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PostSubject: Rectal Cancer Free Download   Wed Jun 08, 2011 5:21 pm

Rectal Cancer

Synonyms and Keywords

rectal cancer, mucosa, muscularis propria, mesorectum, colorectal
cancer, adenocarcinoma, rectal adenocarcinoma, rectal bleeding, colorectal screening,
fecal occult blood test, FOBT, endoscopy, digital rectal examination,
DRE, flexible sigmoidoscopy, rigid sigmoidoscopy, colonoscopy,
endoscopic ultrasound, EUS, carcinoembryonic antigen,CEA, transanal excision, mesorectal surgery, low anterior resection, LAR, abdominoperineal resection, APR

  • Rectal Cancer Overview
  • Rectal Cancer Causes
  • Rectal Cancer Symptoms
  • When to Seek Medical Care
  • Questions to Ask the Doctor
  • Exams and Tests
  • Rectal Cancer Treatment
  • Medical Treatment
  • Medications
  • Surgery
  • Other Therapy
  • Next Steps
  • Follow-up
  • Prevention
  • Outlook
  • Support Groups and Counseling
  • For More Information
  • Web Links
  • Synonyms and Keywords
  • Authors and Editors
  • Read more on Rectal Cancer from Healthwise

Rectal Cancer Overview

The rectum is the lower part of the colon that connects the large bowel to the anus. The rectum's primary function is to store formed stool in preparation for evacuation. Like the colon, the3 layers of the rectal wall are as follows:

  • Mucosa: This layer of the rectal wall lines the inner surface. The mucosa is composed of glands that secrete mucus to help the
     passage of stool.
  • Muscularis propria: This middle layer of the rectal
     wall is composed of muscles that help the rectum keep its shape and contract
     in a coordinated fashion to expel stool.
  • Mesorectum: This fatty tissue surrounds the rectum.

In addition to these 3 layers, another important component of the rectumis the surrounding lymph nodes (also called regional lymph nodes). Lymph nodes are part of the immune system and assist in conducting surveillance for harmful materials (including viruses and bacteria) that may be threatening the body. Lymph nodes surround every organ in the body, including the rectum.
Of the 150,000 cases of colorectal cancer
diagnosed each year in the United States, more than 40,000 people are
diagnosed with rectal cancer. The most common type of rectal cancer is adenocarcinoma,
which is a cancer arising from the mucosa. Cancer cells can also spread
from the rectum to the lymph nodes on their way to other parts of the
Like colon cancer, the prognosis
and treatment of rectal cancer depends on how deeply the cancer has
invaded the rectal wall and surrounding lymph nodes. However, although
the rectum is part of the colon, the location of the rectum in the pelvis poses additional challenges in treatment when compared with colon cancer.
This article only discusses issues related to rectal adenocarcinoma.
Rectal Cancer Causes

Rectal cancer usually develops over several years, first growing as a precancerous growth called a polyp. Some polyps have the ability to turn into cancer and begin to grow and penetrate the wall of the rectum.

The actual cause of rectal cancer is unclear.However, the following are risk factors for developing rectal cancer:

  • Increasing age
  • Smoking
  • Family history of
     colon or rectal cancer
  • High-fat diet and/or a diet mostly from animal
  • Personal or family history of polyps or colorectal cancer

Family history is a factor in determining the risk of rectal cancer. If a family history of colorectal cancer is present in a first-degree relative (a parent or a sibling), then endoscopy of the colon and rectum should begin 10 years before the age of the relative's diagnosis or atage 50 years, whichever comes first.
An often forgotten risk factor,
but perhaps the most important, is the lack of screening for rectal
cancer.Routine cancer screening of the colon and rectum is the best way
to prevent rectal cancer.

Colon and Rectal Cancer: A Comprehensive Guide for Patients & Families (Patient Centered Guides)

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Rectal Cancer Symptoms

Rectal cancer can cause many symptoms that require a person to seek
medical care.However, rectal cancer may also be present without any
symptoms, underscoring the importance of routine health
screening.Symptoms to be aware of include the following:

  • Bleeding

    • Seeing blood mixed with stool is a sign to seek immediate medical care.Although many peoplebleed due tohemorrhoids, a doctor should still be notified in the event of rectal bleeding.
    • Prolonged rectal bleeding (perhaps in small quantities that is not seen in the stool) may lead to anemia, causing fatigue, shortness of breath, light-headedness, or a fast heartbeat.

  • Obstruction

    • A rectal mass may grow so large that it prevents the normal passage of stool.This blockage may lead to the feeling of severe constipation or pain when having a bowel
         movement.In addition, abdominal pain or
         cramping may occur due to the blockage.
    • The stool size may appear narrow so that it can be
         passed around the rectal mass.Therefore, pencil-thin stool may be
         another signof an obstruction from rectal cancer.
    • A person with rectal cancer may have a sensation that the stool cannot be completely evacuated after a bowel movement.

  • Weight loss:
    Cancer may cause weight loss. Unexplained weight loss (in the absence
    of dieting or a new exercise program) requires a medical evaluation.
  • When to Seek Medical Care
    Questions to Ask the Doctor

    If a person has been diagnosed with rectal cancer, the doctor should be asked the following questions:
  • Where is my cancer located?
  • How far has the cancer spread?
  • What treatment options do I have?
  • What is the overall goal of treatment in my case?
  • What are the risks and side effects of the proposed
  • Am I eligible for a clinical trial?
  • How do I find out if I am eligible for a clinical trial?
  • Exams and Tests

    Appropriate colorectal screening leading to the detection and removal
    of precancerous growths is the only way to prevent this disease.
    Screening tests for rectal cancer include the following:
  • Fecal occult blood test (FOBT): Early rectal cancer may damage blood vessels of the rectal lining and cause small amounts of blood to leak into the feces. The stool
     appearance may not change. The fecal occult blood testrequires placing a
     small amount of stool on a special paper that is provided by a doctor. The
     doctor then applies a chemical to that paper to see if blood is present in the
     stool sample.
  • Endoscopy: During endoscopy, a doctor inserts a flexible tube with a camera at the end (called an endoscope)
    through the anus and into the rectum and colon. During this procedure,
    the doctor can see and remove abnormalities on the inner lining of the
    colon and rectum.

If rectal cancer is suspected, the tumor can be physically detected through either digital rectal examination (DRE) or endoscopy.

  • A digital rectal examination is performed by a doctor
     using a lubricated gloved finger inserted through the anus to feel the cancer
     on the rectal wall.Not all rectal cancers can be felt this way, and
     detection is dependent on how far the tumor is from the anus. If an
     abnormality is detected by a digital rectal examination, then an endoscopy is
     performed for further evaluation of the cancer.
  • Flexible sigmoidoscopy is the insertion of a
     flexible tube with a camera on the end (called an endoscope) through the anus
     and into the rectum. An endoscope allows a doctor to see the entire rectum,
     including the lining of the rectal wall.
  • Rigid sigmoidoscopy is the insertion of a rigid optical scope
    inserted through the anus and into the rectum. Rigid sigmoidoscopy is
    usually performed by either a gastroenterologist or a surgeon.The
     advantage of rigid sigmoidoscopy is that a more exact measurement of the
     tumor's distance from the anus can be obtained, which may be relevant if
     surgery is required.
  • A colonoscopy
    may be performed. For a colonoscopy, a flexible endoscope is inserted
    through the anus and into the rectum and colon. A colonoscopy allows a
    doctor to see abnormalities in the entire colon, including the rectum.

Because the depth of the cancer's growth into the rectal wall is important in determining treatment, an endoscopic ultrasound
(EUS) may be performed during endoscopy.An endoscopic ultrasound uses an ultrasound probe
at the tip of an endoscope that allows a doctor to see how deeply the
cancer has penetrated.In addition, a doctor can measure the size of the
lymph nodes around the rectum during an endoscopic ultrasound.Based on
the size of the lymph nodes, a good prediction can be made as to whether
the cancer has spread to the lymph nodes.

