Colo-rectal Tumours
TUMOURS OF THE COLON AND RECTUM: COLO-RECTAL CANCER STUDY CENTRE
The treatment of colon and rectal cancer requires a multidisciplinary approach in which sharing of knowledge by every specialist involved in diagnosing and treating cancer leads to true synergy and “tailor made” treatment for each patient.
For colon and rectal cancer, this multidisciplinary approach, effective for over 10 years now, has been applied successfully by the CPTCR or Cancer and Colo-Rectal Studies Centre.
EPIDEMIOLOGY
Over 7,000 cases of colon or rectal cancer are diagnosed in Belgium each year. This type of cancer is the third commonest in men, after lung and prostate cancer. In women, it is second behind breast cancer.
We treat almost 200 patients suffering from these tumours each year. Of this total, about fifty are cases of rectal cancer. Although the term “colo-rectal cancer” is often used in everyday language, it is more correct, especially when referring to treatment, to draw a distinction between colon cancer and rectal cancer.
If diagnosed and treated at an early stage, colon cancer can be cured in 95-100% of cases. Screening is therefore of utmost importance.
RISK FACTORS
Some colo-rectal cancer cases are “sporadic”, that is, they occur in isolation in patients not really predisposed to the condition. Others occur in families that show a clear genetic predisposition.
Sporadic cancers usually occur at age 65-70. Excessive consumption of red meat, not enough fibre in the diet, and lack of physical exercise, can favour it. Environmental factors are also implicated.
Finally, inflammatory intestinal conditions, such as Crohn’s Disease and haemorrhagic or ulcerative colitis, can also contribute.
Sporadic colo-rectal cancer develops slowly; several decades can pass between its inception and the onset of initial symptoms.
Familial adenomatous polyposis is a hereditary pre-cancerous condition in which a mutant gene is passed from one generation to the next. This disease accounts for 1% of colo-rectal cancer cases in Belgium. As the risk of malignant degeneration is 100%, preventive surgery, involving complete removal of colon and rectum and reconstruction of the intestinal tract, is necessary before the cancer appears.
The CPTCR members were among the first to research these mutations. They were therefore in on the beginning, in 1993, of the national polyposis register managed by FAPA (the Familial Adenomatous Polyposis Association).
Hereditary non-polyposis colo-rectal cancer, also known as Lynch’s syndrome, is another form of hereditary cancer, accounting for 5% of colo-rectal cancers.
Hereditary cancers occur at an earlier age than sporadic cancers. They are sometimes multiple and can affect other organs. This only stresses the importance of early detection in families at risk.
The genetic problem behind this cancer was discovered in 1998. Since then, it has been systematically looked for in all colonic tumours operated on at our centre. This process has enabled the diseases behind the problem to be identified and the necessary screening to be carried out within families affected, via genetic advice consultations.
Une partie de l'équipe de la Clinique des Pathologies Tumorales du Côlon et du Rectum
SCREENING
In families at risk, screening should begin before age 50, preferably at 40 or 10 years before the earliest cancer onset age within the family. In this case, screening should initially be carried out by means of coloscopy.
Colon polyps are lesions from which cancers develop. They very rarely present any symptoms. They can be removed during the coloscopy to prevent them from degenerating into cancer.
SYMPTOMS
A change in defecation patterns (unusual increase in frequency of stools, or alternating diarrhoea and constipation) is often a first sign of the disease. Bleeding through the anus can also indicate it. This loss can often be significant, but is frequently intermittent and wrongly dismissed as something trivial.
SURGICAL TREATMENT
Surgery is still the cornerstone for treatment of colo-rectal cancer. It is often combined with other treatments such as radiotherapy and chemotherapy.
The treatment programme is discussed during CPTCR meetings.
Surgical techniques have improved greatly. The laparoscopy has revolutionised surgical treatment of early-stage colon cancer, having been applied by the Colo-Rectal Surgery Unity since 1998. Its importance has now been clearly demonstrated.
During a laparoscopy, the surgeon views the operation site using a camera linked to an optical fibre, and handles instruments introduced into the interior of the body through small openings.
This approach helps preserve bodily integrity and removes tumours completely without excessive mutilation.
Post-operative complications are less frequent, as aesthetic consequences are very discreet. Recovery is much more rapid than with conventional surgery. Armed with its experience of the laparoscopy, our team has now produced the “fast track concept”, which reduces the impact of surgery on patients as far as possible, requiring a stay in hospital of only three days in most cases.
Surgical treatment of rectal cancer, like that of colon cancer, has some very specific aspects. Depending on the location and the extent of the tumour, three techniques are used.
Dissection intersphinctérienne partielle
Transanal endoscopic surgery allows small rectal tumours to be treated through natural channels. It is testimony to the efforts made to find a surgical technique that is both highly effective and much less invasive.
More advanced rectal cancer carries a higher risk of local recurrence. Its removal may lead to major changes in urinary function and sexual performance, in both men and women. It is therefore essential to choose a technique that helps prevent these complications. A technique known as “total mesorectal excision” completely removes the cancer while fully preserving both urinary function and sexual performance.
The CPTCR surgical team has been using this technique for over 10 years and is also involved in the “Procare” national teaching programme aimed at all surgeons wishing to learn the technique.
Previously, rectal surgery usually involved removal of the pelvic floor and anus, requiring insertion of a pocket or bag, also known as a stoma. Highly sophisticated sphincter protection procedures, pushed to the extreme and practised in reference centres, now mean that the anal sphincter can be preserved in some patients, thus sparing them the major inconvenience and discomfort of the stoma.
In cases of liver metastases, common in this type of cancer, each patient’s case is discussed jointly by specialists from the CPTCR and from the multidisciplinary Hepatic, Biliary and Pancreatic Cancer Group. To find out more about this multidisciplinary group, click here.
RADIO-CHEMOTHERAPY
Other treatments used in colo-rectal cancer cases are radiotherapy and chemotherapy. Radiotherapy is used only in cases of rectal cancer, not for colon cancer, and is not indicated in cases of advanced rectal cancer.
Chemotherapy can also be very useful after surgical treatment of certain rectal or colonic cancers.
Major steps have been made in pharmacological treatment of colo-rectal cancer. New “target” treatments have been introduced and are being used within huge international studies in which reference centres, such as our centre, take part. Most treatments are given intravenously in the outpatients’ department, meaning that patients do not have to be admitted to hospital. Some drugs are also administered orally.
Système de drains, capteurs de pression et de température en place pour la chimio-hyperthermie intra-péritonéale à ventre fermé
Finally, intraperitonal chemohyperthermia or “CHIP”, for generalised colo-rectal cancer within the abdomen, is another fruit of the multidisciplinary approach. Used in some cases of generalised colo-rectal cancer, it involves complete removal of all intraperitonal tumour tissue followed by localised heated chemotherapy aimed at destroying any cancer cells that may have escaped the surgery.
These approaches are now improving patient prognoses and providing cures, even in advanced cases of the disease.
RESEARCH
In addition to clinical research, our multidisciplinary group is also distinguished for its intensive basic research.
Two post-graduate students are working within the group, one on the basic mechanisms behind colo-rectal cancer and the other on the risk factors for recurrence of the cancer. They work closely with the National Cancer Register, within the framework of the Procare national project, in which all the CPTCR specialists are heavily involved.
