Anal cancer, an uncommon cancer, is a disease in which malignant cells are found in the anus. The anus is the opening at the end of the rectum (the end part of the large intestine) through which body waste passes. Cancer in the outer part of the anus is more likely to occur in men; cancer of the inner part of the rectum (anal canal) is more likely to occur in women. If your anus is often red, swollen, and sore, you have a greater chance of getting anal cancer. Tumours found in the area of skin with hair on it just outside the anus are skin tumours, not anal cancer.

Like most cancers, anal cancer is best treated when it is found early. You should see your doctor if you have one or more of the following symptoms: bleeding from the rectum (even a small amount), pain or pressure in the area around the anus, itching or discharge from the anus, or a lump near the anus.

If you have signs of cancer, your doctor will usually examine the outside part of the anus and give you a rectal examination. In a rectal examination, your doctor, wearing thin gloves, puts a greased finger into the rectum and gently feels for lumps. Your doctor may also check any material on the glove to see if there is blood in it. If you feel pain when touched in the anal area, your doctor may give you medicine to put you to sleep (general anaesthesia) in order to continue the examination. Your doctor may cut out a small piece of tissue and look at it under a microscope to see if there are any cancer cells. This procedure is called a biopsy.

Your prognosis (chance of recovery) and choice of treatment depend on the stage of your cancer (whether it is just in the anus or has spread to other places in the body) and your general state of health.

Stages Of Anal Cancer
Once anal cancer is found (diagnosed), more tests will be done to find out if cancer cells have spread to other parts of the body. This testing is called staging. To plan treatment, your doctor needs to know the stage of your disease. The following stages are used for anal cancer.

Stage 0 Or Carcinoma In Situ Stage 0 anal cancer is very early cancer. The cancer is found only in the top layer of anal tissue.

Stage I The cancer has spread beyond the top layer of anal tissue and is smaller than 2 centimetres (less than 1 inch).

Stage II Cancer has spread beyond the top layer of anal tissue and is larger than 2 centimetres (about 1 inch), but it has not spread to nearby organs or lymph nodes. (Lymph nodes are small, bean-shaped structures found throughout the body. They produce and store infection-fighting cells.)

Stage IIIA  Cancer has spread to the lymph nodes around the rectum or to nearby organs such as the vagina or bladder.

Stage IIIB Cancer has spread to the lymph nodes in the middle of the abdomen or in the groin, or the cancer has spread to both nearby organs and the lymph nodes around the rectum.

Stage IV Cancer has spread to distant lymph nodes within the abdomen or to organs in other parts of the body.

Recurrent Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the anus or in another part of the body.

How Anal Cancer Is Treated
There are treatments for all patients with anal cancer. Three kinds of treatment are used: surgery (taking out the cancer in an operation) radiation therapy (using high-dose x-rays or other high-energy rays to kill cancer cells) chemotherapy (using drugs to kill cancer cells).

Surgery is a common way to diagnose and treat anal cancer. Your doctor may take out the cancer using one of the following methods:

Local resection is an operation that takes out only the cancer. Often the ring of muscle around the anus that opens and closes it (the sphincter muscle) can be saved during surgery so that you will be able to pass your body wastes as before.

Abdominoperineal resection is an operation in which the doctor removes the anus and the lower part of the rectum by cutting into the abdomen and the perineum, which is the space between the anus and the scrotum (in men) or the anus and the vulva (in women). Your doctor will then make an opening (stoma) on the outside of the body for waste to pass out of the body. This opening is called a colostomy. Although this operation was once commonly used for anal cancer, it is not used as much today because radiation therapy with or without chemotherapy is an equally effective treatment option but does not require a colostomy. If you have a colostomy, you will need to wear a special bag to collect body wastes. This bag, which sticks to the skin around the stoma with a special glue, can be thrown away after it is used. This bag does not show under clothing, and most people take care of these bags themselves. Lymph nodes may also be taken out at the same time or in a separate operation (lymph node dissection).

Radiation therapy uses x-rays or other high-energy rays to kill cancer cells and shrink tumours. Radiation may come from a machine outside the body (external radiation therapy) or from putting materials that produce radiation (radioisotopes) through thin plastic tubes in the area where the cancer cells are found (internal radiation therapy). Radiation can be used alone or in addition to other treatments.

Chemotherapy uses drugs to kill cancer cells. Chemotherapy may be taken by pill, or it may be put into the body by a needle in a vein or muscle. Chemotherapy is called a systemic treatment because the drugs enter the bloodstream, travel through the body, and can kill cancer cells throughout the body. Some chemotherapy drugs can also make cancer cells more sensitive to radiation therapy. Radiation therapy and chemotherapy can be used together to shrink tumours and make an abdominoperineal resection unnecessary. When only limited surgery is required, the sphincter muscle can often be saved.

STAGE 0 ANAL CANCER
Your treatment will probably be local resection.

STAGE I ANAL CANCER
Your treatment may be one of the following: 1. Local resection (for some small tumours). 2. External radiation therapy with chemotherapy. Some patients may also receive internal radiation therapy. 3. If cancer cells remain following therapy, you may need surgery of the anal canal to remove the cancer.

STAGE II ANAL CANCER
Your treatment may be one of the following: 1. Local resection (for small tumours). 2. External radiation therapy with chemotherapy. Some patients may also receive internal radiation therapy. 3. If cancer cells remain following therapy, you may need surgery of the anal canal to remove the cancer.

STAGE IIIA ANAL CANCER
Your treatment may be one of the following: 1. Radiation therapy with chemotherapy. 2. Surgery. Depending on how much cancer remains following chemotherapy and radiation, local resection or surgery to remove cancer in the anal canal may be done. 3. Clinical trials of surgery (resection) followed by external radiation therapy. 4. Clinical trials of surgery followed by chemotherapy if chemotherapy has not been used prior to surgery.

STAGE IIIB ANAL CANCER
Your treatment will probably be radiation therapy and chemotherapy followed by surgery. Depending on how much cancer remains following chemotherapy and radiation, local resection or surgery to remove the anus and the lower part of the rectum (abdominoperineal resection) may be done. During surgery, the lymph nodes in the groin may be removed (lymph node dissection).

STAGE IV ANAL CANCER
Your treatment may be one of the following:

1. Surgery to relieve symptoms
2. Radiation therapy to relieve symptoms
3. Chemotherapy and radiation therapy to relieve symptoms
4. Clinical trials

BACK

Gastric cancer is a disease in which malignant cells form in the lining of the stomach. The stomach is a J-shaped organ in the upper abdomen. It is part of the digestive system, which processes nutrients (vitamins, minerals, carbohydrates, fats, proteins, and water) in foods that are eaten and helps pass waste material out of the body. Food moves from the throat to the stomach through a hollow, muscular tube called the oesophagus. After leaving the stomach, partly-digested food passes into the small intestine and then into the large intestine (the colon).

The wall of the stomach is made up of 3 layers of tissue: the mucosal (innermost) layer, the muscularis (middle) layer, and the serosal (outermost) layer. Gastric cancer begins in the cells lining the mucosal layer and spreads through the outer layers as it grows.

Stromal tumours of the stomach begin in supporting connective tissue and are treated differently from gastric cancer. Age, diet, and stomach disease can affect the risk of developing gastric cancer. Risk factors include the following:

• Helicobacter pylori infection of the stomach.
• Chronic gastritis (inflammation of the stomach).
• Older age.
• Being male.
• A diet high in salted, smoked, or poorly preserved foods and low in fruits and vegetables.
• Pernicious anaemia.
• Smoking cigarettes.
• Intestinal metaplasia.
• Familial adenomatous polyposis (FAP) or gastric polyps.
• A mother, father, sister, or brother who has had stomach cancer.

Possible signs of gastric cancer include indigestion and stomach discomfort or pain. These and other symptoms may be caused by gastric cancer or by other conditions. In the early stages of gastric cancer, the following symptoms may occur:

• Indigestion and stomach discomfort
• A bloated feeling after eating
• Mild nausea
• Loss of appetite
• Heartburn

In more advanced stages of gastric cancer, the following symptoms may occur:

• Blood in the stool
• Vomiting
• Weight loss (unexplained)
• Stomach pain
• Jaundice (yellowing of eyes and skin)
• Ascites (build-up of fluid in the abdomen)
• Difficulty swallowing

A doctor should be consulted if any of these problems occur.

Tests that examine the stomach and oesophagus are used to detect (find) and diagnose gastric cancer. The following tests and procedures may be used:
Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.

Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that produces it.

Complete blood count: A procedure in which a sample of blood is drawn and checked for the following:
The number of red blood cells, white blood cells, and platelets.
The amount of haemoglobin (the protein that carries oxygen) in the red blood cells. The portion of the sample made up of red blood cells.
 

Upper endoscopy: A procedure to look inside the oesophagus, stomach, and duodenum (first part of the small intestine) to check for abnormal areas. An endoscope (a thin, lighted tube) is passed through the mouth and down the throat into the oesophagus.

Faecal occult blood test: A test to check stool (solid waste) for blood that can only be seen with a microscope. Small samples of stool are placed on special cards and returned to the doctor or laboratory for testing.

Barium swallow: A series of x-rays of the oesophagus and stomach. The patient drinks a liquid that contains barium (a silver-white metallic compound). The liquid coats the oesophagus and stomach and x-rays are taken. This procedure is also called an upper GI series.

Biopsy: The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. A biopsy of the stomach is usually done during the endoscopy.

CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.

Certain factors affect treatment options and prognosis (chance of recovery). The treatment options and prognosis (chance of recovery) depend on the stage and extent of the cancer (whether it is in the stomach only or has spread to lymph nodes or other places in the body) and the patient’s general health.

After gastric cancer has been diagnosed, tests are done to find out if cancer cells have spread within the stomach or to other parts of the body. The process used to find out if cancer has spread within the stomach or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan the best treatment.

The following tests and procedures may be used in the staging process:

ßHCG (beta human chorionic gonadotropin), CA-125, and CEA (carcinoembryonic antigen) assays: Tests that measure the levels of ßHCG, CA-125, and CEA in the blood. These substances are released into the bloodstream from both cancer cells and normal cells. When found in higher than normal amounts, they can be a sign of gastric cancer or other conditions.

Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.

Endoscopic ultrasound (EUS): A procedure in which an endoscope (a thin, lighted tube) is inserted into the body. The endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. This procedure is also called endosonography.

CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.

Laparoscopy: A surgical procedure to look at the organs inside the abdomen to check for abnormal areas. An incision (cut) is made in the abdominal wall and a laparoscope (a thin, lighted tube) is inserted into the abdomen. Tissue samples and lymph nodes may be removed for biopsy.

