In the last two issues, we discussed how Colorectal cancers were on the rise in Kashmir and across the Globe. However, being diagnosed with cancer is not the end of the world. Many treatment options are available for patients.
A multidisciplinary approach is needed which involves a gastroenterologist, surgeon, oncologist, pathologist and a radiologist to determine the location, extent, vascular, nodal involvement and local or distant spread of the disease and to formulate an adequate treatment plan for the patient.
The management plan of each patient is individualised and depends on the factors mentioned and also the comorbidities ,treatment resources and expertise.
The most important thing in the management of colorectal cancers is the stage at which the cancer is diagnosed. Some clinical predictors of prognosis are mentioned include:
Patients presenting with intestinal obstruction(constipation, abdominal pain, vomiting) or perforation have poor prognosis.
Tumours of left side of colon have better survival than patients with tumours of the right side of colon.
Prognosis is worse for patients with onset of cancer before 30 years of age and is extremely poor in paediatric population. The reason is the advanced cancers diagnosed in these age groups and higher percentage of mucinous adenocarcinomas in the age groups.
Patients with higher preoperative CEA levels have higher recurrence rates.
Patients diagnosed in early stages have an excellent prognosis with 5-year survival of more than 95%.
Endoscopic treatment
With advancements in the endoscopic field, many early colorectal cancers which would require surgery in the past can be managed endoscopically which has decreased the morbidity of surgical procedures significantly. These endoscopic techniques include Endoscopic Mucosal resection(EMR), Endoscopic Submucosal dissection(ESD) and Endoscopic Full thickness resection(EFTR).
These novel endoscopic treatment options have excellent results both in terms of short term morbidity and mortality and long term survival of patients.
Early colorectal cancer with a submucosal invasion depth of ≤1000 µm and without lymphovascular/vascular invasion or tumor budding is traditionally considered as a low-risk cancer with a risk of lymph node (LN) metastasis of <1%
Endoscopic Mucosal resection (EMR):
EMR is performed using a snare and usually after the submucosal lifting of the lesion by fluid injection. EMR is usually indicated for benign adenomas and smaller lesions (<20 mm).
However, with flat lesions exceeding a particular size, EMR often results in a “piecemeal” strategy that has a relatively high risk of recurrence.
Endoscopic Submucosal dissection (ESD):
ESD involves the circumferential mucosal incision around the lesion or tumor and subsequently the stepwise dissection of the submucosa underneath the tumor and just above the proper muscle layer.
Endoscopic full-thickness resection (EFTR):
The endoscopic treatment of neoplasms in the GI tract experienced a major breakthrough with the introduction of the EFTR technique. EFTR leads to a complete resection of the neoplasm including the underlying muscularis propria as well as the immediate closure of the resulting defect.
The endoscopic treatment of early colorectal cancer is effective and minimally invasive and has a low recurrence rate, and it can be rightfully postulated that endoscopy has overtaken surgery in many cases of early colorectal cancer.
Surgery:
Surgery is the removal of the tumor and some surrounding healthy tissue during an operation. It is often called surgical resection. This is the most common treatment for colorectal cancer. Part of the healthy colon or rectum and nearby lymph nodes will also be removed.
Different types of surgeries can be performed depending on the type and location of the tumor, nature of surgery(emergent or planned), resources and expertise available.
The surgeries can be performed traditionally (open laparotomy), laparoscopically, or minimally invasive surgical methods for a full-thickness resection of an early rectal cancer include transanal endoscopic microsurgery (TEMS) and transanal minimally invasive surgery (TAMIS).
Radiation therapy:
Radiation therapy is the use of high-energy x-rays to destroy cancer cells. It is commonly used for treating rectal cancer because this kind of tumor tends to recur near where it originally started. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time.
External-beam radiation therapy:
External-beam radiation therapy uses a machine to deliver x-rays to where the cancer is located. Radiation treatment is usually given 5 days a week for several weeks.
Stereotactic radiation therapy:
Stereotactic radiation therapy is a type of external-beam radiation therapy that may be used if a tumor has spread to the liver or lungs. This type of radiation therapy delivers a large, precise radiation dose to a small area. This technique can help save parts of the liver and lung tissue that might otherwise have to be removed during surgery. However, not all cancers that have spread to the liver or lungs can be treated in this way.
Other types of radiation therapies:
For some people, specialized radiation therapy techniques, such as intraoperative radiation therapy or brachytherapy, may help get rid of small areas of cancer that cannot be removed with surgery.Intraoperative radiation therapy: Intraoperative radiation therapy uses a single, high dose of radiation therapy given during surgery.
Brachytherapy: Brachytherapy is the use of radioactive “seeds” placed inside the body. In 1 type of brachytherapy with a product called SIR-Spheres, tiny amounts of a radioactive substance called yttrium-90 are injected into the liver to treat colorectal cancer that has spread to the liver when surgery is not an option.
Radiation therapy for rectal cancer. For rectal cancer, radiation therapy may be used before surgery, called neoadjuvant therapy, to shrink the tumor so that it is easier to remove. It may also be used after surgery to destroy any remaining cancer cells. Both approaches have worked to treat this disease. Chemotherapy is often given at the same time as radiation therapy, called chemoradiation therapy, to increase the effectiveness of the radiation therapy.
Chemoradiation therapy is often used in rectal cancer before surgery to avoid colostomy or reduce the chance that the cancer will recur.A newer approach to rectal cancer is currently being used for certain people. It is called total neoadjuvant therapy (or TNT). With TNT, both chemotherapy and chemoradiation therapy are given for about 6 months before surgery.
Therapies using medication:
Treatments using medication are used to destroy cancer cells. Medication may be given through the bloodstream to reach cancer cells throughout the body.
The types of medications used for colorectal cancer include: Chemotherapy Targeted therapy Immunotherapy
Chemotherapy:
Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells.
A chemotherapy regimen, or schedule, usually consists of a specific number of cycles given over a set period of time.
A patient may receive 1 drug at a time or a combination of different drugs given at the same time.
Targeted therapy:
Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells and limits damage to healthy cells.
It includesa)Anti-angiogenesis therapy focused on stopping angiogenesis, which is the process of making new blood vessels. Because a tumor needs the nutrients delivered by blood vessels to grow and spread, the goal of anti-angiogenesis therapies is to “starve” the tumor. egBevacizumab (Avastin),Regorafenib (Stivarga) and Ziv-aflibercept (Zaltrap) and ramucirumab (Cyramza). And b) Epidermal growth factor receptor (EGFR) inhibitors. that block EGFR may be effective for stopping or slowing the growth of colorectal cancer(Cetuximab (Erbitux),Panitumumab (Vectibix)).
Immunotherapy:
Also called biologic therapy, is designed to boost the body’s natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function.
Checkpoint inhibitors are an important type of immunotherapy used to treat colorectal cancer.
Lets spread the information regarding the Colon cancers and Know colon cancer for No Colon cancer.
The author is DM Gastroenterology and is presently working as Consultant Gastroenterologist and Therapeutic Endoscopist at Asian Institute of Gastroenterology Hyderabad.
Disclaimer: The views and opinions expressed in this article are the personal opinions of the author.
The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK.