The young lady is waiting for me in the consultation room. Her pale skin is matching the color of the fading anonymous washable wallpaper … her eyes are fixing questioningly the plate on the wall depicting the digestive system… her hand is shaking and her grip is quite weak… She is expecting to receive bad news. She knows. In fact, she has had a camera test some days ago and a growth of the large bowel has been found.
For a strange decision of the destiny, she has the same disease of her mum and her granny, the same demon who stole the life of her sister. How can I be so cold to tell her the dreadful word? But I have to. It is my job. I get paid for this. Fortunately this has been found at an early stage, so it can be treated with curative intent.
Bowel cancer is one of the most diffuse cancers and one of the leading causes of mortality worldwide. What is a cancer? We may say a cancer is a sort of “growth”, a “lump” made of cells that went mad and started growing and replicating without any regulation. Cancers can infiltrate close by organs and spread into distant organs.
Cancer of the bowel can give symptoms due to bleeding – anaemia, tiredness, shortness of breath – or stricture – progressive constipation up to total bowel obstruction, pain. Metastases give symptoms related to the specific organ where they spread. Liver metastases can cause jaundice or other symptoms of liver failure. Lung metastases can cause cough and chest pain.
Usually, a cancer of the bowel starts as a benign polyp that grows up. At a specific point in its natural history, some of the cells of the polyp lose their benign behavior and get an infiltrating pattern with cells that grow very rapidly and tend to replace the normal surrounding tissues. When some of those cancer cells get into a blood or lymph vessel, they can travel within the bloodstream or the lymph stream and get into distant organs or lymph nodes.
Mrs Z is 39. She is a very active woman, practicing many sports. In the last months she noticed she was not longer able to run the same distance she was used before. At the beginning she considered this as one of the downsides of her age… One day, after her usual jogging, back home her husband was shocked by her paleness and urged her to go to her GP.
After getting a thorough personal and family history and performing a physical examination that was unremarkable, the GP requested urgent blood tests. These showed frank anaemia. Worried by this, and mostly by Mrs Z’s strong family history of bowel cancer, he referred Mrs Z to the surgeon through the suspected bowel cancer referral pathway. When I received the referral letter, I immediately arranged a colonoscopy to be performed within 2 weeks. Unfortunately, colonoscopy revealed a tumour of the right part of the colon and biopsy confirmed this was malignant. CT scan was reassuring as there was no evidence of any spread beyond the bowel.
Symptoms of bowel cancer may vary in accordance with the precise location of the tumour. Right-sided masses usually grow symptomless for a long period before being detected. They tend to cause anaemia as first symptom, whereas obstruction is very late, usually one of the terminal symptoms. On the contrary, more distal colon and rectal tumours have a stricturing pattern of growth and give constipation and obstruction as first symptoms. They can also cause overt bleeding through the rectum.
Sometimes, cancer of the bowel can be detected at an early stage when it is still asymptomatic, with an investigation done for other diseases – i.e., a CT scan done for kidney stones – or as a screening for strong family history or simply as part of the Bowel Cancer Screening Programme. Bowel screening is supposed to pick up bowel cancers at an early stage and preferably at the stage of pre-cancer, where an early stage malignancy or a benign polyp can be easily removed without this affecting survival.
Usually, the first investigation is done with a camera – colonoscopy – introduced through the back passage and pushed forward to go all the way round to investigate the whole large bowel. If a cancer is detected, a small specimen taken with long forceps can confirm the diagnosis. After the initial diagnosis of “cancer” of the bowel, it is important to know how advanced this cancer is. A CT scan and, sometimes, a MRI are mandatory to rule out the presence of lymph node involvement or metastases in distant organs and can be helpful to understand the degree of infiltration of the bowel wall. At the end of the diagnostic phase we should be able to have a precise idea of the “stage” of the tumour. Clearly, early stages are associated with better survival.
Mrs Z’s tumour is quite big but fortunately there is no CT evidence of lymphatic involvement or distant spread. Clinically, it can be labeled as stage 2, as it is a T2N0M0 tumour. Mrs Z is shocked at the bad news but fortunately there is a word of hope and I can manage to divert her attention and her thoughts from the negativity of the words “cancer” and “survival” to the positive idea of the possibility to remove the tumour with a radical operation.
In our clinical practice, we consider three main parameters, that are T for tumour, N for lymph nodes and M for metastases. Each parameter is associated with a number; 0 to 4 for T, 0 to 2 for N and 0/1 for M. The T parameter gives information on the depth of mural infiltration of the tumour. N states the number of lymph nodes involved. M can be 0 if no metastases can be seen or 1 if there are any distant metastases.
Giving “bad news” is one of the downsides of our job, but it must be done. Luckily, in the very most of cases this is just the first step to start the discussion about treatment, and the idea that something can be cured is a huge relief. Long minutes are spent discussing about surgery, possible outcomes, and eventual complications and mostly on what the future will look like afterwards.
Three weeks later the same lady is again waiting for me in the same room. This time she’s cheerful and her cheeks have a more reassuring pink color. Her grip is steady and her breath smells of coffee. She’s been operated and her tumour has been completely removed. It was a small tumour of the bowel and all the lymph nodes were clear. She did not need any further treatment.
The demon had been kicked out. Her tummy was still flat and without any scar, the only mark being a small reddish line well hidden under the line of her waist, as if to remind her that life is here to be enjoyed. This time, I too was relaxed and less professional. It wasn’t time of bad news any more. I was there just to tell her to come back to her life, to her family, to her kids. A big hug was my reward…
Colorectal surgery has its roots in the mists of time…
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