Did you know that the human colon, with its winding twists and turns, can span up to 150cm in length? The colon is part of the large intestine, together with the rectum and anus. As food reaches the end of its journey through the small intestine, it carries on to the colon, where water and some nutrients and electrolytes from partially-digested food are removed. The remaining material — solid waste also known as stools — moves through the colon, is stored in the rectum, and leaves the body through the anus.
Colorectal cancer
Colorectal cancer relates to the colon and rectum. It is the most commonly-diagnosed cancer in Singapore. “Even so, it is one of the most preventable and treatable cancers with regular screening and early detection,” says Dr Wong Neng Wei, Associate Consultant, Department of Surgery, Changi General Hospital (CGH).
Some factors that could increase the risk of colorectal cancer include:
Additional risk factors that may contribute to increased risk of colorectal cancer include smoking, a sedentary lifestyle and dietary-related factors such as the excessive consumption of processed foods, red meat and alcohol.
Colorectal cancer screening is recommended for anyone with the above risk factors.
Polyps
Polyps in the large intestine are outgrowths from the inner lining of the colon and rectum. Most polyps are small and harmless. However, colorectal cancers can still originate from non-cancerous polyps. These are polyps with cell changes that are inclined to develop into cancer over time.
Anyone can develop polyps in the colon and rectum. The prevalence of colorectal polyps increases with age, with patients aged 50 years old and older at an increased risk. Other risk factors include smoking, being overweight, and a personal or family history of colorectal polyps or colorectal cancer.
Polyps usually do not manifest any symptoms. However, some patients with polyps that have turned cancerous may experience a change in their bowel habits, have blood in the stool, or experience pain or symptoms of anaemia (low haemoglobin).
A colonoscopy or computed tomography (CT) colonography is usually used to detect polyps in the body. “As a leading centre for artificial intelligence research in Singapore, CGH was one of the first institutions to use computer-aided detection (CADe) to assist in the detection of polyps, which has been demonstrated in studies to increase the polyp detection rate,” says Clinical Assistant Professor James Li, Consultant, Department of Gastroenterology and Hepatology, CGH. “Although most polyps detected during colonoscopy are small and can be removed at the first colonoscopy, larger polyps, or polyps with advanced histology (at higher risk of turning cancerous or are at an early stage of cancer), require more highly-specialised techniques for removal.”
CGH offers the full range of services for endoscopic resection of these large polyps with advanced histology. These techniques include endoscopic submucosal dissection and endoscopic mucosal resection, which are performed endoscopically and may minimise the need for surgery in patients with such polyps. Lifestyle modifications, such as quitting smoking, having a diet with plenty of vegetables and fruits, and maintaining a healthy body weight, can also help reduce the risk of colorectal polyps.
Spotting the silent signs
A large proportion of patients who are diagnosed with colorectal cancer are usually asymptomatic, especially for those diagnosed in the early stage. Colorectal cancer typically develops from a polyp (benign growth). The importance of screening is not only for early detection of the cancer but also for the removal of polyp(s) before it becomes cancerous.
Should colorectal cancer symptoms occur, they may include:
Determining the diagnosis
“One of the recommended tests that can help diagnose colorectal cancer is colonoscopy,” says Dr Li. Colonoscopy refers to the insertion of a long, flexible tube with a micro camera at the tip through the anus into the rectum, and then to the caecum (the start of the large intestine and where the opening of the appendix is located). Patients undergoing colonoscopy will require bowel preparation before the procedure to allow the doctor to inspect the entire colon and not miss abnormalities that may be hidden by faecal material.
“A colonoscopy can help the doctor to investigate the causes of symptoms such as abdominal pain, changes in bowel habits and rectal bleeding,” says Dr Li. “It is not only the most accurate method of detecting colorectal polyps, but also allows for the doctor performing the colonoscopy to remove the detected polyps to decrease the risk of colorectal cancer.”
The Faecal Immunochemical Test (FIT) can be performed in the comfort of your own home to detect the presence of small amounts of blood in faeces.
Dr Wong shares that CT colonography is an alternative to colonoscopy. “X-rays are used to detect the presence of growths in the large intestine during the CT colonography by gently pumping air into the intestine to expand the colon while the patient lies on a CT machine for the scan, he says. “It is potentially less invasive than a colonoscopy, but is unable to detect growths that are smaller than 6mm in size. A colonoscopy will still be required in the event of an abnormal CT colonography finding for assessment and biopsy of the growth.”
Another screening option is the Faecal Immunochemical Test (FIT), a simple and convenient test that detects the presence of small amounts of blood in faeces, that can be performed in the comfort of your own home. If abnormal results are detected, appropriate medical follow-up can be carried out.
Reduce the risk of colorectal cancer
Leading a healthy lifestyle is important in lowering the risk of developing colorectal cancer.
Ms Belinda Tay believes that staying positive has helped her on her recovery journey.
“I have always had constipation since I was young. I would see the doctor and would be prescribed medication. Nothing serious was ever noted,” shares Ms Belinda Tay, 70. “One day, I realised that there was blood in my stool. My friends said that it might be piles or haemorrhoids, so I went to see a GP and was referred to CGH.”
At CGH, tests revealed that she had stage 3B colorectal cancer. Ms Tay proceeded with the surgery, which went smoothly. “The doctors and nurses at CGH took very good care of me. Ms Madalinah Tan, CGH Assistant Nurse Clinician, and Ms Josephine Ong, CGH Senior Staff Nurse, looked after my health and well-being from the very beginning, enabling me to have a successful surgery and recovery. I recovered well and fast and was quickly able to walk by myself to the toilet with little assistance,” says Ms Tay. “The CGH doctor also checked on me every morning until I was discharged.”
“My advice to those facing cancer is to stay strong and positive as it plays an instrumental part in your recovery. The healthcare team will do their part and be there for you every step of the way,” says Ms Tay, who continues to go for regular follow-ups at CGH to check for any relapse.
Managing colorectal cancer at CGH
A stoma may be created from one or both ends of the intestines, where an opening is created in the abdominal wall to allow the discharge of waste into a colostomy bag.
At CGH, colorectal cancer management is a multi-disciplinary effort to provide comprehensive care for patients. CGH colorectal surgeons work with fellow surgeons, medical oncologists, radiation oncologists, gastroenterologists, nurses and allied health professionals to provide holistic care. “The treatment strategies depend on the stage of the cancer and how extensive it is — for example, whether it involves other organs like the liver or lungs,” explains Dr Wong. For very early tumours or cancerous polyps, endoscopic therapy in the form of removal via colonoscopy is an option that can be provided by gastroenterologists or colorectal surgeons.
For most stages of colorectal cancer, surgery remains the most common form of treatment. It entails removal of the part of the intestine containing the cancer with its surrounding lymph nodes. After removal of the affected portion of intestine, the two ends of colon are typically reconnected to restore continuity of the gut. However, there may be situations where a stoma may be created from one or both ends of the intestines, where an opening is created in the abdominal wall to allow the discharge of faeces into a colostomy bag. This may be temporary or permanent.
At CGH, the majority of colorectal cancer surgeries are performed with minimally-invasive techniques (keyhole surgery) either via laparoscopy (using instruments to perform surgery, via smaller incisions, with the aid of a micro camera inserted through the abdominal wall) or with robotic assistance. These have shown to improve patients’ recovery time and causes less post-operative pain.
In certain circumstances, chemotherapy and/or radiotherapy may be required for the patient before surgery or after surgery. Advanced colorectal cancer treatment now also includes targeted therapy and immunotherapy, which targets specific genes or enhances the body’s immune system to fight cancer. Robotic surgery is an extension of laparoscopic (keyhole) surgery and is a developing field, with many new surgical systems being developed worldwide. The multi-disciplinary team at CGH will discuss the optimal treatment plan with patients to best suit their needs.
Minimally-invasive surgeries have helped to improve patients’ recovery times and reduce post-operative pain.
Mr Wong, 64, first felt that something was amiss when passing motion. His stomach was bloated, and he had no appetite. He eventually decided to have a colonoscopy at CGH, where he was subsequently diagnosed with colorectal cancer.
Dr James Ngu, Senior Consultant, Department of Surgery, CGH, explained the necessary surgery to Mr Wong. “I was quite worried at first but Dr Ngu was very detailed in explaining the procedure, giving me the confidence to go through with the operation,” says Mr Wong. “Ms Josephine Ong, Senior Staff Nurse, was also very detailed in explaining how to care for my wounds, which gave me more confidence to do so myself.”