Once an abnormality is seen with endoscopy, a biopsy specimen is obtained using the endoscope and sent to a pathologist.
The pathologist can confirm that the abnormality is a cancer and needs
treatment.A person may experience small amounts of bleeding after a
biopsy is performed.If this bleeding is heavy or lasts longer than a few
days, a doctor should be notified immediately.

A chest x-ray and a CT scan of the abdomen and pelvis are most likely performed to see whether the cancer has spread further than the rectum or surrounding lymph nodes.

Routine blood studies are performed to assess how a person might tolerate the upcoming treatment.
In addition, a blood test called CEA (carcinoembryonic antigen)
is obtained.The CEA is often produced by colorectal cancers and can be a
useful gauge of how the treatment is working. After the treatment, the
doctor may regularly check the CEA level as one indicator of whether the
cancer has returned.However, checking the CEA level is not an absolute
test for colorectal cancers, and other conditions may cause a rise in
the CEA level.Likewise, a normal CEA level is not a guarantee that the
cancer is no longer present.
Rectal Cancer Treatment

Medical Treatment

The treatment and prognosis of rectal cancer depend on the stage of the cancer, which is determined by the following 3 considerations:

  • How deeply the tumor has invaded the wall of the
  • Whether the lymph nodes appear to have cancer in
  • Whether the cancer has spread to any other locations in the body(Organs that rectal cancer commonly spreads to include the liver and the lungs.)

The stages of rectal cancer are as follows:

  • Stage I: The tumor involves only the first or second
     layer of the rectal wall and no lymph nodes are involved.
  • Stage II: The tumor penetrates into the mesorectum,
     but no lymph nodes are involved.
  • Stage III: Regardless of how deeply the tumor
     penetrates, the lymph nodes are involved with the cancer.
  • Stage IV: Convincing evidence of the cancer exists in other parts of the body, outside of the rectal area.

Localized rectal cancer includes stagesI-III. Metastatic rectal cancer is stage IV.

The goals of treating localized rectal cancer are to ensure the removal of all the cancer and to prevent a recurrence of the cancer, either near the rectum or elsewhere in the body.

stage I rectal cancer is diagnosed, then surgery is likely to be the
only necessary step in treatment.The risk of the cancer coming back
after surgery is low, and, therefore, chemotherapy is not usually offered.

after the removal of a tumor, the doctor discovers that the tumor
penetrated into the mesorectum (stage II) or that the lymph nodes
contained cancer cells (stageIII).In these cases, chemotherapy and radiation therapy are
offered after recovery from the surgery to reduce the chance of the cancer
returning.Chemotherapy and radiation therapy given after surgery is called adjuvant therapy.

the initial exams and tests show a person to have stage II or III
rectal cancer, then chemotherapy and radiation therapy should be
considered before surgery. Chemotherapy and radiation given before
surgery is called neoadjuvant therapy. This therapy lasts approximately 6
weeks.Neoadjuvant therapy is performed to shrink the tumor so it can be
more completely removed by surgery.In addition, a person is likely to
tolerate the side effects of combined chemotherapy and radiation therapy
better if this therapy is administered before surgery rather than
afterward.Afterrecovery from the surgery, a person who has undergone
neoadjuvant therapy should meet withtheoncologist to discuss the need for more chemotherapy.

the rectal cancer is metastatic, then surgery and radiation therapy
would only be performed if persistent bleeding or bowel obstruction from
the rectal mass exist. Otherwise, chemotherapy alone is the standard
treatment of metastatic rectal cancer.At this time, metastatic rectal
cancer is not curable.However,
average survival times for people with metastatic rectal cancer have lengthened
over the past several years because of the introduction of new medications.


