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Colorectal Cancer: Balancing Treatment with Managing Side Effects

January 05, 2021

Dr. Christine Marie Bartus
Colorectal Surgeon
Hartford HealthCare Cancer Institute

Colorectal cancer, or cancer of the colon and the rectum, is the third-most common cancer for men and women, and is the second-most common cause of cancer death in both men and women.

It is second only to lung cancer. It affects men and women nearly equally. It is cancer of the “large bowel,” or “large intestine.”

The intestinal tract runs from the mouth, through the esophagus (swallowing tube), through the entire small bowel, and finally the roughly six feet of colon that escorts waste out past the rectum. The rectum is the last six inches or so of large intestine before the stool exits the body through the anus. It carries out multiple functions that we take for granted until problems occur.

The rectum allows us to defer defecation (running to the bathroom). This occurs through a complex process involving the sphincter muscles, which give you control of your bowel movements. It is able to distinguish liquid stool from solid stool from gas. The anus, the final 2-3 inches, is also involved. A complex interaction between nerves and muscles allows us to carry out our daily lives predictably.

Adenocarcinoma of the colon and rectum will affect nearly 5 percent of the general population, with increased risk in certain populations — those with inflammatory bowel disease, those with inherited gene mutations and older people. More than 90 percent of colorectal cancers occur over the age of 50. Although risk-factor modification and screening have led to an overall decrease in incidence of colorectal cancer over the past few decades, the incidence in people under 55 has increased by nearly 2 percent each year from 2007 to 2016. Despite making up only 15 percent of the large intestine, the rectum is the site of nearly 40 percent of colorectal cancers.

Management of rectal cancer is unique, requiring a multidisciplinary approach. Although surgery is generally involved, radiation therapy and chemotherapy are integral parts of treatment. The colon sits inside the abdominal cavity, but the rectum is housed in the pelvis, surrounded by bones, arteries and nerves. It sits close to the bladder, the uterus in women and the prostate in men. This becomes relevant when we discuss survival after treatment and potential long-term side effects.

Once your multidisciplinary team outlines a management plan for the patient, follow-up typically revolves around surveillance and managing recurrence. Equally important, however, is the management of symptoms related to the treatment.

Bowel Function

Removing the “storage unit” of the intestinal tract has its own consequences. Patients who had tumors in locations that allow them to maintain continuity of their bowels (and still excrete stool  through their anus) may find that the frequency of their bowel movements increases and the control of their bowel movements suffers. This is particularly relevant in patients who have had prior lower-back problems, pregnancies or compromised bowel function prior to treatment.

Tumors that involve the very last part of the rectum cannot be removed completely without taking out the sphincter muscles with the tumor. Deciding the best management for the patient long term involves a thoughtful and honest discussion about expectations following treatment.

For this reason, some patients may be faced with their team recommending a permanent colostomy. Colostomies can be problematic. They have significant negative effects on quality of life, and they present management problems ranging from skin irritation to need for repeat surgeries.

A team of providers specialized in choosing the best ostomy site preoperatively is crucial to mitigating postoperative problems. Patients with a colostomy or ileostomy should be paired with an experienced enterostomal therapist to help navigate the problems that frequently occur with new stomas. Dietary modifications and medications  as well as support groups to help troubleshoot problems along the way are all important in making life with an ostomy more manageable.

For patients without an ostomy, there can still be significant erratic function following radiation and surgery. Here again, nutrition and outlined bowel regimens can be useful in improving quality of life while dealing with sometimes unpredictable bowel issues.

Urinary Function

Low pelvic surgery can introduce problems with urinary function both short term and long term for patients following radiation therapy and surgery. Men in particular may find early postoperative difficulty with urinary retention (inability to urinate). Men with a history of enlarged prostate have a higher chance of having troubles postoperatively. A urologist is often involved in coordinating a successful improvement in symptoms.

Sexual Function

Prevalence of sexual dysfunction is sometimes difficult to define because of poor assessment of pretreatment function as well as variable methods of data collection. But there does seem to be a higher percentage of patients suffering from sexual dysfunction with rectal cancer compared to patients with colon cancer.

This includes decreased libido, dyspareunia in women and erectile dysfunction and ejaculatory disorders in men. Studies have shown that post-treatment sexual dysfunction is often not addressed. To lead a fulfilling life, it is important that you address those issues with your physician after surgery.

Psychosocial

Depression and decreased quality of life can affect patients with colorectal cancer.  Approximately 15 percent of five-year survivors screen positive for depression. This likely reflects multiple issues, including bowel function, fatigue, fear of recurrence and sexual dysfunction. It is important that providers ask patients about depression and quality of life so that some of these symptoms can be mitigated.

The treatment of rectal cancer is complex, life-changing and often marked by post-treatment complications. It takes a group of dedicated physicians to provide the most appropriate care for the patient. It is imperative that you understand changes caused by rectal cancer treatment.

Successful treatment not only involves getting rid of the cancer, but also preparing for life after treatment.

Dr. Christine Marie Bartus is a colorectal surgeon with the Hartford HealthCare Cancer Institute.