Diagnosis of bowel cancer

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According to the information of National Cancer Research Institute, presented at the Cancer Conference in 2017, about one third of all patients are diagnosed with bowel cancer only after an emergency hospital visit. Most of theses patients are admitted to the hospital due to red flag cancer symptoms, such as massive rectal bleeding, severe anemia or bowel obstruction and subsequent change in bowel habits. A late diagnosis leads to a worse prognosis, which means that the outcome of the disease after all possible treatment will still be poor. Actually, the stage of the disease at the time of the start of treatment is one of the most important predictors of long-term survival and good quality of life.

The main aim of the specialists in the field of oncology is to ensure an early diagnosis of bowel cancer and appropriate staging of the disease. That is why patients and general practitioners now have more information about widespread cancer symptoms and bowel cancer diagnosis.

Content

1. Symptoms of bowel cancer and first appointment
2. Laboratory tests for bowel cancer diagnosis
3. Instrumental examination for bowel cancer diagnosis
4. Biopsy for bowel cancer diagnosis
5. Screening programs for bowel cancer
6. Choosing an appropriate clinic for bowel cancer diagnosis

Symptoms of bowel cancer and first appointment

At early stages cancer may not cause certain and obvious symptoms. This means that you should pay particular attention to your physical state in order to notice the disease in due time. The most successful bowel cancer diagnosis stories start from timely preventive examination and referral to oncologist. You should not be embarrassed to tell doctor about all your symptoms in a great detail. To be precise during the appointment you may prepare at home – just write down important complaints and your questions. At the beginning this kind of cancer can be clinically similar to different pathological conditions, including acute appendicitis, neurological disorders, and gynecological pathology. In certain cases you will need coordinated work of a multidisciplinary team to establish or exclude the diagnosis. You may go through numerous investigations, nevertheless, correct diagnosis and effective treatment is worth this.

There are the main symptoms that should make you visit your general practitioner in order to give a correct diagnosis of bowel cancer :

• Constant chronic pain or expressed discomfort in different parts of abdomen or back passage
• Unexplained change in bowel habits (diarrhea or constipation up to bowel blockage by a tumor)
• Feeling of not empty bowel after the defecation
• Acute rectal bleeding, presence of blood in stools or on the toilet paper
• Weight loss despite normal feeding
• Fatigue, shortness of breath and dizziness (due to anemia)

Nevertheless, all the above symptoms are not unique just for bowel cancer, so you should not be scared in advance.

For example, such frightening sign as rectal bleeding may accompany numerous non-cancer conditions such as:

• Hemorrhoids (usually you know about this diagnosis, so you should plan regular visits to your proctologist)
• Anal fissures (this condition is usually accompanied by acute pain, you will need an urgent consultation in the surgical department)
• Infections and inflammatory diseases of the bowel
• Acute and chronic ulcers, especially in the left part of the bowel
• Diverticular disease of the bowel (this is usually a congenital condition)
• General problems with blood vessels and blood coagulation

Telling  your doctor about your complaints and symptoms is the first important step. The doctor totally understands your concerns and will give you maximum attention at this point. He may ask you additional questions in order to understand your situation more clearly. After discussing the entire clinical picture, the doctor will proceed further with the examination.

The next steps will include:

1. Family history taking. It is important to establish if you are a part of the high-risk group or not. In general, risk is more significant if your close relatives have had a diagnosis of bowel cancer or certain inherited conditions (for example, familial adenomatous polyposis).
2. General clinical examination. The doctor will perform all routine aspects of examination with special attention to your abdomen. No doubt, early stages of the disease will not show themselves during palpation of the abdomen, but in particular cases a doctor will be able to find the tumor. Also during the palpation bowel blockage by a tumor may be revealed, as well as localization and severity of pain syndrome.
3. Digital rectal examination. If the suspicion regarding bowel cancer diagnosis is present, the doctor will check your  rectum for pathological changes. Digital rectal examination is performed both in men and women. During this examination doctor inserts a gloved finger into your rectum and investigates all the available space. This investigation is helpful in revealing tumors and abnormal lymphatic nodes. You don`t need to prepare for the examination in advance. It may feel a little bit uncomfortable, but takes only few minutes.

After the initial conversation and clinical examination  the doctor will give you a short conclusion about the disease and further recommendations. You will receive information about your general state, presumable diagnosis (if it is possible at this point) and the next diagnostic steps. If it is necessary, ask to explain your situation in simple words, so that you`ll be able to understand everything perfectly.

According to the primary results, investigations for confirming or excluding diagnosis of bowel cancer may include such outpatient and inpatient procedures:

• Laboratory tests
• Instrumental examination
• Endoscopic examination
• Different types of CT/MRI
• Biopsy with histological and immunohistochemical study
• Genetic testing

 

Laboratory tests for bowel cancer diagnosis

The doctor will elaborate an individual diagnostic plan for your case, so you will go through most informative procedures. The first traditional diagnostic step is the laboratory examination. Some analyses will be performed repetitively, to track the dynamics during the course of treatment.

