Bowel cancer

Bowel cancer (also called colorectal cancer) is cancer in any part of the large bowel (colon or rectum). It may also be called colon cancer or rectal cancer, depending on where in the bowel it is.

The cancer starts in the lining of the inner bowel wall (called the mucosa). It usually develops from small growths called polyps. Most polyps are harmless (benign), but some may turn into cancer. Removing polyps during a colonoscopy reduces the risk of bowel cancer.

If untreated, bowel cancer can grow into the deeper layers of the bowel wall. It can also spread to the lymph nodes. If the cancer advances further, it can spread to other organs, such as the liver or the lungs.

Bowel cancer is the 4th most common cancer in Australia. Each year, about 15,500 Australians are diagnosed with bowel cancer. It is more common in people over 50, but it can happen at any age. The number of adults under 50 with bowel cancer is increasing, with research yet to give a clear reason for this.

Some people have no symptoms and the cancer is found through screening. However, many people with bowel cancer experience some of the symptoms listed below.

Other conditions can also cause the same symptoms, including irritable bowel syndrome (IBS), diverticulitis (inflammation of pouches in the bowel), inflammatory bowel disease, haemorrhoids, or an anal fissure (cracks in the skin lining the anus). Having some of the symptoms on this list does not mean that you definitely have bowel cancer.

Talk to your doctor if you have any of these symptoms, especially if they are ongoing, get worse, or if there is any bleeding:

• blood in or on faeces (poo) or on the toilet paper; this might be bright red or make the poo look dark brown or black
• a persistent or unexplained change in bowel habits, such as diarrhoea or loose stools, constipation or smaller, more frequent bowel movements
• a change in the look of faeces (e.g. narrower or with mucus)
• a feeling of fullness or bloating in the abdomen (belly) or a strange sensation in the rectum, often during a bowel movement
• a feeling that the bowel hasn’t emptied completely after you have done a poo
• losing weight without trying to
• rectal or anal pain
• a lump in the rectum or anus
• abdominal pain or swelling
• weakness or fatigue, dizziness or breathlessness
• a low red blood cell count (anaemia or iron deficiency)
• a blockage in the bowel.

Anything that can increase your risk of cancer is called a risk factor. For bowel cancer, these include:

• older age – bowel cancer is more common in people over 50, but the number of younger people being diagnosed is increasing
• polyps – most polyps can become bowel cancer; having a large number of polyps in the bowel is a strong risk factor
• dietary factors – a diet that is low in fibre, fruit, vegetables and wholegrains, and high in red and processed meats such as salami, ham and bacon
• smoking – increases your risk of bowel cancer and bowel polyps
• drinking alcohol – the less alcohol you drink, the lower your risk. If you choose to drink, follow the Australian Alcohol Guidelines
• body weight – being above a healthy weight
• physical inactivity – not moving your body enough. Be active on most days and minimise long periods of sitting
• strong family history – a small number of bowel cancers and types of polyps run in families
• other bowel diseases – inflammatory bowel diseases, such as Crohn’s disease or ulcerative colitis, significantly increase risk, particularly if you have had the disease for more than 10 years (IBS does not increase your risk)
• other cancers – people who have had bowel cancer are more likely to develop a second bowel cancer; some people who have had ovarian cancer or cancer of the uterus, or who have had radiation treatment to the abdomen/pelvis, may also have an increased risk of bowel cancer
• type 2 diabetes – this may increase your risk of bowel cancer
• rare genetic disorders – some bowel cancers are linked to an inherited gene or condition (e.g. cystic fibrosis).

Sometimes bowel cancer runs in families. The risk of developing bowel cancer may be higher if one or more of your close family members (a parent, brother or sister) has had bowel cancer. The risk is higher if they were diagnosed before the age of 50, or if 2 or more close relatives have had bowel cancer. A family history of some other cancers, such as cancer of the uterus (endometrial cancer), may also increase the risk.

Some people have an inherited faulty gene that increases their risk of developing bowel cancer. These faulty genes are responsible for a small number of bowel cancers in the population. There are 2 main genetic conditions that occur in some families:

Lynch syndrome – Less than 5% of bowel cancers are linked to Lynch syndrome, which causes a fault in the gene that helps repair a cell’s DNA. People with Lynch syndrome have an increased risk of developing bowel cancer, cancer of the uterus, and other cancers such as kidney, bladder and ovarian. Bowel cancer may also happen at a younger age than usual.

Familial adenomatous polyposis (FAP) – This condition is linked to about 1% of bowel cancers. It causes hundreds of polyps to form in the bowel. If these polyps are not removed, they may become cancerous. If you have a family history, talk to your doctor about regular check-ups or ask for a referral to a family cancer clinic. To find out more, call Cancer Council 13 11 20.

Your general practitioner (GP) will arrange the first tests to assess your symptoms, or further tests if you have had a positive screening test. If these tests do not rule out cancer, you will usually be referred to a specialist, such as a gastroenterologist or colorectal surgeon. The specialist will arrange further tests. If bowel cancer is diagnosed, the specialist will consider treatment options. Often these will be discussed with other health professionals at what is known as a multidisciplinary team (MDT) meeting. During and after treatment, you may see a range of health professionals who specialise in different aspects of your care.

Health professionals you may see

GP – assists you with treatment decisions and works in partnership with your specialists in providing ongoing care

Colorectal surgeon – diagnoses bowel cancer; performs bowel surgery; may perform colonoscopy

Gastroenterologist – diagnoses and treats disorders of the digestive system, including removing bowel polyps; performs colonoscopy

Radiation oncologist, radiation therapist – a radiation oncologist treats cancer by prescribing and overseeing a course of radiation therapy; a radiation therapist plans and delivers radiation therapy

Medical oncologist – treats cancer with drug therapies such as chemotherapy, targeted therapy and immunotherapy (systemic treatment)

Cancer care coordinator – coordinates your care, liaises with other members of the MDT, and supports you and your family throughout treatment; care may also be coordinated by a clinical nurse consultant (CNC), cancer nurse specialist or colorectal cancer nurse, or patient navigator

Nurse – administers drugs and provides care, information and support throughout treatment

Stomal therapy nurse – provides information about surgery and can help you to adjust to life with a temporary or permanent stoma

Dietitian – helps with nutrition concerns, weight issues and suggests diet changes during treatment and recovery

Genetic counsellor – provides advice for people with a strong family history of bowel cancer or with a genetic condition linked to bowel cancer

Social worker – links you to support services and helps you with emotional, practical and financial issues

Physiotherapist, exercise physiologist – help restore movement and mobility, and improve fitness and wellbeing

Continence physiotherapist – provides exercises to help your pelvic floor muscles recover and improve bowel and bladder control

Occupational therapist – assists in adapting your living and working environment to help you resume usual activities after treatment

Counsellor, psychologist – help you manage your emotional response to diagnosis and treatment

Palliative care specialist and nurses – work closely with the GP and cancer team to help control symptoms and maintain quality of life

Screening is the process of looking for cancer or abnormalities that could lead to cancer in people who do not have any symptoms. Screening is particularly important for bowel cancer, which often has no symptoms in its early stages.

Screening program

Through the National Bowel Cancer Screening Program, people aged 50–74 are automatically sent a free iFOBT kit every 2 years, and people aged 45–49 can request a free test to be sent to them. You do the test at home and send it back. You don’t need to change what you eat or stop taking your medicines. A test kit can also be purchased from some pharmacies or online.

If the screening test is negative, it means no traces of blood were found in your sample and you’ll be sent another test in 2 years. If you have symptoms between screening tests, let your doctor know. If the screening test is positive, it means there were traces of blood in your sample and you need more tests.

It is important to do the screening test, as it can find early cancers and some precancerous polyps in the bowel. Removing polyps reduces the risk of developing bowel cancer. Finding bowel cancer early improves the chance of surviving the disease.

If you want to order a test, have questions about how to do the test, need to update your contact details, or haven’t received your test kit, call 1800 627 701 or visit the Department of Health, Disability and Ageing. If you are an Indigenous Australian, visit Get 2 it.

People with a higher risk

The National Bowel Cancer Screening Program is for people without symptoms of bowel cancer.

If you have:

• symptoms of bowel cancer – talk to your doctor about having a colonoscopy or other tests
• another bowel condition, such as chronic inflammatory bowel disease – talk to your doctor about how they will monitor your risk of developing bowel cancer
• a strong family history or a genetic condition linked to bowel cancer – talk to your doctor about when you need to start iFOBTs or screening colonoscopies.

Physical examination

Your doctor will ask to feel your abdomen for any swelling. To check for problems in the rectum and anus, they may also do an internal examination. The doctor puts a gloved, lubricated finger into the anus to feel for any lumps or swelling. This is called a digital rectal examination (DRE). If you feel embarrassed or scared about a DRE, let your doctor know. A nurse may be present, but you can also ask for a family member or friend to be in the room with you for support.

The DRE may be uncomfortable, but it shouldn’t be painful. Because the anus is a muscle, it can help to try to relax during the examination. The pressure on the rectum might make you feel like you are going to have a bowel movement, but it is very unlikely that this will happen.

Blood test

You may have a blood test to check your general health and look for signs that you are losing blood from your bowel. The blood test may measure chemicals from your liver and check your red blood cell count (haemoglobin level). Having low red blood cells (anaemia) is common with bowel cancer, but it may also be caused by other conditions.

Checking your faeces (poo) for signs of blood

A test called the immunochemical faecal occult blood test (iFOBT) looks for tiny amounts of blood in your faeces. It is commonly used as a screening test for bowel cancer.

An iFOBT is generally not recommended for people who are bleeding from the rectum or have other bowel symptoms (e.g. a change in bowel habit, anaemia, unexplained weight loss, abdominal pain). People with these symptoms are usually referred for a colonoscopy straightaway.

For an iFOBT, you usually collect a sample of your faeces at home. The sample is sent to a laboratory and examined for traces of blood, which may be a sign of polyps, cancer or another condition. Only a small number (around 3–4%) of positive iFOBT tests are due to cancer or large precancerous polyps; more commonly the traces of blood are from benign conditions like haemorrhoids. However, if the test finds blood in your faeces, your doctor will recommend you have a colonoscopy.

"I had very light blood streaks on toilet paper when wiping my bottom. After 2 weeks of this, I went to my doctor thinking it was haemorrhoids but he sent me for a colonoscopy.” RICHARD

Colonoscopy – This is the main test to look for bowel cancer. It lets your doctor look at the lining of the entire large bowel. Before a colonoscopy, you clear out the bowel with a preparation. It’s very important to follow the instructions – the cleaner the bowel, the more likely it is that the doctor can see polyps or areas of concern.

Most colonoscopies are done as day surgery at a hospital. On the day of the procedure, you will usually be given a sedative or light anaesthetic so you don’t feel anything. This will make you drowsy or may put you to sleep. A colonoscopy usually takes 20–30 minutes.

During the procedure, the doctor puts a colonoscope (a flexible tube with a camera on the end) through your anus and up into the rectum and colon. Carbon dioxide or air is passed through the colonoscope to inflate the colon and make it easier for the doctor to see the bowel.

Polypectomy – During the colonoscopy, any precancerous polyps will be removed – this is called a polypectomy. Most polyps are small (less than 1 cm) and the procedure is very safe and usually has no side effects.

Biopsy – If the doctor sees abnormal-looking areas, including polyps, they will remove a sample of the tissue. This is called a biopsy. A pathologist looks at the sample under a microscope to check for cancer or specific gene changes.

Side effects – You may be weak or drowsy so someone will need to take you home afterwards. You won’t be able to drive until the day after your procedure. The gas used to inflate the bowel can sometimes cause bloating or wind pain. Rare complications include bleeding, or damage to the bowel (perforation) or spleen. Your doctor will explain the risks.

CT colonography – Also called a virtual colonoscopy, it uses a CT scanner to create images of the colon and rectum. Bowel preparation is usually needed before the test. A CT colonography is done by a radiologist (who analyses x-rays and scans).

You may have a CT colonography if a colonoscopy didn’t show all of the colon or when a colonoscopy is not safe. However, a CT colonography is not often used because it exposes you to radiation and is not as accurate as a colonoscopy. It can see only bigger polyps, not small ones.

If any abnormality is detected, you will need to have a colonoscopy so that the doctor can take tissue samples. A CT colonography is covered by Medicare only in limited circumstances.

Flexible sigmoidoscopy – This test is similar to a colonoscopy but only lets the doctor see the rectum and about the lower half of the colon (sigmoid and descending colon). Before a flexible sigmoidoscopy, you will need to have a light bowel clean-out, usually with an enema. You may be given light sedation for the procedure.

You will then lie on your left side while a colonoscope (or, sometimes, a shorter but similar tube called a sigmoidoscope) is put into your anus and guided up through the bowel. The colonoscope or sigmoidoscope blows carbon dioxide or air into the bowel to inflate it slightly so the doctor can see the bowel wall more clearly.

A light and camera at the end of the colonoscope or sigmoidoscope show up any unusual areas or polyps, and your doctor can take tissue samples (biopsies).

Before some tests, you will have to empty your bowel completely so the doctor can see the bowel clearly. This is called bowel preparation (or washout) and can vary, so ask your doctor what you need to do. It’s important to follow the instructions so you don’t have to repeat the test.

Change diet – For 5–7 days before, don’t eat any seeds or grains – including fruit and vegetables that contain seeds (e.g. tomatoes and kiwifruit). For breakfast, morning tea and lunch the day before, eat from the white food diet, which includes white rice, white bread, white potato, cheese, eggs, white fish, skinless chicken breast, plain pasta or rice noodles, milk, plain yoghurt and mayonnaise.

Take prescribed laxatives – You will be prescribed a strong laxative as a powder to mix with water, or as a tablet. You will take the laxative over several hours, starting 12–18 hours before the test. This will cause you to have several episodes of watery diarrhoea and you will need to stay home to be near a toilet.

Drink clear fluids – After lunchtime the day before your test, you will usually have nothing but clear fluids (e.g. clear apple juice, certain coloured sports drinks and soft drink, broth, water, black tea and coffee). The fluids will help to prevent dehydration.

Have an enema, if required – One common way to clear the lower part of the bowel is using an enema. You may be given an enema by a nurse at the hospital before a colonoscopy if the laxative hasn’t completely cleaned out the bowel, or if you are only having a flexible sigmoidoscopy. An enema involves putting liquid directly into the rectum. The liquid washes out the lower part of the bowel, along with any faeces.

If tests show you have bowel cancer, more tests will be done to see if it has spread to other parts of your body. Before you book any test, ask how much it will cost.

CEA blood test

You may be tested for carcinoembryonic antigen (CEA), a protein produced by some (not all) bowel cancers. Low levels are normal – but if you have a high level, your doctor may do more tests. Smoking, pregnancy and other factors can also raise CEA levels. If CEA is high, it will be retested after treatment to see if it has returned to normal.

CT scan

A CT (computerised tomography) scan uses x-rays and a computer to create a detailed picture of the inside of the body. CT scans are usually done at a hospital or radiology clinic.

A dye is injected into a vein to make the pictures clearer. It may make you feel hot, have a strange taste in your mouth or feel that you need to urinate (wee or pee), but these sensations won’t last long.

During the scan, you lie still on a table that moves in and out of the machine. Your chest, abdomen and the area between your hip bones (pelvis) will be scanned to see if the cancer has spread to these areas. The scan itself takes 5–10 minutes and is painless.

MRI scan

An MRI (magnetic resonance imaging) scan uses a powerful magnet and radio waves to create detailed pictures of the inside of your body. MRIs are mostly used only for cancers in the rectum, not cancers higher in the bowel. An MRI may also be used to scan the liver if there was an abnormality seen on a CT scan that needs to be checked.

Before the scan, let your medical team know if you have a pacemaker or any other metallic object in your body. If you do, you may not be able to have an MRI scan as the magnet can interfere with some metallic objects. Newer devices are often safe to go into the scanner.

Before the MRI, you may be injected with a dye to help make the pictures clearer. During the scan, you lie on a table that slides into a large metal tube open at both ends. The noisy, narrow machine makes some people feel anxious or claustrophobic. If you might feel distressed, talk to your medical team beforehand. You may be given medicine to help you relax. You will wear headphones or earplugs. The scan may take 30–90 minutes, depending on the area being scanned.

PET–CT scan

A positron emission tomography (PET) scan combined with a CT scan is a specialised imaging test. The 2 scans provide more detailed and accurate information about the cancer. A PET–CT scan is most commonly used before surgery to help find out where the cancer has spread to in the body. It can also be used after surgery to check if the cancer has come back after treatment.

When you make the appointment for the scan, you will be given instructions to follow about how to prepare for the scan, including what you can eat and drink.

Before the scan, you will be injected with a glucose solution containing a small amount of radioactive material. Cancer cells show up brighter on the scan because they take up more glucose solution than the normal cells do. You will then be asked to sit very quietly or lie down for 30–90 minutes as the glucose spreads through your body. Then you will have the scan itself, which usually takes around 30 minutes.

You will also usually have a CT scan, before or after the PET scan.

Medicare will only cover the cost of a PET–CT scan for bowel cancer in limited circumstances. If this test is recommended, check with your doctor what you will have to pay.

Before having scans, tell the doctor if you have any allergies or have had a reaction to dyes during previous scans. You should also let them know if you have diabetes or kidney disease, are pregnant or breastfeeding, or are claustrophobic (afraid of confined spaces).

Genomic testing

If you are diagnosed with bowel cancer, the tissue removed during surgery will usually have more tests. Called genomic (or molecular) tests, they look for gene changes (mutations) and other features in the cancer cells that may cause them to multiply and grow. Results can help decide which treatments may or may not work for you. Some targeted therapy drugs only work for people with a RAS gene mutation. Immunotherapy drugs also only work for people with a fault in the gene that helps the cell’s DNA repair itself (called mismatch repair or MMR genes).

Your doctor will discuss the surgery best suited for you, depending on where the cancer is and your preferences. The aim of surgery is to remove the area of the bowel with cancer and the nearby lymph nodes. You will be given a general anaesthetic and have either open or keyhole surgery. Your doctor will discuss which method is best suited for you.

Open surgery – This is usually done with one long cut (incision) down the middle of your tummy. Open surgery leaves a larger wound and scar, and has a longer recovery time and hospital stay. It is widely available.

Keyhole surgery – Also called minimally invasive, laparoscopic or robotic surgery. The surgeon makes some small cuts in the abdomen and passes a thin tube with a light and camera (laparoscope) into one opening. They insert tools into the other cuts to remove the section of the bowel with cancer, using the camera as a guide. Keyhole surgery usually means less pain, scarring, time in hospital and a faster recovery.

Surgery for cancer in the colon

The most common surgery for colon cancer is a colectomy (removal of part of the colon). Lymph nodes near the cancer are also removed. The surgeon cuts the bowel on either side of the cancer (with a small border of healthy tissue called the margin) and then joins the 2 ends of the bowel back together. This join is called an anastomosis.

Having a stoma – Sometimes one end of the bowel is brought through an opening made in your abdomen and stitched to the skin. Called a stoma, it lets faeces out to be collected in a bag. The stoma is usually temporary, and the operation is reversed later. In some cases, the stoma is permanent. Improved surgical techniques mean fewer people need a permanent stoma.

Types of colectomies

There are different types of colectomies depending on which part of the colon is removed. The surgery may be done as open or keyhole surgery.

Right hemicolectomy – The right side of the colon is removed.

Surgery for cancer in the rectum

The type of operation you have depends on where in the rectum the cancer is, whether the bowel can be rejoined, and where in the rectum the join can be made. There are 2 main types of operation – an anterior resection or an abdominoperineal resection (which may also be called an abdominoperineal excision).

Anterior resection – This is the most common operation. You may have a high anterior resection or an ultra-low anterior resection. As part of the procedure, the surgeon may create a temporary stoma (which will usually be reversed later).

Abdominoperineal resection – This procedure may be recommended if the cancer is near the anal sphincter or it is too low to be removed without causing incontinence (loss of control over bowel movements). After an abdominoperineal resection, you will need a permanent stoma (colostomy). Speak to your surgeon about any concerns you may have.

Types of resections

There are different types of operations for cancer in the rectum. The surgery may be done as open or keyhole surgery.

High anterior resection – The surgeon removes the lower left part of the colon and the upper part of the rectum. Nearby lymph nodes and surrounding fatty tissue are also removed. The lower end of your bowel is rejoined to the top of the remaining rectum.

Ultra-low anterior resection – The lower left part of the colon and all or part of the rectum are removed, along with nearby lymph nodes and surrounding fatty tissue. The end of the remaining bowel is joined to the lowest part of the rectum, just above the anus. In some cases, the surgeon may make a pouch using the remaining colon and join this pouch to the anus to improve ongoing bowel function. This is known as a colonic J-pouch.

Abdominoperineal resection or excision (APR or APE) – The sigmoid colon, the entire rectum and the anus are removed. Your surgeon uses the descending colon to create a permanent stoma (known as a colostomy) for faeces to leave the body. The anal area will be stitched up and permanently closed.

Other types of surgery for colon or rectal cancer

Endoscopic resection – Used for larger benign polyps. Some very early cancers that involve only the inner lining of the bowel may be suitable for endoscopic resection (also called endoscopic mucosal resection or EMR). This involves cutting out the tumour during a colonoscopy. A bowel resection may also still be needed.

Local excision – People who have very early-stage rectal cancer or are not fit for a major operation may have a local excision. The surgeon puts instruments into the anus to remove the cancer from the lining of the rectum, along with a margin of healthy tissue, without cutting into the abdomen. Methods include transanal excision (TAE), transanal endoscopic microsurgery (TEMS), and transanal minimally invasive surgery (TAMIS).

If there are 2 cancers – In a small number of people, 2 separate cancers may be found in the large bowel at the same time. The cancers may be discovered through tests or during surgery. In this case, there are several options for surgery, including to remove:

• 2 sections of the bowel
• one larger section of the bowel that includes both areas with cancer
• all of the colon and rectum (proctocolectomy) to prevent any chance of another cancer forming.

In some locally advanced cancers, other organs that the bowel cancer is attached to may also be removed along with the bowel containing the cancer. The type of surgery your doctor recommends depends on several factors, including your age, where the tumours are in the bowel, genetic and other risk factors, and your preferences.

Surgery for a blocked bowel (bowel obstruction)

Sometimes bowel cancer grows and completely blocks the bowel. This is called a bowel obstruction. Waste matter cannot pass through the blocked bowel easily, and may cause bloating and abdominal pain; constipation; and nausea and vomiting.

Sometimes the obstruction is found and cleared during the surgery to remove the cancer. In other cases, you will need emergency surgery to clear the blockage.

If a section of the bowel needs to be removed, it may be possible to rejoin the bowel during the surgery, but some people may need a stoma. Sometimes a stoma is made before or “upstream” from the obstruction to relieve the blockage and allow time for staging scans of the cancer or chemoradiation before surgery.

Having a stent – If only one area of the bowel is blocked or you are not fit enough for major bowel surgery, you may have a small hollow tube (stent) put in to help keep the bowel open and relieve symptoms.

A stent may be permanent, or it can be used to help manage the blockage until you are fit enough to have a colectomy or resection. The stent is inserted through the rectum using a colonoscope.

Preventing bowel blockages – A dietitian or your surgeon or stomal therapist may suggest you take a stool softener or add more fluid to your diet to help food or waste pass through the blockage or stent more easily. Other people may be advised to eat low-fibre foods. Talk to a dietitian about suitable foods for your situation.

If you are unable to have bowel surgery or a stent, you may be given medicine to help control the symptoms of a bowel obstruction.

Risks of bowel surgery

Your surgeon will talk to you about the risks and complications of bowel surgery. As with any major operation, surgery for bowel cancer has risks. These may include infection, bleeding, blood clots, damage to nearby organs, or leaking from the joins between the remaining parts of the bowel. After the operation, you will be carefully monitored for any complications.

What to expect after surgery

This is a general overview of what to expect. Your recovery time after the operation will depend on your age, whether you had open or keyhole surgery, whether you have a stoma, and your general health. You will probably be in hospital for 2–7 days, but it can take 2–3 months to fully recover. While in hospital you will start a plan (called enhanced recovery after surgery or ERAS) to help you recover and minimise the time spent in hospital.

Recovery time

• In hospital you will have to wear compression stockings to keep the blood flowing in your legs.
• You will also be given a daily injection of a blood thinner to reduce the risk of developing
  blood clots.
• Some people also wear special cuffs around the legs to keep the calf muscles moving.
• Some people may have to wear the compression stockings and have the injections for a couple of weeks after the surgery.
• You will need to avoid driving after the surgery until you can move freely without pain. Discuss this issue with your doctor. Check with your car insurer for any exclusions about major surgery and driving.

Pain relief

• You will have some pain and discomfort for several days after surgery, but this can be controlled with pain medicines.
• Pain medicines may be given:
  • by an injection under the skin
  • through a drip you can control with a button (patient-controlled analgesia or PCA)
  • by an injection near your spinal column (epidural or spinal anaesthetic)
  • as pills or tablets
  • through little tubes giving local anaesthetic near the wound (transversus abdominis plane or TAP block catheters).
• Let your doctor or nurse know if you are in pain so they can adjust the medicines to make you as comfortable as possible. Do not wait until the pain is severe.

Drips and tubes

• You will be given fluids through a drip (also called an IV or intravenous infusion) until you start drinking and eating again. You may need to have a drip for a few days.
• You may also have other tubes – from your bladder to drain urine (catheter) or from your abdomen to drain fluid from around the surgical area.
• In most hospitals, you will be given water to drink a few hours after the surgery, and you will usually start on solid foods the day after the surgery (or even on the day of the surgery if you feel well). You may also be given nutritional supplements to drink.

