Understanding Colorectal Cancer with Dr. Rahul Kumar Gupta

Dr. Rahul: I am Dr.Rahul. I am currently an Oncosurgery Resident at Mohandai Cancer Institute, Ludhiana, Punjab, India. I was previously working at, AIIMS, Bhubaneshwar. Before that, I did my PG from Jabalpur Medical College and my UG from AIIMS, Raipur.

Dr. Rahul Kumar Gupta: In a simple definition, Colorectal cancer is cancer of that part of the gastrointestinal system that is usually meant for storage that is the colon and rectum. This is also known as large bowel cancer because we have two types of bowel, one is a small bowel which is used for absorption and a another is large bowel which is used for storage and then absorption.

Dr. Rahul Kumar Gupta: Basically colorectal cancer is a cancer of late adults and the elderly so if people are around 40, 50, 60, and have altered bowel habits. They might have constipation then diarrhea or stools having bleeding per rectum then we should be suspicious about that and should get them diagnosed with a good or at least they should see a clinician so that he/she can refer us to the right place where we can get ourselves checked because if diagnosed at an early stage it will be curable and if it is in late stage that is stage 4 or stage 3b then it will be difficult for us. Because the major part of dissection will be done and then chemotherapy will be followed by then. So, if it’s a readily curable cancer if we get it early if we can detect it early we can do the surgery. It will be minor and the small part of our bowel will be dissected so it will be helpful.

Dr. Rahul Kumar Gupta: Cancer has a very vast domain. It includes all major organs. Different cancers are present at different stages. Some cancers are pediatric, some are in females, some are in males, and some are in geriatric so depending upon the symptoms which are not usual for a normal human being, if you think that this is not normal, this symptom is not usual, this growth is not usual, this tumor is not behaving usually or this is bleeding or there is some change in the mechanics or there is some change in our pattern or some weakness is there then we should think that we should seek medical attention and if taken right step or we are moving towards the right step then it is curable.

Dr. Rahul Kumar Gupta: The scenario in our country as compared to the U.S. or the U.K. is different. In the U.S. and the U.K., their main diet is non-vegetarian, they eat red meat more often, and they eat a less fiber diet. So, the prevalence of colon cancer is higher in the U.S. and the U.K., but due to changes in the pattern of eating habits in India, it is now growing steadily. Now, we often take a less fibrous diet and are switching towards pizza, burgers, a high-fat diet, and red meat. These all are risk factors for carcinoma colon and unlike other cancers, this cancer is relatively silent. We get cases when there is frank bleeding or frank obstruction most of the time. We don’t have any screening programs like in the U.S. and U.K. because the prevalence is higher over there. So, whenever we are having alternate diarrhea constipation or blood in stool and we are elderly or we have a family history of cancer, then we should seek medical attention, should get a fecal occult blood test. It means whenever we do the stool sampling we can see RBCs in that and this is a silent marker that we can pick up in that patient we can do a colonoscopy and diagnose this cancer early so that less part of the bowel will be resected and it will be in less we will be diagnosed at the earliest.

Dr. Rahul Kumar Gupta: Yes now colorectal surgeons are doing screening with two modalities. One is fecal occult blood and another is colonoscopy. Whenever there is frank blood in the stool or in stool report there is fecal occult blood, then we go for a colonoscopy. In colonoscopy we can see the mass, we can take a biopsy, and then after proving that it is carcinoma in the colon. Then we stage the disease. That is if the disease is in the bowel, outside the bowel, in the lymph nodes, or in the liver or lungs. Depending upon that we characterize and stage the patient.

Dr. Rahul Kumar Gupta: Till now there is no marker that can detect colonic carcinoma in blood and maybe free DNAs /free cancer DNAs may be in down the line it might happen. But still, it is very far.

Dr. Rahul Kumar Gupta: Cancer risk will increase when the content of fat is high in our stool. So for that, we use a fibrous diet, we can add cucumber, and other spinach green leafy vegetables to our diet so that this will, this fatty meal content and the red meat will decrease in our diet which will be helpful.