Recommended laboratory tests will include 2 main blocks of analysis:

1. General tests to check your overall state of health and body function.
2. Tests to find cancer and determine type of the tumor.

Laboratory tests are performed as an outpatient procedure. In order to receive reliable results you`ll need to fast for 9 hours before specimens of your blood and urine will be taken.

When preparing for fecal occult blood test (FOBT) you should pay attention to the following:

• Don`t take non-steroid anti-inflammatory drugs three days before the test
• Avoid excessive amounts of vitamin C three days before the test
• Avoid raw fruits and vegetables three days before the test
• Restrict amount of lamb, beef and blood products in your diet three days before the test (you may eat chicken and pork instead)

The main general laboratory tests used for the diagnosis of bowel cancer include:

• Complete blood count. This general test may reveal anemia (low amounts of hemoglobin connected with loss of blood) and a high erythrocyte sedimentation rate (ESR). These signs are not unique for bowel cancer, but give useful additional information and influence the treatment plan.
• Biochemical blood test. This test includes several aspects and reflects protein metabolism, blood lipid picture, functions of the liver and kidneys. It is important to perform biochemical blood test before the start of treatment so you`ll be able to track changes in the liver and kidneys function.
• Fecal occult blood test (FOBT). This test is a part of widespread screening program. Many bowel cancer diagnosis stories started from the positive result of screening test. FOBT reveals the tiniest, invisible amounts of blood in the stool and helps to find the disease during the early stages. FOBT is also useful for detecting non-cancer background conditions, such as polyps. The important point is you should follow all recommendations of your general practitioner and prepare for this test properly.
• Fecal calprotectin test. Calprotectin is a protein, produced by white blood cells (leukocytes). Production of this protein is mainly stimulated by inflammation in the digestive tract. Oncological process damages wall of the intestine and the level of calprotectin in the stool increases dramatically. You may not go through this additional test in case FOBT gives strong positive result.

More specific for the diagnosis of bowel cancer tests include tumor markers analysis. There are two main types of tumor markers. The first one is produced by the tumor or is a part of the tumor. The second one is produced by the human body as a response to the cancer process.

Currently healthcare professionals give preference to the following analysis:

• Carcinoembrionic antigen (CEA), blood test. CEA is a protein, normally produced in the gastrointestinal tract of the fetus. In adults CEA level remains low, except for certain types of cancer. More than 60 % of patients with the diagnosis of bowel cancer have high levels of CEA during laboratory examination. Nevertheless, CEA test is mainly used not for establishing primary diagnosis, but for the assessment of treatment quality, making prognosis regarding expectancy of life and early revelation of cancer relapses. Also we should notice that CEA test may give false-positive results in case of smoking or pregnancy.
• Cancer antigen 19-9 (CA 19-9), blood test. This test is helpful when the doctor is suspicious regarding both bowel cancer and pancreatic cancer. The level of CA 19-9 is elevated in case of pancreatic cancer, this marker is not typical for the diagnosis of bowel cancer.

Modern science is still looking for precise blood screening test for the bowel cancer diagnosis. At this point the most successful variant is blood test by biomedicine company Universal Diagnostics. The test estimates about 30-40 parameters – both biomarkers released by cancer cells and specific changes in protein/fat/carbohydrates metabolism related to the oncological process.

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Instrumental examination for bowel cancer diagnosis

The next set of diagnostic tests includes instrumental examination. Usually you will need more than one investigation to receive a comprehensive clinical picture. The doctor will explain to you the necessity of each procedure and it`s possible risks. Most instrumental investigations of the abdomen require preliminary bowel preparation. This ensures the possibility of receiving more reliable results and improving their quality significantly.

Below you can find the most effective ways of bowel preparation:

• Diet. Three days before the examination is done you should avoid high-fiber foods (raw vegetables and fruits, seeds, cereals).
• Fermentative drugs intake. Drugs that contain gastro-intestinal ferments will ease the process of food digestion, reduce amount of food remains in the bowel and suppress excessive formation of intestinal gas.
• Laxative drugs. The doctor may recommend you to take this kind of drug 12-18 hours before the test. Laxative drugs cause watery diarrhea and clear the bowel content this way. To make the period of active drug action more comfortable, you should plan your time and stay at home. You should also drink a lot of clear fluids to prevent dehydration (pathologic water loss).
• Enema. During this procedure small amount of special liquid is put in your rectum to clear lower part of the intestine before the examination for bowel cancer diagnosis.

