In patients with potentially curable colon cancer, a properly performed surgical operation is essential for optimal results. In the majority of such cases, operative intervention involves a resection (removal) of the primary cancer and regional lymph nodes, along with the removal of sections of normal bowel on both sides of the cancer. There are several different types of surgical procedures used in the treatment and management of colon cancer. The size and spread of the cancer, as well as the experience of the surgeon determine the appropriate procedure.
Some patients with colon cancer will already have small amounts of cancer that have spread outside the colon and can not be removed by surgery. Undetectable areas of cancer outside the colon are referred to as micrometastases and cannot be detected with any of the currently available tests. The presence of micrometastases causes relapses that occur after treatment with surgery alone. Surgery is only one component in the treatment of colon cancer and is often followed by adjuvant chemotherapy to cleanse the body of micrometastases.
Hemicolectomy: A hemicolectomy (radical resection) is currently the standard surgical procedure used to remove colon cancer. A hemicolectomy is recommended for cancers at high risk for recurrence, which is the case for most cancers of the colon. A hemicolectomy is an invasive surgery that requires surgeons to create a large opening in the abdomen in order to reach the cancer. During a hemicolectomy, the cancer, and a margin of normal bowel and lymph nodes on all sides of the cancer are removed. The two cut ends of the colon are then sewn back together. In some instances, a colostomy is created and the two ends of the colon are reconnected at a later time. A colostomy is an opening where the large intestine is attached to the abdominal wall and allows passage of stool into a replaceable bag. In some situations, the cancer cannot be completely removed, the two ends are not re-sewn together and the patient has a permanent colostomy.
Laparoscopic Surgery: Extensive surgery can cause serious side effects, including infections, severe pain and prolonged convalescence. As a result, surgeons have worked to develop less invasive surgical techniques for performing a hemicolectomy. Recent advances in minimally invasive technology have allowed complex procedures to be performed with the aid of a video camera. A laparoscopic procedure has recently been shown to be effective for performing a hemicolectomy, while decreasing the side effects caused by extensive surgery. During laparoscopic surgery, a few one-centimeter incisions are made in the patient’s abdomen. Then, a very small tube that holds a video camera is inserted through the incision, creating a live picture of the inside of the patient’s body. This picture is continually displayed on a television screen so that physicians can perform the entire surgery by watching the screen. Before the section of the colon containing the cancer is removed from the body, the incision through which it will be removed is enlarged to allow its passage with minimal contact. Although this approach is thought to be associated with reduced pain and shortened hospitalization, a recent clinical trial indicated that quality of life benefits of laparoscopic surgery were not significantly better than conventional surgery.1
Colonoscopy: Some small cancers are limited to the head of a single polyp. These cancers present no evidence of spread to the lymph system, blood vessels, or nervous system, and therefore, may be removed with a local excision. In an effort to avoid unnecessary invasive surgery, these cancers can be treated by colonoscopy. During a colonoscopy, a long flexible tube that is attached to a camera is inserted through the rectum, and is used both to view the internal lining of the colon and to perform a local excision. A properly performed local excision can be a safe and effective procedure.
Palliative Surgery: Palliative treatment is treatment that is intended to relieve symptoms, such as pain, but is not expected to cure disease. The main purpose of palliative treatment is to improve the patient’s quality of life. Approximately 20% of patients with colon cancer already have distant metastases at the time of diagnosis. Since the 5-year survival rate in this group of patients is only five percent, palliative colon resection is generally recommended to prevent bleeding, obstruction and symptoms related to local organ invasion.
With any treatment of cancer, you must first understand your responsibility, your medical team’s role, explore treatment options and get a second opinion(s) before you begin treatment. Since the emotional and physical side effects of surgery for the treatment of colon cancer can be significant, talk to your surgeon and medical team about the specific kind of surgery you will undergo, the expected side effects and potential risks before surgery. The following list of questions is meant as a guide to issues you should discuss with your surgeon and medical team before undergoing treatment of colon cancer.
Questions to Ask When Exploring Your Options
- What is the stage of my cancer?
- Why do you recommend surgery?
- What are my options besides surgery?
- Is surgery the standard therapy for my stage of disease?
- Are there clinical trials for my stage of disease?
- Will I need adjuvant therapy after my surgery?
- Are there any protocols for neoadjuvant therapy for my stage of disease?
- What are the pros and cons of each type of colon cancer surgery for the treatment of my particular cancer?
- What diagnostic tests are needed prior to surgery and how will these assist in surgical planning?
- Do you feel it is appropriate to perform surgery even if there are metastases present in more than one place? If yes, under which conditions?
Questions to Ask about the Surgery
- Do you have a specialty in surgical oncology and are you board certified?
- At which hospital(s) do you have privileges?
- Have my hospital stay and surgical procedures been approved by my insurance?
- What type of surgery do you recommend?
- What is the goal of surgery?
- How many times have you performed the recommended surgery?
- Will you be performing the surgery or assisting a resident or other physician?
- What is your success rate and how do you define success?
- What is your experience with complications?
- If you find that the disease is more extensive than originally believed, what will you do?
- Considering my age and general health, am I at a higher or lower risk for complications and side effects?
- Will I need blood transfusions and can my family donate blood?
- Why is bowel preparation necessary for abdominal surgery?
- Will I have a catheter to drain my bladder and, if so, how long will it be in?
- Will you perform a pelvic lymph node dissection?
- I have read that at least 12 lymph nodes need to be examined to accurately stage colon and rectal cancers, do you routinely accomplish this?
- What happens if one or more of the lymph nodes is found to be positive?
- Do you use drains and how do you decide?
- How long will I be unable to eat?
- Will I have a nasogastric tube (NG) after surgery?
- What are my options for pain control after surgery?
Questions to Ask About a Colostomy
- Will I have a colostomy?
- If I have a colostomy, will it be temporary or permanent?
- If I have a temporary colostomy, when will I have additional surgery to have the stoma removed?
- Will I be assigned a colostomy nurse to provide detailed information and to answer questions?
- What type of colostomy will I have?
- Will I be required to change my diet?
- How will the colostomy be placed to minimize discomfort and inconvenience?
Questions to Ask About Side Effects
- What should I expect as far as complications and side effects?
- What kind of impact will this surgery have on my bladder and bowels?
- Will the surgery damage nerves to sexual organs?
- How will my sexual relations be affected and when can I resume sexual intercourse?
- What kind of pain relief will I have?
- If I have a lymph node dissection, will this cause me to be at risk for lymphedema and, if so, what steps can I take to avoid it?
Questions to Ask About Recovery
- How long will I be in the hospital?
- How long will my recovery take?
- What steps can I take to speed up my recovery?
- Who can I call with questions or concerns during my recovery?
- Who will be my follow-up doctor?
Determining that surgery for colon cancer is the right treatment for you as well as asking your doctor about surgical procedures, associated side effects and potential risks are critical to making informed decisions about your disease. Exploring the emotional and physical side effects of having colon surgery will give you some insight into potential problems before they occur. Although managing and living with these side effects may still be difficult, at least you will be aware and informed if they occur. Before undergoing any treatment for your disease, you should understand your responsibility, your medical team’s role, explore treatment options, ask questions and get a second opinion(s).
Information presented in The Daily Tip is offered as a guide to augment a patient’s research of cancer and treatment and does not replace the advice of a doctor. For more information on a specific cancer, go to CancerConsultants.com ,www.cancer.gov, and consult your physician. For more information on colorectal cancer, patients can visit the Web sites of the Colon Cancer Alliance and the Colorectal Cancer Network.
1. Journal of the American Medical Association, Vol 287, No 3, pp 321-328, 2002