PET scan (positron emission tomography scan): A procedure to find malignant tumour cells in the body. A small amount of radionuclide glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumour cells show up brighter in the picture because they are more active and take up more glucose than normal cells.

The following stages are used for gastric cancer:

Stage 0 (Carcinoma in Situ)
In stage 0, cancer is found only in the inside lining of the mucosal (innermost) layer of the stomach wall. Stage 0 is also called carcinoma in situ.

Stage I
Stage I gastric cancer is divided into stage IA and stage IB, depending on where the cancer has spread.
Stage IA: Cancer has spread completely through the mucosal (innermost) layer of the stomach wall.
Stage IB: Cancer has spread: completely through the mucosal (innermost) layer of the stomach wall and is found in up to 6 lymph nodes near the tumour; or to the muscularis (middle) layer of the stomach wall.

Stage II
In stage II gastric cancer, cancer has spread: completely through the mucosal (innermost) layer of the stomach wall and is found in 7 to 15 lymph nodes near the tumour; or to the muscularis (middle) layer of the stomach wall and is found in up to 6 lymph nodes near the tumour; or to the serosal (outermost) layer of the stomach wall but not to lymph nodes or other organs.

Stage III
Stage III gastric cancer is divided into stage IIIA and stage IIIB depending on where the cancer has spread.
Stage IIIA: Cancer has spread to:
the muscularis (middle) layer of the stomach wall and is found in 7 to 15 lymph nodes near the tumour; or the serosal (outermost) layer of the stomach wall and is found in 1 to 6 lymph nodes near the tumour; or organs next to the stomach but not to lymph nodes or other parts of the body.
Stage IIIB: Cancer has spread to the serosal (outermost) layer of the stomach wall and is found in 7 to 15 lymph nodes near the tumour.

Stage IV
In stage IV, cancer has spread to: organs next to the stomach and to at least one lymph node; or more than 15 lymph nodes; or other parts of the body.

There are different types of treatment for patients with gastric cancer
Different types of treatments are available for patients with gastric cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the "standard" treatment, the new treatment may become the standard treatment.

Four types of standard treatment are used:
Surgery
Surgery is a common treatment of all stages of gastric cancer. The following types of surgery may be used:

• Subtotal gastrectomy: Removal of the part of the stomach that contains cancer, nearby lymph nodes, and parts of other tissues and organs near the tumour. The spleen may be removed. The spleen is an organ in the upper abdomen that filters the blood and removes old blood cells.
• Total gastrectomy: Removal of the entire stomach, nearby lymph nodes, and parts of the oesophagus, small intestine, and other tissues near the tumour. The spleen may be removed. The oesophagus is connected to the small intestine so the patient can continue to eat and swallow.

If the tumour is blocking the opening to the stomach but the cancer cannot be completely removed by standard surgery, the following procedures may be used:

• Endoluminal stent placement: A procedure to insert a stent (a thin, expandable tube) in order to keep a passage (such as arteries or the oesophagus) open. For tumours blocking the opening to the stomach, surgery may be done to place a stent from the oesophagus to the stomach to allow the patient to eat normally.
• Endoscopic laser surgery: A procedure in which an endoscope (a thin, lighted tube) with a laser attached is inserted into the body. A laser is an intense beam of light that can be used as a knife.
• Electrocautery: A procedure that uses an electrical current to create heat. This is sometimes used to remove lesions or control bleeding.

Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly in the spinal column, a body cavity such as the abdomen, or an organ, the drugs mainly affect cancer cells in those areas. The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Chemoradiation
Chemoradiation combines chemotherapy and radiation therapy to increase the effects of both. Chemoradiation treatment given after surgery to increase the chances of a cure is called adjuvant therapy. If it is given before surgery, it is called neoadjuvant therapy.

Other types of treatment are being tested in clinical trials. These include the following:

Biologic therapy
Biologic therapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defences against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

Treatment Options by Stage
Stage 0 Gastric Cancer (Carcinoma in Situ)
Treatment of stage 0 gastric cancer may include the following:

Surgery (total or subtotal gastrectomy).
Stage I and Stage II Gastric Cancer
Treatment of stage I and stage II gastric cancer may include the following:

Surgery (total or subtotal gastrectomy).
Surgery (total or subtotal gastrectomy) followed by chemoradiation therapy.
A clinical trial of chemoradiation therapy given before surgery.

Stage III Gastric Cancer
Treatment of stage III gastric cancer may include the following:

Surgery (total gastrectomy).
Surgery followed by chemoradiation therapy.
A clinical trial of chemoradiation therapy given before surgery.

Stage IV Gastric Cancer
Treatment of stage IV gastric cancer that has not spread to distant organs may include the following:

Surgery (total gastrectomy) followed by chemoradiation therapy. A clinical trial of chemoradiation therapy given before surgery.
Treatment of stage IV gastric cancer that has spread to distant organs may include the following:

Chemotherapy as palliative therapy to relieve symptoms and improve the quality of life.
Endoscopic laser surgery or endoluminal stent placement as palliative therapy to relieve symptoms and improve the quality of life.
Radiation therapy as palliative therapy to stop bleeding, relieve pain, or shrink a tumour that is blocking the opening to the stomach.
Surgery as palliative therapy to stop bleeding or shrink a tumour that is blocking the opening to the stomach.

Treatment Options for Recurrent Gastric Cancer
Treatment of recurrent gastric cancer may include the following:

Chemotherapy as palliative therapy to relieve symptoms and improve the quality of life.
Endoscopic laser surgery or electrocautery as palliative therapy to relieve symptoms and improve the quality of life.
Radiation therapy as palliative therapy to stop bleeding, relieve pain, or shrink a tumour that is blocking the stomach.
A clinical trial of new anticancer drugs or biologic therapy.

BACK

The small intestine is the portion of the digestive system most responsible for absorption of nutrients from food into the bloodstream. The pyloric sphincter governs the passage of partly digested food from the stomach into the duodenum. This short first portion of the small intestine is followed by the jejunum and the ileum. The ileocecal valve of the ileum passes digested material into the large intestine

Cancer of the small intestine, a rare cancer, is a disease in which cancer cells are found in the tissues of the small intestine. The small intestine is a long tube that folds many times to fit inside the abdomen. It connects the stomach to the large intestine (bowel). In the small intestine, food is broken down to remove vitamins, minerals, proteins, carbohydrates, and fats.

A doctor should be seen if there are any of the following:

• Pain or cramps in the middle of the abdomen.
• Weight loss without dieting.
• A lump in the abdomen.
• Blood in the stool.

If there are symptoms, a doctor will usually order an upper gastrointestinal x-ray (also called an upper GI series). For this examination, a patient drinks a liquid containing barium, which makes the stomach and intestine easier to see in the x-ray. This test is usually performed in a doctor’s office or in a hospital radiology department.

The doctor may also do a CT scan, a special x-ray that uses a computer to make a picture of the inside of the abdomen. An ultrasound, which uses sound waves to find tumours, or an MRI scan, which uses magnetic waves to make a picture of the abdomen, may also be done.

The doctor may put a thin lighted tube called an endoscope down the throat, through the stomach, and into the first part of the small intestine. The doctor may cut out a small piece of tissue during the endoscopy. This is called a biopsy. The tissue is then looked at under a microscope to see if it contains cancer cells.

The chance of recovery (prognosis) depends on the type of cancer, whether it is just in the small intestine or has spread to other tissues, and the patient’s overall health.

Stages of cancer of the small intestine
Once small intestine cancer is found, more tests will be done to find out if cancer cells have spread to other parts of the body. Although there is a staging system for cancer of the small intestine, for treatment purposes this cancer is grouped based on what kind of cells are found. The types of cancer found in the small intestine include adenocarcinoma, sarcoma, and carcinoid tumours.
 
Adenocarcinoma
Adenocarcinoma starts in the lining of the small intestine and is the most common type of cancer of the small intestine. These tumours occur most often in the part of the small intestine nearest the stomach. These cancers often grow and block the bowel.

Leiomyosarcoma
Leiomyosarcomas are cancers that start growing in the smooth muscle lining of the small intestine.

Recurrent
Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the small intestine or in another part of the body.

How cancer of the small intestine is treated
There are treatments for all patients with cancer of the small intestine. Three kinds of treatment are used:

• Surgery (taking out the cancer).
• Radiation therapy (using high-dose x-rays to kill cancer cells).
• Chemotherapy (using drugs to kill cancer cells).

Surgery to remove the cancer is the most common treatment. Lymph nodes in the area may also be removed and looked at under a microscope to see if they contain cancer. If the tumour is large, a doctor may cut out a section of the small intestine containing the cancer and reconnect the intestine.

Radiation therapy uses high-energy x-rays to kill cancer cells and shrink tumours. Radiation may come from a machine outside the body (external radiation therapy) or from putting materials that produce radiation (radioisotopes) through thin plastic tubes in the area where the cancer cells are found (internal radiation therapy). Drugs that make the cancer cells more sensitive to radiation (radio sensitizers) are sometimes given along with radiation. Radiation can be used alone or in addition to surgery and/or chemotherapy.

Chemotherapy uses drugs to kill cancer cells. Chemotherapy may be taken by pill, or it may be put in the body through a needle in a vein or muscle. Chemotherapy is called a systemic treatment because the drug enters the bloodstream, travels through the body, and can kill cancer cells outside the intestine.

If the doctor removes all the cancer that can be seen at the time of the operation, the patient may be given chemotherapy after surgery to kill any cancer cells that are left. Chemotherapy given after an operation is called adjuvant chemotherapy.

Biological therapy (using the body’s immune system to fight cancer) is being studied in clinical trials. Biological therapy tries to get the body to fight cancer. It uses materials made by the body or made in a laboratory to boost, direct, or restore the body’s natural defences against disease. Biological therapy is sometimes called biological response modifier (BRM) therapy or immunotherapy.

Small Intestine Adenocarcinoma
Treatment may be one of the following:

1. Surgery to cut out the tumour.
2. Surgery to allow food in the small intestine to go around the cancer (bypass) if the cancer cannot be removed.
3. Radiation therapy to relieve symptoms.
4. A clinical trial of radiation plus drugs to make cancer cells more sensitive to radiation (radio sensitizers), with or without chemotherapy.
5. A clinical trial of chemotherapy or biological therapy.

Small Intestine Leiomyosarcoma
Treatment may be one of the following:

1. Surgery to remove the cancer.
2. Surgery to allow food in the small intestine to go around the cancer (bypass) if the cancer cannot be removed.
3. Radiation therapy.
4. Surgery, chemotherapy, or radiation therapy to relieve symptoms.
5. A clinical trial of chemotherapy or biological therapy.

