Understanding Colorectal Cancer, its prevention and treatment
By Dr. (Prof) G.S. Moirangthem, MBBS,MS (PGI), FRCS Ed (UK), FICS (GE), FAIS, FIAGES, FMAS, FCLS
Director & CEO, Karkinos Manipur Cancer Care Institute, Imphal, Manipur
Colorectal cancer (CRC) is a disease in which abnormal cells in the colon or rectum divide uncontrollably, ultimately forming a malignant tumor. Colon cancer is a kind of cancer that starts in the colon (the last section of the digestive system) or rectum and spreads to other parts of the body such as liver, lungs etc., if not treated on time. It is known as colorectal cancer because the phrase combines colon with rectal cancer.
Globally, colorectal cancers are the third leading cause of cancer related deaths, contributing 8.9% of all cancers in both males and females. When compared to the western world, the incidence of Colorectal Cancer (CRC) is comparatively low in India. However, CRC is becoming more common in India, and health officials are concerned with this rising incidence. Most cases of colorectal cancer occur in people of ages 45 and older, but the disease is now increasingly affecting younger people too.
According to the National Tumor Registry, the early CRC incidence rate of 4 per 100,000 people had gradually increased to 5.8 per 100,000 people in 2004-2005 and to 6.9 per 100,000 people in 2012-2014. Also, the North Eastern states have a higher rate of colorectal cancer overall in the country. The increased prevalence can be ascribed to changing lifestyles, which include eating a calorie-rich, low-fiber diet, consuming excessive amounts of red meat and processed foods, and engaging in less physical activities.
The best part of CRC is that unlike most cancers, colorectal cancer is mostly preventable with screening and is highly treatable, but only if and when detected early.
What causes Colorectal Cancer?
What causes colon cancer in an individual depends on several factors. As said, carcinoma of the colon and rectum is a relatively uncommon malignancy in India when compared with the western world, owing to our traditional eating habits and diet. However, our eating habits have changed in recent years. Western country-based fast foods and cuisines have created a change in the diet pattern of Indians, especially among the millennials. Hence, poor dietary and personal habits are the most significant contributors that cause Colorectal Cancer (CRC).
People have begun to consume an increasing amount of red meat, spices, intoxicants such as alcohol, and tobacco-based cigarette and gutka. People have also decreased the intake of fiber foods such as fresh vegetables, fresh fruits, and water in their diet. The absence of a balanced diet in one’s lifestyle is causing a lot of digestive related problems in most people. Lack of optimum fiber and water in the diet has led to constipation in many, causing the colon-fecal contact time to lengthen. Such individuals are at higher risk of acquiring CRC. The easiest and preventive way to avoid CRC is to increase the transit time of fecal matter in the colon by eating a lot of vegetables, eating a fibrous diet, and drinking a lot of water. Apart from the diet, the other predisposing factors for developing colon cancer are Multiple Polyposis Coli, adenomas, inflammatory bowel diseases such as ulcerative colitis and Crohn’s Colitis.
Before we understand the predisposing factors of CRC, it is important to understand the anatomy of the colon. The human intestine is approximately 8 m long. It consists of 2 main parts – small intestine having a length of about 6 meter and large intestine known as colon having a length of 2 meter. Whatever is required in the body such as protein, vitamins, fats, nutrients, minerals, fluid, etc., are absorbed in the small intestine. Whatever is not absorbed such as water, electrolyte, mostly potassium, solid waste in the form of stools moves to the colon. The main function of the colon is absorption of water, electrolytes, some vitamins, fermentation of indigestible materials by bacteria, storage and then transportation of fecal matters to the rectum, which is sub classified into upper, middle, and lower portion having a length of 4 cm each with a total of 12 cm in length. The fully formed stool then moves to anal canal, which is about 3.7 cm in length and the fecal matter is then excreted from the body through the anus.
If early diagnosis and intervention is missed, then some factors, almost invariably, lead to Colorectal Cancer at a later point in a person’s life. The major risk factors for colorectal cancer are older age and having certain inherited conditions (such as Lynch syndrome and familial adenomatous polyposis), but several other factors have also been associated with increased risk, including a family history of the disease, excessive alcohol use, obesity, being physically inactive, cigarette smoking, and, imbalanced diet. In addition, people with a history of inflammatory bowel disease (such as ulcerative colitis or Crohn’s disease) have a higher risk of colorectal cancer than people without such conditions.
It is more common in older people, although it can affect anybody at any age. It generally starts as polyps, which are tiny, noncancerous (benign) collections of cells that develop on the colon’s interior. Some of these polyps can become cancerous over time.
Most colorectal cancers begin as a growth, or lesion, in the mucosa that lines the inner surface of the colon or rectum. The lesions may appear as raised polyps, or, less commonly, they may appear flat or slightly indented. Raised polyps may be attached to the inner surface of the colon or rectum. Colorectal polyps are common in people older than 50 years of age, and most do not become cancerous. However, a certain type of polyp known as an adenoma is more likely to become a cancer. There are 3 types of adenomas: a non-cancerous tumor of the colon initially – 1) Villous, 2) Tubular-villous, 3) Tubular. Out of these types, the risks of developing colon cancer in Villous adenoma is as high as 60%, the tubular-villous is about 40% and that of tubular is as low as 5%.
