Treatment For Bowel Cancer In The Elderly

Introduction

Bowel cancer is also called colorectal cancer; in this article the two terms will be used interchangeably.

The bowel is part of the digestive system. It is made up of two parts, the small bowel (the small intestine) and the large bowel (comprised of the large intestines, colon and the rectum). The role of the small intestine is to receive food from the stomach and break it down even further to allow for absorption of nutrients. The waste (undigested food) then moves through the colon which allows for water to be absorbed in the large intestines and moving along to the rectum where it is stored until it passes out of the body. Bowel Cancer UK has an interactive model on their website that allows you to take a closer look at the structure of the bowel.  

Cancer in the small bowel is rarer than that of the large bowel. 

The statistics for bowel cancer are: 

• 1 in 15 people assigned male at birth and 1 in 18 people assigned female at birth will be diagnosed with bowel cancer in their lifetime
• Bowel cancer is the 4^th most common cancer in the UK 
• Almost 43,000 people are diagnosed each year in the UK
• Approximately 268,000 people in the UK are currently living with the disease
• The majority of people diagnosed with bowel cancer are aged 50+, but it can occur at any age

Signs and symptoms of bowel cancer

The NHS states that there are 3 main signs of bowel cancer, each is subtle and won’t necessarily make you feel unwell:

• Blood in the faeces
• Changes to your bowel habits; this could mean going to the toilet more or less frequently than what is usual for you, a change in the consistency of your faeces eg. Looser and more watery stools. 
• Stomach pain

The symptoms of bowel cancer often occur in combinations such as:

• Blood in stools without other haemorrhoid symptoms 
• Passing persistently loose stools with blood
• Passing loose stools without blood but with stomach pain
• Stomach pain or discomfort brought on by eating 

Other symptoms include feeling like your bowel hasn’t fully emptied, fatigue, and a general feeling of lethargy and weakness. 

It’s very important to note that even if you have the above symptoms, bowel cancer is unlikely to be the cause. The symptoms are similar to that of many other conditions such as haemorrhoids or digestive issues. However, they also should not be ignored. Getting your symptoms checked out is absolutely vital. If you were to be diagnosed with bowel cancer, as with all cancers, the earlier it’s caught, the easier it is to treat and the better the prognosis.

Diagnosis and screening of bowel cancer 

The NHS offers bowel cancer screening for individuals aged 60-74. Screening comprises of a simple test that can detect small amounts of blood in faeces. All that is needed is a stool sample, you can do this at home and put your kit in the post to be sent to the laboratory for testing. Although blood in your faeces is a sign of cancer, it can also indicate that you may have bowel polyps; whilst not cancerous themselves, in some cases they are a precursor to developing bowel cancer.³  If you have symptoms, do not wait for a screening test, see your doctor straight away. 

Geriatric assessment

A comprehensive geriatric assessment is an approach that aims to determine the medical, psychological, and functional capabilities of elderly patients so that a multi-disciplinary treatment plan can be put in place. Geriatric assessments are not just carried out for those with cancer but it’s relevant because often older patients with cancer also have other conditions that impact their lives. An assessment helps to gain insight into an individuals lives, how they manage their activity and what support they have around them. Up-to-date have a detailed guide to the assessment.

There’s also other tools that can be used such as the chemotherapy risk assessment scale for high risk patients (CRASH) and a toxicity tool (Chemo-Toxicity Calculator)) that can help to give an insight into side effects patients might experience from chemotherapy. One study found that both of the scores obtained by these assessments are a good indication of the severity of chemotherapy-related toxicity that a patient may experience, and should be used as standard oncology practice.¹

Biological features of bowel cancer in the elderly

There is not much literature detailing the biological differences found in colorectal cancers between younger and older people. Where the research is available, it rarely explains why some variabilities exist. Additionally, there is limited research concerning colorectal cancer in the elderly.

However, differences in mucin production have been found between colorectal cancers in the young and elderly. Tumours in patients aged 50+ appear to produce more mucin but this did not impact survival rates.²  

The same study² found significantly higher MSI-H in the younger patients. High MSI means that there is a lot of instability in the tumour and the MSI level gives a medical professional a reasonable idea of how the cancer might behave. It is not necessarily a bad thing, but it is of interest that it seems to occur more frequently in younger patients. The staging of the cancer was also more likely to be N2 in younger patients; this means that the cancer has unfortunately spread to at least 4 nearby lymph nodes. These differences did not result in a worse prognosis.

It should also be noted that between the two groups study, there were large age parameters. ‘Young’ was considered to be patients under 50 years of age whilst ‘older’ was 50+. A patient in their early 50’s can hardly be described as elderly and so the results of this study are not able to give a full overview of potential biological variations in the elderly.  Therefore there needs to be more research to investigate the reasons why biological differences between age groups occurs.

Diagnosis 

Other than being diagnosed by the screening programme, there are several steps to being diagnosed with bowel cancer.

