Tokushukai Medical Group

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Digestive System Surgery: Bowel Cancer

Numbers of affected is ranked as #1 among cancers.

Bowel cancer is a kind of malignancy developed in bowel, where food is digested and absorbed in stomach and small intestine, then water is absorbed from remaining food, lastly, they change into slops, and it takes the most part of the bowel malignancy.

Bowel is basically divided in, colon (blind gut, ascending colon, colon transverse, colon descendent, colon sigmoid), and rectum (rectosigmoid, rectum above the peritoneal reflection, lower rectum). Attaching with these including, appendix, anal canal, anal skin, cancer developed at each portion is bowel cancer. For example, bowel cancer developed in colon sigmoid is called as colon sigmoid cancer.

Bowel cancer is developed from the large-intestinal mucosa tissue in the most inside of bowel, together with its progress it breaks into deeper inside (T: invasion depth), moves from surrounding lymphatic node to gradually distanced lymphatic node (N: lymphatic node metastasis), or develop metastasis in liver or lung (M: distanced metastasis). As it is a cancer, if it is left uncured, it ends with death.

Regarding the development from bowel mucosa, there are; the one developed directly from mucosa, the one in which benignant polyp, named as adenoma, is increased then turned into cancer.

Recently, the numbers of bowel cancer patients are increasing, and according to 2015 Statistic, numbers of affected patients is #1, with 130 thousands. This is the most common cancer among Japanese. By gender, male is ranked at 4th, female is ranked at 2nd. Regarding the numbers of death, bowel cancer is ranked at 2nd following to lung cancer, and by gender, male is ranked at 3rd, and female is ranked at 1st.

Risk factor is alcoholic drink and obesity.

They say high aged and westernized meals are the cause of bowel cancer. Japan is a world leading country with long living people so that the numbers of cancer infected people also increases, and this is a common issue. Also, there is no question about living habit gives the large effect on this, for example, comparing Japanese living in Japan with Japanese living in western countries, cancer development rate is high in latter case, the data says. This means the circumstances gives a big effect on cancer development.

It is often heard that “we have cancer affected family member.” or “we are cancer oriented ancestry.”. But genetic contributor of cancer is said about 5%, so that the most of factors are depend on its own life style. Since meals, lifestyle habit and environment substances has stuck in years of life, certain gene gets hurt then tissue turns into cancer.

It is difficult to specify each patient individual cause of bowel cancer, excluding the part of genetic tumor like familial polyposis coli, and this won’t help any for post operation treatment.

Risk factors for developing bowel cancer is evaluated the same as other cancer. The most assured cause is alcoholic drinking. Followed by obesity, and its related lack of physical exercise are considered as assured risk. Following to this, and is considered as possible cause are, smoking, diabetes, meat (processed/ red meat).

For aged person, care for constipation.

Symptom may differ depend on the position of bowel cancer although they are called as the same name.

They say that the symptoms hardly appear on bowel at right side of the body, such as blind gut or ascending colon, then the one at left side of the body, such as lower rectum, sigmoid colon or rectum.

It is common that there is no symptom in early stage, so that it may be found at Cancer exam happen to find out at complete medical check-up or exam for other purpose.

It can list up for the symptom in accompany with bowel cancer, but they are, constipation, gargling sound, abdominal bloating, anemia or lose weight. But sometimes, there is a case called large bowel obstruction which no symptom appears, or even with symptom is appeared it is left as is with no medical check at hospital, or no constipation by bowel inner cavity stuck resulted sudden abdominal pain, abdominal bloating or vomiting are appeared.

Due to abnormality in weakened water absorption power by bowel cancer, or hardness of constipation at the part of cancer, symptom like diarrhea, constipation, or thin stool may appear. Sometimes diarrhea and constipation is repeated. Specially for high aged person, it is not unusual that person think it is just a constipation, but it is caused by bowel cancer, thus to be suspicious for bowel cancer may lead to early stage findings to the constipation of high aged person.

When passage of slops is getting worse by cancer, flatulence becomes easy to occur at its exit side so that bowel is getting full of gas, then gas goes rapidly through narrow part, then its sound becomes large like gurgling sound. Abdominal pain may also come along with it.

In case bleeding occur from cancer, blood feces or in case cancer is close to anus, fresh blood melena may occur. Especially in case of rectum cancer, it is close to anus so that it bleeds directly from anus. There is a case that as the one assumes as the symptom of hemorrhoid by oneself, it has advanced much or developed metastasis already when received medical check at hospital.

Cancer require much nutrition than normal tissues and consumes, so that body weight become reduced even with eating amount unchanged. In this case, it does not appear when cancer become advanced. When nutrition condition is getting worse, edema may occur then the one recognized as first time.

In case of large bowel obstruction, diagnose from cut-off specimen of emergency surgical operation.

