Colon Cancer- Symptoms, Treatment and Prevention (Aster Medcity)

Dr. Ashok Komaranchath
Consultant Medical Oncologist
Aster Medcity,
Aster Medcity, Kochi.i

Mr. Mathew* (Name changed) had just turned 74 years old. One morning, he noticed some blood in his stools after going to the toilet. He wasn’t worried as he had had a history of piles and the doctor had warned him then that it might happen. But being the responsible person he always was, he consulted his family doctor who then referred him to a famous gastroenterologist in Kochi. On further questioning, he said he did notice some difference in his bowel movements over the past month. A colonoscopy was done and a large tumour was found growing in his colon. He was told that colon cancers are not uncommon at his age and it could probably be cured. A CT scan of his abdomen and chest was done to look if there was any spread. Unfortunately, there was a large 11cm mass in his liver which was proven to have spread from his tumour in the colon. He was diagnosed with Stage IV colon cancer.

There are few words which generate as much fear as the word cancer, even fewer when it is preceded by another word and number. “Stage 4”. Especially when concerned with oneself and to loved ones. Our highly educated population are well read enough to recognize that in most cancers, there are four stages and the 4th and last one usually means one cannot be cured. Mr. Mathew was no different. He had a wonderful wife whom he was married to for over 40 years and three wonderful sons. They were all in shock and despair over the news. Someone in the medical field known to them said to one of the sons that he probably had only 6 months to live. But the person who handled it best was the patient himself. He was a retired engineer who had overcome many obstacles in his life and he was determined to fight and overcome this too.

Colon cancer is one of the most common cancers in the world but much less common in India. It’s the 3rd most common cancer and the 2nd when it comes to death due to cancers worldwide. In India, it is only the 13th in the list of common cancers and death due to cancers. One of the reasons is thought to be due to the different dietary habits of Indians. A disturbing trend seen in Kerala is a higher incidence and death rate due to colon cancers. There are likely several reasons for the same. However, with the recent finding that processed meat and to a lesser extent, red meat having strong links to cancer (especially colon cancer). There have been doubts as to whether Kerala’s higher meat (both processed and red meat) consumption than most other states have some role to play. Processed meat is any meat which has been modified to improve taste or extend shelf life. For example: Bacon, salami, smoked ham and sausages. Red meat is any meat from cows, buffaloes, goats, sheep or pig. However, there are other factors implicated in a higher incidence of colon cancers. This includes smoking, alcohol intake, a sedentary lifestyle, lack of exercise, reduced intake of fruits and vegetables and to a small extent, even hereditary factors. The sad fact is that every single of the above risk factors can be changed. But most of us, don’t take enough care to do so.

Diagnosis

Another peculiarity of colon cancers is that it is one of the few cancers that can be detected early by screening programs. Most international guidelines recommend that, after the age of 45 years, a screening test like Sigmoidoscopy or Colonoscopy be done once in 10 years for both men and women. This test is mandatory in health check ups of people above the age of 45 years in some western countries like the USA. It has been found that such screening programs help to detect the cancer at a very early stage and greatly improve the chance of a cure. In fact, one study found that with a simple sigmoidoscopy done once in 5 years reduced the colon cancer deaths by over 1/4th! There is very little awareness about this in developing countries like India and consequently, the cases detected late are much higher than in the west. There are even simpler tests like a Fecal Occult Blood Test (FOBT) which detect minute amounts of blood in a person’s stools which may be an early indicator of a colon cancer. But this has to be done once a year after the age of 45 years.

Treatment

Once a diagnosis of colon cancer is made, the only chance of a cure is through surgery and complete removal of the tumour. In many cases, a surgery alone is enough and the patient will not require any further treatment like chemotherapy or radiotherapy. But if the cancer reaches stage IV (that is, spread of the cancer from the primary site to another organ or location), in most cancers, surgery will not make a difference to the outcome and it is like a death sentence. In recent years, this concept has changed in certain cancers and it has been found that operating and removing both the primary tumour and any spread to other organs (Called metastasis); along with chemotherapy and sometimes, newer drugs called targeted therapies, we can dramatically improve the chances of long term survival and even cure for many patients. Just 20 years ago, the chances that a patient with stage IV colon cancer would survive for 5 years was less than 10%. With newer drugs and newer surgical techniques, this percentage has reached as high as 50%!

However, the treatment in such cases is not easy. There can be many complications and setbacks which needs to be managed with great care and skill. Our Mr. Mathew, decided to take the best possible treatment and was started on chemotherapy and a new targeted therapy drug called ‘Panitumumab’. After 4 cycles of treatment, his colon cancer had shrunk significantly and even the liver mass reduced by over 50%. The surgeon was called in and in two long and skillful operations, the tumour in both the colon and the liver was successfully removed. However, he had many difficulties including infections after the surgery and high blood sugar. To remove the unseen tumour cells in his body, he was restarted on chemotherapy once he recovered. He was a fighter and bravely endured all this without complaint. He had full faith in his team of doctors. But unfortunately, 2 months after his last surgery, he developed tuberculosis in his lungs. Tuberculosis is a common disease in our country and is even more common in persons with poor immunity. With his age, and recent spate of infections, his immunity was on the lower side. We had to stop all further therapy and start on treatment for his tuberculosis. With treatment, he started recovering well from the tuberculosis but another bit of bad news came. His tumour had come back in the liver and lymph nodes of the abdomen. We explained the situation to him and his family. They decided to continue a form of palliative treatment meant to prolong life and improve his quality of living. With this, he pulled on for nearly another year and spent some good times with his sons and grandchildren. Finally, nearly 3 years after his diagnosis, his cancer became resistant to further treatment and spread to his lungs. After a short hospital stay, he passed away in his sleep, surrounded by his wife and children.

Prevention

March is Colon Cancer Awareness Month. There are 5 simple things we can do in all our lives which will greatly reduce the chance of developing this dreaded disease.

- Stop smoking and limit alcohol intake (if you do take either).
- Limit the amount of red meat in your diet and try to avoid all processed meats.
- Have a balanced diet and include more fruits and vegetables daily.
- Exercise regularly (30-45 minutes at least 5 days a week).
- If you are above the age of 45 years, please get a colonoscopy done once in 10 years.

Towards the end, I had the unenviable task of telling Mr. Mathew that we had run out of options and the end was fast approaching. He was still strong, unwavering and was in fact a pillar of strength for the rest of his family. He said, “In the three years you have given me, I have spent more time with my children who are well settled and are happy. I have played with my grandchildren and met with my friends. I have come to terms with this disease and it’s end, and I know that you and your team have tried their best to save me.” He thanked me for this with his hand on my head, but as I walked away with a heavy heart, I felt that I had failed miserably. As always, I keep praying every day that each and every one of my patients with cancer are diagnosed at an early stage as possible and that I may be able to cure them.

So, most importantly, if you do have any doubtful symptoms like a change in bowel habits, blood in stools, unexplained weight loss, persistent abdominal pain; please don’t ignore them. Consult your local doctor or gastroenterologist for further evaluation. Many patients (especially women) ignore their symptoms for reasons like family functions or children’s exams and keep ignoring them until it becomes unbearable. But many a time by then, the stage of the tumour changes, and what was once curable, becomes incurable.