that is considered standard based on its effectiveness in a number of similar past cases as yours. But, each case is different. Not all patients are cured with standard therapy and some standard treatments may have more side effects than others. For these reasons, you should discuss the details with your doctor. If surgery alone is not sufficient, he may ask an oncologist (on KOL o jist) to take over your case. This is a doctor who specializes in treating cancer.

Pre-Cancerous Polyp - If found early, most colon polyps can be removed by outpatient colonoscopy without the need for major surgery. With mild sedation, the procedure is usually painless. Most patients are back to work in a few days. Occasionally, a few cancer cells are found in the tip of the polyp after removal. If there is no involvement of the polyp's stem, colonoscopic removal of polyp is usually felt to be sufficient. However, larger polyps and those with invasive cancer, require an open surgical procedure.

Stage A Colon Cancer - Treatment is usually surgery to remove the cancer. About 90% of patients with colon cancers discovered at this early stage can be cured by surgery alone.

Stage B1-2 Colon Cancer - Treatment is usually surgery to remove the cancer. If your tumor has spread to nearby tissue, you may also receive adjuvant chemotherapy or radiation therapy following surgery.

Stage C1-2 Colon Cancer - Treatment is usually surgery to remove the cancer often followed by chemotherapy. Radiation therapy is sometimes also used. Clinical trials are evaluating new combinations of chemotherapy drugs and radiation therapy.

Stage D Colon Cancer - Your treatment may be surgery to remove the cancer or to make the colon go around the cancer so that it can still work. In some cases surgery is performed to remove parts of other organs such as the liver, lungs, and ovaries, where the cancer may have spread. Chemotherapy and radiation therapy may be used to help relieve symptoms and prolong survival.

Recurrent Colon Cancer - If, after initial treatment, the cancer has come back (recurred) in only one part of the body, treatment may consist of another operation to take out the cancer. If the cancer has spread to several parts of the body, your doctor may give you either chemotherapy or radiation therapy. You may also choose to participate in a clinical trial testing new treatment programs.

Once your have recovered from surgery, chemotherapy may be begun if indicated. This is usually within 6 weeks after surgery. "Chemo" can be conveniently administered at the Sewickley Valley Oncology Clinic under the supervision of your oncologist. Each case is different. But on average, treatments are given over 6 to 12 months. This varies with each case and the patient's tolerance to treatment. Usually done as an outpatient, each visit takes about 2 to 3 hours.

As with any potent therapy, side effects can be expected. Chemotherapy works mainly on rapidly dividing cancer cells. But healthy cells, especially those that divide rapidly, can be harmed as well. This may cause unwanted side effects which are unpleasant but don't last forever. Most side effects are mild and can be limited with your doctor's help. They will go away gradually after treatment is stopped.

Your oncologist will work closely with your family doctor in planning your treatment plan, administering the "chemo," and following your response to treatment.

Follow Up Visits

Colon cancer can return at or near the site of original surgery, and it can spread to organs in other parts of the body. After initial therapy, a program of regular follow-up visits allows your doctors to evaluate your response to treatment and may help detect early recurrence of cancer. Patients treated for colon cancer also have a high risk of developing new colon polyps which could lead to another cancer in the colon. It is important for patients to be followed carefully, so that if these problems occur, they can be found and treated as early as possible.

A surveillance program usually includes physical examinations, blood tests and colonoscopy examinations. X-rays may be requested. These exams are done most frequently in the first five years after surgery when the risk of recurrent colon cancer is the highest.

Because this disease is often hereditary, it is also recommended that your blood relatives (brothers, sisters, and children) over the age of 40 consult with their physician about a program of periodic colon examinations. This may be lifesaving if a colon polyp is discovered and removed before cancer develops.

Additional Support While medical care is your most important concern, support services can help with other problems your or your family may face. Besides your doctor, there are many other places you can get information about cancer treatment and services to help you.

The Department of Social Services at your local hospital is trained to help cancer patients and their families. Working with your doctor at the Oncology clinic, their professional staff offers counseling to help the patient and family deal with the problems of having cancer. They can provide much needed emotional support. They can also assist with referrals to local and national agencies which help with your finances, getting to and from treatment, and care at home. The Sewickley Valley Hospital Ostomy Resource Nurse or the United Ostomy Association can help with colostomy training and supplies. The American Cancer Society offers many services to assist cancer patients.

The Future....

No one likes the thought of cancer. The very word "cancer" is frightening. The diagnosis of cancer may make you feel lonely, scared, angry, and sad. Those feelings are to be expected especially in the beginning. However, you are not alone. Much help is available.

Most cancers are treatable and research is constantly improving treatment of all cancers. Today, doctors know more than ever about how to fight cancer. Surgical techniques have improved. New drugs and other agents are working for many patients. Radiation treatment is stronger and more exact. Because of better cancer treatment, more patients are surviving cancer than ever before.

Good cancer care is a team effort, and you, the patient, are the most important part of the team. By working closely with your doctor, you can learn how to live with your illness so you can continue to do all those things that are part of your normal life. A positive attitude is very important. Try to stay as active as possible, even if it hurts a bit. Keep a sense of humor and a little faith. They can help you get through this ordeal. Remember, you are not alone. If you have any questions, do not hesitate to consult your doctor.