Colorectal Cancer:
Don't Die of Embarrassment

BY ANNE PAILLARD

MYFANWY TRUSCOTT kept putting off going to see her family doctor. What began as a suspected upset stomach, along with bouts of diarrhea, eventually progressed to bloody diarrhea. It's probably hemorrhoids, she thought. It will clear up soon. But as the weeks passed, Truscott, a 50-year-old librarian from Regina, suffered increasing abdominal discomfort and more frequent bloody diarrhea. Then, three months later she developed tenesmus (a feeling of incomplete emptying of the bowel accompanied by ineffective straining). Concerned, she finally decided to see her doctor.

       Truscott was suffering from the classic symptoms of colorectal cancer -- cancer of the colon or rectum. By the time she was referred to Pasqua Hospital in Regina, she had a tumour in her rectum the size of an orange. The cancer was so advanced that it had extended outside the intestinal wall and spread to surrounding lymphoid tissue.

       After removing part of her lower intestine, doctors reattached the two ends of her bowel and performed a colostomy. She then began a treatment program of chemotherapy and radiotherapy.

       Why had Truscott delayed seeking help? "I was young, physically very active and generally health conscious," she says. "Cancer was the last thing on my mind."

       Thirteen years later her cancer hasn't returned. Truscott knows she has been extremely lucky.

IN 1999, 6,300 lives will be lost due to colorectal cancer. It's Canada's third highest cancer killer for both men and women.

       Yet, detected early enough, it is one of the most curable types of cancer, with a 90-percent survival rate with localized disease -- thanks to modern diagnostic equipment.

       Colorectal cancer is a malignancy that usually develops from a benign polyp, a small growth on the lining of the colon or the rectum. Removal of these polyps early on, before they become cancerous, is the best prevention.

       The tragedy is that Canadians delay on average 2-1/2 months after the onset of symptoms before seeking medical help. By that time the growth of a tumour can lead to an emergency complication -- either an obstruction or perforation of the bowel. Once the bowel wall has burst, and certainly when the cancer has advanced into the liver, the chances of successful treatment are limited. Forty percent of the 16,600 Canadians who come forward for the first time each year are beyond hope of a cure.

       Few other diseases are surrounded by as much ignorance, embarrassment and neglect. In a 1998 poll by Canada Health Monitor, a private survey organization, only 16 percent of Canadians 35 years and older reported discussing testing for colorectal cancer with their physician.

       There was no discussion of cancer anywhere in the National Population Health Survey, a 1996 Statistics Canada study questioning Canadians on their health. "The federal and provincial governments definitely need to do more towards prevention and public education on colorectal cancer," says Dr. Zane Cohen, professor of surgery at the University of Toronto and surgeon-in-chief at Toronto's Mount Sinai Hospital. This laxity at official levels is too often mirrored in the doctor's office: For instance, general practitioners are still failing to recognize that the disease can strike in the relatively young.

       For months Gisella Bonanno kept going back to her family doctor in Montreal. On each occasion the 30-year-old product manager for a pharmaceutical company complained of rectal bleeding, blood and mucus in her stools, and chronic fatigue. The doctor told her she had anal fissures caused by bouts of constipation and that she had nothing to worry about.

       "Although I wasn't in pain, I had a strong feeling that my condition was more serious," she says.

       In desperation she insisted on a second opinion. A gastroenterologist did a colonoscopy -- a test to examine the entire length of the colon using a flexible viewing instrument that is inserted through the rectum into the colon -- and found a large tumour in Bonanno's rectum.

       She was immediately booked for surgery. Doctors removed part of her rectum and, since the cancer had spread, six lymph nodes. They then rejoined the rectum and the colon.

       Bonanno underwent six months of chemotherapy and radiotherapy. Her comparative youth and her determination helped her to survive.

       More commonly, cancer can be mistaken for hemorrhoids or irritable-bowel syndrome.

       Ramiro Puerta's ordeal began four years ago. At first the 46-year-old Toronto filmmaker reported strong stomach cramps that returned periodically. His family doctor told him that he was suffering from irritable-bowel syndrome and to eat more foods high in fibre.