Confirmed diagnosis for bowel cancer is made, first macroscopically (to the sight) finds the cancer by endoscope so called large intestine camera, picks up part of tissue, called as biopsy, and then conducting the pathological test which observe the specimen by microscope. When cancer is confirmed, confirmed diagnosis for cancer is made. Normally, almost all cases come with this flow.

However afore mentioned bowel obstruction case, as it becomes an acute condition, cut cancer off straight away by emergency surgery operation, and after cut-off, confirmed diagnosis is made by checking the cut-off specimen in pathological test.

Other than above, CT, PET-CT, Echo or intestinal infusion contrast (Barium test) is made to check systemic metastasis to lung, liver, or bone, relative position of cancer, relation with surrounding tissue, effect of infiltration. Especially for rectum cancer, there is a case to check the effect to surrounding tissue by MRI.

At blood drawing, change in tumor marker increase may indicate bowel cancer history or recurrence, or metastasis. The main one is CEA, CA19-9. These two need to be checked periodically in case of bowel cancer. Other than these, whether any disorder of liver function by treatment or liver metastasis exist, also check general blood drawing items like anemia caused by cancer. Test including above is made prior to the surgical operation, and at first, cancer progression level (Disease stage classification) is assumed. T: invasion depth, N: lymphatic metastasis, M: level of distanced metastasis, with or without are evaluated. After that, cut-off cancer from surgical operation is checked at pathological test and postoperative diagnosis determine the progress level as confirmed diagnosis.

Scheduled medical exam is performed after the operation.

Progress level of bowel cancer is grouped into Stage 0, I, II, IIIa, IIIb and IV. There is a case which is diagnosed as stage IV without conducting surgical operation when metastasis is found in lung or liver by CT, and surgical operation is unable to conduct. Or called as surveillance, at post operation of bowel cancer, these tests are conducted periodically to check there is no recurrence or metastasis. These tests is conducted for the period of 5 years.

When unable to conduct surgical operation so that latter chemotherapy or radiation therapy may take place, treatment effect is periodically checked through above mentioned blood drawing, roentgen, echo, or CT.

Also, recently as no diagnosis, there is an exam checking the development risk for bowel cancer at gene level by blood drawing, named as genome. This may become a one of indicator, but this exam is self-pay treatment thus become expensive. This test is conducted only at limited clinic medical equipment.

Surgical operation may apply for Stage IV.

Standard treatment for the cancer is common around the world. They are Surgery, chemotherapy (anti-cancer agent), radiation therapy. Bowel cancer is applied this as well.

In Japan domestically, for bowel cancer, treatment and cure is commonly made in accordance with the treatment plan specified in “Bowel Cancer Treatment Guideline” made by Bowel Cancer Research Association. Surgery is the basic premise for the permanent cure of bowel cancer. There is no other method available for complete cure, so that when surgery is possible for the first hand, surgery is conducted anyway. 

Surgery is depending on cancer progress level, and divided into endoscopic treatment and surgical cut-off.

Endoscopic Treatment
Polypectomy, Endoscopic Mucosal Removal (EMR), Endoscopic Submucosal Decollement (ESD)
Surgical Cut-off
Abdominal Cut-off Method, Laparoscopic Excision

Area is different from the position of cancer, they are; ileocecal resection, Right hemicolectomy, Partial Ablation, Left hemicolectomy, Sigmoid colon resection, Lower anterior resection, Super Lower anterior resection, Mile’s operation (Rectum resection + colostomy), and dissection each appropriate lymph node. Currently, more than 50% of bowel cancer surgery is made by Laparoscope in Japan. Guideline designated laparoscopic surgery is for bowel cancer at rectum and rectosigmoid.

Endoscopic treatment is possible for shallow invasion depth bowel cancer at stage 0 and stage I. More advanced stage I with deeper invasion depth, stage II and stage III will be subject to surgical operation.

Stage IV is different from other cancer, because it becomes subject to surgical operation for the case where it can cut-off including transition nest. Most of the cancers, when it becomes stage IV, cut-off is not only becoming the permanent cure, not extending life, but also possibly deteriorate the function thus shorten person’s life by surgical operation. Therefore, almost all stage 4 cancer is not subject to the surgery. But, in case of bowel cancer, it may fit to surgical operation if transition nest to lung or liver can be cut-off. However, even if it can cut-off, more than 50% will recur.

Prevent recurrence by post operation supplemental chemotherapy.

The next is Chemotherapy. They are divided into Postoperative supplemental chemotherapy performed to prevent recurrence after the operation, and chemotherapy performed to unable to cut-off or recurrence of the disease symptom. They both have, drip infusion only, drip infusion and medicinal drink combined, and medicinal drink only therapy. It uses traditional anti-cancer drug, or recently so called molecular-target drug which affect only to cancer tissue is the mainstream. It will use with combining these.