Exercise

• Your treatment team will encourage you to walk the day after the surgery.
• Avoid heavy lifting (more than 3–4 kg) for about 4–6 weeks.
• A physiotherapist will teach you breathing or coughing exercises to help keep your lungs clear. This will reduce the risk of getting a chest infection.
• Gentle exercise has been shown to help people manage some of the common side effects of treatment and help them return to their usual activities faster.
• See an exercise physiologist or physiotherapist for advice. Visit Exercise and Sports Science Australia to find an exercise physiologist, and visit the Australian Physiotherapy Association to find a physiotherapist.
• Your doctor may advise you to avoid sexual intercourse for a few weeks after surgery. Ask them when you can have penetrative sex again, and explore other ways you and your partner can be intimate, such as massage.

Side effects of bowel surgery

Temporary or permanent stoma – Some people go home with a stoma. A stomal therapy nurse will see you after the operation to teach you how to look after the stoma and attach bags. You will stay in hospital until you feel confident managing the stoma.

Changes in bowel and bladder function – You may notice changes to how your bowel and bladder work. These changes usually improve within a few months but, for some people, it can take longer. Internal scar tissue (adhesions) from bowel surgery can increase the risk of developing a bowel obstruction. This may occur even many years after the surgery.

Changes in sexual function – In males, removing the rectum may affect the nerves controlling erections or ejaculation. You may have trouble getting or keeping an erection firm enough for intercourse or other sexual activity. In females, if the rectum is removed, there may be a different feeling in the vagina during intercourse. It may be uncomfortable, as the rectum no longer cushions the vagina.

Download our booklet ‘Sexuality, Intimacy and Cancer’

Changes to what you can eat – see our section on ‘Changes to your diet and bowel habits’.

Fatigue – It is normal to feel tired after surgery. Although it’s a good idea to stay active and do gentle exercise as recommended by your doctor, you may find that you tire easily and need to rest during the day. Take breaks if you feel tired, and follow your doctor’s advice about restrictions, such as avoiding heavy lifting. You might have to remind your family and friends that it may take you several months to recover from surgery.

Download our fact sheet ‘Fatigue and Cancer’

Radiation therapy (or radiotherapy) uses a controlled dose of radiation to kill or damage cancer cells so they can’t grow, multiply or spread. Radiation therapy may be given on its own or with chemotherapy (chemoradiation), which makes cancer cells more sensitive to radiation.

When radiation therapy is used

Radiation therapy may be recommended for rectal cancer but is rarely used to treat colon cancer. You may have radiation therapy:

Before surgery (neoadjuvant) – Radiation therapy is used before surgery to shrink the tumour. This makes it easier for the surgeon to remove the cancer and reduces the risk of the cancer coming back.

After surgery (adjuvant) – If rectal cancer is more advanced than expected, radiation therapy may be used after surgery to kill remaining cancer. This is only if radiation therapy wasn’t given before surgery.

Having radiation therapy

External beam radiation therapy (EBRT) is the most common radiation therapy for rectal cancer. A machine called a linear accelerator delivers a high dose to the affected area, with lower doses to surrounding tissue, reducing side effects.

You will meet with your radiation oncologist for them to explain details about treatment, the number of sessions you need to have and whether you will have chemotherapy with your radiation treatment. For your radiation oncologist to design your treatment, a planning CT scan will be done in the treatment position. Small marks, like a freckle, may be made on your skin to help set you up in the exact same position for each treatment. It may take a few weeks to plan the treatment.

Treatment is given daily on weekdays. During treatment, you lie on the table of the radiation therapy machine. Each time you have treatment, you lie in the same position as you were in when you had the planning CT scan.

Each treatment only takes a few minutes, but you may be on the treatment table for 10–20 minutes because of the time it takes to set you up accurately. The treatment is painless and can’t be seen or felt.

After finishing neoadjuvant treatment, there will be a break before surgery. This gives time for the radiation therapy to have its full effect.

Side effects of radiation therapy

Most side effects are temporary and go away weeks or months after treatment. Feeling tired is common. Radiation therapy for rectal cancer is usually given over the pelvic area, which can affect your sexual function and ability to have children.

Radiation therapy can irritate the bowel and bladder. This may mean needing to pass urine (wee or pee) more often or burning when you do (cystitis); redness and soreness in the treatment area; needing to poo urgently/suddenly or incontinence; diarrhoea; constipation; and mucus or small amounts of blood coming out of the anus. Radiation therapy can cause the skin or internal tissue to become less stretchy and harden (fibrosis). It can also inflame the lining of the rectum (radiation proctitis).

People react to radiation therapy differently, so some people may have few side effects, while others have more. Your treatment team will talk to you about possible side effects and how to manage them.

Sexual function and fertility after radiation therapy

You may find it helpful to share your feelings about any sexual or fertility issues with your partner, a counsellor, a sexual therapist or a fertility specialist.

For males

• Radiation therapy can damage sperm or reduce sperm production. This may be temporary or permanent.
• Most doctors suggest using contraception and not having unprotected sex during and for one month after radiation therapy treatment.
• Radiation therapy can damage the blood vessels and nerves that produce erections. This sometimes leads to problems getting and keeping erections. Your doctor may prescribe medicine or refer you to a specialist clinic to manage erection issues.
• You will be able to store sperm at a hospital or fertility clinic before treatment starts. Talk to your doctor about this.

For females

• Radiation therapy can cause the vagina to become shorter and narrower, making intercourse painful.
• Your doctor may suggest using a vaginal dilator after treatment ends and the area has healed. A vaginal dilator can help gradually widen the entrance and prevent the side walls sticking together. Your doctor or a physiotherapist can provide practical advice on how to use a dilator.
• Talk to your doctor about creams and moisturisers to help with vaginal discomfort and dryness.
• Extra lubrication may make sexual intercourse more comfortable. Choose a water-based or silicone-based lubricant without perfumes or colouring.
• In some cases, radiation therapy can stop the ovaries producing oestrogen and progesterone. This can cause menopause – after menopause you will not be able to conceive a child.
• Menopause hormone therapy (MHT) may help with menopause symptoms.

Download our booklet ‘Understanding Radiation Therapy’

Chemotherapy uses drugs to kill or slow the growth of cancer cells while doing the least possible damage to healthy cells. If the cancer has spread to lymph nodes or to other organs, you may have chemotherapy:

Before surgery (neoadjuvant) – Some people with rectal cancer have chemotherapy before surgery to shrink it so it’s easier to remove. You may have only chemotherapy or with radiation therapy (chemoradiation).

After surgery (adjuvant) – Chemotherapy after surgery for colon or rectal cancer aims to destroy any remaining cancer cells and reduce the chance of the cancer coming back. If your doctor recommends chemotherapy, you usually start treatment within 6–8 weeks, when your wounds have healed and you’ve recovered your strength.

On its own – If the cancer has spread to other organs, such as the liver or lungs, chemotherapy may be used either to shrink the tumours or to reduce symptoms and make you more comfortable.