The following chemotherapy drugs may be used at various points during therapy:

  • 5-Fluorouracil (5-FU):
    This drug is given intravenously either as a continuous infusion using a
    medication pump or as quick injections on a routine schedule. This drug
    has direct effects on the cancer cells and is often used in combination
    with radiation therapy because it makes cancer cells more sensitive to
    the effects of radiation. Side effects include fatigue, diarrhea, mouth sores, and hand-and-foot syndrome (redness,
     peeling, and pain in the palms of the hands and the soles of the feet).
  • Capecitabine
    (Xeloda): This drug is given orally and is converted by the body to a
    compound similar to 5-FU. Capecitabine has similar effects on cancer
    cells as 5-FU and can be used either alone or in combination with
    radiation therapy. Side effects are similar to intravenous 5-FU.
  • Oxaliplatin
    (Eloxatin): This drug is given intravenously once every 2 or 3 weeks.
    Oxaliplatin has recently become the most common drug to use in
    combination with 5-FU for the treatment of metastatic rectal cancer.
    Side effects include fatigue, nausea, increased risk of infection, anemia, and peripheral neuropathy (tingling or numbness of the fingers and toes). This drug may also cause a temporary sensitivity to cold temperatures up
     to 2 days after administration. Inhaling cold air or drinking cold liquids
     should be avoided if possible after receiving oxaliplatin.
  • Irinotecan
    (Camptosar, CPT-11): This drug is given intravenously once every1-2
    weeks. Irinotecan is also commonly combined with 5-FU. Side effects
    include fatigue, diarrhea, increased risk of infection, and anemia.
    Because both irinotecan and 5-FU cause diarrhea, this symptom can be severe
     and should be reported immediately to a doctor.
  • Bevacizumab (Avastin): This drug is given intravenously once every2-3 weeks. Bevacizumab is an antibody to vascular endothelial growth factor (VEGF)
    and is given to reduce blood flow to the cancer. Bevacizumab is used in
    combination with 5-FU and irinotecan or oxaliplatin for the treatment
    of metastatic rectal cancer. Side effects include high blood pressure, nose bleeding, blood clots, and bowel perforation.
  • Cetuximab (Erbitux): This drug is given intravenously once every week. Cetuximab is an antibody to epidermal growth factor receptor (EGFR) and is given because rectal cancer has large amounts of EGFR on the cell
    surface. Cetuximab is used alone or in combination with irinotecan for
    the treatment of metastatic rectal cancer. Side effects include an allergic reaction to the medication and an acnelike rash on the skin. Clinical trials are underway to evaluate this antibody for the treatment of localized rectal cancer.

Medications are available to alleviate the side effects of
chemotherapy and antibody treatments. If side effects occur, an
oncologist should be notified so that they can be addressed promptly

Surgical removal of a tumor is the cornerstone of curative therapy
for localized rectal cancer. In addition to removing the rectal tumor,
removing the fat and lymph nodes in the area of a rectal tumor is also
necessary to minimize the chance that any cancer cells might be left
However, because the rectum is in the pelvis and is close to the anal sphincter (the muscle
that controls the ability to hold stool in the rectum), rectal surgery
can be difficult. With more deeply invading tumors and when the lymph
nodes are involved, chemotherapy and radiation therapy are usually
included in the treatment course to increase the chance that all microscopic cancer cells are removed or killed.
Four types of surgeries are possible, depending on the location of the tumor in relation to the anus.

  • Transanal excision: If the
     tumor is small, located close to the anus, and confined only to the mucosa
     (innermost layer), then performing a transanal excision, where the tumor is
     removed through the anus, may be possible. No lymph nodes are removed with
     this procedure. No incisions are made in the skin.
  • Mesorectal surgery: This surgical procedure involves the careful dissection of the
     tumor from the healthy tissue. Mesorectal surgery is beingperformed
     mostly in Europe.
  • Low anterior resection
    (LAR): When the cancer is in the upper part of the rectum, then a low
    anterior resection is performed. This surgical procedure requires an abdominal incision, and the
     lymph nodes are typically removed along with the segment of the rectum
     containing the tumor. The two ends of the colon and rectum that are left
     behind can be joined, and normal bowel function can resume after surgery.
  • Abdominoperineal resection (APR): If the tumor is located close
    to the anus (usually within 5 cm), performing an abdominoperineal
    resection and removing the anal sphincter may be necessary. Lymph nodes
    are also removed during this procedure. With an abdominoperineal
    resection, a colostomy is necessary. A colostomy is an opening of the colon to the front of the abdomen, where feces are eliminated into a bag.
  • Other Therapy

