Unpacking Colorectal Cancer and Surgical Decisions

Colorectal cancers are the sixth most common cancer in India, and increasingly becoming common in India, with an estimated 65,000 new cases every year. Dr. Ramakrishnan AS, a surgical oncologist unpacks colorectal cancer, the symptoms, diagnosis, role of biomarker testing, and largely focus on the surgical decisions. We also discuss how patients can be better prepared to handle the surgery and post-surgery recovery.

This is adapted from the podcast episode where Aparna Mittal of PatientsEngage speaks with Dr Ramakrishnan

Is Colorectal cancer one condition or multiple cancers together?

There are two ways to look at this. If you look at the part of the body from which the cancer arises, the colon and rectum are two separate locations. The colon is the large intestine, and the rectum is the motion passage. That is the last part of the gastrointestinal tract. The cancers can arise either in the colon in the left side, the right side or the middle part of the colon. Or it could arise from the rectum.

Types of cancers that arise in the colon or rectum are not the same, they could be different types. The most common type of cancer that rises from the colon or rectum is what we call as a carcinoma. So, there are slight differences in the location of these cancers and the types of cancers. Put together, we generally refer them loosely as colorectal.

What are the causes and risk factors of Colorectal cancers?

Basically, colorectal cancer, for that matter, any cancer, usually arises because of mutations. These are changes in the genes, which are the basic building blocks of our human body. There are many reasons why these changes happen to these genes. Most commonly, it is because of age. Age is probably the single most important factor for developing colorectal cancer. As we age, we tend to accumulate these kinds of mutations.

For colorectal cancer, there is a pattern of mutations that happen, which transforms a normal cell into a precancerous condition, and then cancer, and then helps the cancer spread to other parts of the body. So at each step, there are different changes. So, collective of these mutations happen as we age.

Sometimes these mutations tend to be inherited in families. These are called familial cancers but these form probably a very small proportion around 5% in the spectrum of all colorectal cancers. There are some dietary risk factors, that have been associated with colorectal cancers, like consumption of red meat, deep-fried meat, processed meat, Ultra-processed food, sugary drinks. All these are associated with a higher risk of along with smoking and alcohol consumption. Sedentary lifestyle, lack of any physical activity, obesity are other causes. Sometimes you might have, some other conditions that affect the large intestine such as inflammatory bowel disease, which could also lead to colorectal cancer.

Globally, we are now hearing that colorectal cancer is impacting younger population. Is that true in India as well?

Incidence is rising in the younger population, without a doubt. The term early-onset colorectal cancer is used when it is diagnosed before a person turns 50 or older. In the Western countries, the average age when a person develops colorectal cancer is around 50 to 70, whereas in India, it is much lower, around 45 to 50.

Whether it is truly an increase in the incidence of colorectal cancer in the young population, it is difficult to say, because India's population pyramid is largely a young population. It could be that we are seeing more number of the younger population with colorectal cancer, just because of the volume of population. Another reason could be that screening usually happens in patients who are above 50. So, polyps if detected are removed, decreasing the chance of these polyps turning malignant. Whereas screening is rarely offered to younger patients. We tend to miss the opportunity to detect precancers. There are a multitude of factors, but on the whole, we are seeing more younger patients. One study I was part of at the Cancer Institute showed that nearly 50% of all colorectal cancers were age less than 50 and nearly 30% were aged less than 40.

Related Reading:  Personal Voices of Colorectal Cancer

Do we have a Colon cancer screening protocol or guideline in India?

Yes, it is based on symptoms reported by people or those with a familial risk come for checks. We do not have a national screening program for colorectal cancer. In fact, we do not have a national screening program for cancer.

As far as colorectal cancer is concerned, although there are screening tests available, the incidence of colorectal cancer in India is not very high when compared to Western countries, so it doesn't really make sense for the government to initiate national screening. Screening is done when you do not have any symptoms. Once you have presence of symptoms of the disease, then it is no longer screening, it is diagnosis.

The most common reason why, in India somebody would go for screening is if somebody close to them, or somebody in their family had a cancer, they are anxious, they want to know whether they are at risk of cancer.