Having chemotherapy

Chemotherapy is usually given through a drip into a vein (intravenously). To avoid repeated needles, you may have it through a device inserted beneath your skin, such as a port-a-cath or peripherally inserted central catheter (PICC). Sometimes chemotherapy is taken as tablets (orally).

Chemotherapy is commonly given as a period of treatment followed by a break. This is called a cycle. Adjuvant chemotherapy is usually given for 3–6 months, in cycles that last for 2–3 weeks each. Your medical oncologist will explain your treatment schedule. Usually, you have chemotherapy during day visits to a hospital or treatment centre. Some people have chemotherapy at home through a portable pump.

Side effects of chemotherapy

The side effects of chemotherapy vary, depending on the drugs used and the dose. Your medical oncologist or nurse will talk to you about the likely side effects, including how they can be prevented or controlled. If side effects are hard to manage, the chemotherapy treatment can be adjusted to reduce the side effects while still giving you a good result.

Side effects may include tiredness; neutropenia (low white blood cells); feeling sick (nausea and vomiting); diarrhoea; lip and mouth sores; changes in appetite, taste and smell; sore hands and feet (peripheral neuropathy); and hair loss or thinning.

The chemotherapy drug oxaliplatin may make your hands, feet, mouth and throat sensitive to cold items (e.g. cold food and drinks, air conditioning), causing pins and needles and numbness. Skin rash and increased sensitivity to sunburn are more common if using the chemotherapy drug fluorouracil or capecitabine.

Keep a record of the doses and names of your chemotherapy drugs handy. This will save time if you get an infection and need to visit the emergency department. You may also find it helpful to keep a symptom diary when you start chemotherapy, so you can monitor side effects as they occur.

If you are having chemotherapy, you have a higher risk of getting an infection or bleeding. If you have a temperature of 38°C or higher, or the “shivers and shakes”, contact your doctor or go to the emergency department immediately. Tell your doctor if you feel more tired than usual, or if you bruise or bleed easily.

Download our booklet ‘Understanding Chemotherapy’

Advanced bowel cancer is commonly treated with drugs that reach cancer cells throughout the body. This is called systemic treatment, and includes chemotherapy, targeted therapy and immunotherapy.

The drugs used for bowel cancer are rapidly changing as clinical trials find newer drugs. Your medical oncologist will discuss which combination of drugs is best for your situation. You may also be able to get other drugs through a clinical trial.

Scans and blood tests will be used to monitor your response to systemic treatments. If results show that the cancer is shrinking or is under control, you’ll continue to have chemotherapy or targeted therapy or both. If the cancer is growing, that treatment will stop and your doctor will discuss other treatments.

Targeted therapy

This is a type of drug treatment that attacks specific features of cancer cells to stop the cancer growing and spreading. Monoclonal antibodies are the main type of targeted therapy drug used in Australia for advanced bowel cancer.

There are a range of different targeted therapy drugs. These drugs will only work for bowel cancers with particular gene changes (mutations). Your medical oncologist will usually do tests on the biopsy sample (or may do blood tests) to see which targeted therapy is likely to work for you.

Some targeted therapy drugs are given as tablets, while others are given as a drip into a vein in hospital. They may sometimes be given at the same time as chemotherapy, or given after you have stopped chemotherapy treatment.

Side effects – The side effects of targeted therapy vary depending on which ones are used. For a detailed list of side effects, visit eviQ and search for the drug you are being given. Some of the more common side effects may include: tiredness, skin problems, diarrhoea, joint pain, skin problems and sore eyes.

Download our fact sheet ‘Understanding Targeted Therapy’

Immunotherapy

Immunotherapy is a type of drug therapy treatment that uses the body’s own immune system to fight cancer.

Checkpoint inhibitors are the main type of immunotherapy drug used for the small number of advanced bowel cancers that have a fault in the mismatch repair (MMR) gene. The drug pembrolizumab is given directly into a vein through a drip (infusion) and the treatment is repeated every 3 or 6 weeks. How many infusions you receive will depend on how you respond to the drug.

Side effects – Checkpoint inhibitor immunotherapy acts on the immune system, so it can sometimes cause the immune system to attack healthy cells in any part of the body. This can lead to a variety of side effects such as rash, itchy skin, diarrhoea, breathing problems, inflammation of the liver, hormone changes and temporary arthritis. Your doctor will discuss possible side effects with you.

Download our fact sheet ‘Understanding Immunotherapy’

Radiation therapy can be used as a palliative treatment for both advanced colon and advanced rectal cancer. It can be used to control the growth of the tumour and relieve symptoms such as bleeding. If the cancer has spread to the bone or formed a mass in the pelvis, radiation therapy can reduce pain.

If the tumour has spread to the liver, you may be offered a specialised type of radiation therapy. Options may include selective internal radiation therapy (SIRT, also called radioembolisation) or stereotactic body radiation therapy (SBRT).

Download our fact sheet ‘Understanding Secondary Liver Cancer’

Some people are able to have surgery to remove bowel cancer that has spread. Generally, surgery is not recommended if you are unwell or the cancer has spread to many places in the body.

• If the cancer has spread, surgery may remove parts of the bowel along with all or part of other affected organs. This is called an en-bloc resection and is usually for locally advanced bowel cancer. If the liver, lungs or other organs are affected, a separate surgery (called metasectomy) may remove some or all of the cancer in that organ.
• If the cancer has spread to the lining of the abdomen (peritoneum), some people have surgery to try to remove all of the cancer – however, this can only be done when there is limited cancer and spread. This is known as a peritonectomy or cytoreductive surgery. Sometimes, a heated chemotherapy solution is put into the abdomen for 60–90 minutes during a peritonectomy. This is called hyperthermic intraperitoneal chemotherapy (HIPEC).

If the cancer has spread to only a small number of places in a single area, such as the liver or lungs, your doctor may recommend thermal ablation. This may use heat to destroy the tumour. The heat may come from radio waves (radio frequency ablation) or microwaves (microwave ablation). It is best performed in a specialised centre. Cryoablation is a similar process that may sometimes be offered, and uses cold or freezing instead of heat.

This is treatment that aims to slow the spread of cancer and relieve symptoms, such as pain, without trying to cure the disease. Treatments given palliatively for advanced bowel cancer may include surgery, chemotherapy, radiation therapy or targeted therapy.

Download our booklet ‘Understanding Palliative Care’

Download our booklet ‘Living with Advanced Cancer’

Listen to our podcast series ‘The Thing About Advanced Cancer’

When the bowel moves, wind and waste matter come out through the stoma. You can’t control when this happens, so a small bag on the outside of the body collects the waste matter. This is called a stoma bag or an appliance. Stoma bags have adhesive (glue) on the back so they stick securely to the skin and are leakproof and don’t smell. A filter lets out wind (but not the smell), to stop it inflating the bag. If your bag fills with air, talk to your stomal therapy nurse for ways to prevent this.