An initial visit to your GP will involve them asking several questions about your symptoms such as how long the patient has been experiencing them and if there is a family history of the disease. They may also feel the stomach area to see if there are any areas that might be painful or if there’s anything irregular they can feel. A rectal exam might also be performed. Blood tests are also likely to be carried out to check the patient’s general health.

There is a specific test that your GP should carry out called the faecal immunochemical test (FIT). Like the screening programme, it can detect small levels of blood if they are present in a faecal sample.  Further tests would be carried out at the hospital by a colorectal specialist. These include an endoscopy and colonoscopy; where a small scope is passed through your body. These tests may be uncomfortable but do not usually cause pain. Bowel cancer UK provide more information about what to expect if you are referred for these procedures.

Treatment of bowel cancer in the elderly

When diagnosed with cancer, a multidisciplinary team are responsible for looking after the patient. This team will likely include a surgeon, an oncologist and a specialist nurse. Treatment depends on how advanced the cancer is, again highlighting the importance of early detection. The location of your colorectal cancer can also influence the choice of treatment. Considering that the majority of colorectal cancer patients are members of the older population, it is important to consider whether they are physically able to withstand the treatment and side effects that come alongside it. The likelihood of cancer recurrence also needs to be taken into account. The main treatment for bowel cancer is surgery to remove part of the bowel, and whilst many patients will find this tolerable, there are more risks associated with operating on older patients. Chemotherapy and radiation therapy are common methods used to treat cancer, again they come with unpleasant side effects. There often isn’t one single method of treatment used, for example, surgery may be combined with chemotherapy, where chemotherapy is given post-operatively to destroy any remaining cancer cells.³

One study has examined the differences in treatment approach in young and elderly colorectal cancer patients.⁴

 The main takeaways from the study are:

• Stoma surgery is less likely to be reversed in elderly people, meaning that the patients will have to live with a colostomy  long term. Older people may find this more challenging to adapt to and the risk of infection is increased
• Younger patients were more likely to receive surgery, radiotherapy and chemotherapy
• Older patients were more likely to receive palliative care
• Overall, elderly patients are undertreated due to their age, not due to the severity of their cancer and this undertreatment contributes to their shorter tumour-specific survival time

The attitudes of older people to cancer treatment may differ from younger patients. For example, older patients are keen to avoid a permanent stoma and are more likely to accept less invasive treatments even though they may be less effective at preventing recurrence of the cancer.⁵

Recovery programs after treatment

Using an enhanced recovery programme after bowel cancer surgery speeds up recovery.

It aims to:

• Ensure that patients are as healthy as possible before the receive the treatment
• Ensure the best care is provided during and after their operation

The main aspects of the programme centre around getting the patient moving about and eating as soon as possible after surgery. This benefits recovery by getting bowel habits back to normal more quickly, reducing fatigue and reducing the risk of complications such as blood clots. The recovery from bowel cancer surgery usually requires 1 week-10 days in hospital but with the enhanced recovery programme, most can be discharged after 1 week to continue their recovery at home. Imperial college healthcare provide a leaflet with information on the recovery programme for patients, relatives and carers.

For those receiving the ERAS (enhanced recovery after surgery) intervention, pre-operative care included counseling and carbohydrate loading. 

Peri-operative care (just before surgery) included fluid restriction and a different anesthetic protocol than what is used in standard practice. 

Postoperative care included enforced feeding and early removal of the urine catheter. 

The researchers concluded that both pre and post-operative stoma education resulted in a significantly shorter hospital stay but did not make any difference to further admission to hospital rates or stoma-related complications that may occur early on post-surgery. ⁶  It is not clear if elderly patients were included in this study and it has to be considered that in most cases, older patients are unable to move around as ably as younger patients. Therefore, more research detailing which aspects of the recovery programme would be beneficial to the older population, and which changes could be made to make the programme more accessible for a wider range of abilities is required. 

Palliative care

Palliative care does not begin when a person is approaching the end of their life. It begins when the person is diagnosed with a terminal illness such as incurable bowel cancer. Older people with bowel cancer often have more than one health condition, one in six people over the age of 80 also have dementia. This means that their palliative care may need to begin earlier and not just when their diagnosis is considered terminal. They may need more intervention to understand what is happening to them and to manage the side effects of treatments. Measures to improve quality of life and symptom management can be put into place to ensure that the patient and their loved ones are as comfortable and supported as possible. It is carried out by many health professionals. Treatments such as chemotherapy do not need to stop during palliative care; the most important thing is to make sure that the patient is comfortable. End-of-life care is the final stage of palliative care that is put in place as the patient is approaching the end of their life.

Summary

To summarise, bowel cancer is a very prevalent disease that can affect people of all ages although it is more common in older adults. There appear to be differences in the ways that the cancer behaves in elderly people when compared to younger patients, but there needs to be more investigation into why this occurs. Different treatment regimes can also be used depending on the overall fitness of the patient and the severity of the cancer. Having a multi-disciplinary care team around elderly patients is vital to ensure that they are supported and can make an informed choice about their treatment.