What are the typical symptoms, and are they different in men versus women?

Unfortunately, there is no one symptom for colorectal cancer. Also, the symptoms of colorectal cancer can also be due to other non-malignant conditions. So, the usual symptoms for colorectal cancer would include, noticing blood in the stools, or a recent change in the bowel habits. It could be constipation, or it could be diarrhoea or excessive stool passage. Besides this, you could have abdominal pain, unexplained weight loss. Sometimes patients will just complain of tiredness. This is quite common in right-sided colon cancers, where there is loss of blood from the tumour through the stools, leading to a drop in blood haemoglobin levels, and this could manifest as just tiredness or fatigue. Many times, colorectal cancer is diagnosed because of this symptom, and on testing, the patient is found to have anaemia, and on further testing with endoscopy, they are found to have colorectal cancer. The symptoms are generally similar in men and women, and there are no major differences in how colorectal cancer presents based on sex.

What are the typical diagnostic tests prescribed when somebody presents with any of these symptoms?

Most often, at least at the primary healthcare level, the physical examination is done. Many times the rectal cancer is identified just by physical examination and a rectal exam. Sometimes the clinician might find that there is a lump in the tummy, and that could be evaluated further. Typically, many patients undergo a simple test like an ultrasound. Now, that may not always reveal anything, but it could identify something abnormal in the tummy, which could prompt further evaluation. To diagnose a colorectal cancer, you need to do a procedure called colonoscopy. This is passing a tube with a camera attached at the tip, through the anus, to the insides of the large intestine, so the doctor is able to observe whether there is any growth in the large intestine, and if there is, biopsy a small bit of the tumour tissue. From the biopsy, cancer diagnosis is confirmed.

Once the diagnosis of cancer is established, then the next test that is performed is to stage the cancer. That is to see whether the cancer is confined only to the intestines, whether it has gone outside the intestines, whether it has spread to any other parts of the body. For this, we use some imaging techniques, some scans, most commonly a CT scan. But for rectal cancer, we prefer another scan called the MRI scan. Sometimes, not very commonly, but on special occasions, we also ask for a PET scan, which is also to determine spread to any other parts of the body. Additional blood tests may be done to aid the treatment options.

Sometimes during a colonoscopy, polyps are found. Do they need to be biopsied, or are polyps different from tumours?

So polyps could be called a tumour, because any abnormal growth is called a tumour. Polyp is definitely not a normal thing to have, it's an abnormal growth. Polyps are, however, mostly benign. One thing that we need to understand is almost all cancers in the colon or rectum, begin as a polyp. It takes around anywhere between 10 to 15 years for a polyp to transform into a cancer. But that doesn't mean that all polyps transform. Probably around 5–15% of polyps actually transform into cancer. But most cancers arise from the polyp. When a colonoscopy is performed and a polyp is identified, usually the polyp is removed, or at least a biopsy is taken, to know whether it is a benign or has undergone malignant transformation.

Many of the symptoms are common GI symptoms esp in people with IBS. What is the guidance for people with IBS, and when should they get checked for cancer?

IBS is a very loosely defined term since there is no specific diagnostic test for it. It is based on the symptoms that a patient has due to no other known cause. In general, anyone with persistent symptoms that do not improve with treatment particularly if they have blood in their stool, should be evaluated for the possibility of colorectal cancer. If a colonoscopy has not already been performed as part of the assessment of these symptoms, it is important to consider undergoing one at this stage.

What are biomarkers, and is there a role for biomarker testing in colorectal cancer?

Biomarkers are biological substances that you detect either in the blood, or other body fluids, or from the tumour tissue. These are substances that are produced by the cancer cells, or sometimes produced by the normal cells as a reaction to these cancer cells. In colorectal cancer, biomarkers have a very important role to play, not only in the diagnosis, but more importantly in knowing what would be the response to certain forms of treatment. Whether the tumour is likely to respond to a particular type of treatment, sometimes to see how fast the tumour is growing and sometimes to determine the prognosis, or whether this cancer is likely to come back. There are a lot of uses for biomarker testing in colorectal cancer. In patients with stage 3 or 4 colorectal cancer, biomarkers play a very important role in determining what kind of treatment they should receive.