Symptoms, diagnosis and treatment of Colorectal Cancer
The symptoms of colorectal cancer depend on the types and location of the tumor. In general, the individual becomes gradually anemic, lethargic, and will lose appetite. There are two types of colon cancer, the first one being ulcerative, which usually involves the right half of the colon and the 2nd being annular, which usually involves the left side of the colon.
The symptomatology of right sided colon cancer is more of vague pain abdomen, malabsorption syndrome such as diarrhea mixed with mucus, altered blood and that of left sided colon is more of an obstructive in nature in the form of abdominal distention, feeling of a lump, not passing of stools, flatus for days together and incomplete sense of defecation with blood in stool time to time.
Karkinos Healthcare looks out for these symptoms in suspected CRC patients:
- Persistent change of bowel habits either diarrhea mixed with altered blood and mucus or constipation
- Gradually becoming anemic,
- Gradual and significant weight loss,
- Bleeding per rectum usually mixed with mucus,
- Increased frequency of Stools mixed with altered blood,
- Incomplete sense of defecation,
- Abdominal cramps and fullness
As for rectal cancer, the symptomatology is slightly different from colon cancer. In this condition, the patient will definitely be having tenesmus, incomplete sense of defecation, and frequency to pass stools. This frequent passing of small amounts of stool mixed with blood and mucus is one of the most important symptoms of rectal cancer. The common people think that they have the symptoms of piles, they consult amateurs/inexperienced doctors for treatment. By the time the patient reports to the GI physician or surgeon, the disease would have advanced. This is why physicians advise routine screening tests to help prevent colon cancer by detecting and removing polyps before they develop into cancers.
If a person suspects that he/she is suffering from colon cancer, he/she should immediately contact either a GI Surgeon/Onco-Surgeon or any general surgeon having special interest in colorectal diseases. The surgeon in return shall examine the patient whether he/she is anemic, any lump in the abdomen.
Simple digital rectal examination can rule-out or confirm 99% of mid and lower rectal cancer. If the investigations reveal low hemoglobin, positive stool for occult blood for 3 days, positive FIT (FAECAL IMMUNOCHEMICAL TEST), high presence of tumor marker CEA (Carcino Embryonic antigen), one must suspect that something is going wrong in the colon. The individual must be subjected to a procedure called colonoscopy, direct visualization of the entire colon through a flexible, well illuminated endoscope. The colonoscopy will be able to tell whether there are any growth or predisposing factors such as Adenoma, Polyps, Ulcerative colitis etc.
A piece of tissue from the lesion can be taken for histopathological examination. If the aforementioned pre-cancerous or predisposing factors are present, then the patient should comply with the treating surgeon’s advice for early surgery as a preventive measure. Once confirmed the patient should be ready for timely operation with resection or palliative procedure depending on the stage of the diseases. (I have detected one of my patients to be suffering from Villous type of Adenoma which is 60% pre-cancerous. I have advised prophylactic colon resection as a treatment but this patient refused surgery. Six months later, he reported back to me with fully grown colon cancer).
How to detect CRC early?
Ideally, Direct Visualization of the entire colon and rectum by a procedure called Colonoscopy can only detect premalignant conditions of colorectal cancer. But it is technically not possible for a mass scale screening program as this procedure is hospital and expertise-based procedure involving higher cost.
Owing to this, Karkinos Healthcare, which conducts frequent, mass cancer screening programs for early detection, proposes to do a hemoglobin, fecal occult blood test for 3 consecutive days, FIT (Faecal Immunochemistry Test) and Tumor Marker CEA (Carcino Embryonic Antigen) assay. Earlier, CEA was used only to detect the recurrence of the tumor after surgical resection. But, in recent times, this assay performed before the surgery proved beneficial. If the CEA score is exceptionally high, one can suspect that the patient may be having colorectal cancer. If an individual is having very low hemoglobin, fecal occult blood or if FIT is positive and the CEA is on the higher side, it indicates that the person carries a high risk of already having colorectal cancer or likely to be having a precancerous condition.
Patient in this category and those people having early warning signs and symptoms must be subjected to early colonoscopy to confirm whether the cancer has already set in or is in the precancerous stage (in any part of the colorectum). This is how we can detect colorectal cancer at an early stage.
Prognosis of Colorectal Cancer
CRCs spread in the body through three routes: 1) via direct invasion to the surrounding structures, 2) through lymphatic systems, 3) via the bloodstream.
Physicians predict the outcome or prognosis by staging the disease based on the characteristics of the tumor and the extent to which it has spread in the body.