Attaching the bag – When you’re in hospital, a stomal therapy nurse will teach you how to change your bag, help you choose a bag that suits your body shape and explain how to attach it securely.

Emptying the bag – Stoma bags can be drainable (able to be emptied) or closed (thrown out after each bowel movement). After a colostomy, you may be able to wear a drainable or closed bag, depending on how thick or watery your waste matter is. After an ileostomy, you wear a drainable bag. How often you need to empty or change a stoma bag is affected by what you eat and drink.

• Closed bags may need changing 1–3 times a day. They should be put in a rubbish bin, not flushed down the toilet.
• Drainable bags have to be emptied in the toilet when they are about one-third full, and replaced every 1–3 days. A colostomy bag may need emptying 1–3 times a day. An ileostomy bag may need emptying 4–6 times a day, depending on what you eat and drink, because the waste is no thicker than a paste (more watery).

If you have a colostomy in your descending colon, you may be able to wash out the colon with water (colostomy irrigation) to remove waste, then wear a small cover rather than a stoma bag. Ask your doctor or stomal therapy nurse about this option.

Having a stoma, even temporarily, is a big change and takes some getting used to. Thousands of Australians have a stoma and lead a mostly normal life. The stoma may sometimes affect your lifestyle, but most issues can be managed, especially with some planning.

How a stoma bag might look – You may worry about the bag being seen under clothing. Although the bag may seem obvious to you, most people won’t notice the bag unless you tell them. The stoma’s location may make some clothes less comfortable (e.g. tight waistbands, belts), but you will generally be able to keep wearing your normal clothes. You can also buy underwear that is designed for people with a stoma.

How a stoma might affect your sex life – You may worry that the stoma will affect your ability to have sex. Getting used to looking after the stoma will help you feel more confident. Sex when you have a stoma may need a little planning, but can still be satisfying and fulfilling. However, it is dangerous to use the stoma hole in any sexual activity.

Download our booklet ‘Sexuality, Intimacy and Cancer’

Stoma prolapse – This is when some of the bowel comes out through the stoma opening. Sometimes the prolapse will slide back in by itself, but it may pop in and out. Your stomal therapy nurse or surgeon can tell you how to look after the prolapsed stoma and adapt the stoma bag.

You may need to change what you eat at first to help the stoma settle. Eating a diet of bland, soft, low-fibre food for the first 4–6 weeks will help – the stoma hole is swollen at first so the opening is narrower. Foods that irritate the stoma vary from person to person.

Sometimes food can build up and cause a blockage, stopping solids, fluids and gas moving through. You may need to change what and how you eat to help avoid this. A stoma blockage can be uncomfortable and cause a bloated feeling or nausea. If symptoms of a blockage last for 2 hours or you vomit, contact your nurse or hospital.

How much waste comes out depends on how, what and when you eat. Over time, most people find they can eat a normal healthy diet. If you have concerns, talk to a stomal therapist or ask to see a dietitian. Bowel Cancer Australia has recipes for people recovering from surgery or with a stoma.

Ways to manage stoma blockages

• Eat regular meals.
• Avoid eating a large amount of food at one time.
• Try to maintain a balanced diet so your body gets the nutrients it needs.
• Drink 8–10 glasses of fluid a day to stay well hydrated.
• Cut food into small, bite-sized pieces, and chew slowly and thoroughly.
• Limit high-fibre foods, raw vegetables, the skin on fruit and vegetable, nuts, seeds, kernels (e.g. corn, popcorn) and sausage skins. These foods are more likely to cause blockages.
• If you have trouble eating certain foods, talk to a dietitian about alternatives.
• You may find cooked foods easier to digest.
• Try new foods one at a time, in a small amount, and note any reaction. If it doesn’t irritate the stoma, try a larger amount next time.
• Massage your belly and the area around the stoma. Lie on your back, pull your knees up to your chest and roll from side to side. This may help move a blockage through the stoma.

See a stomal therapy nurse – If there is a chance you could need a stoma, the surgeon will usually refer you to a stomal therapy nurse before surgery. Stomal therapy nurses are registered nurses with special training in stoma care. They are available at most major hospitals, district nursing agencies and in private practice. A stomal therapy nurse can talk to you about the best position for the stoma, answer questions about your surgery and recovery, and give you information about adjusting to life with a stoma. To find a nurse, visit the Australian Association of Stomal Therapy Nurses.

Join a stoma association – The stomal therapy nurse will ask if you’d like to join a stoma (or ostomy) association. For a small yearly membership fee, you will be able to get free stoma appliances and products. Some stoma associations provide assistance and information and coordinate support groups. Visit the Australian Council of Stoma Associations for more information.

Register for the Stoma Appliance Scheme – The Australian Government’s Stoma Appliance Scheme (SAS) provides free stoma supplies to people with a temporary or permanent stoma. To apply for the SAS, you must hold a Medicare card and belong to a stoma association.

Find a support group – There are many support groups or forums on social media you can follow or join including at Bowel Cancer Australia.

Incontinence is when you can’t control your bowel or bladder.

Faecal incontinence – After surgery or radiation therapy, the movement of waste through the large bowel can become faster. You may feel that you can’t wait when you need to go to the toilet (urgency), you need to go more often, or you have less control over bowel movements. Bowel surgery or radiation therapy may weaken the anus, making it difficult to hold on when you feel the need to empty your bowels, particularly if you have loose bowel movements (diarrhoea).

Urinary incontinence – This is when urine (wee or pee) leaks from your bladder without you being able to control it. Bladder control may change after surgery or radiation therapy. For example, radiation therapy can irritate the lining of your bladder, because the bladder is located near the large bowel. Some people find they need to urinate more often, need to go in a hurry or don’t fully empty the bladder.

While you may feel embarrassed if you have bowel or bladder changes, there are ways to manage the symptoms. Incontinence usually improves in a few months, but sometimes takes years. Talk to your treatment team about whether any bowel or bladder changes are likely to be permanent.

Ways to manage incontinence

• Talk to your surgeon or GP about available treatments. They may refer you to a continence nurse or physiotherapist, who can suggest exercises to strengthen your pelvic floor muscles.
• Call the National Continence Helpline on 1800 33 00 66 to talk to a continence nurse about continence aids, if needed, or visit Continence Health Australia.
• Find out the location of toilets near where you are. Visit the National Public Toilet Map or download the National Public Toilet Map App to your smartphone.
• The Australian Government’s Improving Bowel Function After Bowel Surgery booklet has helpful tips about managing bowel problems.
• Bowel Cancer Australia has Bowel Care Nurses and a nutritionist specially trained to help manage and improve bowel dysfunction from LARS or bowel cancer. Visit Bowel Cancer Australia or call them on 1800 727 336.