Recurrent Small Intestine Cancer
If the cancer comes back in another part of the body, treatment will probably be a clinical trial of chemotherapy or biological therapy.

If the cancer has come back only in one area, treatment may be one of the following:

1. Surgery to remove the cancer.
2. Radiation therapy or chemotherapy to relieve symptoms.
3. A clinical trial of radiation with drugs to make the cancer cells more sensitive to radiation (radio sensitizers), with or without chemotherapy.

BACK

Extrahepatic bile duct cancer, a rare cancer, is a disease in which malignant cells are found in the tissues of the extrahepatic bile duct. The bile duct is a tube that connects the liver and the gallbladder to the small intestine. The part of the bile duct that is outside the liver is called the extrahepatic bile duct. A fluid called bile, which is made by the liver and breaks down fats during digestion, is stored in the gallbladder. When food is being broken down in the intestines, bile is released from the gallbladder through the bile duct to the first part of the small intestine.

A doctor should be seen if there are any of the following symptoms:

Yellowing of the skin (jaundice)
Pain in the abdomen
Fever
Itching

If there are symptoms, a doctor will perform an examination and order tests to see if there is cancer. A patient may have an ultrasound, a test that uses sound waves to find tumours. A patient may also have a CT (computed tomographic) scan, which is a special type of x-ray that uses a computer to make a picture of the inside of the abdomen. Another special scan called magnetic resonance imaging (MRI), which uses magnetic waves to make a picture of the inside of the abdomen, may be done as well.

A doctor may perform a test called an ERCP (endoscopic retrograde cholangiopancreatography). During this test, a flexible tube is put down the throat, through the stomach, and into the small intestine. The doctor can see through the tube and inject dye into the drainage tube (duct) of the pancreas so that the area can be seen more clearly on an x-ray.

PTC (percutaneous transhepatic cholangiography) is another test that can help find cancer of the extrahepatic bile duct. During this test, a thin needle is put into the liver through the right side of the patient. Dye is injected through the needle into the bile duct in the liver so that blockages can be seen on x-rays.

If tissue that is not normal is found, the doctor may remove a small amount of fluid or tissue from the bile duct and look at it under the microscope to see if there are any cancer cells. This procedure is called a biopsy and is usually done during the PTC or ERCP.

Because it is sometimes hard to tell whether a patient has cancer or another disease, surgery may be needed to see if there is cancer of the bile duct. If this is the case, the doctor will cut into the abdomen and look at the bile duct and the tissues around it for cancer. If there is cancer and if it looks like it has not spread to other tissues, the doctor may remove the cancer or relieve blockages caused by the tumour.

The chance of recovery (prognosis) and choice of treatment depends on the location of the cancer in the bile duct, the stage of the cancer (whether it is only in the bile duct or has spread to other places), and the patient’s general health.

Stages of extrahepatic bile duct cancer
Once extrahepatic bile duct cancer is found (diagnosed), more tests will be done to find out if cancer cells have spread to other parts of the body. This is called staging. To plan treatment, a doctor needs to know the stage of the cancer. The following stages are used for extrahepatic bile duct cancer:

Localized
The cancer is only in the area where it began and can be removed in an operation.

Unresectable
All of the cancer cannot be removed in an operation. The cancer may have spread to nearby organs and lymph nodes or to other parts of the body. (Lymph nodes are small bean-shaped structures that are found throughout the body. They produce and store infection-fighting cells.)

Recurrent
Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the bile duct or in another part of the body.

How extrahepatic bile duct cancer is treated
There are treatments for all patients with extrahepatic bile duct cancer. Two kinds of treatment are used:

• Surgery (taking out the cancer or taking steps to relieve symptoms caused by the cancer)
• Radiation therapy (using high-dose x-rays to kill cancer cells)

Other treatments for extrahepatic bile duct cancer are being studied in clinical trials. These include:

• Chemotherapy (using drugs to kill cancer cells)
• Biological therapy (using the body’s immune system to fight cancer)

Surgery is a common treatment of extrahepatic bile duct cancer. If the cancer is small and is only in the bile duct, a doctor may remove the whole bile duct and make a new duct by connecting the duct openings in the liver to the intestine. The doctor will also remove lymph nodes and look at them under the microscope to see if they contain cancer. If the cancer has spread outside the bile duct, a surgeon may remove the bile duct and the tissues around it.

If the cancer has spread and it cannot be removed, the doctor may do surgery to relieve symptoms. If the cancer is blocking the small intestine and bile builds up in the gallbladder, the doctor may do surgery to go around (bypass) all or part of the small intestine. During this operation, the doctor will cut the gallbladder or bile duct and sew it to the small intestine. This is called biliary bypass. Surgery or x-ray procedures may also be done to put in a tube (catheter) to drain bile that has built up in the area. During these procedures, the doctor may make the catheter drain through a tube to the outside of the body or the catheter may go around the blocked area and drain the bile to the small intestine. In addition, if the cancer is blocking the flow of food from the stomach, the stomach may be sewn directly to the small intestine so the patient can continue to eat normally.

Radiation therapy is the use of high-energy x-rays to kill cancer cells and shrink tumours. Radiation may come from a machine outside the body (external-beam radiation therapy) or from putting materials that produce radiation (radioisotopes) through thin plastic tubes into the area where the cancer cells are found (internal radiation therapy).

Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy may be taken by pill, or it may be put into the body by inserting a needle into a vein or muscle. Chemotherapy is called a systemic treatment because the drug enters the bloodstream, travels through the body, and can kill cancer cells outside the bile duct.

Biological therapy tries to get the body to fight cancer. It uses materials made by the body or made in a laboratory to boost, direct, or restore the body’s natural defences against disease. Biological therapy is sometimes called biological response modifier (BRM) therapy or immunotherapy. This treatment is currently only being given in clinical trials.

Localized Extrahepatic Bile Duct Cancer
Treatment may be one of the following:

1. Surgery to remove the cancer.
2. Surgery to remove the cancer followed by external-beam radiation therapy.

Unresectable Extrahepatic Bile Duct Cancer
Treatment may be one of the following:

1. Surgery or other procedures to bypass blockage in the bile duct.
2. Surgery or other procedures to bypass blockage in the bile duct followed by external-beam radiation therapy or internal radiation therapy.
3. Clinical trials of radiation therapy with drugs to make the cancer cells more sensitive to radiation (radiosensitizers).
4. Clinical trials of chemotherapy or biological therapy.

Recurrent Extrahepatic Bile Duct Cancer
Treatment depends on many factors, including where the cancer came back and what treatment the patient received before. Clinical trials are testing new treatments.

BACK

Gastrointestinal carcinoid tumours are cancers in which malignant cells are found in certain hormone-making cells of the digestive, or gastrointestinal, system. The digestive system absorbs vitamins, minerals, carbohydrates, fats, proteins, and water from the food that is eaten and stores waste until the body eliminates it. The digestive system is made up of the stomach and the small and large intestines. The last 6 feet of intestine is called the colon. The last 10 inches of the colon is the rectum. The appendix is an organ attached to the large intestine.

There are often no signs of a gastrointestinal carcinoid tumour in its early stages. Often the cancer will make too much of some of the hormones, which can cause symptoms. A doctor should be seen if the following symptoms persist:

• Pain in the abdomen.
• Flushing and swelling of the skin of the face and neck.
• Wheezing.
• Diarrhoea.
• Symptoms of heart failure, including breathlessness.

If there are symptoms, a doctor may order blood and urine tests to look for signs of cancer. Other tests may also be done. If there is a carcinoid tumour, the patient has a greater chance of getting other cancers in the digestive system, either at the same time or at a later time.

The chance of recovery (prognosis) and choice of treatment depend on whether the cancer is just in the gastrointestinal system or has spread to other places, and on the patient's general state of health.

There are treatments for all patients with gastrointestinal carcinoid tumours. Four kinds of treatment are used:

• Surgery (taking out the cancer).
• Radiation therapy (using high-dose x-rays to kill cancer cells).
• Biological therapy (using the body's natural immune system to fight cancer).
• Chemotherapy (using drugs to kill cancer cells).

Depending on where the cancer started, the doctor may take out the cancer using one of the following operations:

1. A simple appendectomy removes the appendix. If part of the colon is also taken out, the operation is called a hemicolectomy. The doctor may also remove lymph nodes and look at them under a microscope to see if they contain cancer.
2. Local excision uses a special instrument inserted into the colon or rectum through the anus to cut the tumour out. This operation can be used for very small tumours.
3. Fulguration uses a special tool inserted into the colon or rectum through the anus. An electric current is then used to burn the tumour away.
4. Bowel resection takes out the cancer and a small amount of healthy tissue on either side. The healthy parts of the bowel are then sewn together. The doctor will also remove lymph nodes and have them looked at under a microscope to see if they contain cancer.
5. Cryosurgery kills the cancer by freezing it.
6. Hepatic artery ligation cuts and ties off the main blood vessel that brings blood into the liver (the hepatic artery).
7. Hepatic artery embolization uses drugs or other agents to reduce or block the flow of blood to the liver in order to kill cancer cells growing in the liver.

Radiation therapy uses high-energy x-rays to kill cancer cells and shrink tumours. Radiation may come from a machine outside the body (external radiation therapy) or from putting materials that produce radiation (radioisotopes) through thin plastic tubes in the area where the cancer cells are found (internal radiation therapy).

Chemotherapy uses drugs to kill cancer cells. Chemotherapy may be taken by pill, or it may be put into the body by a needle in the vein or muscle. Chemotherapy is called a systemic treatment because the drug enters the bloodstream, travels through the body, and can kill cancer cells outside the digestive system.

Biological therapy tries to get the patient's body to fight the cancer. It uses materials made by the body or made in a laboratory to boost, direct, or restore the body's natural defences against disease. Biological therapy is sometimes called biological response modifier (BRM) therapy or immunotherapy.

Treatment by type
Treatment of gastrointestinal carcinoid tumour depends on the type of tumour, the stage, and the patient's overall health.

Standard treatment may be considered because of its effectiveness in patients in past studies, or participation in a clinical trial may be considered. Not all patients are cured with standard therapy and some standard treatments may have more side effects than are desired. For these reasons, clinical trials are designed to find better ways to treat cancer patients and are based on the most up-to-date information.

Localized Gastrointestinal Carcinoid tumours
If the cancer started in the appendix, the treatment will probably be surgery to remove the appendix (appendectomy) with or without removal of part of the colon (hemicolectomy) and lymph nodes.

If the cancer started in the rectum, treatment will probably be simple surgery to remove the cancer, surgery using electric current to burn the cancer away, surgery to remove part of the rectum, or surgery to remove the anus and part of the rectum. An opening will be made for waste to pass out of the body (colostomy) into a disposable bag attached near the colostomy (colostomy bag).