After the successful procedure, Mr Wong recovered in a few days and was able to carry on with his life with only minor adjustments. “I used to have to lift heavy items in my work. Now, I delegate the heavy lifting to other staff, or get assistance to do so.” He also regained his appetite and now has a more positive outlook on life. “Based on my experience, I encourage people who have had symptoms like mine to go for a screening. I thought that I was very healthy and did not realise that there was something wrong with my body. That was my one regret — it would have been much better if I had detected the colorectal cancer earlier,” shares Mr Wong.
CGH colorectal nurses advise and educate patients on pain management and wound care management after their surgery.
CGH colorectal nurses support patients and their families in the wards or in the specialist outpatient clinics once their symptoms are indicative of colorectal cancer. “We aim to provide evidence-based care, support and advice for patients through information and education prior to their admission,” says Ms Josephine Ong, Senior Staff Nurse, CGH. “We share on the treatment plans to alleviate patients’ fears and anxieties, and reduce the psychological impact.”
During the counselling sessions, CGH colorectal nurses conduct a series of assessments to holistically evaluate the patients’ health status so that the patients are aware of their condition and care plan. This empowers patients to take charge of their own health through the setting of realistic goals and expectations to facilitate and enhance their post-surgery recovery, as well as formulating their early discharge plan.
Inpatient care
CGH colorectal nurses and surgeons go on ward rounds to conduct initial assessments. Empowered to manage patient care, the colorectal nurses advise and educate patients on pain management after their surgery and wound care management, as well as provide dietary advice and a discharge care plan.
One of the key components recommended for patients after their surgery is to regain mobility as soon as possible. As such, referrals to physiotherapists are made for their rehabilitation. Patients who require step-down care and continuity of care may be recommended to a community hospital. “This seamless coordination is a key component of our work, so as to ensure that there is no lapse in care or communication between the ward nurses, physiotherapists and step-down care at the community hospitals,” says Ms Ong.
CGH colorectal nurses and physiotherapists help post-operative colorectal cancer patients with stoma management at hydrotherapy sessions.
Continued care in the community
To ensure the continuity of care for patients from hospital to home, CGH colorectal nurses conduct nursing assessments in a structured manner with discharged patients through a phone consultation, to follow up with them on their recovery progress.
This targeted practice is used to empower patients and their families with the relevant knowledge so that they can cope better in the community, and helps to prevent readmission to the hospital. In partnership with patients and their families, the colorectal nurses also further develop a care plan that will enable them to pick up early signs of complications that may arise and require immediate medical treatment.
CGH support group for patients
For many patients, going through the cancer journey is difficult and can cause frustration, anger and helplessness. Recognising that there are many cancer survivors with similar experiences, a CGH support group enables patients to not go through this alone. The support group consists of a team of doctors, nurses, colorectal cancer patients and survivors, as well as caregivers. Volunteers aid the nurse-led support group every week, providing emotional and psychological assistance to newly-diagnosed colorectal cancer patients and their caregivers to help them overcome the challenges and adjust to changes in their lifestyles. The support has also expanded to additional platforms such as a mobile chat group and an online support hub for patients.
CGH physiotherapists attend to colorectal cancer patients immediately after their surgeries to prevent respiratory complications and help them regain functional mobility. “Both of these are crucial in the prevention of post-operative complications and in reducing the length of stay in the hospital, says Ms Wong Fu Foong, Senior Physiotherapist, CGH. “The immediacy of care also allows us to attend to patients’ rehabilitative needs and begin discussions on care plans with patients and their loved ones.”
After patients are discharged from CGH back to home, physiotherapists continue to care for them at CGH’s specialist outpatient clinic, to ensure a smooth recuperation journey towards optimised function and quality of life. “A cancer diagnosis can be daunting, and their hospital stay and surgery may leave patients wary of what activities they can safely return to,” adds Ms Wong. “Physiotherapists help them to return to function, exercise and participation in activities of interest with confidence and assurance.”
CGH Senior Physiotherapist Wong Fu Foong (left) helps to strengthen patients physically through water-based exercises and minimise their fear of the stoma bag getting contaminated.
In recent times, some CGH patients expressed interest in resuming water-based activities with a stoma. This led to the CGH care team starting hydrotherapy sessions catering specially to colorectal cancer patients with a stoma. Conducted by physiotherapists and colorectal nurses, the hydrotherapy sessions focus on techniques to help patients manage their stomas in water and engage in water-based activities. They also help develop patients’ cardiovascular strength, core strength and general strength. This service, which is unique to CGH, aims to not only strengthen patients physically through water-based exercises, but also addresses their fears of water activities with a stoma bag and concerns about their body image.
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