Is genetic counselling a norm in an Indian context? Are patients and their families referred to a genetic counsellor?

A decade ago, genetic counselling was not being performed very commonly here but these days, it is quite common to refer a patient for genetic counselling. Genetic counselling is not a test. It's a conversation that the patient has with someone who's trained to do this sort of counselling. Counselors guide the patient or family member through the process of identifying whether he or she is at risk for developing a cancer, especially when somebody in their family has had a history of this cancer. This is becoming more and more common in India, especially because we are seeing more patients with early-onset colorectal cancers, and now we also have tests to easily identify whether a particular type of cancer is a hereditary or a familial cancer.

Are there specific types of colorectal cancers that can be inherited?

Only around 5% of colorectal cancers are actually hereditary or familial. The two most common types of inherited colorectal cancers are what we call Familial Adenomatous Polyposis, or FAP, and the other one is HNPCC, or what we call Lynch syndrome. These are two different types of hereditary colorectal cancers.

FAP is a condition where there are multiple polyps that form in the colon or rectum. More than 100 polyps form in the colon at an early age, sometimes as early as 12 years, and usually by the time the person turns 40, some of these polyps would have turned into cancer. In Lynch syndrome, also cancer develops at an early age, around 40–45 years, but they are not associated with such a large number of polyps. This syndrome may also be associated with various other cancers, especially uterine or ovarian cancers.

When somebody is diagnosed, is surgery the first line of treatment? How do you decide the treatment plan for a patient?

Traditionally, surgery has been the most important form of treatment for colorectal cancers. Till around 30 years back, surgery was the only mode of treatment available. Now that we have chemotherapy and radiation therapy, increasingly patients require one or both of these treatments in addition to surgery. The treatment is quite different for colon cancers versus rectal cancers. In colon cancer, most patients still undergo surgery as the first treatment, and many times surgery may be the only treatment they require. Again, it depends on the stage. If it is an early stage, like stage 1 or 2, patients do not need any treatment other than surgery. Whereas in more advanced stages, especially stage 3, after surgery they would require chemotherapy. Nowadays, in patients with very large tumors, we give chemotherapy before surgery.

In rectal cancers, apart from early-stage cancers, all patients require some additional form of treatment like radiation and chemotherapy. Earlier, we used to give radiation, then surgery, then chemotherapy. But nowadays, we are trying to push all the treatments before surgery. This is called total neoadjuvant therapy, where you give all the radiation and all the chemotherapy first, and then subsequently do surgery.

Are there cases where there is no role for surgery?

Yes. In the recent past, there has been a growing trend to avoid surgery in patients who have rectal cancer. As of now, avoiding surgery is not an option in colon cancer. However, in rectal cancer, it is possible to avoid surgery, if patient has a very good response to radiation and chemotherapy. This is called a complete clinical response, where there is no detectable tumour on clinical examination, endoscopy, or MRI.

Sometimes patients hear terms like KRAS, NRAS, or MSI testing. What are these tests, and what is their role?

These are the biomarkers that talked about earlier. KRAS and NRAS are biomarkers that predict response to certain form of treatment called Targeted therapy. Biomarkers are identified in the tumour tissue by a special test called Next Generation Sequencing or NGS. Based on the results of this NGS test, the oncologist is able to decide whether the patient is likely to respond to any form of targeted therapy. There are other biomarkers like MSI, commonly done now. Other tests for biomarker are Immunohistochemistry or Mismatch repair (MMR). Both of them try to predict response to chemotherapy, but more importantly, response to immunotherapy. There is a panel of biomarkers used in colorectal patients.

Pathology reports often talk about staging, grade and differentiation. How should patients understand these terms?

Grade is basically what the pathologist reports by looking at the tumour under a microscope. It denotes how fast the tumour is growing. A low-grade tumour multiplies slower and grows slower, whereas a high-grade tumour multiplies fast and grows faster. Consequently, a higher-grade tumour has a higher chance of spreading to other parts of the body and a higher chance of disease recurrence.