If the cancer started in the small intestine, the treatment will probably be surgery to remove part of the bowel (bowel resection). Lymph nodes may also be taken out and looked at under the microscope to see if they contain cancer.

If the cancer started in the stomach, pancreas, or colon, the treatment will probably be surgery to remove the organ affected by the cancer and possibly other nearby organs.

Regional Gastrointestinal Carcinoid tumours
The treatment will probably be surgery to remove the organ affected by the cancer and possibly other nearby organs.

Metastatic Gastrointestinal Carcinoid tumours
Treatment may be one of the following:

1. Surgery to relieve symptoms caused by the cancer. Surgery to freeze and kill the cancer may also be performed.
2. Chemotherapy to relieve symptoms caused by the cancer.
3. Chemotherapy injected directly into the hepatic artery to block the artery and kill cancer cells growing in the liver.
4. Radiation therapy to relieve symptoms caused by the cancer.
5. Radioactive substances injected into the cancer to relieve the symptoms caused by the cancer.
6. Biological or immunological therapy.

Carcinoid syndrome
Treatment options for metastatic carcinoid tumour may be one of the following:

1. Surgery to remove the cancer.
2. Surgery to cut and tie the main artery that goes to the liver (hepatic artery ligation) or injecting chemotherapy into the liver through the hepatic artery to block the artery and kill cancer cells growing in the liver.
3. Drugs designed to relieve symptoms caused by the cancer.
4. Biological therapy to relieve symptoms caused by the cancer.
5. A clinical trial of new combinations of chemotherapy drugs.

BACK

The colon is part of a section of the digestive tract called the large intestine. The large intestine is a tube that is 5 to 6 feet in length. The first 5 feet make up the colon, which connects to about 6 inches of rectum, and ends with the anus. By the time food reaches the colon (about 3 to 8 hours after eating), the nutrients have been absorbed and it has become a liquid waste product. The colon's function is to change this liquid waste into stool. The stool can spend anywhere from 10 hours to several days in the colon. It has been suggested that the longer stool remains in the colon, the higher the risk for colon cancer, but this has not been proven.

What is colon cancer?
Colon cancer is malignant tissue that grows in the wall of the colon. The majority of tumours begin when normal tissue in the colon wall forms an adenomatous polyp, or pre-cancerous growth projecting from the colon wall. As this polyp grows larger, the tumour is formed. This process can take many years, which allows time for early detection with screening tests.

Some tumours and polyps may bleed intermittently, and this blood can be detected in stool samples by a test called faecal occult blood testing (FOBT). By itself, FOBT only finds about 24% of cancers. The sigmoidoscope is a slender, flexible tube that has the ability to view about ﾽ of the colon. If a polyp or tumour is detected with this test, the patient must be referred for a full colonoscopy.

The colonoscope is similar to the sigmoidoscope, but is longer, and can view the entire colon. If a polyp is found, the physician can remove it, and send it to a pathology lab to determine if it is adenomatous (cancerous). As a screening method, the American Cancer Society recommends that a colonoscopy be done every 10 years after age 50. Patients with a family or personal history should have more frequent screenings, beginning at an earlier age than their relative was diagnosed. Patients with a history of ulcerative colitis are also at increased risk and should have more frequent screening than the general public. Patients should talk with their doctor about which screening method is best for them, and how often it should be performed.

What are the Signs of Colon Cancer?
Unfortunately, the early stages of colon cancer may not have any symptoms. This is why it is important to have screening tests done even though you feel well. As the polyp grows into a tumour, it may bleed or obstruct the colon, causing symptoms. These symptoms include:

• Bleeding from the rectum
• Blood in the stool or toilet after a bowel movement
• A change in the shape of the stool (i.e. thinning)
• Cramping pain in the abdomen
• Feeling the need to have a bowel movement when you don't have to have one

As you can see, these symptoms can also be caused by other conditions. If you experience these symptoms, you should be checked by a doctor.

How is Colon Cancer Diagnosed and Staged?
After a cancer has been found, the stage must be determined to decide on appropriate treatment. The stage tells how far the tumour has invaded the colon wall, and if it has spread to other parts of the body.

• Stage 0 (also called carcinoma in situ) - the cancer is confined to the outermost portion of the colon wall.
• Stage I - the cancer has spread to the second and third layer of the colon wall, but not to the outer colon wall or beyond. This is also called Dukes' A colon cancer.
• Stage II - the cancer has spread through the colon wall, but has not invaded any lymph nodes (these are small structures that help in fighting infection and disease). This is also called Dukes' B colon cancer.
• Stage III - the cancer has spread through the colon wall and into lymph nodes, but has not spread to other areas of the body. This is also called Dukes' C colon cancer.
• Stage IV - the cancer has spread to other areas of the body (i.e. liver and lungs). This is also called Dukes' D colon cancer.

After the tumour and lymph nodes are removed by a surgeon, they are examined by a pathologist, who determines how much of the colon wall and lymph nodes have been invaded by tumour. Patients with invasive cancer (stages II, III, and IV) require a staging workup, including full colonoscopy, carcinoembryonic antigen (CEA) level (a marker for colon cancer found in the blood), chest x-ray, and CT scan of the abdomen and pelvis, to determine if the cancer has spread.

What are the Treatments for Colon Cancer?
Surgery
Surgery is the most common treatment for colon cancer. If the cancer is limited to a polyp, the patient can undergo a polypectomy (removal of the polyp), or a local excision, where a small amount of surrounding tissue is also removed. If the tumour invades the bowel wall or surrounding tissues, the patient will require a partial resection (removal of the cancer and a portion of the bowel) and removal of local lymph nodes to determine if the cancer has spread into them. After the tumour is removed, the two ends of the remaining colon are reconnected, allowing normal bowel function. In some situations, it may not be possible to reconnect the colon, and a colostomy (an opening in the abdominal wall to allow passage of stool) is needed.

Chemotherapy
Despite the fact that a majority of patients have the entire tumour removed by surgery, as many as 40% will develop a recurrence. Chemotherapy is given to reduce this chance of recurrence. There is some controversy over patients with stage II disease receiving chemotherapy. Studies have not consistently shown a benefit in treating these patients. Generally, patients with stage II disease who present with a bowel perforation or obstruction, or have poorly differentiated tumours (determined by a pathologist), are considered at higher risk for recurrence, and are treated with 6 to 8 months of Fluorouracil (5-FU) and Leucovorin (LV) (both chemotherapy agents). Other patients with stage II disease are followed closely, but generally receive no chemotherapy. Patients who present with stage III colon cancer are typically treated with a regimen of Fluorouracil and Leucovorin for 12 months.

Forty to fifty percent of patients have metastatic (disease that has spread to other organs) at the time of diagnosis, or have a recurrence of the disease after therapy. Unfortunately, the prognosis for these patients is poor. The standard therapy for patients with advanced disease is Fluorouracil, Leucovorin, and irinotecan (CPT-11). This regimen was found to be more effective than Fluorouracil and Leucovorin alone in these patients. With this therapy, an average of 39% of patients have a response, but the average survival is still only 15 months. Patients and their physicians must weigh the benefits of therapy versus the side effects of the treatment. Younger patients and those in better physical shape are better able to tolerate therapy.

Two new medications, capecitabine (Xeloda) and oxaliplatin, are also being used in the treatment of advanced colon cancer. Capecitabine is currently approved by the FDA for the treatment of advanced colon cancer that has failed treatment, but is still being investigated in untreated patients. Oxaliplatin is widely used in Europe, but has not yet been approved by the FDA for use in the United States. Currently, patients can only receive this medication in a clinical trial.

Radiotherapy
Colon cancer is not typically treated with radiation therapy. If the cancer has invaded another organ, or adhered to the abdominal wall, radiation therapy may be one option. One way to understand this is that radiation needs a "target". If the tumour has been surgically resected, there is no target to radiate. If the tumour has spread to other organs, chemotherapy is needed to reach all the tumour cells, whereas radiation can only treat a small area.

BACK

Oesophageal cancer is a disease in which malignant cells form in the tissues of the oesophagus.
The oesophagus is the hollow, muscular tube that moves food and liquid from the throat to the stomach. The wall of the oesophagus is made up of several layers of tissue, including mucous membrane, muscle, and connective tissue. Oesophageal cancer starts at the inside lining of the oesophagus and spreads outward through the other layers as it grows. The two most common forms of oesophageal cancer are named for the type of cells that become malignant (cancerous):

• Squamous cell carcinoma: Cancer that forms in squamous cells, the thin, flat cells lining the oesophagus. This cancer is most often found in the upper and middle part of the oesophagus, but can occur anywhere along the oesophagus. This is also called epidermoid carcinoma.
• Adenocarcinoma: Cancer that begins in glandular (secretory) cells. Glandular cells in the lining of the oesophagus produce and release fluids such as mucus. Adenocarcinomas usually form in the lower part of the oesophagus, near the stomach.

Smoking, heavy alcohol use, and Barrett’s oesophagus can affect the risk of developing oesophageal cancer. Risk factors include the following:

• Tobacco use
• Heavy alcohol use
• Barrett’s oesophagus: A condition in which the cells lining the lower part of the oesophagus have changed or been replaced with abnormal cells that could lead to cancer of the oesophagus. Gastric reflux (the backing up of stomach contents into the lower section of the oesophagus) may irritate the oesophagus and, over time, cause Barrett’s oesophagus
• Older age
• Being male
• Being African-American

The most common signs of oesophageal cancer are painful or difficult swallowing and weight loss.
These and other symptoms may be caused by oesophageal cancer or by other conditions. A doctor should be consulted if any of the following problems occur

• Painful or difficult swallowing

• Weight loss

• Pain behind the breastbone

• Hoarseness and cough

• Indigestion and heartburn

Tests that examine the oesophagus are used to detect (find) and diagnose oesophageal cancer. The following tests and procedures may be used:

Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
Barium swallow: A series of x-rays of the oesophagus and stomach. The patient drinks a liquid that contains barium (a silver-white metallic compound). The liquid coats the oesophagus and x-rays are taken. This procedure is also called an upper GI series.
Oesophagoscopy: A procedure to look inside the oesophagus to check for abnormal areas. An oesophagoscope (a thin, lighted tube) is inserted through the mouth and down the throat into the oesophagus. Tissue samples may be taken for biopsy.
Biopsy: The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. The biopsy is usually done during an oesophagoscopy. Sometimes a biopsy shows changes in the oesophagus that are not cancer but may lead to cancer. Certain factors affect prognosis (chance of recovery) and treatment options. The prognosis (chance of recovery) and treatment options depend on the following:

• The stage of the cancer (whether it affects part of the oesophagus, involves the whole oesophagus, or has spread to other places in the body)
• The size of the tumour
• The patient’s general health
• When oesophageal cancer is found very early, there is a better chance of recovery. Oesophageal cancer is often in an advanced stage when it is diagnosed. At later stages, oesophageal cancer can be treated but rarely can be cured. Taking part in one of the clinical trials being done to improve treatment should be considered.