Dr. Rahul Kumar Gupta: Colorectal cancer also has TNM staging. But what is different here is that the depth of penetration is regarded as more important than the size of the tumor. If the tumor is in the mucosa and submucosa, then it is T1. If it is going towards the muscle, it is T2 and if it is crossing the serosa, it is T4. If it is crossing the serosa and affecting the organ it is T4a or T4b depending upon the organ it is affecting. Then, it metastasizes mostly to the liver but sometimes to the lungs and bones as well. According to the stage of the cancer, we decide on the modalities. Sometimes we have to do Neoadjuvant therapy where we sink the tumor, make it operable, and then operate it.

Dr. Rahul Kumar Gupta: In the liver, it is through hematogenous spread. However, this cancer is mostly known for lymphatic spread.

Dr. Rahul Kumar Gupta: Due to the lack of statistical data, we are still not having robust information for this. However, it is seen that the incidence is increasing.

Dr. Rahul Kumar Gupta: The main symptom is occult blood in the stool. Other symptoms are constipation and diarrhea. A person who is in the age group 40s or 50s could check on the frequencies of altered bowel movements, and their pattern of diet and also consider their family history, then they should seek medical attention.

Dr. Rahul Kumar Gupta: The patient outcomes are excellent. Even if the tumor metastasizes and it is solitary, we can remove the metastasized part as well as the tumor itself and the patient will be ultimately improved.

Dr. Rahul Kumar Gupta: People from lower socioeconomic status do not have access to tertiary care that’s why here the diagnosis is late. So if possible we should keep it at the district level or at least in CSC. So that people from low socioeconomic status can also be treated.

Dr. Rahul Kumar Gupta: Yes, in this same field, there is an MSI (Microsatellite instability) gene, which has an interrupt and was useful for the identification of a medication used to treat colorectal cancer. The 2018 Nobel Prize was awarded for the same. So the new advancement and now the treatment is up to the genetic level. Previously it was said that if you have rectal cancer then the only option is to remove the whole of the rectum. But now we are talking about rectal preservation, which means we are giving chemotherapy, and radiotherapy and we are following up with the patient and we are seeing that only with chemotherapy, and radiotherapy can spare the rectum. So in those cases, around 10 to 15 percent of patients are sparing the rectum. Previously it was like resection and now it has changed to chemotherapy, radiotherapy, and immunotherapy. Now we are advancing towards that.

Dr. Rahul Kumar Gupta: We have to work in a collaborative way to make people aware of the early symptoms so that they can reach their primary physician, specialist, or family medicine doctors to consult about their symptoms and get a diagnosis in the early stage then it is easy to treat.

Dr. Rahul Kumar Gupta: Actually, public health professionals will be more helpful for us because they are the actual representation of our society or our fraternity towards the common people. So, they are the ones who can reach to masses, can help us reach masses, and knowing all the symptoms and referring that patient back to us will be their responsibility. So, I will be requesting you all that you should spread, at least prevent, with a hashtag that prevent colorectal cancer today so that people and even tag me or tag Prevent Cancer Association so that we can create awareness so even if we can save a life of one people then it will be great.

Dr. Rahul Kumar Gupta: Basically, when we talk about rectum and other private part cancers people refrain from showing their symptoms till it is in the last stage. Or if we get rectal bleeding or people tend to hide and people say that it is hemorrhoid or some other disease fissure or fistula. But when they reach us it is too late so we have to teach them that this is the stigma that it is rectal cancer and we have to reach a specialist to show our rectum this is a big problem in lower socio-economic status. This barrier should be removed it should be treated like other cancers like breast cancers or oral cancers which are easily diagnosed so people should come to us for their regular checkups because it is easily diagnosed and can be treated and the cure rate is good.

Dr. Rahul Kumar Gupta: Yes, yes basically previously it was a disease of the rich meant they could afford pizza, burgers, and red meat. But, now things have changed because in rural areas they are consuming junk food, bread, pizza, and cheese and avoiding green leafy vegetables. So this is a pattern shift which is the culprit. We have to add fiber to our diet also we cannot say that stop this but we can say that add this diet to our diet so that it can be a balanced diet which will help the content of fiber help decrease the transit time. It is all about the transit time through the bowel whenever we take fatty meals the transit time increases so there is more chance of reaction and more reaction leads to metaplasia and carcinoma and we usually study that a fibrous diet will help it.