Lower digestive system cancers

lower digestive system body diagram

Small bowel: consists of 3 sections: duodenum, jejunum and ileum. 
Large bowel: caecum, colon, rectum and anus.

Small bowel cancer

Facts and figures

Small bowel cancer is rare; only around 1,300 new cases a year are diagnosed in the UK. There is a very slightly higher incidence in men.

Age related, incidence rises after the age of 40 years with the highest incidence being in the 55-75 year age group. Approximately 40% are adenocarcinomas arising in the duodenum, 30% neuroendocrine commonly developing in the appendix or ileum, the remaining being much rarer lymphomas or sarcomas.

Risk factors include medical conditions such as Crohn’s disease, coeliac disease, Peutz-Jegher’s syndrome, previous colorectal cancer and familial adenomatous polyposis (FAP). Smoking and obesity are also possible risk factors.The symptoms are quite vague, so the disease is often advanced at diagnosis.

Symptoms may include:

  • Dark or black stools.
  • Abdominal pain/cramps.
  • Anaemia.
  • Diarrhoea.
  • Nausea and vomiting.
  • Weight loss.

Diagnosis

Investigations may include:

  • Physical examination.
  • Endoscopy or colonoscopy – tissue samples may be taken for analysis.
  • Capsule endoscopy.
  • Chest X-ray.
  • CT scan.
  • MRI scan.

Treatment

Depends on several factors:

  • The type of tumour.
  • The position of the tumour in the small bowel.
  • The stage of the cancer.
  • General health.

Surgery

Surgery is the main treatment for small bowel cancer. The tumour and an area of healthy surrounding tissue will be removed; the amount of bowel removed will depend on the size and position of the tumour.

Sometimes it is necessary to remove other organs such as the pancreas or part of the large bowel and lymph nodes near the tumour site will often be removed during the surgery.

In most cases the two sections of bowel either side of the resection can be joined together to enable normal bowel function to be maintained but occasionally this may not be possible and a section of the bowel is brought to the surface of the abdomen to form a stoma (Ileostomy), this is temporary sometimes to allow the bowel to heal and reversed later.

In advanced cases, surgical removal of the disease may not be possible but surgery may be performed to remove any blockage in the bowel.

Radiotherapy

Radiotherapy may be used to treat advanced small bowel cancer to help relieve or control symptoms such as a blocked bowel or it may be used if the disease recurs after surgery.

Chemotherapy

Chemotherapy can be used to treat advanced lymphomas of the small bowel or to help relieve symptoms in other forms of small bowel cancer. It is sometimes used in combination with radiotherapy (usually fluorouracil) to improve the effect of radiotherapy.

Large bowel cancer (colorectal)

Facts and figures

Bowel cancer is the 4th most common cancer in the UK, accounting for 13% of all new cases. Approximately 66% arise in the colon and 34% in the rectum.

Higher incidence in men, male to female ratio being approximately 13:10, with the greater variation being in those diagnosed with rectal cancer rather than colon cancer.

Age related, incidence rises sharply from the age of 50 years, 95% being diagnosed in those over 50 years and an average of 43% in the 75+years age group. 98% are adenocarcinomas.

Risk factors include a diet high in red and processed meat, being overweight or obese, high alcohol intake and smoking. Also, increased by some medical conditions; adenomas/polyps, inflammatory bowel disease (Crohn’s or ulcerative colitis), metabolic syndrome, familial adenomatous polyposis (FAP), hereditary non-polyposis colorectal cancer (HNPCC), BRCA1 gene mutation (particularly in younger women) and having a first degree relative diagnosed with colorectal, this increases the risk by 80% and is higher again in those with more than one relative or relative diagnosed at a young age.

The NHS National Bowel Screening Programme introduced in 2006 offers screening every two years to anyone aged between 60 and 69 years of age (older patients can request screening) and studies have shown that bowel cancer deaths in those screened have already decreased by about 25% and it has the potential to reduce these deaths by 60%.

Screening involves a faecal occult blood test of the stools and if the result is abnormal then referral for a colonoscopy.

Symptoms may include:

  • There may be no symptoms for those detected at screening as diagnosis from this may occur 2-3 years prior to those presenting with symptoms.
  • Change in bowel habit.
  • Constipation/diahorrea.
  • Blood or mucus in the stools.
  • Straining with an empty bowel (tenesmus).
  • Pain on defeacation.
  • Loss of appetite or weight loss.
  • Nausea and vomiting.
  • Abdominal/pelvic pain.

Diagnosis

Investigations may include:

  • FOBT and further colonoscopy/sigmoidoscopy following screening.
  • Physical examination (including rectal examination).
  • Blood tests (including FOBT if not participant in screening programme).
  • Flexible sigmoidoscopy and possibly proctoscopy.
  • Colonoscopy.
  • Barium enema.
  • Chest X-ray.
  • Ultra sound scan.
  • CT scan.
  • PET scan.
  • MRI scan.

Treatment

Depends on several factors:

  • The position of the tumour.
  • The type and size of the tumour.
  • The grade of the cancer cells.
  • The stage of the cancer.
  • General health.

Surgery

Surgery is the main treatment for bowel cancer; approximately 80% of patients will have surgery. The type of operation i.e the section removed depends on where the tumour is in the large bowel.