Stages of Oesophageal Cancer

After oesophageal cancer has been diagnosed, tests are done to find out if cancer cells have spread within the oesophagus or to other parts of the body.
The following stages are used for oesophageal cancer:
Stage 0 (Carcinoma in Situ)
Stage I
Stage II
Stage III
Stage IV

After oesophageal cancer has been diagnosed, tests are done to find out if cancer cells have spread within the oesophagus or to other parts of the body. The process used to find out if cancer cells have spread within the oesophagus or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:

Bronchoscopy: A procedure to look inside the trachea and large airways in the lung for abnormal areas. A bronchoscope (a thin, lighted tube) is inserted through the nose or mouth into the trachea and lungs. Tissue samples may be taken for biopsy.
Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
Laryngoscopy: A procedure in which the doctor examines the larynx (voice box) with a mirror or with a laryngoscope (a thin, lighted tube).
CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This test is also called computed tomography, computerized tomography, or computerized axial tomography.
Endoscopic ultrasound (EUS): A procedure in which an endoscope (a thin, lighted tube) is inserted into the body. The endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. This procedure is also called endosonography.
Thoracoscopy: A surgical procedure to look at the organs inside the chest to check for abnormal areas. An incision (cut) is made between two ribs and a thoracoscope (a thin, lighted tube) is inserted into the chest. Tissue samples and lymph nodes may be removed for biopsy. In some cases, this procedure may be used to remove portions of the oesophagus or lung.
Laparoscopy: A surgical procedure to look at the organs inside the abdomen to check for abnormal areas. An incision (cut) is made in the abdominal wall and a laparoscope (a thin, lighted tube) is inserted into the abdomen. Tissue samples and lymph nodes may be removed for biopsy.
PET scan (positron emission tomography scan): A procedure to find malignant tumour cells in the body. A small amount of radionuclide glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumour cells show up brighter in the picture because they are more active and take up more glucose than normal cells. The use of PET for staging oesophageal cancer is being studied in clinical trials.
The following stages are used for oesophageal cancer:

Stage 0 (Carcinoma in Situ)
In stage 0, cancer is found only in the innermost layer of cells lining the oesophagus. Stage 0 is also called carcinoma in situ.

Stage I
In stage I, cancer has spread beyond the innermost layer of cells to the next layer of tissue in the wall of the oesophagus.

Stage II
Stage II oesophageal cancer is divided into stage IIA and stage IIB, depending on where the cancer has spread.

Stage IIA: Cancer has spread to the layer of oesophageal muscle or to the outer wall of the oesophagus.
Stage IIB: Cancer may have spread to any of the first three layers of the oesophagus and to nearby lymph nodes.
Stage III
In stage III, cancer has spread to the outer wall of the oesophagus and may have spread to tissues or lymph nodes near the oesophagus.

Stage IV
Stage IV oesophageal cancer is divided into stage IVA and stage IVB, depending on where the cancer has spread.

Stage IVA: Cancer has spread to nearby or distant lymph nodes.
Stage IVB: Cancer has spread to distant lymph nodes and/or organs in other parts of the body.

Recurrent Oesophageal Cancer
Recurrent oesophageal cancer is cancer that has recurred after it has been treated. The cancer may come back in the oesophagus or in other parts of the body.

There are different types of treatment for patients with oesophageal cancer.
Different types of treatment are available for patients with oesophageal cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the “standard” treatment, the new treatment may become the standard treatment.

Five types of standard treatment are used:
Surgery
Surgery is the most common treatment for cancer of the oesophagus. Part of the oesophagus may be removed in an operation called an oesophagectomy. The doctor will connect the remaining healthy part of the oesophagus to the stomach so the patient can still swallow. A plastic tube or part of the intestine may be used to make the connection. Lymph nodes near the oesophagus may also be removed and viewed under a microscope to see if they contain cancer. If the oesophagus is partly blocked by the tumour, an expandable metal stent (tube) may be placed inside the oesophagus to help keep it open.

Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated. A plastic tube may be inserted into the oesophagus to keep it open during radiation therapy. This is called intraluminal intubation and dilation.

Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly in the spinal column, a body cavity such as the abdomen, or an organ, the drugs mainly affect cancer cells in those areas. The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Laser therapy
Laser therapy is a cancer treatment that uses a laser beam (a narrow beam of intense light) to kill cancer cells.

Electrocoagulation
Electrocoagulation is the use of an electric current to kill cancer cells.

Patients have special nutritional needs during treatment for oesophageal cancer.
Many people with oesophageal cancer find it hard to eat because they have difficulty swallowing. The oesophagus may be narrowed by the tumour or as a side effect of treatment. Some patients may receive nutrients directly into a vein. Others may need a feeding tube (a flexible plastic tube that is passed through the nose or mouth into the stomach) until they are able to eat on their own.

Treatment Options By Stage
Stage 0 Oesophageal Cancer (Carcinoma in Situ)
Treatment of stage 0 oesophageal cancer (carcinoma in situ) is usually surgery.

Stage I Oesophageal Cancer
Treatment of stage I oesophageal cancer may include the following:

Surgery.
Clinical trials of chemotherapy plus radiation therapy, with or without surgery.
Clinical trials of new therapies used before or after surgery.

Stage II Oesophageal Cancer
Treatment of stage II oesophageal cancer may include the following:

Surgery.
Clinical trials of chemotherapy plus radiation therapy, with or without surgery.
Clinical trials of new therapies used before or after surgery.

Stage III Oesophageal Cancer
Treatment of stage III oesophageal cancer may include the following:

Surgery.
Clinical trials of chemotherapy plus radiation therapy, with or without surgery.
Clinical trials of new therapies used before or after surgery.

Stage IV Oesophageal Cancer
Treatment of stage IV oesophageal cancer may include the following:

External or internal radiation therapy as palliative therapy to relieve symptoms and improve quality of life.
Laser surgery or electrocoagulation as palliative therapy to relieve symptoms and improve quality of life.
Chemotherapy.
Clinical trials of chemotherapy.

Treatment Options for Recurrent Oesophageal Cancer
Treatment of recurrent oesophageal cancer may include the following:
Use of any standard treatments as palliative therapy to relieve symptoms and improve quality of life.
Clinical trials of new therapies used before or after surgery.

BACK

Cancer of the gallbladder, an uncommon cancer, is a disease in which cancer cells are found in the tissues of the gallbladder. The gallbladder is a pear-shaped organ that lies just under the liver in the upper abdomen. Bile, a fluid made by the liver, is stored in the gallbladder. When food is being broken down (digested) in the stomach and the intestines, bile is released from the gallbladder through a tube called the bile duct that connects the gallbladder and liver to the first part of the small intestine. The bile helps to digest fat.

Cancer of the gallbladder is more common in women than in men. It is also more common in people who have hard clusters of material in their gallbladder (gallstones).

Cancer of the gallbladder is hard to find (diagnose) because the gallbladder is hidden behind other organs in the abdomen. Cancer of the gallbladder is sometimes found after the gallbladder is removed for other reasons. The symptoms of cancer of the gallbladder may be like other diseases of the gallbladder, such as gallstones or infection, and there may be no symptoms in the early stages. A doctor should be seen if the following symptoms persist:

• Pain above the stomach
• Loss of weight without trying
• Fever
• Yellowing of the skin (jaundice)

If there are symptoms, a doctor may order x-rays and other tests to see what is wrong. However, usually the cancer cannot be found unless the patient has surgery. During surgery, a cut is made in the abdomen so that the gallbladder and other nearby organs and tissues can be examined.

The chance of recovery and choice of treatment depend on the stage of cancer (whether it is just in the gallbladder or has spread to other places) and on the patient’s general health.

Stage Explanation

Stages of cancer of the gallbladder
Once cancer of the gallbladder is found, more tests will be done to find out if cancer cells have spread to other parts of the body. A doctor needs to know the stage to plan treatment. The following stages are used for cancer of the gallbladder:

Localized
Cancer is found only in the tissues that make up the wall of the gallbladder, and it can be removed completely in an operation.

Unresectable
All of the cancer cannot be removed in an operation. Cancer has spread to the tissues around the gallbladder, such as the liver, stomach, pancreas, or intestine and/or to lymph nodes in the area. (Lymph nodes are small, bean-shaped structures that are found throughout the body. They produce and store infection-fighting cells.)

Recurrent
Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the gallbladder or in another part of the body.

How cancer of the gallbladder is treated
There are treatments for all patients with cancer of the gallbladder. Three treatments are used:

• Surgery (taking out the cancer or relieving symptoms of the cancer in an operation)
• Radiation therapy (using high-dose x-rays to kill cancer cells)
• Chemotherapy (using drugs to kill cancer)

Surgery is a common treatment of cancer of the gallbladder if it has not spread to surrounding tissues. The doctor may take out the gallbladder in an operation called a cholecystectomy. Part of the liver around the gallbladder and lymph nodes in the abdomen may also be removed.

If the cancer has spread and cannot be removed, the doctor may do surgery to relieve symptoms. If the cancer is blocking the bile ducts and bile builds up in the gallbladder, the doctor may do surgery to go around (bypass) the cancer. During this operation, the doctor will cut the gallbladder or bile duct and sew it to the small intestine. This is called biliary bypass. Surgery or other procedures may also be done to put in a tube (catheter) to drain bile that has built up in the area. During these procedures, the doctor may place the catheter so that it drains through a tube to the outside of the body or so that it goes around the blocked area and drains the bile into the small intestine.

Radiation therapy is the use of high-energy x-rays to kill cancer cells and shrink tumours. Radiation for gallbladder cancer usually comes from a machine outside the body (external-beam radiation therapy). Radiation may be used alone or in addition to surgery.

Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy for cancer of the gallbladder is usually put into the body by a needle inserted into a vein. Chemotherapy is called a systemic treatment because the drug enters the bloodstream, travels through the body, and can kill cancer cells outside the gallbladder. Chemotherapy or other drugs may be given with radiation therapy to make cancer cells more sensitive to radiation (radiosensitizers).

Treatment by stage
Treatments for cancer of the gallbladder depend on the stage of the disease and the patient’s general health.

