Colorectal Cancer

Content written by Don S. Dizon, MD

Colorectal cancer affects over 148,000 people each year and will cause almost 50,000 deaths on an annual basis.[American Cancer Society. Colorectal Cancer Facts & Figures 2008-2010. Atlanta: American Cancer Society, 2008] In the United States it is the third most common cancer diagnosed and third most common cause of death from cancer. For most patients, treatment will begin with surgical resection of the primary disease. This may entail removal of the involved bowel by an open abdominal procedure (also known as an abdominoperineal resection) or, if low or involving the rectum, the low anterior resection. In some cases, the anus may need to be removed, in which case patients would have a loop of bowel brought forward to empty via a stoma created on the abdominal wall, known as a colostomy. This may or may not be permanent. Following surgery, chemotherapy, radiation, or both may be employed with curative intent.

RISK FACTORS FOR SEXUAL DYSFUNCTION

That patients treated for colorectal cancer suffer from sexual dysfunction is well documented to impact anywhere between 18 and 50% of patients.[Quah HM, Jayne DF, Eu KW, et al. Br J Surg 2002; 89:1551-6] Most of the available literature has emphasized the surgical impact on sexual dysnfuction with data indicating that for women, resection of the rectum is tied to an increased incidence of sexual dysfunction.[Bohn G, Kirschner-Hermanns R, Decius A, et al. Int J Colorectal Dis 2008; 23:893-900] This is also consistent with the differential report of sexual dysfunction by survivors of colon cancer versus rectal cancer where in one study the incidence was 39% vs. 76%, respectively.[DiFabio F, Koller M, Nascimbeni R, et al. Tumori 2008; 94:30-35]

The types of surgery will vary depending on the location of the primary tumor but can require abdominoperineal resection, anterior resection, total mesorectal excision, and may require the formation of a colostomy. Historically, surgery was a major factor that impacted subsequent sexual function as older techniques did not take in to account neural supplies to the pelvic organs. Schmidt, et al. looked at the ten-year follow-up of patients treated for colorectal cancer and demonstrated that sexual dysfunction was worse in those who underwent an abdominoperineal resection.[Schmidt CE, Bestmann BE, Kuchler T, et al. Diseases of the Colon and Rectum 2005; 48:483-92] Among women, age was a risk for sexual problems with those 65 and under having more issues with sexuality than older women. In another study, compared to women who had not undergone surgery, women who had undergone pelvic surgery for rectal cancer were more likely to feel less attractive, have issues with vaginal penetration due to decreased elasticity or vaginal length shortening, eperience pain during intercourse, and complain of fecal incontinence with intercourse.[Platell CF, Thompson PJ, Makin GB. Br J Surg2004; 91:465-8] However, with refinement of technique aimed at preservation of the autonomic nerves, particularly in regards to the treatment of rectal cancer, more women are able to preserve sexual function. Havenga, et al. retrospectively looked at a cohort of 136 patients (54 were women) who underwent mesorectal excision with autonomic nerve preservation to assess both sexual and urinary function [Havenga K, Enker WE, McDermott K, et al. J Am Coll Surg 1996; 182:495-502] They found that 85% of women had preserved vaginal lubrication and 91% were able to achieve orgasm.

Other risk factors have not been examined sufficiently, but in at least one recent study, Tekkis et al. reported on data prospectively obtained from 295 women treated for rectal cancer.[Tekkis PP, Cornish JA, Remzi FH, et al. Dis Colon Rectum 2009; 52:46-54]. Again the type of surgey was tied to an increased incidence of sexual dysfuction with those undergoing abdominoperineal resection experiencing less sexual activity and more dyspareunia compared to those who had undergone an anterior resection. Other risk factors identified including the use of radiation therapy, a prior episode of intra-abdominal sepsis, and age over 65. Interestingly, the use of chemotherapy did not predict a higher incidence of sexual dysfunction.

TREATMENT

Among the most important aspects of treatment is the ability to recognize the problem. In fact, studies indicate that sexual dysfunction is potentially a late but long-term problem among colorectal cancer survivors.[Donovan KA, Thompson LM, Hoffe SE. Cancer Control 2010; 17:44-51] Managing these issues requires a thoughtful yet longitudinal approach, often best implemented in the context of a survivorship plan.

For patients with ostomies, the visual appearance of their bag, concerns regarding foul odors and spillage, may be distressing and affect one’s self esteem, inner spirit and limit their ability to pursue new friendships and sexual relationships. However, the four P’s of intimacy may be useful in establishing a new or re-establishing a closer sexual relationship (See Table 1). Before that, however, the acceptance that an ostomy may be permanent is the first step in overcoming these challenges. Preparing for social events by changing the bag frequently may alleviate some of the fear of accidents, and the use of specially designed odor controlling tablets that can be placed within the bag can help to minimize offensive odors. Dietary modifications may help reduce flatus and orders (table 2). For intimate encounters, pouch covers are available to mask the bag itself. Finally, choosing sexual positions that are comfortable and have minimal pressure on ostomy bags is encouraged. And finally, agreement that the goal of a sexual encounter is aimed at pleasure, and not performance, can help enhance intimacy and manage expectations.

DIETARY MODIFICATIONS FOR PATIENTS WITH OSTOMIES

Problem

Foods associated with increased risk

Obstruction/Ileus

Celery, coconut, corn, coleslaw, dried fruits, grapefruit, nuts, peas, popcorn, rice

Gas production/Odors

Legumes, cabbage, brussel sprouts, avocados, artichokes, asparagus, broccoli, spinach, melons, apples, prunes, cheese, fish, eggs, carbonated drinks

Diarrhea

Cabbage, green beans, buttermilk, applesauce, tapioca, boiled rice, milk, yogurt

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