Staging denotes the stage at which the cancer has been diagnosed. Early-stage tumours are confined to the large intestine or rectum from where they actually started. As the stage progresses, it means that the tumour has spread to other sites. Commonly, stage 3 means the tumour has spread to lymph nodes. Stage 4 indicates that the tumour has spread to other organs like the lungs or the liver. That's the difference between grade and stage.

Differentiation is again another way of talking about the grade. A well-differentiated tumour is usually a low-grade tumour, where the pathologist can easily identify the glands under the microscope. A poorly differentiated tumour corresponds to a higher-grade tumour, where the architecture of the tumour is not well defined. That is again something the pathologist sees under the microscope.

Are there different types of colorectal surgeries that are possible, and how do you decide the surgical option?

The surgery for the colon is different from surgery for the rectum. The basic principle of surgery is to remove the tumour, along with a margin of a normal part of the intestine on either side of the tumour. Margin of normal tissue is removed because cancer cells can spread beyond what is visible to the surgeon by the naked eye. To make sure that these cancer cells are removed completely, the surgeon removes part of the normal-appearing intestine on either side of the tumour. In a colon cancer, the tumour could be on the right side, middle part, or left side of the colon. Based on the location of the tumour, the surgeon decides to remove that particular part of the colon. This kind of surgery is called a colectomy. It is also equally important to remove the lymph nodes to which the tumour would have likely spread. Based on the well-documented patterns of spread, the surgeon removes the colon as well as the relevant lymph nodes
In rectal cancer, there are two types of surgery:

• Removal of the entire rectum and anus, resulting in a permanent stoma.
• Sphincter-preserving surgery, where the anus is preserved and continuity is restored.

In cases of sphincter-sparing surgery, do they preserve normal bowel movement?

Sphincter-sparing surgeries preserve the normal passage of stools, but the consequence includes change in the pattern of bowel movements. Patients are likely to experience a loose collection of symptoms called Low Anterior Resection Syndrome, which includes:

• More than normal frequency of passing stools (between 5 times to 20 times a day).
• There might be urgency, where you are not be able to hold back your stools for a long time.
• Clustering or fragmentation, where you tend to pass stools in clusters.
• May lead to incontinence.

These are all consequences of sphincter-sparing surgery. But usually around a year from the time of surgery, most of these symptoms reduce. That is a trade-off that you need to accept if you want to preserve normal anatomical passage.

Can patients try sphincter-sparing surgery and later switch to a stoma if things do not improve?

Conversion to a permanent stoma is the last option. It is not very common for patients to request a switch over. In India, there is a lot of social taboo around the word stoma. Patients are willing to accept these changes in bowel movements, but refuse to convert to a permanent stoma. Very rarely, it is converted to a permanent stoma when side-effects have continued beyond one or two years and prevented the patient from having a normal quality of life.

What should patients keep in mind when making treatment decisions along with their surgeon?

It's very important that patients ask questions and not feel shy or scared. They need to understand the treatment that they are going to undergo and the various options. They need to tell the surgeons or oncologists what their priorities are and what they value more. Do they value cure? Do they value recovery from different types of surgeries? Some patients might not mind a stoma. Some patients might want to avoid a stoma because they are office-goers or have particular professions. They need to share their priorities with the oncologists or surgeons so that a shared decision can be made regarding the treatment that would suit them best.

What is the difference between neoadjuvant and adjuvant treatment?

Any treatment like radiation or chemotherapy that is given before surgery is called neoadjuvant treatment. Any treatment that is given after surgery is called adjuvant treatment. In colon cancer, most treatment is given as adjuvant treatment where surgery is done first followed by chemotherapy. Whereas in rectal cancer, we are trying to give all the treatment before surgery. That is why it is called total neoadjuvant treatment, where radiation and chemotherapy are before surgery.

What is a J-pouch, and is it safe and effective?