Localized Gallbladder Cancer
Treatment may be one of the following:

1. Surgery to remove the gallbladder and some of the tissues around it (cholecystectomy).
2. External-beam radiation therapy with or without chemotherapy, possibly followed by surgery.
3. A clinical trial evaluating radiation therapy plus chemotherapy or drugs to make the cancer cells more sensitive to radiation (radiosensitizers).

Unresectable Gallbladder Cancer
Treatment may be one of the following:

1. Surgery or other procedures to relieve symptoms.
2. Surgery to bypass the obstructed ducts of the gallbladder.
3. External-beam radiation therapy with or without chemotherapy possibly followed by surgery.
4. Chemotherapy to relieve symptoms. Clinical trials are testing new chemotherapy drugs.
5. A clinical trial evaluating radiation therapy plus chemotherapy or drugs to make the cancer cells more sensitive to radiation (radiosensitizers).

Recurrent Gallbladder Cancer
Treatment for recurrent cancer of the gallbladder depends on the type of treatment the patient received before, the place where the cancer has recurred and other facts about the cancer, and the patient’s general health. The patient may wish to consider taking part in a clinical trial.

BACK

The liver is the largest of the body's organs. It lies in the upper right side of the abdomen, with most of it protected by the ribs It weighs about 3 pounds (1.5 kilogrammes), making it the largest organ in the body. It pulses continuously as 1 1/2 litres (2 1/2 pints) of blood pass through it every minute. There are reservoirs of blood in the liver called venous sinuses which can hold up to 3 1/2 litres (6 pints) for boosting blood volume in  emergencies. The liver is a 24 hour chemical plant responsible for the production, storage, metabolism and distribution of a multitude of nutrients essential to a healthy body. It takes in waste products, converts some of them into useable elements and excretes those which are harmful. At the same time the liver produces Vitamin A and stores Vitamins A, D and B12. A chemical company would require a plant covering several acres to perform its simpler tasks. The more complicated ones it could not do at all.

Adult primary liver cancer is a disease in which malignant cells form in the tissues of the liver. The liver is one of the largest organs in the body, filling the upper right side of the abdomen inside the rib cage. It has two parts, a right lobe and a smaller left lobe. The liver makes enzymes and bile that help digest food and change it into energy. The liver also filters and stores blood.

This summary refers to the treatment of primary liver cancer (cancer that begins in the liver). Treatment of metastatic liver cancer, which is cancer that begins in other parts of the body and spreads to the liver, is not discussed in this summary. Primary liver cancer can occur in both adults and children. Treatment for children, however, is different than treatment for adults. Having hepatitis or cirrhosis can affect the risk of developing adult primary liver cancer. The following are possible risk factors for adult primary liver cancer:

• Having hepatitis B and/or hepatitis C
• Having a close relative with both hepatitis and liver cancer
• Having cirrhosis
• Eating foods tainted with aflatoxin (poison from a fungus that can grow on foods, such as grains and nuts, that have not been stored properly)
• Possible signs of adult primary liver cancer include a lump or pain on the right side

These symptoms may be caused by swelling of the liver. These and other symptoms may be caused by adult primary liver cancer or by other conditions. A doctor should be consulted if any of the following problems occur:

• A hard lump on the right side just below the rib cage

• Discomfort in the upper abdomen on the right side

• Pain around the right shoulder blade

• Unexplained weight loss

• Jaundice (yellowing of the skin and whites of the eyes)

• Unusual tiredness

• Nausea

• Loss of appetite.

Tests that examine the liver and the blood are used to detect (find) and diagnose adult primary liver cancer. The following tests and procedures may be used:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that produces it. An increased level of alpha-fetoprotein (AFP) in the blood may be a sign of liver cancer. Other cancers and certain non-cancerous conditions, including cirrhosis and hepatitis, may also increase AFP levels.

Complete blood count: A procedure in which a sample of blood is drawn and checked for the following:

• The number of red blood cells, white blood cells, and platelets
• The amount of haemoglobin (the protein that carries oxygen) in the red blood cells. The portion of the sample made up of red blood cells
• Laparoscopy: A surgical procedure to look at the organs inside the abdomen to check for abnormal areas. An incision (cut) is made in the abdominal wall and a laparoscope (a thin, lighted tube) is inserted into the abdomen. Tissue samples and lymph nodes may be removed for biopsy.
  Biopsy: The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. The sample may be taken using a fine needle inserted into the liver during an x-ray or ultrasound. This is called needle biopsy or fine-needle aspiration. The biopsy may be done during a laparoscopy.
• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
• Ultrasound: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.

Certain factors affect prognosis (chance of recovery) and treatment options.
The prognosis (chance of recovery) and treatment options depend on the following:

• The stage of the cancer (the size of the tumour, whether it affects part or all of the liver, or has spread to other places in the body).
• How well the liver is working.
• The patient’s general health, including whether there is cirrhosis of the liver.

Prognosis is also affected by alpha-fetoprotein (AFP) levels. After adult primary liver cancer has been diagnosed, tests are done to find out if cancer cells have spread within the liver or to other parts of the body. The process used to find out if cancer has spread within the liver or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:

Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.

CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.

MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).

Bone scan: A procedure to check if there are rapidly dividing cells, such as cancer cells, in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones and is detected by a scanner.

Doppler ultrasound: A type of ultrasound that uses differences in the ultrasound echoes to measure the speed and direction of blood flow.

The following stages are used for adult primary liver cancer:

Stage I
In stage I, there is one tumour and it has not spread to nearby blood vessels.

Stage II
In stage II, one of the following is found: one tumour that has spread to nearby blood vessels; or more than one tumour, none of which is larger than 5 centimetres (about 2 inches).

Stage III
Stage III is divided into stage IIIA, IIIB, and IIIC.

Stage IIIA: In stage IIIA, one of the following is found: more than one tumour larger than 5 centimetres; or one tumour that has spread to a major branch of blood vessels near the liver.

Stage IIIB: In stage IIIB, there are one or more tumours of any size that have either: spread to nearby organs other than the gallbladder; or broken through the lining of the peritoneal cavity.

Stage IIIC: In stage IIIC, the cancer has spread to nearby lymph nodes.

Stage IV
In stage IV, cancer has spread beyond the liver to other places in the body, such as the bones or lungs. The tumours may be of any size and may also have spread to nearby blood vessels and/or lymph nodes.

For adult primary liver cancer, stages are also grouped according to how the cancer may be treated. There are 3 treatment groups:

Localized resectable
The cancer is found in the liver only, has not spread, and can be completely removed by surgery.

Localized and locally advanced unresectable
The cancer is found in the liver only and has not spread, but cannot be completely removed by surgery.

Advanced
Cancer has spread throughout the liver or has spread to other parts of the body, such as the lungs and bone.

There are different types of treatment for patients with adult primary liver cancer.

Different types of treatments are available for patients with adult primary liver cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the “standard” treatment, the new treatment may become the standard treatment.

Four types of standard treatment are used:

Surgery
The following types of surgery may be used to treat liver cancer:

• Cryosurgery: A treatment that uses an instrument to freeze and destroy abnormal tissue, such as carcinoma in situ (cancer that involves only the cells in which it began and that has not spread to nearby tissues). This type of treatment is also called cryotherapy. The doctor may use ultrasound to guide the instrument.
• Partial hepatectomy: Removal of the part of the liver where cancer is found. The part removed may be a wedge of tissue, an entire lobe, or a larger portion of the liver, along with some of the healthy tissue around it. The remaining liver tissue takes over the functions of the liver.
• Total hepatectomy and liver transplant: Removal of the entire liver and replacement with a healthy donated liver. A liver transplant may be done when the disease is in the liver only and a donated liver can be found. If the patient has to wait for a donated liver, other treatment is given as needed.
• Radiofrequency ablation: The use of a special probe with tiny electrodes that kill cancer cells. Sometimes the probe is inserted directly through the skin and only local anaesthesia is needed. In other cases, the probe is inserted through an incision in the abdomen. This is done in the hospital with general anaesthesia.

Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. Radiation therapy is given in different ways:

• External radiation therapy uses a machine outside the body to send radiation toward the cancer.
• Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.
• Drugs called radio sensitizers may be given with the radiation therapy to make the cancer cells more sensitive to radiation.
• Radiation may be delivered to the tumour using radio-labelled antibodies. Radioactive substances are attached to antibodies made in the laboratory. These antibodies, which target tumour cells, are injected into the body and the tumour cells are killed by the radioactive substance.

The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, a body cavity such as the abdomen, or an organ, the drugs mainly affect cancer cells in those areas. This is called regional chemotherapy.

Regional chemotherapy is usually used to treat liver cancer. A small pump containing anticancer drugs may be placed in the body. The pump puts the drugs directly into the blood vessels that go to the tumour.

Another type of regional chemotherapy is chemo-embolization of the hepatic artery. This involves blocking the hepatic artery (the main artery that supplies blood to the liver) and injecting anticancer drugs between the blockage and the liver. The liver’s arteries then deliver the drugs throughout the liver. Only a small amount of the drug reaches other parts of the body. The blockage may be temporary or permanent, depending on what is used to block the artery. The liver continues to receive some blood from the hepatic portal vein, which carries blood from the stomach and intestine.

The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Percutaneous ethanol injection
Percutaneous ethanol injection is a cancer treatment in which a small needle is used to inject ethanol (alcohol) directly into a tumour to kill cancer cells. The procedure may be done once or twice a week. Usually local anaesthesia is used, but if the patient has many tumours in the liver, general anaesthesia may be needed.

Other types of treatment are being tested in clinical trials. These include the following:

Hyperthermia therapy
Hyperthermia therapy is the use of a special machine to heat the body for a period of time to kill cancer cells. Because some cancer cells are more sensitive to heat than normal cells are, the cancer cells die and the tumour shrinks.

Biologic therapy
Biologic therapy is treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defences against disease. This type of cancer treatment is also called biotherapy or immunotherapy.

Treatment Options for Adult Primary Liver Cancer
Localized Resectable Adult Primary Liver Cancer
Treatment of localized resectable adult primary liver cancer may include the following:

Surgery (partial hepatectomy).
Surgery (total hepatectomy) and liver transplant.

Localized and Locally Advanced Unresectable Adult Primary Liver Cancer
Treatment of localized and locally advanced unresectable adult primary liver cancer may include the following:

Chemotherapy (regional chemotherapy or chemo-embolization).
Surgery (cryosurgery or radiofrequency ablation).
Surgery (total hepatectomy) and liver transplant.
Percutaneous ethanol injection.
Radiation therapy with radio sensitizers.
A clinical trial of regional or systemic chemotherapy and/or radio-labelled antibodies.
A clinical trial of a combination of surgery, chemotherapy, and radiation therapy. Hyperthermia therapy may also be used. Chemotherapy and radiation therapy may be used to shrink the tumour before surgery.