The most simple and non-invasive way to assess the state of abdomen organs is ultrasound (US) examination. In the US, this examination is an outpatient procedure. You should prepare your bowel in advance according to doctor`s recommendations and fast for 9-12 hours. In the US scans show the tumor itself or reveal indirect signs of oncological process. The doctor (sonographer) should be qualified enough to perform the procedure in a proper way, as US examination is quite subjective. If the doctor suspects colorectal cancer, he may perform rectal ultrasound with the help of a special probe.

Another procedure, aimed to confirm or exclude the diagnosis of colorectal cancer, is proctoscopy. It gives the possibility to examine rectum and lower part of colon (sigmoid colon) directly. Proctoscopy is performed with the help of proctoscope, a metal or plastic hollow tube about 15-25 cm long with small light bulb at the end. At the beginning of the manipulation; lubricated proctoscope is placed into the rectum and small amount of the air is pumped inside to enlarge the rectum. During the procedure your doctor will carefully examine the intestinal wall and take a biopsy from the suspected areas, if necessary. Proctoscopy is a little bit uncomfortable, but a well tolerated procedure. It is performed as an outpatient procedure and doesn`t require anesthesia.

Flexible sigmoidoscopy is widely used for bowel cancer diagnosis, as it helps to examine the rectum and lower part of the large bowel in a greater detail. Majority of polyps with increased oncological alertness are located exactly in these areas. Sigmoidoscopy requires proper preparation, including special diet, drugs and enema. The procedure is performed with the help of a long flexible tube with a small camera and light. Your doctor sees the intestine wall on the monitor, in addition he is able to take a biopsy from the suspicious areas, if indicated clinically. It is important to tell your doctor about all possible contraindications to biopsy taking (for example, blood clotting disorders) before the procedure is started. Sigmoidoscopy is quite uncomfortable, so the anesthesia may be administered. Nevertheless, the procedure takes only about 15-20 minutes and you may go home immediately after everything is finished.

Colonoscopy is a more advanced endoscopic examination as it covers the entire large bowel. In general, the technique is similar to the sigmoidoscopy; the main difference is in the length of sigmoidoscope and colonoscope. When we talk about colonoscopy, thorough preparation is really significant, as a poor state of the bowel may cause serious mistakes (for example, missing small polyps, etc.). The procedure is comprehensive in establishing diagnosis of bowel cancer, that is why it takes about an hour and requires sedation. Your doctor will check if you tolerate the anesthetic well and give you all the necessary medications. During colonoscopy the doctor examines the state of the bowel wall, makes photos and takes a biopsy. If necessary, dye may be sprayed onto the bowel wall – this shows abnormal and suspicious areas. Such manipulation is called chromoscopy. Colonoscopy is an outpatient procedure, you will be able to go home once the effect of anesthesia wears off.

If medical contraindications are present, colonoscopy may be substituted with similar non-invasive examination – computed tomography (CT) colonography. Another name of this investigation is virtual colonoscopy. Preparation for the procedure includes the same measures as preparation for the colonoscopy. In addition, you will take the contrast substance (gastrografin) which enhances efficiency of the investigation. During the CT colonography your bowel will be filled with gas, after that doctor will get a series of a few images from your back and front. On the basis of this information 3D picture of your bowel will be constructed.

CT colonography is not used often due to a few reasons:

• Procedure includes exposition to the radiation
• Procedure has lower accuracy in comparison with colonoscopy
• It is impossible to take biopsy during the investigation
• Procedure is not available in all hospitals

CT and MRI scans with contract (dye substance) give your doctor information about general state of abdominal organs, localization and size of the tumor and spreading of oncological process (presence of metastases). Also CT/MRI of the chest may be required for the assessment of cancer spreading. CT and MRI in terms of bowel cancer diagnosis have all the usual limitations; don`t forget to inform your doctor about an allergy, pregnancy, diabetes mellitus or problems with kidneys and liver.

One of the most specific investigations is FDG-PET (fluorodeoxyglucose-positron-emission-tomography). Before FDG-PET you will take substance with special modified glucose molecules. Glucose is the main source of energy for most cells. Oncological cells have very active metabolism and thus cumulate significant number of contrast substance. Due to modification glucose molecules are perfectly seen on the PET scan, their focuses reflect presence, localization and size of the tumor.

Once you go through all recommended investigations, your doctor will tell you all the results and explain them in simple words.

Biopsy for bowel cancer diagnosis

Biopsy with histological and immunohistochemical study remains golden standard in establishing the diagnosis of bowel cancer. Laboratory tests, endoscopic and visualizing techniques give the doctor important information, but the biopsy is an obligatory option when it concerns cancer. Results of the biopsy are the basis for choosing a treatment regimen and making individual prognosis.

