Colorectal (bowel) cancer – Part 2

Treatment choices

Information for patients

This leaflet can be made available in other formats including large

print, CD and Braille and in languages other than English, upon

request.

Your surgeon will discuss all treatment choices with you and explain the risks and benefits of each type of treatment.

Surgery Surgery is the most common treatment for colorectal cancer and can be very successful. If you and your consultant decide you need surgical treatment, he or she will discuss this with you when you receive your results at your outpatient appointment, and tell you how long you should expect to wait for your operation. Your surgeon will offer you an operation date dependent upon the results of your tests. As with any operation you will need to sign a consent form to confirm you understand your operation and you will be given a copy to keep. You will be invited to attend a pre-assessment clinic before coming into hospital for your operation. Operations for colorectal cancer are usually performed under general anaesthetic (a state of carefully controlled and supervised unconsciousness (deep sleep). This means you are unable to feel any pain). You will be given a leaflet, 'You and your anaesthetic', and your anaesthetist will see you before your operation to discuss any worries or concerns you may have. An operation usually involves removing the piece of your bowel which contains the cancer and joining the two open ends back together. The joining of the two ends is called an anastomosis. Sometimes the end of the bowel has to be brought out on to the skin of your abdominal wall to form a stoma (opening). The stoma may be temporary and will allow your bowel to rest and heal. However, it may have to be permanent. If there is a possibility you might need a stoma, this will be discussed with you and you will be given more information.

Before or after your operation, additional treatments for colorectal cancer may be needed. These can be:

radiotherapy

chemotherapy

a combination of radiotherapy and chemotherapy before surgery.

The treatment you need will depend on the type of cancer you have and the kind of operation you need, or have had.

How will my surgeon know if my cancer has spread? Cancer cells can sometimes spread to your lymph nodes (glands). Your colorectal surgeon needs to know whether there are any cancer cells in your lymph nodes as this helps in deciding what further treatments you may need. Lymph nodes and vessels form the lymphatic system which helps maintain fluid balance in your body and control infection. During your operation, some lymph nodes will be removed because this is often the first place to which the disease may spread. After your operation, the lymph nodes will be sent, along with the section of the bowel removed, to a laboratory to see if any cancer cells are present. It can take between 7 - 14 days to get the results of this test.

What types of operation are there? The type of operation you need depends on the sort of cancer you have and where in your bowel your cancer is. Your doctor will explain which operation you need. You will be given more detailed information about your operation to read.

Types of operation include:

left hemicolectomy

anterior resection

right hemicolectomy

low anterior resection

sigmoid colectomy

abdominoperineal excision of rectum (APER) with formation of stoma.

Left hemicolectomy

This means removing part of the left side of your colon (see diagram below).

Large intestine (bowel or colon) Small intestine Rectum Anus Shaded area shows part of bowel removed

The two ends will be joined together. The joining up of the two ends of your bowel is called anastomosis. You will pass your motion through your anus. Very occasionally, the joining up of the two ends of your bowel can be difficult. During your operation air will be pumped into your rectum to check the join is leak-proof.

If it is not, you will need a stoma to allow your bowel to rest and recover. It is unlikely you will need a stoma but you must be aware it is a possibility. Anterior Resection This means removing part of your lower bowel and part of your rectum (see diagram below). The two ends will be joined together. The joining up of the two ends of your bowel is called anastomosis.

Large intestine (bowel or colon) Small intestine Rectum Anus The shaded area shows part of bowel removed

You will pass your motion through your anus. Very occasionally, the joining up of the two ends of your bowel can be difficult. During your operation, air will be pumped into your rectum to check the join is leak-proof. If it is not, you will need a stoma to allow your bowel to rest and recover. Right Hemicolectomy

This means removing the right side of your colon (see diagram overleaf). The two ends will be joined together. The joining up of the two ends of your bowel is called anastomosis.

Large Intestine (bowel or colon) Small intestine Rectum Anus The shaded area shows part of bowel removed

You will pass your motion through your anus. It is unlikely that you will need a stoma but you must be aware that it is a possibility. Low Anterior Resection

This means removing part of your rectum and the colon (see diagram below). The two ends will be joined together. The joining up of the two ends of your bowel is called anastomosis. You will pass your motion through your anus.

Large intestine (bowel or colon) Small intestine Rectum Anus Shaded area shows part of bowel removed

During your operation air will be pumped into your rectum to check the join is leak-proof. If it is not, you will need a stoma to allow the bowel to rest and recover.