Advanced Adult Primary Liver Cancer
There is no standard treatment for advanced adult primary liver cancer. Patients may consider taking part in a clinical trial. Treatment may include the following:

A clinical trial of biologic therapy, chemotherapy, and/or radiation therapy with or without radio sensitizers. These treatments may be given as palliative therapy to help relieve symptoms and improve the quality of life.

Recurrent Adult Primary Liver Cancer
Treatment of recurrent adult primary liver cancer may include the following:

Surgery (partial hepatectomy).
Surgery (total hepatectomy) and liver transplant.
Chemotherapy (chemo-embolization or systemic chemotherapy).
Percutaneous ethanol injection.
A clinical trial of a new therapy.

BACK

Pancreatic cancer is a disease in which malignant cells form in the tissues of the pancreas. The pancreas is a gland about 6 inches long that is shaped like a thin pear lying on its side. The wider end of the pancreas is called the head, the middle section is called the body, and the narrow end is called the tail. The pancreas lies behind the stomach and in front of the spine.

The pancreas has two main jobs in the body:

• To produce juices that help digest (break down) food.
• To produce hormones, such as insulin and glucagon, that help control blood sugar levels. Both of these hormones help the body use and store the energy it gets from food.
• The digestive juices are produced by exocrine pancreas cells and the hormones are produced by endocrine pancreas cells. About 95% of pancreatic cancers begin in exocrine cells.
• Smoking and health history can affect the risk of developing pancreatic cancer.

The following are possible risk factors for pancreatic cancer:

• Smoking
• Long-standing diabetes
• Chronic pancreatitis
• Certain hereditary conditions, such as hereditary pancreatitis, multiple endocrine neoplasia type 1 syndrome, hereditary nonpolyposis colon cancer (HNPCC; Lynch syndrome), von Hippel-Lindau syndrome, ataxia-telangiectasia, and the familial atypical multiple mole melanoma syndrome (FAMMM)

Possible signs of pancreatic cancer include jaundice, pain, and weight loss. These symptoms can be caused by pancreatic cancer or other conditions. A doctor should be consulted if any of the following problems occur:

• Jaundice (yellowing of the skin and whites of the eyes)
• Pain in the upper or middle abdomen and back
• Unexplained weight loss
• Loss of appetite
• Fatigue

Pancreatic cancer is difficult to detect (find) and diagnose early. Pancreatic cancer is difficult to detect and diagnose for the following reasons:

• There aren’t any noticeable signs or symptoms in the early stages of pancreatic cancer
• The signs of pancreatic cancer, when present, are like the signs of many other illnesses
• The pancreas is hidden behind other organs such as the stomach, small intestine, liver, gallbladder, spleen, and bile ducts

Tests that examine the pancreas are used to detect, diagnose and stage pancreatic cancer.
Pancreatic cancer is usually diagnosed with tests and procedures that produce pictures of the pancreas and the area around it. The process used to find out if cancer cells have spread within and around the pancreas is called staging. Tests and procedures to detect, diagnose, and stage pancreatic cancer are usually done at the same time. In order to plan the best treatment, it is important to know the stage of the disease and whether or not the pancreatic cancer can be removed by surgery. The following tests and procedures may be used:

Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.

Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.

CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. A spiral or helical CT scan takes detailed pictures of areas inside the body as it scans the body in a spiral path.

MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).

PET scan (positron emission tomography scan): A procedure to find malignant tumour cells in the body. A small amount of radionuclide glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumour cells show up brighter in the picture because they are more active and take up more glucose than normal cells.

Endoscopic ultrasound (EUS): A procedure in which an endoscope (a thin, lighted tube) is inserted into the body. The endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. This procedure is also called endosonography.

Laparoscopy: A surgical procedure to look at the organs inside the abdomen to check for abnormal areas. An incision (cut) is made in the abdominal wall and a laparoscope (a thin, lighted tube) is inserted into the abdomen. Tissue samples and lymph nodes may be removed for biopsy.

Endoscopic retrograde cholangiopancreatography (ERCP): A procedure used to x-ray the ducts (tubes) that carry bile from the liver to the gallbladder and from the gallbladder to the small intestine. Sometimes pancreatic cancer causes these ducts to narrow and block or slow the flow of bile, causing jaundice. An endoscope (a thin, lighted tube) is passed through the mouth, oesophagus, and stomach into the first part of the small intestine. A catheter (a smaller tube) is then inserted through the endoscope into the pancreatic ducts. A dye is injected through the catheter into the ducts and an x-ray is taken. If the ducts are blocked by a tumour, a fine tube may be inserted into the duct to unblock it. This tube (or stent) may be left in place to keep the duct open. Tissue samples may also be taken.

Percutaneous transhepatic cholangiography (PTC): A procedure used to x-ray the liver and bile ducts. A thin needle is inserted through the skin below the ribs and into the liver. Dye is injected into the liver or bile ducts and an x-ray is taken. If a blockage is found, a thin, flexible tube called a stent is sometimes left in the liver to drain bile into the small intestine or a collection bag outside the body. This test is done only if ERCP cannot be done.

Biopsy: The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. There are several ways to do a biopsy for pancreatic cancer. A fine needle may be inserted into the pancreas during an x-ray or ultrasound to remove cells. Tissue may also be removed during a laparoscopy (a surgical incision made in the wall of the abdomen).

Certain factors affect treatment options and prognosis (chance of recovery).
The treatment options and prognosis (chance of recovery) depend on the stage of the cancer (the size of the tumour and whether the cancer has spread outside the pancreas to nearby tissues or lymph nodes or to other places in the body) and the patient’s general health. Lymph nodes are small, bean-shaped structures found throughout the body. They filter substances in a fluid called lymph and help fight infection and disease.

Pancreatic cancer can be controlled only if it is found before it has spread, when it can be removed by surgery. If the cancer has spread, palliative treatment can improve the quality of life by controlling the symptoms and complications of this disease.

Tests and procedures to stage pancreatic cancer are usually done at the same time as diagnosis.

The following stages are used for pancreatic cancer:

Stage I

In stage I, cancer is found in the pancreas only. Stage I is divided into stage IA and stage IB, depending on where the cancer has spread.

• Stage IA: Cancer is found only in the pancreas and is 2 centimetres or less in size.
• Stage IB: Cancer is found only in the pancreas and is greater than 2 centimetres in size.

Stage II

In stage II, cancer may have spread to nearby tissue and organs, and may have spread to lymph nodes near the pancreas. Stage II is divided into stage IIA and stage IIB, depending on where the cancer has spread.

• Stage IIA: Cancer has spread to nearby tissue and organs but has not spread to nearby lymph nodes.
• Stage IIB: Cancer has spread to nearby lymph nodes and may have spread to nearby tissue and organs.

Stage III

In stage III, cancer has spread to the major blood vessels near the pancreas, such as the celiac axis (the junction where the celiac artery branches off from the aorta, just below the diaphragm) and the superior mesenteric vein (the vein that returns blood from the rectum and colon to the heart) and aorta, and may have spread to nearby lymph nodes.

Stage IV

In stage IV, cancer may be of any size and has spread to distant organs, such as the liver, lung, and peritoneal cavity (the body cavity that contains most of the organs in the abdomen (such as the lungs). It may have also spread to organs and tissues near the pancreas or to lymph nodes.

There are different types of treatment for patients with pancreatic cancer.

Different types of treatment are available for patients with pancreatic cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the “standard” treatment, the new treatment may become the standard treatment.

Three types of standard treatment are used:

Surgery
One of the following types of surgery may be used to take out the tumour:

• Whipple procedure: A surgical procedure in which the head of the pancreas, the gallbladder, part of the stomach, part of the small intestine, and the bile duct are removed. Enough of the pancreas is left to produce digestive juices and insulin.
• Total pancreatectomy: This operation removes the whole pancreas, part of the stomach, part of the small intestine, the common bile duct, the gallbladder, the spleen, and nearby lymph nodes.
• Distal pancreatectomy: The body and the tail of the pancreas and usually the spleen are removed.

If the cancer has spread and cannot be removed, the following types of palliative surgery may be done to relieve symptoms:

• Surgical biliary bypass: If cancer is blocking the small intestine and bile is building up in the gallbladder, a biliary bypass may be done. During this operation, the doctor will cut the gallbladder or bile duct and sew it to the small intestine to create a new pathway around the blocked area.
• Endoscopic stent placement: If the tumour is blocking the bile duct, surgery may be done to put in a stent (a thin tube) to drain bile that has built up in the area. The doctor may place the stent through a catheter that drains to the outside of the body or the stent may go around the blocked area and drain the bile into the small intestine.
• Gastric bypass: If the tumour is blocking the flow of food from the stomach, the stomach may be sewn directly to the small intestine so the patient can continue to eat normally.

Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly in the spinal column, a body cavity such as the abdomen, or an organ, the drugs mainly affect cancer cells in those areas. The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Other types of treatment are being tested in clinical trials.

Biologic therapy
Biologic therapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defences against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

There are treatments for pain caused by pancreatic cancer.

Pain can occur when the tumour presses on nerves or other organs near the pancreas. When pain medicine is not enough, there are treatments that act on nerves in the abdomen to relieve the pain. The doctor may inject medicine into the area around affected nerves or may cut the nerves to block the feeling of pain. Radiation therapy with or without chemotherapy can also help relieve pain by shrinking the tumour.

Patients with pancreatic cancer have special nutritional needs. Surgery to remove the pancreas may interfere with the production of pancreatic enzymes that help to digest food. As a result, patients may have problems digesting food and absorbing nutrients into the body. To prevent malnutrition, the doctor may prescribe medicines that replace these enzymes.

Treatment Options By Stage
Stage I Pancreatic Cancer
Treatment of stage I pancreatic cancer may include the following:

Surgery alone.
Surgery with chemotherapy and radiation therapy.
A clinical trial of surgery followed by radiation therapy with chemotherapy. Chemotherapy is given before, during, and after the radiation therapy.

Stage IIA Pancreatic Cancer
Treatment of stage IIA pancreatic cancer may include the following:

Surgery with or without chemotherapy and radiation therapy.
Radiation therapy with chemotherapy.
Palliative surgery to bypass blocked areas in ducts or the small intestine.
A clinical trial of surgery followed by radiation therapy with chemotherapy. Chemotherapy is given before, during, and after the radiation therapy.
A clinical trial of radiation therapy combined with chemotherapy and/or radiosensitizers (drugs that make cancer cells more sensitive to radiation so more tumor cells are killed), followed by surgery.
A clinical trial of chemotherapy.
A clinical trial of radiation therapy given during surgery or internal radiation therapy.