In early stage disease, it may be possible to remove the tumour and some of the surrounding healthy tissue. Lymph nodes near the tumour site will often be removed during the surgery.

In most cases the two sections of bowel either side of the resection can be joined together to enable normal bowel function to be maintained but occasionally this may not be possible and a section of the bowel is brought to the surface of the abdomen to form a stoma (colostomy), sometimes this is temporary to allow the bowel to heal and a stoma reversal operation can be performed later. However, this is not always possible so the colostomy may be permanent, particularly in tumours low in the rectum. In advanced cases, surgery may be required to remove a bowel obstruction.

Radiotherapy

Radiotherapy is not often used for colon cancer due to the sensitivity of the bowels to radiation. However it may used pre-operatively (neoadjuvant) in early stage in rectal cancer, often combined with chemotherapy to try and reduce the tumour, allowing a surgical resection and possibly reducing the necessity for a colostomy and reduce the risk of recurrence.

Radiotherapy/chemoradiation may be prescribed post-operatively (adjuvant) if the tumour was difficult to remove, if there is thought to be a risk of recurrence or if the lymph nodes were found to contain malignant cells. Palliative radiotherapy may be advised in advanced cases where the disease has spread outside of the bowel to try and shrink the tumour and slow the disease progression to relieve symptoms such as pain in the pelvis or rectum.

Chemotherapy

Chemotherapy is sometimes used in combination with radiotherapy (chemoradiation. The chemotherapy makes the cancer cells more sensitive to the radiation, so this combined treatment is likely to be more successful than radiotherapy on its own. It may be given before or after surgery either to reduce the size of the tumour and reduce the risk of recurrence or if it is indicated at surgery as described above.

The chemotherapy drugs usually used are fluorouacil (5FU) or capecitabine.

Biological therapy

Cetuximab is a monoclonal antibody that is being used in some advanced bowel cases. Cetuximab blocks epidermal growth factor (EGF) which is a protein that attaches to receptors on cancer cells and encourages them to grow.

Cetuximab with chemotherapy has been shown to extend the survival of some patients with advanced bowel cancer and improve their quality of life. It is usually given with the chemotherapy drugs 5FU (fluorouracil), oxaliplatin, or irinotecan.

Anal cancer

Facts and figures

Anal cancer is rare, approximately 1,200 new cases each year in the UK which accounts for about 0.4% of all new cancer cases. Higher incidence in women, male to female ratio is approximately 10:18.

Age related, incidence rises sharply from the 35 years, approximately 50% diagnosed in those over 65 years and an average of 25% of cases are in the 75+ years age group.

Majority of them are squamous cell carcinomas with a very small number of adenocarcinomas which behave differently and therefore should be treated like rectal cancers. Risk factors include HPV infection (90% are linked to HPV infection), multiple sexual partners, anal intercourse, genital warts and previous cancer of the cervix, vaginal or vulva, smoking and HIV infection.

Symptoms may include:

  • 20% of patients have no symptoms at diagnosis.
  • Rectal bleeding – often ascribed to haemorrhoids, subsequently diagnosis can be delayed.
  • Small lumps around the anus- often ascribed to haemorrhoids.
  • Ulcers around the anus.
  • Pain, discomfort or itching in the area.
  • Passing mucus from the rectum.

Diagnosis

Investigations may include:

  • Physical examination (including internal examination).
  • Biopsy.
  • Anoscopy – tissue samples may be taken for analysis.
  • Proctoscopy.
  • Endo-anal or endo-rectal ultra sound.
  • CT scan.
  • PET scan.
  • MRI scan.

Treatment

Depends on several factors:

  • The type of tumour.
  • The position of the tumour.
  • The stage of the cancer.
  • General health.

Surgery

Surgery is not often used for anal cancer now, the preferential treatment being a combination of radiotherapy and chemotherapy. Occasionally used for small tumours if the chemoradiation hasn’t cleared the disease. This may be a local resection removing small tumours on the outside of the anus (if this is the initial treatment, chemoradiation may be recommended after surgery).

In some cases, more extensive surgery may be recommended and this involves the removal of the anus and rectum (abdominoperineal resection), which will require a permanent colostomy.

Radiotherapy

Radiotherapy in combination with chemotherapy is usually the main treatment for anal cancer as it can be effective and avoids major surgery.

Intensity Modulated Radiotherapy (IMRT) is now being used in some radiotherapy centres and in some cases of anal cancer is proving to increase the effectiveness of treatment by enabling the disease to be targeted very accurately hence reducing dose to healthy tissue and reducing side effects.

Image guided radiotherapy (IGRT) also enables the radiotherapy to be precisely delivered to the intended area which reduces potential radiation dose to healthy tissues by allowing the radiography team to review organ position and ideally adapt the patient position on a daily basis to ensure precision.

Chemoradiation will also treat disease that has grown into nearby tissues and lymph nodes. Palliative radiotherapy may be given to try and shrink the tumour to relieve symptoms.

Chemotherapy

Chemotherapy is used with radiotherapy (chemoradiation). The chemotherapy drugs are usually fluorouracil (5FU) and mitomycin C. Chemotherapy may be given if the disease has recurred in other parts of the body to help control and relieve symptoms.

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