Tissue samples for histological and immunohistochemical study may be taken:

• During endoscopic examination (proctoscopy, sigmoidoscopy, colonoscopy)
• During surgery (express biopsy) or after the completion of surgical intervention
• In certain cases – via fine needle biopsy with CT or ultrasound control

Pathologist, who is keen on oncological diseases, analyses all the samples under the microscope. In addition, molecular testing of the tumor may be performed in order to determine unique gens and superficial tumor proteins. The more information the doctor has, more specific and effective treatment he will be able to prescribe in accordance with the individual’s needs. In case the clinic has technical background for genetic testing, more profound analysis is performed.

During genetic testing doctor investigates peculiarities of the tumor and possible problems in your genome, such as:

• DNA ploidy – this is an amount of genetic material in oncological cells
• P53 gene – this gene is often absent or broken in cancer cells
• Ras gene – this gene is often damaged in colorectal cancer
• Genetic testing for FAP (familial adenomatous polyposis) – this condition is often connected with the diagnosis of bowel cancer

Unlike laboratory tests and instrumental investigations, results of biopsy and genetic testing are ready in 2 weeks or even later. When medical reports are ready, your doctor will contact you immediately and discuss further diagnostic and treatment plan.

Screening programs for bowel cancer

Early diagnosis of bowel cancer and timely treatment significantly improves prognosis and full recovery rates. That is why screening tests become more popular and widespread.

Optimal screening tests should correspond to general requirements:

• Be reliable
• Be easy in performing
• Be quick
• Cause no harm or have significant benefits, that outweigh possible risks

Screening programs primarily include people over 50 years old, as risk of developing bowel cancer increases with age.

Modern screening program consists of two blocks:

1. Fecal occult blood test (FOBT) or fecal immunochemical test for calprotectin. FOBT is typically performed once per year. It should be noted, that this test may be negative in patients with cancer or give false-positive results. The most common causes of false-positive FOBT results are reached with red meat and blood products diet, dental manipulations, problems with blood clotting, etc.
2. Flexible sigmoidoscopy every 5 years. If the procedure reveals presence of a polyp, it is removed and referred to histological study. After the initial biopsy doctor performs more informative procedure – colonoscopy.

People of high risk groups may go through screening tests earlier and start from colonoscopy avoiding flexible sigmoidoscopy.

Main causes of bowel cancer increased risk are the following:

• Familial adenomatous polyposis (healthcare professionals even advise such patients to remove large bowel by the age of 25, as the risk is really significant)
• Family history of bowel cancer diagnosis, especially when we are talking about close relatives
• Ulcerative colitis
• Crohn's disease

Additional factors, which may increase risk in this group even more, are:

• Poor with fibre and reach with red meat diet
• Overweight and obesity
• Low physical activity

You may take part in the screening program even if you don`t have any threatening symptoms. Your wish to take care about your health is enough to be referred to the test.

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Choosing an appropriate clinic for bowel cancer diagnosis

Timely and precise diagnosis of bowel cancer depends on the availability of laboratory tests, instrumental investigations and qualified healthcare professionals. Skilled doctors will notice the most intricate signs of the disease, while tests will provide him with all necessary information. When choosing a clinic for screening or more profound examination you should take into consideration all of these aspects. Nowadays many patients seek medical help abroad in order to go through more precise diagnosis and effective subsequent treatment. When talking about bowel cancer diagnosis, particular attention should be paid to Germany. For more than 20 years German clinics have been admitting foreign patients for comprehensive check-ups in the sphere of oncology. Leading German clinics update equipment every 6 months or even more often; all doctors constantly improve practical skills and refresh their knowledge.

In certain cases you may need medical and organizational support at the stage of planning your trip. For example, you may need competent advice regarding the hospital choice, as it may be difficult to select the most appropriate  hospital for your case; institution between private gastroenterological practices and university hospitals. Another point is the language barrier and arranging all investigations into one comprehensive program.

In such situation the trusted services of Booking Health company will be really helpful for you. The aim of our work is to assist foreign patients in receiving medical care in Germany, and we are officially authorized by clinics to provide such services.

Booking Health will give you a helping hand and:

• Recommend the best doctor and clinic for your case
• Book an appointment at a convenient date
• Organize comprehensive medical program
• Provide you with transfer, interpreter and medical coordinator
• Provide you with medical insurance
• Prepare for you all the medical reports and further recommendations
• Help you in further communication with your treating physician

To start planning your medical trip leave a request on the web-site of Booking Health company. You will be contacted by our patient case manager the same day to discuss all the details. We will be glad to help you in maintaining and improving your health.

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Choose treatment abroad and you will for sure get the best results!

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Authors:

The article was edited by medical experts, board certified doctors Dr. Nadezhda Ivanisova and Alexandra Solovey. For the treatment of the conditions referred to in the article, you must consult a doctor; the information in the article is not intended for self-medication!

 

Sources:

American Cancer Society

National Center for Biotechnology

Cancer. Net

 

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