Stage IIB Pancreatic Cancer
Treatment of stage IIB pancreatic cancer may include the following:

Surgery with or without chemotherapy and radiation therapy.
Radiation therapy with chemotherapy.
Palliative surgery to bypass blocked areas in ducts or the small intestine.
A clinical trial of surgery followed by radiation therapy with chemotherapy. Chemotherapy is given before, during, and after the radiation therapy.
A clinical trial of radiation therapy combined with chemotherapy and/or radiosensitizers (drugs that make cancer cells more sensitive to radiation so more tumor cells are killed), followed by surgery.
A clinical trial of chemotherapy.
A clinical trial of radiation therapy given during surgery or internal radiation therapy.
Stage III Pancreatic Cancer
Treatment of stage III pancreatic cancer may include the following:

Surgery with or without chemotherapy and radiation therapy.
Radiation therapy with chemotherapy.
Palliative surgery or stent placement to bypass blocked areas in ducts or the small intestine.
A clinical trial of surgery followed by radiation therapy with chemotherapy. Chemotherapy is given before, during, and after the radiation therapy.
A clinical trial of radiation therapy combined with chemotherapy and/or radiosensitizers, followed by surgery.
A clinical trial of chemotherapy.
A clinical trial of radiation therapy given during surgery or internal radiation therapy.

Stage IV Pancreatic Cancer
Treatment of stage IV pancreatic cancer may include the following:

Chemotherapy.
Palliative treatments for pain, such as nerve blocks, and other supportive care.
Palliative surgery or stent placement to bypass blocked areas in ducts or the small intestine.
Clinical trials of chemotherapy or biological therapy.
Treatment Options for Recurrent Pancreatic Cancer
Treatment of recurrent pancreatic cancer may include the following:

Chemotherapy.
Palliative surgery to bypass blocked areas in ducts or the small intestine.
Palliative radiation therapy.
Other palliative medical care to reduce symptoms, such as nerve blocks to relieve pain.
Clinical trials of chemotherapy or biological therapy.

BACK

A colostomy, or stoma, is an artificial opening created when a healthy part of your large bowel is brought out onto the surface of your abdomen.

What does the large bowel do?
Your bowel is a hollow tube coiled up in your abdomen. It is a part of the gut, which breaks down the food you eat into protein for growth, and energy.

When the food has been digested, waste products pass into the large bowel. In the colon, the first part, water is absorbed back into the body. The waste products become more solid and are passed out of the body through the rectum (back passage) as faeces or stools.

What happens when a colostomy is formed?
When a colostomy is formed your stools will be passed through the stoma instead of through your rectum. The stoma has no muscle control and you will wear an appliance (bag) to collect the stools.

What does a colostomy look like?
The colostomy may be oval or round in shape. It is similar in colour to the lining to the lining of your mouth. The stoma will be about two finger breadths across - three to four centimetres. It may be swollen at first but this will settle in about seven to 10 days.

Although the stoma may stand out a couple of centimetres from the surface of your abdomen, other people won't notice this when you are dressed.

Are there different types of colostomy?
Yes, a colostomy may be temporary or permanent.

A temporary colostomy may be formed to:

• relieve a blockage in the bowel. Other treatment may be given to remove the blockage and start the bowel working normally again.
• rest your bowel and allow healing to take place after an operation.

A permanent colostomy will be formed if a cancer is sited low in your rectum and there isn't enough bowel left to join together after the tumour has been removed.

Examinations of your bowel
There are several ways in which the doctor can examine your bowel. Whatever examination is used your bowel will need to be prepared. It must be as empty as possible so that the doctor can get a clear view inside.

What happens before the operation?
You will usually be admitted to hospital two or three days before your operation. This gives you time to get used to the ward and to meet the staff who will be looking after you.

You will usually be given a light diet for 24 hours, followed by fluids only for the next 24 hours in the two days before your operation. You will then be asked not to eat or drink for several hours.

You will be given a laxative and / or enema to make sure your bowel is empty

A stoma care nurse will visit you. S/he is a specialist nurse trained to help people with colostomies. The nurse will mark the site of your colostomy on your abdomen with a pen. The site will be discussed with you to make sure it is an easy place for you to manage, for example to change your appliance. The nurse will also make sure that the site is away from your naval, hip bones and creases.

The stoma care nurse will show you some of the available appliances and may leave you a general information booklet. S/he can also discuss all aspects of your operation and any concerns you may have about how having a colostomy will affect your life.

What happens after the operation?
After your operation you will be taken to the recovery room. Here the nurses can check you closely while you are waking up. When the anaesthetist is satisfied with your condition, you will be taken back to your ward.

People experience pain in different ways and at different levels. If you do feel sore or uncomfortable, please tell the nurses straight away. They can give you some analgesia (pain relief) and, if you are felling sick, some anti-emetic (anti-sickness) drugs. During your operation the surgeon has to handle your bowel and, because of this, it takes some time to start working normally again. You won't be able to drink or eat at first but gradually you will begin to take fluids and food again. You will probably be eating normally seven to ten days after your operation.

You will also have a thin tube inserted up your noise and down into your stomach. This is to drain off any fluid and stop you from being sick. It won't affect your ability to speak. You will be given fluids, and any drugs you need, by an infusion ('drip') into a vein, usually in your arm. This will stay in place for a few days until you are able to drink normally again. A catheter (tube) will be placed in your bladder to drain away urine and prevent you from becoming uncomfortable. This won't be left in place any longer than necessary.

When any tissue is cut it is normal for blood and fluid to be produced. You may have a wound drain (tube) in place to remove this. Your wound will be stitched together and your nurse will tell you when the stitches can be removed. If you have had your rectum removed, your back passage may be stitched together or a wound drain may be in place. The drain will be removed after a few days. A little discharge or bleeding may continue for several weeks while the area is healing. You will be encouraged to get up and move around, with help, within 24 hours of your operation.

Care of your colostomy
Your colostomy may be swollen for the first week or 10 days because your bowel was handled during the operation. For the same reason your colostomy may not function for a few days. However, you may pass wind in the bag which means your bowel is recovering.

At first the nurses will look after your colostomy and then they will teach you to do this. Gradually you will learn how to change your bag, dispose of used ones and care for your skin. You will be able to select an appliance which suits you.

You will be able to go home when you feel confident changing your bag and looking after your colostomy, and after your stitches have been removed. Your colostomy will continue to shrink in size during the six weeks after your operation.

How am I likely to feel?
Many people find it takes time, and support from others, to adjust to living with a stoma. As well as this, you may be experiencing many different emotions following your diagnosis of cancer.

Your feelings may change from day to day and it isn't unusual to have 'up' days and 'down' days. It may take several weeks or months to feel you have really adjusted physically and emotionally to what has happened. After any operation people often feel tired and sometimes depressed or low. This is normal.

Some people say they lost their self confidence at this time, either related to life in general or feelings about the change to their body caused by the formation of the stoma. If you feel like this, talk to your partner or others close to you. A lot of people say this has helped them to regain their confidence and to realise they are the same person as before their operation and valued as such.  All these reactions are normal.

Will I look different?
You may be concerned that you'll look different after the formation of your stoma. Don't worry, it's unlikely that people will know about your operation unless you tell them. There is no reason why you should need to change your wardrobe or buy different clothes. Occasionally some change may be necessary if you have a transverse colostomy because of the position of the stoma. Specialist swim wear is available but, again, may not be necessary.

What about my usual activities?
Having a colostomy shouldn't prevent you from doing many of the things you did before your operation. In fact the formation of your stoma may relieve symptoms and you may be able to do more. However, other effects of your cancer and your general health may limit your activities.

During the first few weeks after your operation don't overdo things. Don't do energetic activities such as shopping, lifting heavy items, using a vacuum cleaner or gardening for at least six weeks. Accept offers of help from family and friends. Try to take some gentle exercise each day and increase this gradually, for example walking. Take care not to overtire yourself and make sure you get enough rest. If you used to play sports regularly, you shouldn't start again for at least six weeks. Ask your doctor or stoma care nurse what you can and can't do.

If you were working before your operation, you will probably be able to return after six or eight weeks. You may choose to work part-time at first. If you're not sure about when you can return, perhaps because of the type of job you do, check with your doctor. After any big operation it takes a while for your concentration and reflexes to return as normal. Don't start driving again without checking with your doctor that it's all right to do so.

You should be able to go on holiday as before, including travelling abroad. Remember to take extra supplies of your appliances in case you develop "holiday tummy". Always carry supplies in your hand luggage in case of emergency.

What about eating and drinking?
You should be able to eat a wide variety of foods although you may find that some foods upset you. Most people do make some changes to their diet.

Your cancer, previous treatment or the reasons why you needed a stoma may mean you have to follow a special diet. You will be given advice as necessary.

There is no reason why you shouldn't drink alcohol in moderation. However some people choose to avoid beer and other carbonated (fizzy) drinks because these can cause wind.

If you have any problems or questions about diet, speak to your stoma care nurse or ask to see the dietician.

What about sex?
Your general health, the stress of your illness or the after effects of your operation may affect your ability to have intercourse. If you have questions about his, speak to your stoma care nurse. You may resume sexual activity about six weeks after your operation, if you wish to. Many people find their libido (sex drive) decreases. If you do lose interest in sex, don't worry - this isn't unusual.

You may be more tired than usual. If this is a problem, you may want to set aside time for physical intimacy after a period of rest. Following your operation you may need to try different sexual positions until you find one which is comfortable for both of you. Loss of confidence and a change in the way you see yourself may affect your sexual relationship. Again, this isn't unusual - you may find it helps to talk to your partner about your feelings.

If you have had your rectum removed the tissues nearby may be affected. You may find it difficult to have intercourse.

For men: You may have difficulty gaining or maintaining an erection. This can be embarrassing and difficult to discuss such a personal subject or try to ignore the problem. However, your doctor or stoma care nurse is used to discussing these problems and even if they are unable to help you themselves, they can refer you to someone who can. Your partner can also be present, if you wish.

For women: Your vagina may be scarred and narrowed. This may make intercourse difficult and painful. You may find it embarrassing to talk about such a personal subject. However, your doctor or stoma care nurse is used to discussing these problems and even if they are unable to help you themselves, they can refer you to someone who can. Your partner can also be present, if you wish.

Remember enjoyable sex needn't depend on intercourse alone. There are other ways of showing love and sharing pleasure.

USEFUL INFORMATION POINTS

British Colostomy Association
15 Station Road
Reading
RG1 1LG

Tel: 0033 173 439 1537 WEBSITE

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