Sigmoid Colectomy

This means removing part of your large bowel called the sigmoid colon (see diagram left). The two ends will be joined together. The joining up of the two ends of your bowel is called anastomosis which will allow you to pass your motion through your anus.

Large intestine (bowel or colon) Small intestine Rectum Anus Shaded area shows part of bowel removed

During your operation air will be pumped into your rectum to check the join is leak-proof. If it is not, you will need a stoma to allow your bowel to rest and recover. Abdominoperineal excision of rectum (APER) with formation of stoma This operation removes your rectum and closes your anus (so you will no longer have an opening for your bowel in your bottom), (see diagram on the next page). The end of your bowel that is left will be brought out onto your abdomen and fixed in place with stitches. This is called a stoma and this is permanent. You will pass your motion through the stoma into a bag that sticks to your abdomen and fits around the stoma. The motion passed will be of a semi-formed/formed consistency.

Large intestine (bowel or colon) Small intestine Rectum Anus Shaded area shows part of bowel removed

What if I need a stoma? If there is a possibility a stoma may be needed as part of your treatment, your specialist nurse will visit you before your operation to mark where your stoma will be. Your specialist nurse will visit you as soon as possible after your operation to offer support and training in how to care for your stoma, if you have one. Some stomas are permanent; others are temporary. This is to allow time for your bowel to recover. Temporary can mean anything from 6 weeks - 9 months, before your bowel can be re-joined back together. Your surgeon or specialist nurse will tell you which type of stoma you have.

What are stoma care and specialist colorectal nurses? Stoma care and specialist colorectal nurses have special training and experience in the care of patients with bowel cancer and patients who need bowel surgery for conditions other than cancer. They offer support to families and carers, hospital nursing staff and district nurses, to give extra support before, during and after your operation.

When will I meet my specialist nurse? You will normally be introduced to your specialist nurse before you have your tests.

What do the specialist nurses do? Your specialist nurse is there to help you and your family. He or she will give you practical and emotional support and advice before, during and after your operation and after you go home. Your stoma care or specialist nurse will explain the information given to you by your consultant in the Outpatients Department in more detail. He or she will discuss your treatment choices and see you at the hospital before you are admitted, if needed. If, at any time, you have any problems linked to your bowel cancer please contact your specialist nurse. As there are so many people involved in your care, one of the specialist nurses will become your key worker. He or she will make sure you receive the right care at the right time and liaise with other members of your MDT and any other agencies who may be able to help meet your needs. He or she will answer any questions you may have and advise you how to get any further information and advice you may need. Your key worker's name will be written in your healthcare records so everyone involved in your care knows who he or she is. You will be given a key worker card which gives details of how you can contact your key worker. Should you wish to change your key worker let your specialist nurse know and he or she will arrange this for you.

What other support is available? If you feel you would benefit from meeting someone who has had an operation and has recovered fully, your stoma care or specialist nurse can arrange this for you. People with cancer in England are eligible for free NHS prescriptions. You will be given all relevant details.

What are the risks and possible complications with having colorectal cancer surgery? As with all operations, there are risks you need to consider before you agree to your operation. Your colorectal surgeon will discuss these with you. Risks include: Risks linked with anaesthesia You will be given a leaflet ('You and your anaesthetic') explaining in detail about anaesthesia. Your anaesthetist (a doctor with special training in anaesthetics) will discuss this with you. Deep vein thrombosis DVT (blood clots in the leg veins) or pulmonary embolism PE (blood clots in the lungs)

Some patients may develop a DVT after an operation. This can be due to the effects of the anaesthetic, bed rest and reduced activity during recovery. Your doctor will discuss your individual risks with you. The risk of a DVT can be reduced by:

Slight thinning your blood: Before and after your operation,

you may be given an injection into your abdomen or arm every night during your stay in hospital.

You may notice some bruising around the injection site; this is quite normal and will disappear once the injections stop. This will continue for up to 4 weeks at home. Yourself or a family member can learn how to do this or you can attend your practice nurse at your GP surgery.

Using a mechanical pump: This involves applying either a special slipper to each foot or a special cuff around your calf. This inflates (blows up) every so often and squeezes the veins in your foot or leg to help pump blood around your body.

Wearing special elastic stockings or socks until you are fully mobile: If your doctor advises that you should wear these special stockings, you will be fitted with them before your operation. You will need to wear them during the day and night for 6 weeks after your operation.