CRC is classified as three stages based on its severity:
Stage 1: Localized and confined to the primary tumor (involving the mucosa, submucosa, the innermost layers of the colon and rectum);
Stage 2: Regional where cancer has spread to the lymph nodes; and
Stage 3: Distant where cancer has spread to distant organs such as liver and lungs (also known as metastasis).
If the patient reports to the physician at an early stage i.e., at Stage 1 the outcome of the treatment or the survival is high. If there is neither lymphatic nor metastatic spread in liver, lungs via blood stream, the prognosis is expected to be very good. If a curative resection is done at this stage, the patient can be assured of a 100% cure rate. When a patient reports at Stage 2, i.e., once lymphatic spread occurs, the prognosis is reduced by 50%. If cancer spreads to the lungs or liver, the prognosis/survival chance further drops down to 30% to 40%.
Hence, it is necessary for the general public to be aware of the early warning signs and symptoms of colorectal cancer and contact the concerned specialist for early detection of cancer and pre-cancerous conditions for early surgical interventions and better prognosis.
Treatment options for Colorectal Cancer
The tumor is either surgically removed or poisoned by chemotherapy or burnt by radiotherapy. The patient’s immunity is also improved with medicines to make his/her own body to fight the cancer, which is called immunotherapy. Among all these options, surgical resection is the first line of treatment for colorectal cancer and chemotherapy comes second in the line of treatment for colon cancer.
For rectal cancer radiation plus chemotherapy follows surgical resection. But in certain conditions, where the rectal cancer is quite big, oncologists administer neoadjuvant chemoradiation (anterior chemoradiation) prior to surgery to downsize the tumor.
Due to the advanced stage of the disease when the resection of the tumor is not possible, but the patient has already developed colonic obstruction, we have to do certain palliative surgery in the form of either bypass or taking out a portion of the intestine proximal to the lesion, a procedure called ileostomy or colostomy so that the patient can pass stools and be relieved of the obstruction.
In addition to treatment Karkinos Healthcare believes by adding psychosocial and spiritual components to palliative care, where there will be a special hall for prayer and counseling by trained psychologists and spiritual gurus of different faiths, the patient’s quality of life can be managed until the last days.
A digital technology-based approach to CRC awareness and early intervention
Tackling cancer has 2 main approaches and Karkinos Healthcare is adopting them to eliminate the most common cancers including CRC. The first approach is onco-prevention and the second is early detection. The onco-prevention can only be achieved if we can make people aware of early signs and symptoms of colorectal cancer. Our healthcare workers have been assigned to make periodic field visits to several District Hospitals and Healthcare Centers across the state. Widespread outreach programs are done to create awareness among the communities. KareMitras carry printed messages on early symptoms and warning signs of colorectal cancer. As part of the awareness program and mission of Karkinos Health Care Project in Manipur, my speech on colorectal cancer on early warning signs and symptoms is broadcasted time to time in local networks and on AIR.
In delivering quality and timely cancer care, digital technology is playing a major role, especially in North Eastern states like Manipur. Healthcare related information is delivered on smartphones via the internet. Messaging platforms, Health Apps, and Artificial Intelligence (AI) in healthcare IT have been able to reduce the gap in cancer care.
Digital technology has proved to be a great boon in times like the pandemic. Hospitals and healthcare service providers, owing to the pandemic, have resorted to telemedicine and teleconferencing as a mode of connecting with patients and delivering timely prescriptions and diagnosis. Added to these advantages, digital technology provisions the use and maintenance of patient data electronically. Electronic Health Records (EHRs) help in remote consultations, data analysis, and research to improve healthcare services and also deliver personalized treatments. E-informatics, robotic surgery, etc., are some other examples of digital technology advancement that play a significant role in cancer diagnosis treatment.
Karkinos Healthcare’s Cancer Care in Manipur
The state of Manipur severely lacks cancer care hospitals. The lone oncology private healthcare provider that is currently servicing the citizens of Manipur is not meant for common people from all walks of life. The common people cannot afford treatment at the center. Whereas, Karkinos Manipur Cancer Care Institute (KMCCI) at Imphal is different. It is a joint venture between Govt. of Manipur and Karkinos Healthcare (P) Ltd. Mumbai. The Govt of Manipur has allotted 3.3 acres of land in the Jawaharlal Nehru Institute of Medical Sciences, Imphal Campus.
This center, once functional, will offer cancer care at the most affordable rates to help common people and avail treatment confidently. While cost of care will be affordable, Karkinos Healthcare will deliver the highest standard of care (matching global standards) in cancer treatment. We are also further committed to honor other health care beneficiary cards such as PMJY, AYUSMAN BHARAT and CMHT (Chief Minister HAKSHEL gi TENGBANG ).
Not only will the KMCCI, Imphal center benefit the state of Manipur, neighboring states Nagaland, Mizoram, Arunachal Pradesh and neighboring countries like Myanmar and Bangladesh will also benefit. Our goal is to make KMCCI, Imphal a Centre of Excellence (CoE) and one of the best centers in the country for cancer care, research, and postgraduate training in the field of oncology, yet to make it easily accessible and affordable to the common man.