In sphincter-preserving surgery, where you preserve the normal anatomical pathway through which stools come out. Once you remove the rectum, you need to fill the gap with a substitute. That substitute is the remaining part of the colon. It is brought down and joined with the rest of the rectum or the anus. There are different ways in which this connection can be made. One of the techniques that benefits patients and reduces bowel disturbances is a J-pouch, where the colon that is brought down is turned into the shape of a J. Theoretically, this is supposed to reduce the frequency of stool movements. However, this advantage is limited to the initial few months. After that, it doesn't matter whether you have a J-pouch or not. It is more or less the same. The use of the J-pouch is to try to reduce the bowel disturbance that the patient might experience after surgery.

How should patients prepare, both physically and mentally, for the surgery? What questions would you want them to ask before the surgery?

There is only so much that the surgeon can do. Recovery from surgery is very much dependent on the willpower of the patient. Unless patient is mentally prepared and willing to undergo it with a positive frame of mind, the recovery is likely to be prolonged. The patient first needs to understand the procedure that is going to be performed on him or her. Fear is normal. It is normal to be afraid of surgery but knowing what is going to happen and knowing how the recovery is going to be can to a certain extent, reduce this. Besides that, patients need to quit smoking and alcohol consumption and stay active. I usually tell my patients to walk for at least half an hour a day before surgery. Eat well, because you need a good healthy body reserve to recover from the surgery. Lastly, be prepared mentally. These are some things that the patient can do to help aid in the recovery.

Apart from discussion on stoma, what other questions would you want patients to think about in terms of their priorities?

They need to understand the various treatment options and get to know what are the harms and benefits of these various options. It is also good to know what is the kind of recovery, how long it will take for them to start walking, how long it would take for them to resume taking normal food. Post surgery, we start them first on a liquid diet and then progress on to a solid diet. These days, with the advent of minimally invasive techniques and what we call Enhanced Recovery After Surgery, the ERAS protocol, recovery from surgery for colorectal cancer is faster. So, they need to have an idea of how long they're likely to be in the hospital, how soon they can go home, and how soon they can get back to work. These are some questions that patients commonly ask.

Typically, how long does it take for recovery for people to start going about their day-to-day activities and even get back to work?

It would take around 3 to 4 weeks to get back to their basic activity, and it could be faster if it were a minimally invasive procedure coupled with an ERAS protocol. In terms of full recovery, it would probably take 2–3 months.

When can patients start exercising after the surgery?

Exercise plays a very important role, not only in recovery from surgery, but also in the long-term outcomes of the treatment for the cancer per se. There are two types of exercise. One is prehabilitation and another is rehabilitation. Prehabilitation is some exercise, some physical activity that the patient is required to do before he or she undergoes surgery. This is a relatively new terminology, and it has been found that at least for two weeks before surgery, patients undergoing structured yet simple daily physical exercises help them recover better. After surgery, the patients again are encouraged to move around and do some simple activities. Just walking is enough to help them recover faster. But in the long run, there is recent evidence that has come just last year which supports the fact that if a person, after completion of treatment for colorectal cancer, engages in routine physical activity 2 or 3 times a week for at least 3 years, there is a 25–30% improvement in the chance of long-term survival. This comes as a surprise to many people, including oncologists, that even after all the standard treatments like surgery, chemotherapy, and radiation, something very simple and easy like exercise adds to the better outcomes.

What are the types of surgery options, and what should patients keep in mind when making choices?

Minimally invasive surgery is a medical term for what's commonly known as keyhole or laparoscopic surgery. Nowadays, robotic surgery is also another form of minimally invasive surgery. The advantages of minimally invasive surgery are that you avoid a very long scar or long incision. 4 or 5 very small (less than 1 cm) openings are made. The pain that the patient is likely to experience is much less compared to a traditional open surgery. The recovery is much faster. Patients are able to walk the same or very next day, get discharged and be back to their routine activities much faster. Robotic surgery doesn't mean that the robot does the surgery by itself. It is the surgeon that controls the robot. The robot does the movements that are mirrored by the surgeon moving his hands in a separate part. The correct term would be Robotic assisted surgery, rather than a robotic surgery. In rectal cancer, robotic surgery scores over traditional surgery which has lots of disadvantages. However, robotic surgery is more expensive but in the future it will be used more.