Diarrhoea is the frequent passing of loose, watery faeces (stools or poo). It can also cause abdominal cramping, wind and pain. Different types of treatment can cause diarrhoea:

Surgery – If you have had part of your bowel removed, your bowel movements may be looser than you were used to. This is because the bowel absorbs water to form faeces. With a shorter bowel, the faeces don’t form as solidly as before. This may be ongoing, but there are many ways of managing diarrhoea.

Radiation therapy – Diarrhoea is a common side effect of radiation therapy. It can take some weeks to settle down after treatment has finished. For a small number of people, diarrhoea is ongoing.

Drug therapies – Chemotherapy, immunotherapy and targeted therapy drugs can cause diarrhoea and nausea. These side effects will go away after treatment and you can gradually return to a normal diet.

How to manage diarrhoea

• Eat small frequent meals instead of 3 big ones. Try eating every 2 hours.
• Low-fibre foods may be easier to digest. Examples include bananas, white rice, white pasta, white bread, potatoes, white fish and steamed chicken without the skin.
• Limit foods that increase bowel activity, e.g. caffeine; alcohol; spicy, fatty or oily foods; high-sugar fluids such as juice and soft/fizzy drink; artificial sweeteners.
• Raw fruit and vegetables, wholegrain breads and cereals, or legumes (e.g. lentils, chickpeas) may make diarrhoea worse. If they do, you may want to cut back on these foods for a few days.
• Lactose in dairy foods may make diarrhoea worse. Try low-lactose or soy-based products instead.
• Talk to your treatment team about ways to control diarrhoea, such as using over-the-counter medicines and changing what you eat.
• Watch for warning signs of dehydration. These include a dry mouth, dark yellow urine, dizziness and confusion. If dehydration is left untreated, it can be dangerous.
• Drink plenty of water (about 6 glasses a day) to avoid becoming dehydrated. Consider having an oral rehydration solution, such as Hydralyte or Gastrolyte.
• If your anus becomes sore, clean the area with warm water and a soft cloth or soft/water wipes or anal cleansing wipes (e.g. Rectogesic). Ask your treatment team to recommend a cream. Taking a soothing bath may also help.
• Having diarrhoea can make you feel tired. Try to rest as much as possible and ask family or friends for help.
• Ask for a referral to a dietitian or physiotherapist who looks after bowel issues. If diarrhoea continues for a few days, see a doctor.

Many people who have treatment for bowel cancer find that it gives them wind (gas or farting). This especially happens after you have had surgery. However, it is usually temporary and improves over time.

Working out what foods cause wind and what you can eat without side effects may help – although foods can still affect people differently.

Tips to manage wind

• Try chewing charcoal tablets, eating natural yoghurt and drinking peppermint tea.
• Cut your food into small, bite-sized pieces.
• Chew your food slowly and thoroughly.
• When you have a drink, take small sips and don’t use a straw.
• Talk to your doctor about what types of light exercise you can do to relieve bloating and wind.
• Foods such as eggs, legumes (e.g. lentils and chickpeas), fizzy drinks, and sugar-free foods may increase gas. If they do, you may find it helpful to limit these foods.
• Try keeping a food and symptom diary to help identify foods that cause wind.
• Ask your doctor if there are any medicines that may be helpful to you.

"Three months after the ileostomy, I went in for the reversal surgery. You have to stay in hospital until you pass wind, which took 6 days. Passing wind will never lose its amusement.” RICHARD

Immediately after treatment – particularly surgery – you may be on a modified diet. What you are able to eat might depend on the type of surgery you’ve had, how much of your bowel was removed and whether you have a stoma.

During and after treatment, you may find that certain foods upset your bowel and cause diarrhoea or wind. Your health care team may suggest foods to avoid, but as foods can affect people differently, you will need to experiment to work out which foods cause problems for you. It is better to limit – not exclude – these foods in your diet, as you may find that what you can handle improves over time.

Keeping a diary of what you eat can help. Make a note of the foods that cause constipation, diarrhoea or wind. Your ability to handle different foods usually gets better with time but can take many months. When returning to your usual diet, introduce one food at a time. If something causes a problem, try it again in a few weeks to see if your response has improved. Share this information with the health care team as it can help them figure out how to manage any issues.

Download our booklet ‘Nutrition for People Living with Cancer’

"When I first got put back together after the ileostomy, processed food really messed with me. The more processed it is, the slower my body deals with it. Some of the things I loved – pizza, processed meat, bread, red meat and potato – play with me. The greener the better – salads, fruit, fish, chicken really make me feel sensational.” RICHARD

After treatment ends, you will have regular appointments to monitor your health, manage any long-term side effects and check that the cancer hasn’t come back or spread. You will usually have a physical examination and you may have blood tests (including checking CEA levels), scans and colonoscopies. You will usually have a follow-up colonoscopy a year after the colonoscopy that showed bowel cancer. However, this may be sooner if only part of the bowel was seen during the last colonoscopy.

Check-ups may become less frequent if you have no further problems. Between follow-up appointments, let your doctor know immediately of any symptoms or health problems. Don’t wait for your next appointment. When a follow-up appointment or test is approaching, many people find that they think more about the cancer and may feel anxious. Talk to your treatment team or call Cancer Council 13 11 20 if you are finding it hard to manage this anxiety.

For some people, bowel cancer does come back after treatment, called a recurrence. Regular check-ups are important so if cancer comes back, it can be found early. If the recurrence is only in the bowel and nearby lymph nodes, you may be able to have surgery to remove the cancer.

If bowel cancer has spread beyond the bowel (advanced or metastatic bowel cancer), you may be offered treatment, such as surgery, chemotherapy, targeted therapy, immunotherapy or radiation therapy. These treatments may remove the cancer, help control its growth and relieve symptoms. If your bowel becomes blocked, you will need urgent treatment.

If you have continued feelings of sadness, have trouble getting up in the morning or have lost motivation to do things that previously gave you pleasure, you may be experiencing depression. This is quite common among people who have had cancer.

Talk to your GP, because counselling or medication – even for a short time – may help. Some people can get a Medicare rebate for sessions with a psychologist. Cancer Council SA also runs a free counselling program.

For information about coping with depression and anxiety, visit Beyond Blue or call them on 1300 22 4636. For 24-hour crisis support, visit Lifeline or call 13 11 14.