       By the fourth year, Puerta was having excruciating cramps that lasted four to five days every three weeks. The pain had become so bad that he had to move constantly to find a comfortable position.

       A specialist later found a growth in his colon, but misdiagnosed it as benign. Finally, during a procedure to remove the tumour, a surgeon discovered it was malignant and was forced to remove 30 centimetres of Puerta's colon.

       "This cancer could have been headed off if the proper tests had been done when I first went to the doctor," Puerta says.

GISELLA BONANNO and Ramiro Puerta were right in seeking immediate help, but too many others delay through sheer embarrassment. "Unfortunately, many Canadians are still reluctant to talk openly about their bowel habits and can miss the chance of a cure," says Dr. Warren Rudd, a colorectal surgeon in Toronto and author of Advice from the Rudd Clinic: A Guide to Colorectal Health.

       Many patients delay seeking help out of fear that surgery will automatically mean a colostomy whereby the end of the colon is brought through the wall of the stomach to form an opening, over which a special bag is placed to collect solid waste. But this procedure is permanent only if all or sometimes part of the rectum has to be removed to treat the cancer.

       In fact, bowel surgery has so improved that when tumours are taken from the colon, the two ends can usually be rejoined. Less than ten percent of those who are curable by surgery will end up with a permanent colostomy bag.

       Even that may not be as bad as most fear. Nancy Sunderland, a Vancouver dental receptionist and mother of three, was 49 when cancer attacked her bowel for the second time.

       During a four-hour operation, doctors had to remove her rectum and a cancerous tumour from her pelvic bone. As she had been warned, she awoke from surgery with a colostomy.

       "At the beginning I worried about not being able to cope with this, especially at work," she says. "But to my surprise, I'd adjusted to the changes after a few weeks. Specially trained nurses showed me how to deal with the artificial opening in my abdomen. The colostomy bag fits neatly under my pants or sweater and doesn't show."

       Sunderland, now 54, has to think hard to come up with ways that her colostomy bag has restricted her life. "I can still do all the activities I used to do, like swim and garden. I was horseback riding last summer and felt fine."

       "With today's new appliances, it's very hard to detect that someone has a colostomy," says Dr. Cohen.

SOMETIMES the tumour is too advanced to treat with surgery alone. Chemotherapy is used to help shrink or kill cancer cells that have spread to other organs, most commonly the liver.

       Another method is the delivery of anticancer drugs directly into the liver blood supply. This technique, called chemoembolization, is being used in selected centres around the world.

       Under X-ray guidance, a small catheter is inserted into the liver artery. Drugs and other materials which stop the blood flow to the tumour cells are then injected through the catheter. Chemoembolization deprives the tumour of oxygen and nutrients, then saturates it in drugs yet does not damage the liver.

Warning Signs If any of the following symptoms persist for two weeks or more, consult your doctor. Do not delay. Change in bowel habits. Any significant change, such as diarrhea or constipation. The presence of mucus around the stools. Smaller than usual stool size. Bleeding. Blood passed from the bowel, bright red or especially dark and mixed with the stool. Tenesmus. A constant feeling of incomplete emptying of the rectum. Pain. A cramping pain in the abdomen. This might be accompanied by an increase in flatulence causing pain or discomfort, or a bloated feeling. Anemia. This can be associated with abnormal tiredness or unexplained weight loss.

       A study performed by a team of researchers at the University of Pennsylvania has found that chemoembolization may double the survival time of adult patients with colon cancer that has spread to the liver.

WHAT ARE the main factors associated with colorectal cancer? Inflammatory-bowel disease can be one; diet is another.

       Colorectal cancer is very much an affliction of the Western world, where people eat food high in animal fat and low in fibre. Although one study found no association between the intake of fibre and the risk of colorectal cancer, many doctors still recommend eating more fibre to maintain good bowel habits. Water-insoluble fibres found in whole-grain cereals increase the bulk of the stool and reduce the time it takes to pass through the intestinal tract.