    Radiation therapy uses high-energy rays that are aimed at the cancer
    cells to kill or shrink them. For rectal cancer, radiation therapy may
    be used either before surgery (neoadjuvant therapy) or after surgery (adjuvant therapy), usually in conjunction with chemotherapy.
    The goals of radiation therapy are as follows:
  • Shrink the tumor to make its surgical removal easier
     (if given before surgery).
  • Kill the remaining cancer cells after surgery to
     reduce the risk of the cancer returning or spreading.
  • Treat any local recurrences that are causing symptoms, such as abdominal pain or bowel obstruction.

Typically, radiation treatments are given daily, 5 days a week, for up
to 6 weeks. Each treatment lasts only a few minutes and is completely
painless; it is similar to having an x-ray film taken.

The main side effects of radiation therapy for rectal cancer include mild skin irritation, diarrhea, rectal or bladder irritation, and fatigue. These side effects usually resolve soon after the treatment is complete.
Chemoradiation is often given for stages II and III rectal cancer. Preoperative chemoradiation is sometimes performed to decrease the size of the tumor.

Because a risk exists of rectal cancer coming back after treatment,
routine follow-up care is necessary. Follow-up care usually consists of
regular visits to the doctor's office for physical exams, blood studies,
and imaging studies.

In addition, a colonoscopy is recommended 1
year after a diagnosis of rectal cancer. If the findings from the
colonoscopy are normal, then the procedure can be repeated every 3

Appropriatecolorectal screening leading to the detection and removal
of precancerousgrowths is the only way to prevent this disease.Screening
tests for rectal cancer include fecal occult blood test and endoscopy.

a family history of colorectal cancer is present in a first-degree
relative (a parent or a sibling), then endoscopy of the colon and rectum
should begin 10 years before the age of the relative's diagnosis or at
age 50 years, whichever comes first.

The outlook for recovery from rectal cancer is unique for each
individual. Many factors are involved when considering the chance of
survival after rectal cancer treatment.
Long-term survival generally depends upon the stage of the cancer at the time of diagnosis and treatment.
According to stage, the following approximations of the likelihood of survival 5 years after treatment are as follows:

  • Stage I: The probability of being
     alive in 5 years is approximately 70-80%.
  • Stage II: The probability of being alive in 5 years is
     approximately 50-60%.
  • Stage III: The probability of being alive in 5 years
     is approximately 30-40%.
  • Stage IV: The probability of being alive in 5 years is less than 10%.
  • Authors and Editors

    Author: Timothy Kuo, MD, Fellow, Department of Medical Oncology, Stanford
    University School of Medicine
    Timothy Kuo is a member of the following medical
    societies: Alpha Omega Alpha, American Association for Cancer Education,
    American College of Physicians-American Society of Internal Medicine, American
    Medical Association,
    American Society of Clinical Oncology, and Sigma Xi
    Coauthor(s): George Fisher, MD, PhD, Assistant Professor, Department of
    Internal Medicine, Division of Medical Oncology, Stanford University School of
    Editors: Winston W Tan, MD, Assistant Professor,
    Department of Medicine, Mayo Medical School; Mary L Windle, Pharm D, Adjunct
    Assistant Professor, University of Nebraska Medical Center College of Pharmacy;
    Pharmacy Editor,, Inc; Koyamangalath Krishnan, MD, FRCP, Assistant
    Professor of Medicine, Department of Clinical Cancer Prevention and
    Gastrointestinal Medical Oncology,
    The University of Texas MD Anderson Cancer Center Author and Editor Disclosure

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