Is parastomal hernia common, and how can it be avoided or reduced?

Peristomal hernia, is not common. It can happen, especially in patients who have a long-standing stoma. Normally, we don't see parastomal hernia developing in the first 3 or 6 months. It is quite unusual. It is more common after 5 or 10 years. There are some recent surgical techniques which have been reported to reduce the incidence of parastomal hernia by placing a mesh around the stoma. Parastomal hernia generally tends to develop in patients who have a very lax abdominal wall muscle, so doing regular exercises can strengthen the abdominal wall muscle and help in reducing it.

Is urine incontinence common?

Urine incontinence can happen in a small proportion of patients and not in everybody. With better surgical techniques like laparoscopic or robotic surgery, this complication is not seen that often. This usually happens because surrounding the rectum, there are important nerves that supply the urinary bladder. Sometimes during surgery, inadvertently, these nerves get injured, but these are usually temporary injuries and the nerves tend to recover. Because of these injuries, patients can experience urinary symptoms. It may not just be incontinence; sometimes it might be difficult to pass urine.

Is pregnancy possible with a stoma?

Yes. It's possible with a stoma. A stoma does not affect pregnancy per se. In female patients who undergo radiation for rectal cancer, fertility may be affected because the field of radiation includes the uterus and the ovaries. In such situations, after discussions between the fertility specialist and the colorectal surgeon, a procedure is done before starting radiation to move the ovaries away from the field of radiation and keep them in the upper part of the abdomen so as to prevent them being exposed. Usually in colon cancer, fertility is not an issue.

One thing every patient should know before surgery?

The common myth is that surgical knife will spread the cancer faster? That is not true. Surgery actually helps to cure a patient's cancer, not help to spread cancer. Surgery is often the best chance for cure. Don't be afraid of the surgery. Understand the surgical procedure and prepare yourself mentally.

Is there any innovation in colorectal cancer treatment, especially surgical options?

Yes. One is the approach to the surgical procedure. Laparoscopic and robotic surgeries have a lot of advantages for the patients. There are a lot of innovations in sphincter-sparing surgeries, where we try and avoid a patient's need for a permanent stoma. Other technological advancements include different types of staplers, because staplers are commonly used to join the two ends of the bowel to restore continuity.

Advice for family caregivers of patients

Caregivers are the pillars of support for patients when they need to make a decision about treatment, and to support them during and after the treatment. The role of caregivers is really very important. But during this process, the caregivers also tend to go through a lot of emotional and physical stress. They sometimes tend to neglect themselves. So an important advice to the caregivers is: don't forget about yourself. Take care of yourself, because only if you are in shape, can you take care of your loved one.

Final advice or message

This is my favourite quote. I don't know who originally mentioned it: "Cancer is only a word, it's not a sentence." There is life after cancer, and there are so many new effective treatments, that are available these days. So, there is no need to fear cancer. This used to be a very famous quote of Dr. Shanta: "We do not fear cancer. We fear delayed diagnosis of cancer." People need to be aware of that.

To view the video interview click here: https://www.youtube.com/watch?v=zg2rfs5D6Hk

Dr. Ramakrishnan AS, is a surgical oncologist with more than 24 years of experience in oncology-related clinical care, training, and research, with a special interest in colorectal cancers and peritoneal malignancies. Currently, he's a senior consultant surgical oncologist with the Integrated Cancer Care Group in Chennai. Previously, he helped establish the gastrointestinal and Hepatopancreaticopiliary oncology Services and the multidisciplinary Tumor Board at the Adyar Cancer Institute, and he headed it from 2007 to 2024.

He served the Adyar Cancer Institute in various roles in various departments. He has over 100 publications in national and international journals, and has contributed to many book chapters. He serves on the editorial board of the British Journal of Surgery and Annals of Surgical Oncology. He's also part of the National Gastrointestinal Cancer Treatment Guideline Development Group. He believes very strongly and strives for accessible, equitable, affordable, and quality cancer care for the population. He's also an ally and active supporter of Patient and public involvement in cancer care and research.