       Other studies indicate that a diet low in animal fat and high in vegetables, fresh fruit, beans and whole-grain cereals could reduce the incidence of colorectal cancer by as much as a third.

       Another factor is genetics. Around 25 percent of cases occur in people with a family history of the disease or a predisposition to polyps, which, if left to grow, can turn cancerous.

       In 1985 when Roméo Benoit, a Montreal railway employee for 38 years, complained to his doctor of having stomach pains and feeling tired all the time, he was told that he was fine and had nothing to worry about. Although his sister, Laura, had had colorectal cancer at age 55, Benoit did not think there was any connection between her illness and his symptoms. Fearing instead that he might have prostate cancer, he decided to consult another doctor. This time, tests revealed traces of blood in his stools and Benoit underwent a colonoscopy.

       As the doctor carried out the half-hour examination of his rectum and colon, Benoit was sedated but conscious. "I didn't feel any pain at all," he says. About ten centimetres from the rectum, the doctor found three polyps, like cherries on a stalk, which were then removed.

       Says Benoit, now 75: "This procedure is wonderful -- it probably saved my life."

       As many as half of men and women in their 60s and 70s might have some polyps in their colon, though we don't yet know why some will develop into cancer. Should everyone over the age of 55 be screened?

       The Canadian Cancer Society warns that people over 50 are at risk of developing colorectal cancer based merely on their age and should take every precaution to prevent the disease.

       Various screening tests include a digital rectal examination, considered a normal part of a thorough physical, and a fecal occult (hidden) blood test (FOBT), a lab test of patients' stool samples.

       Neither of these tests, however, can positively determine whether cancer is present. The FOBT still misses some 40 percent of colorectal cancers since not all tumours bleed.

       Unfortunately, screening the whole population by colonoscopy would be prohibitively expensive. Examination with a shorter sigmoidoscope is much less costly but cannot detect all polyps and cancers.

       Experts agree that regular screening, including colonoscopy, should be offered to all patients who have first-degree relatives -- mother, father, sister or brother -- with colorectal cancer. If a close relative has had the disease under the age of 50, or if two first-degree relatives of an older age have had it, ask your doctor to refer you to one of the growing number of family cancer clinics.

       Isabelle Normore, a 45-year-old office clerk in Deer Lake, Nfld., whose mother and younger brother had died of colorectal cancer, was referred to the family cancer clinic at Corner Brook's Western Memorial Regional Hospital. After looking at her family tree, a geneticist, Dr. Jane Green, urged her to have a checkup. Following examination, two polyps in the woman's rectum were painlessly removed. She will return for a checkup every year.

EARLY detection is paramount. Everyone should keep an eye on possible signs of trouble (see box). Should you look at your stools? Most definitely. Distasteful? Maybe. But changes in bowel habits are a vital early warning.

       To reduce the risk of colorectal cancer, most experts agree that men and women should:

• Cut down on animal fat and select leaner cuts of meat.
• Eat more fresh fruit and vegetables -- at least five portions a day -- and foods high in fibre and starch, such as cereals, potatoes (not chips), rice, whole-grain bread, pasta.
• Maintain a healthy weight and exercise regularly -- at least 20 minutes three times a week.
• Keep alcohol intake down to three to four small glasses a day for men; two to three for women.

       Above all, if you are experiencing trouble with your bowels, don't delay as Myfanwy Truscott did -- see your doctor. And as Gisella Bonanno, Ramiro Puerta and Roméo Benoit did, ask for or seek out a second opinion. Thanks to their intuition and determination, they now all live full, vigorous lives.

       If you're unhappy with the treatment you're receiving, or if symptoms persist, go back. Never feel you are wasting the doctors' time.

       In any case, don't hesitate. After all, it would be absurd to die of embarrassment.

You can contact the Canadian Cancer Society's Cancer Information Service at 1-888-939-3333, the United Ostomy Association of Canada Inc. at 1-888-969-9698 or the Colorectal Cancer Association of Canada at 1-888-318-9442.

ADAPTED FROM AN ARTICLE BY JOHN NORTHOVER, M.D.