Last one is Radiation Therapy. Applying radiation direct to cancer, this therapy will restrain the cancer progression. It is divided into supplemental radiation therapy and the one performed as palliative therapy. Regarding the former one, combination therapy with chemotherapy is commonly performed in western and other Asian countries and it contribute for the decrease of postoperative partial recurrence rate, but in Japan this is not so much popular yet. Especially, this is effective for rectum cancer on pelvis where organs are fixed. It is gradually increasing in Japan as well.

Surgical operation may apply for Stage IV.

Bowel cancer is the one, unless other fatal disease is developed, which certainly led to death by cancer itself. Treatment progression is different depend on the case; the case which can cut-off and permanent cure including surgical operation is conducted, the case which permanent cure is impossible so that palliative operation is performed, or the case which is unable to perform operation.

In case permanent treatment is conducted, if no recurrence or metastasis is found after 5 years from operation, it is considered as complete therapy. 5 Year survival rate of the patients diagnosed as bowel cancer in 2007 published by National Cancer Center is as follows.

Male
Stage I Stage II Stage III Stage IV
Colon cancer 87.8% 82.0% 76.3% 16.3%
Bowel cancer 88.2% 81.0% 77.1% 17.1%
Female
Stage I Stage II Stage III Stage IV
Colon cancer 93.3% 80.9% 73.9% 16.3%
Bowel cancer 92.0% 78.1% 75.5% 19.5%

Comparing this data with the same in 1997, 10 years ago, survival rate in Stage II, and III improved by 6 to 10 %. For the patients to have bowel cancer from now on, 10 years future medical treatment from this statistic is applied so that it is looking forward to see how much change or improvement is expected.

And, in case of stage IV with inability for surgery, or at stage III but super high aged or confined to bed person who do not want to have surgery, for those people has no other way but chemotherapy or radiation therapy, however, symptoms of cancer may appear upon the progress sooner or later.

Cancer pain which is a pain by tumor, and as bowel cancer is an alimentary tract, alimentary tract symptoms, like loss of appetite, nausea, vomiting, constipation, diarrhea, aggravation of nutritional condition, lose weight by consumption, emaciation (thin), disorder of liver function or jaundice by metastasis of liver, breathing difficulty by metastasis of lung, can be considered. These are the end-stage symptoms. For these symptoms palliative therapy is applied, and able to improve by drug medicine dosage.

Able to prevent cancer by adenoma polyp cut-off.

There is no assured protection method available at this moment. But based on the risk factor of the causes, avoid those, and by improving, it may possibly protect.

These are evaluated whether scientific evidence (BM, Evidence) exist, and evidence is evaluated based on several research or experiments. There are many on-going things, and there will be the thigs to come up from now on.

“All kinds of Cancer Protection Method for Japanese by Epidemiological Study” is introduced in 2016, by Preventive Research Group, National Cancer Center. In this study;

Smoking

Do not smoke cigarette, avoid from others smoking

Alcoholic drinking When drink, temperate drinking
Meals Take equally balanced foods
(salty food, minimize salt intake, not to be lack of vegetable and fruit. Not to take food in hot)
Physical exercise Be active throughout the daily life
Body shape Appropriate area
Infection Infection test for hepatitis virus and appropriate care, if possible pylori gastritis test.

Above are listed. There is some non-related issue with bowel cancer directly, but the issue which strongly relate with bowel cancer, it is stated specifically as below.

Alcoholic drinking
In case if drinking, it must be up to 23 g a day in alcoholic equivalent. In Japanese Sake it is 1 Gou (carpenter’s square), one big bottle of beer, 2/3 of 1 Gou of distilled spirits, one double glass of whiskey/Brandy, 1/3 of bottle of wine. Person who do not want to drink or person who cannot drink should not take alcoholic drink.
Physical Exercise
For example, walking or its equivalent or even stronger physical exercise shall be done 60 minutes a day. And breathy and sweating exercise needs to be done at least 60 minutes a week.
Body Shape
Appropriate BMI value (Body Mass Index: degree of obesity) for middle and elderly person is 21 to 27. Better to keep body weight in this range.

Other than above, possible risk career is Calcium, alimentary fiber, fat (unsaturated fatty acid from fish).

Other than that, although the evidence is not enough at this moment, but risk decrement item reported are as listed below.

Coffee, Vegetable, Fish, Vitamin D, Glucosamine, Chondroitin (supplement), Aspirin (Drug)

For Glucosamine, Chondroitin and Aspirin, as bowel cancer is a chronic inflammation so that it is considered that their anti-inflammation behavior is engaged with the effect. Coffee is also considered as the effect to anti-inflammation effect, insulin resistance, excessive insulin secretion, etc., diabetes or its related obesity.

Also, by endoscopic exam, there is a research in which bowel cancer can be reduced in the development of cancer for which the found adenoma polyp is cut-off by endoscope and leave with it. So, it may be better to have periodical colon camera exams at the complete medical check-up.

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