A Tale of Two Cancers: Colon & Rectal

It was the best of times, it was the worst of times…

This intro­duc­tion to A Tale of Two Cities by Charles Dick­ens, writ­ten in 1859, could just as eas­i­ly been writ­ten to intro­duce col­orec­tal can­cer. In the best of times, greater under­stand­ing and tools to man­age col­orec­tal can­cer have been devel­oped. In the worst of times, these tools are not being used to their fullest poten­tial. Accord­ing to the Amer­i­can Can­cer Soci­ety, col­orec­tal can­cer is the third most com­mon­ly diag­nosed can­cer in the US. It is believed that a major­i­ty of these can­cers and deaths could be pre­vent­ed by a stronger adher­ence to screen­ing rec­om­men­da­tions and ensur­ing time­ly, stan­dard treat­ment. Progress has been made in screen­ing rates; how­ev­er in 2010 only 59 per­cent of peo­ple eli­gi­ble for screen­ing report­ed hav­ing received col­orec­tal can­cer testing.

One of the great­est tools avail­able for com­bat­ting col­orec­tal can­cer is ear­ly detec­tion through screen­ing tests, BEFORE any symp­toms arise. Screen­ing tests are more wide­ly used for breast, cer­vi­cal and prostate can­cer than for col­orec­tal can­cer. The major dif­fer­ence among these four can­cers is the pre­can­cer­ous stage. Cer­vi­cal can­cer and col­orec­tal can­cer are the only can­cers that have a pre­can­cer­ous change that can be eas­i­ly iden­ti­fied AND removed before malig­nan­cy. In col­orec­tal can­cer, the pre­can­cer­ous change is indi­cat­ed by pres­ence of ade­no­ma­tous colon polyps. A polyp is a growth in the lin­ing of the colon that, if left alone for a long enough peri­od of time, can devel­op into can­cer. A vari­ety of screen­ing tests are avail­able for col­orec­tal can­cer, but your physi­cian is only able to both iden­ti­fy AND remove the pre­can­cer­ous growth through a colonoscopy.

If col­orec­tal can­cer is found at an ear­ly stage, the abil­i­ty to cure the patient is greater. Screen­ing for col­orec­tal can­cer, before symp­toms devel­op, improves the chance that a can­cer will be found at a stage when it is most cur­able. A vari­ety of sur­gi­cal treat­ments are avail­able, although some can only be used for ade­no­ma­tous polyps and ear­ly stage can­cers. Sur­gi­cal treat­ment options will vary depend­ing on if you have colon or rec­tal can­cer. In large part, this is due to the prox­im­i­ty of the rec­tal can­cer to the anus.

Below are details on dif­fer­ent sur­gi­cal tech­niques for col­orec­tal cancers:

Transanal Surgery

Transanal (enter­ing the body through the anal open­ing) surgery has been used for many decades to remove growths with­in the rec­tum. This approach is min­i­mal­ly inva­sive, and helps patients avoid an abdom­i­nal surgery. Plus, a major­i­ty of the rec­tum is pre­served rather than removed, so bow­el func­tion after this type of surgery is bet­ter than with oth­er tech­niques. Tra­di­tion­al­ly, this tech­nique uses an open tube with a light to pro­vide a naked eye view” for growth removal inside the rec­tum. Vis­i­bil­i­ty and instru­ment reach is lim­it­ed to only half of the rec­tum. Polyps that can be removed are lim­it­ed to those that can fit through the open­ing in the oper­at­ing tube; oth­er­wise they can­not be removed in this manner.

Transanal Endo­scop­ic Micro­surgery (TEM)

Transanal endo­scop­ic micro­surgery (TEM) was devel­oped in Ger­many in the 1980s. This tech­nique has dif­fer­ences which pro­vide advan­tages over the transanal surgery. TEM uses a closed tube sys­tem to stretch the rec­tum open with air to pro­vide greater vis­i­bil­i­ty and allows for larg­er growths to be removed. Through the use of a small cam­era, increased vision of the rec­tum lin­ing is achieved for growth removal. The cam­era can be placed close to the growth, at an angle or mag­ni­fied, enhanc­ing pre­ci­sion and vis­i­bil­i­ty through the entire length of the rec­tum. Adop­tion of this tech­nique has been slow in the 30 years since its intro­duc­tion. This, in large part, is due to the cost of the sys­tem and its complexity.

Transanal Min­i­mal­ly Inva­sive Surgery (TAMIS)

Transanal mini­mal­ly inva­sive surgery (TAMIS) is one of the newest tech­niques in treat­ing polyps and ear­ly stage rec­tal can­cer. TAMIS is a min­i­mal­ly inva­sive pro­ce­dure and a hybrid of sev­er­al dif­fer­ent tech­niques that have been devel­oped over many years, first avail­able in 2009. This hybrid approach main­tains the ben­e­fits of transanal surgery (min­i­mal­ly inva­sive with rec­tum preser­va­tion), adds the ben­e­fits of TEM (enhanced vis­i­bil­i­ty and fur­ther reach into the rec­tum), while using con­ven­tion­al laparo­scop­ic instru­ments. The com­bi­na­tion of a transanal approach (with excel­lent vis­i­bil­i­ty) along with use of con­ven­tion­al instru­ments (ease of learn­ing tech­nique and reduced cost) has made this tech­nique very pop­u­lar and more wide­ly uti­lized. It is also lead­ing to addi­tion­al new tech­niques for rec­tal surgery, such as transanal total mesorec­tal exci­sion (taTME). Short term results are very promis­ing. Long term results are not yet avail­able as the tech­nique has only been devel­oped recently.

    While transanal exci­sion has strong ben­e­fits, it is impor­tant to know the right time to use this tech­nique. Care­ful assess­ment and stag­ing of a growth in the rec­tum is crit­i­cal for your sur­geon to rec­om­mend the right approach for you.

    At DMG, we have a team of physi­cians from gas­troen­terol­o­gy, radi­ol­o­gy, and surgery trained in stag­ing and treat­ment of rec­tal polyps and can­cer to help design the best treat­ment plan for you. If you are in need of colon or rec­tal surgery, please con­tact DMG’s surgery depart­ment at 630−790−1700.

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