You may be offered one or more of the above. It is very important that you follow the advice given by your doctor, nurse and physiotherapist, to try to prevent a DVT developing. DVT can lead to the more serious complication of PE. To help prevent these complications, you will be encouraged to start moving about as soon as possible. This is an important part of your recovery. Even if you have to stay in bed, it is important to keep up regular leg movements and deep breathing exercises, as shown by your physiotherapist. Post-operative wound infection Occasionally wounds can become infected. This can happen a few days after your operation, or at any time until the wound is healed. Your doctor and nurses will regularly check to see if:

your wound becomes warm to touch

the area around your wound becomes red or swollen

there is any discharge from your wound

you feel generally unwell or feverish. You will be given antibiotics through a cannula (fine tube) inserted into a vein in the back of your hand or arm using a small fine needle, before and after your operation, to help prevent any infection developing2. Chest infection This can be due to the effects of the anaesthetic, bed rest and reduced activity during your recovery. To help prevent this, a physiotherapist will teach you some breathing exercises to help get air into the bottom of your lungs. You should try to stop or cut down smoking before your operation. Anastomotic leak This happens when the anastomosis (the joined ends of your bowel) break down and open allowing faecal (bowel) contents to leak into your abdominal cavity (inside your abdomen). This can cause faecal peritonitis. This is a very serious and life-threatening complication. If you develop faecal peritonitis you will need to return to the operating theatre for another operation where a temporary stoma will be formed to allow your bowel to rest and recover. Haemorrhage (bleeding) The bowel has a large blood supply. Your surgeon will take great care during your operation to make sure any bleeding is stopped. However, it is possible for some bleeding to occur after your operation. You will be checked regularly for signs of this.

If bleeding does occur, you will need to return to the operating theatre for another operation to stop it. Sexual dysfunction In patients who require rectal surgery, the nerves controlling sexual function are very close to the rectum and sometimes an operation to remove a rectal cancer can damage these nerves, resulting sexual dysfunction. If you experience this, please mention this to your doctor who will refer you to another specialist (urologist) for further management. Death

Research shows a national average of less than 7 patients in every 100 may die following elective surgery for colorectal cancer. There will be a higher risk following emergency surgery for colorectal cancer3.

What other treatments are available for colorectal cancer? If other treatments are recommended, your surgeon or oncologist will explain how they work and what side effects they may have. Other treatments can include: Radiotherapy Radiotherapy uses high energy X-rays to kill cancer cells in the treated area. Treatment is planned for every patient individually. Radiotherapy treatment is painless. It does not make you radioactive and it is safe for you to mix with other people while having this treatment.

Chemotherapy

Chemotherapy uses cytotoxic (anti-cancer) drugs to destroy cancer cells. The drugs are taken by mouth, given by injection, or by an intravenous drip through a cannula placed into a vein in the back of your hand or arm. Most colorectal cancer chemotherapy is given

during an outpatient visit to the hospital. There are many different combinations (mixtures) of chemotherapy drugs and the best treatment choice for you will be fully explained and discussed with you by your oncologist and staff from the Chemotherapy Unit. Chemotherapy does have side effects, for example, sore mouth or nausea (feeling sick), but medication and alternative (other) treatments can be used to help reduce any side effects. You will be given the opportunity to visit the Chemotherapy Unit and discuss any concerns you may have before starting any treatment. You will be given an information pack about chemotherapy and a telephone number if you wish to contact the unit.

Are there any other treatments that can help me? Complementary therapies such as aromatherapy, acupuncture, reflexology and relaxation techniques can help some people.

What are complementary therapies? They are part of a holistic approach which means paying attention to the whole person, including emotional and spiritual needs. If you want to find out more about complementary therapies, ask your specialist nurse.

Many people feel the benefits of mixing complementary therapies with usual cancer treatments. The nearest holistic centre which offers all these treatments is at the James Cook University Hospital in Middlesbrough. Some holistic treatments are available at the Seven Wellbeing Centre, Hardwick, Stockton on Tees. There may be a charge. Telephone: 01642 662785 to arrange an appointment. Both centres can provide further information about what is available. See contact details in Part 5.

This leaflet has been produced in partnership with patients and carers. All patient leaflets are regularly reviewed, and any suggestions you have as to how it may be improved are extremely valuable. Please write to the Clinical Governance Team, North Tees and Hartlepool NHS Foundation Trust, University Hospital of North Tees

or Email: nth-tr.leaflets@nhs.net

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PIL1244 v1 For Review August 2023