For years, Kentucky had some of the highest incidence and mortality rates for colorectal cancer in the nation. Thanks to a statewide coordinated effort to increase screenings that’s taken place over the past 15 years, those numbers have improved significantly. But the disease still strikes far too many Kentuckians at a stage where preventive measures cannot help and surgery and other serious treatment methods are required.
In this week’s Kentucky Health, Dr. Wayne Tuckson speaks with a colorectal surgeon with the University of Louisville about the causes of colorectal cancer, the very subtle early symptoms of the disease, and several promising new and minimally invasive surgical procedures to treat it.
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Dr. Russell Farmer, M.D., is a surgeon and assistant professor specializing in colon and rectal cancer with the University of Louisville’s School of Medicine. He says that colorectal cancer develops when “the lining of the inside of the large intestine somehow becomes different than normal. And when it becomes sufficiently different, it can grow into something like a polyp or eventually a cancer that can become metastatic and lethal if not treated.”
Farmer says that colorectal cancer is very common in the United States, and even with improved screening it is still responsible for the second highest number of cancer deaths. Colorectal cancer has traditionally been regarded as a disease that affects older people, and screenings are recommended for people who have no family history of the disease starting at age 50. For those who have a close relative with colorectal cancer, and for African-Americans, screenings should begin at age 45.
“The screening efforts have resulted in decreasing rates of cancer, but really we’re finding out that, especially in Kentucky, there’s a real problem with young people diagnosed with colon and rectal cancer.” He says. “We lead the nation in patients under the age of 50 with colon and rectal cancer, and rectal cancer especially. The rate of that’s been going up 5 percent per year for the past 10 years.”
Diagnosing a Silent Disease
Farmer presents a diagram of the large intestine, which is shaped like a question mark and straightens out at the rectum. He also shows several photographs of polyps developing on the intestinal wall. The colon and rectum perform crucial gastrointestinal functions, he says, primarily regulating electrolytes, absorbing water, and maintaining stool burden.
Colorectal cancer is notorious for having few detectable symptoms, especially in its early stages, and for developing over months or even years without warning.
“Almost all colon cancers are, not silent, but very nearly so, and that’s one of the reasons that screening remains so important,” he says. “Except for occasional fatigue and chronic, low-grade blood loss with anemia that can happen when the cancer becomes large, often times colon cancer is often undiagnosed until it’s too late.”
Farmer says that patients who develop rectal cancer may have more apparent symptoms than those with colon cancer due to its proximity to the anus. They often experience a feeling of fullness and have more excessive bleeding, which sometimes is misdiagnosed as hemorrhoids.
As mentioned earlier, there are genetic risk factors for colorectal cancer. Still, Farmer says that “the vast majority of colon and rectal cancer simply comes from what we call sporadic cases, meaning people don’t have any sort of inherited predilection to it, they just develop it.”
According to Farmer, research has shown that eating a diet that lacks fiber and/or eating too many smoked meats with high nitrate content, excessive alcohol consumption (particularly red wine), and smoking can all increase risk of developing colorectal cancer.
If you have major changes in normal intestinal functions, such as a change in the appearance of stools or the disruption of normal bowel movements, you should visit your primary care doctor immediately, Farmer says. Physicians can order a variety of tests, from a fecal occult blood test which measures specific chemicals in the stool that indicate cancer, to an endoscopy or colonoscopy, in which a gastrointestinal doctor examines the intestine and rectum in detail.
New Innovations in Treatment
“Any form of cancer regardless of location always follows the pathway of three things: name, stage, and treat,” Farmer says. First, he explains, the medical team will remove polyps and test for malignancy. Then, they will determine if cancer has traveled from the colon and/or rectum to other organs. In its advanced stage, colorectal cancer will spread through the intestinal lining and then travel to lymph nodes. These can in turn transport the colon cancer cells to organs such as the liver or lungs, a process called metastasis.
Treatment for colorectal cancer usually involves chemotherapy and/or radiation, especially if the cancer has metastasized to other organs, but almost always requires surgery to remove the affected part of the colon or rectum.
“There are about five or six different potential operations that we can do in order to remove a colon cancer” Farmer explains. “And the reason we do them in these very specific ways is to remove the lymph nodes that go along with the blood vessels to provide the blood supply to the colon. And when you remove those lymph nodes, you take them all of in kind of one broad piece, in addition to the colon.”
With colon cancer, Farmer says that at least 12 lymph nodes must be removed during surgery along with the affected part of the colon in order to accurately determine staging. For rectal cancer, the lymph nodes are all located in a packet near the rectum itself, he says, and must be removed.
As a certified robotic surgeon, Farmer is well-versed in many of the latest and most innovative techniques for removing and treating colorectal cancer. For many years, the normal surgical method for colon cancer involved by opening up the abdomen, but now, Farmer says, most surgeries are done via laparoscopic methods, where only a few small incisions are required.
Farmer says that his own robotic surgical training involves “literally taking laparoscopic instruments that we’ve been using for 25 years in surgery, adding a third degree of motion – meaning that the tool has a wrist as opposed to just moving up and down – and then giving the surgeon the ability to manipulate that on an almost microscopic level.”
This method requires the surgeon to operate while seated nearby at a console, using 3-D glasses while manipulating the instruments remotely. One drawback to robotic surgery, Farmer says, is that surgeons are not able to receive what he calls “haptic feedback” while operating. This means that they cannot get an accurate tactile sensation when they use their instruments to perform precise movements.
Still, he says these new surgical procedures have greatly reduced the time patients have to spend in the hospital and, in the case of some patients with rectal cancer, have enabled them to preserve their ability to have bowel movements instead of using a colostomy bag for the rest of their lives.
“Ultimately, the operations at their base have not changed in the recent past: it’s still removing the same surgical specimen,” Farmer says. “It’s just finding less invasive and fancier ways to do it.”
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