Abramson Cancer Center

Most risk factors for rectal cancer, like age and family history, cannot be prevented. Patients who feel they are at risk may benefit from consulting with a risk assessment specialist within one of Penn Medicine’s gastrointestinal cancer risk evaluation programs.

Rectal Cancer Risk Factors

Risk factors affect the chance of getting rectal cancer. Having a risk factor, or even several, does not mean that someone will get cancer.

There are different kinds of risk factors. Some factors, like age or race, can't be changed. Some risk factors for rectal cancer include.

• Age. Most people diagnosed with rectal cancer are age 40 or older.
• Hereditary conditions. Having certain hereditary conditions such as familial adenomatous polyposis (FAP) and hereditary nonpolyposis colon cancer, HNPCC or Lynch syndrome.
• Personal history. Having a personal history of colorectal cancer, polyps or, endometrial or ovarian cancer.
• Family history. Having a parent, brother, sister or child with a history of colorectal or related cancer or polyps.
• Lifestyle. Studies suggest that being obese, smoking, excessive alcohol intake and eating a diet high in fat and red meat may play a role in rectal cancer development.

Rectal Cancer Prevention

• Quit smoking. Smoking or chewing tobacco can increase the risk of developing cancer. Patients can get help to stop smoking through Penn Medicine’s Lung Center or through a smoking cessation research program at the Abramson Cancer Center.
• Control weight. Maintaining a healthy weight with diet and exercise can help prevent cancer. 
• Get regular colonoscopies. Since most rectal cancers are found during a colonoscopy, it’s important for people who are at risk to get recommended screenings. Also, it is recommended people over the age of 50 get regular screenings.
• Know your family history. Knowledge of familial risk factors may change the frequency of colonoscopy testing, and lead to better detection of polyps in the precancerous stages. 

In addition to these preventative measures, there are several ongoing studies looking at how vitamins, hormones and other agents may help prevent cancer. Penn Medicine is a leader in cancer prevention. Visit the clinical trials to for available cancer prevention trials. 

Rectal Cancer Risk Assessment

People with a personal or familial history of colorectal cancer, or those with conditions that put them at risk may benefit from consulting with a genetic counselor to determine their risk of developing cancer.

Younger patients who develop rectal cancer sometimes have a family member or close relative who has a history of rectal cancer.

The Gastrointestinal Cancer Risk Evaluation Program at Penn Medicine offer knowledge about the presence of genetic risk factors for rectal cancer and provide patients with important, sometimes life-saving options.

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Symptoms of rectal cancer may be similar to other conditions. Patients with any of the following symptoms should visit their physician.

• Change in bowel habits including: diarrhea, constipation, feeling that the bowel has not completely emptied, stools that are narrow in shape
• Bright red, or dark blood in the stool
• Abdominal discomfort
• Change in appetite
• Losing weight without dieting
• Fatigue

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Staging systems provide doctors with a common language for describing tumors. After cancer is first diagnosed, a series of tests are used to investigate the extent of the cancer and to see whether it has spread to other parts of the body from where it started. Staging is a way of recording the size and growth of a cancer, and determining the plan for treatment. By understanding the stage of their cancer, patients can make informed decisions about their treatment.

Staging cancer attempts to discover the following:

• The size of the tumor
• Whether the cancer has spread to nearby tissues or lymph nodes
• Whether the cancer has spread to other parts of the body

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After being diagnosed with rectal cancer, patients at the Abramson Cancer Center may be evaluated through the Gastrointestinal Cancer Evaluation Center (GICEC). The center provides patients with expert support and evaluation to discuss treatment options and individualized treatment plans.

Patients with pancreatic cancer are treated by a multidisciplinary team of cancer specialists who see more patients with gastrointestinal (GI) cancers in one year than many doctors see in their careers.

The physicians of Penn Medicine’s GI cancer program are nationally recognized for their expertise in the diagnosis and treatment of cancer.

Penn’s GI cancer treatment team includes:

• Nationally recognized medical experts with years of experience in diagnosing and treating GI cancer.
• Nurses with advanced training and experience in caring for patients with GI cancer.
• Oncology Navigation Specialists to help patients navigate the health system.
• Registered dietitians to provide nutrition counseling.
• Cancer counselors to provide individual or family counseling for issues many cancer patients face.
• Rehabilitation therapists who specialize in the diagnosis and treatment of physical effects from cancer and its treatment.

Penn’s GI cancer program is also supported by a robust research program with immediate translation from bench to bedside.

Patients at Penn Medicine can benefit from participating in clinical trials. Patients interested in learning more about clinical trials should speak with someone on their treatment team.

Patient navigation Specialists

Every step of cancer treatment; from a cancer diagnosis, to surgery and treatment to forming a survivorship plan; comes with different needs and issues that should be addressed.

Oncology Navigation Specialists at the Abramson Cancer Center are available to make a patient’s experience as seamless as possible. As experts in navigating complex health care situations, patient support specialists serve as a consistent point of contact and a reliable source for advice, support and direction for patients and families. They can help in a variety of ways including; provide emotional support, identify resources, and ensure access to information, support services, educational programs and community resources.

Learn more about Oncology Navigation Specialists at the Abramson Cancer Center.

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A digital rectal exam is useful for detecting rectal cancers residing in the distal rectum, near the anus. In this test, the anus and lower rectum are examined. The physician or nurse inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else unusual. 

Most rectal cancer is found through a colonoscopy. During a colonoscopy, while the patient is under sedation, the physician places a thin, tube-like instrument with a light and a lens for viewing inside the rectum and colon. The scope also has a tool to remove polyps or tissue samples, which are checked for cancer in a lab.

Colonoscopies are recommended for men and women over the age of 50 as a standard preventive test. People at high risk for colon and rectal cancer or those with a family history of cancer should talk with their physicians about recommendations for screening.

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If physicians suspect rectal cancer, they might perform or order one or more of these tests to diagnosis and stage rectal cancer.

• Medical history and physical exam. An exam of the body to check general signs of health, including checking for signs of disease, and anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments is also taken.
• Digital rectal exam. The anus and rectum are examined by a physician or nurse inserting a lubricated, gloved finger into the lower part of the rectum to feel for abnormalities.
• Colonoscopy. Most rectal cancer is found through a colonoscopy. A colonoscopy is a procedure done while a patient is under sedation. The physician places a thin, tube-like instrument with a light and a lens for viewing inside the rectum and colon. The scope has a tool to remove polyps or tissue samples which are checked for cancer in a lab.
• Imaging tests. Pictures of the inside of the body can help find out whether a suspicious area might be cancerous, to learn how far cancer may have spread, and to help determine if treatment is working.
  • Endoscopic ultrasound (EUS). Ultrasound uses sound waves to create a picture of the internal organs. This procedure is often done at the same time as the upper endoscopy. The endoscopic ultrasound can show enlarged lymph nodes, which may indicate a tumor or advanced disease. EUS is an important tool for staging rectal cancer.
  • Chest X-ray. An X-ray is a type of energy beam that can go through the body creating a picture of areas inside the body. If rectal cancer is found, a chest X-ray may be done to determine if the cancer has spread to the chest.
  • Computed tomography (CT) scan. A CT scan creates a three-dimensional X-ray of the inside of the body. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. A CT scan is used to see if the tumor has spread beyond the rectum to other organs. Sometimes, a contrast medium (dye) is used to provide better detail.
  • Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body. The tumor absorbs the radioactive substance, and a scanner detects this substance to produce images.
  • Magnetic resonance imaging (MRI). Magnetic fields are used to create detailed images of the body. A contrast medium may be injected into a patient’s vein to create a clearer picture.
• Biopsy. When tests find a change that is possibly cancer, a sample of the suspicious area is removed and viewed under a microscope. A biopsy is the only way to tell if cancer is really present.
• Lab tests. A physician may order blood tests that measure the level of carcinoembryonic antigen (CEA) in the blood. CEA is released into the bloodstream from cancer and normal cells. When found in higher than normal amounts, it may be a sign of cancer.

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Staging is a way of describing a cancer. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's chance of recovery.

Staging cancer attempts to discover:

• The size of the tumor.
• Whether the cancer has spread to nearby tissues and lymph nodes.
• Whether the cancer has spread to other parts of the body.

The “staging diagnosis” for rectal cancer is as follows:

• Stage 0. Abnormal cells are found in the innermost layer of the rectum. Also called carcinoma in situ.
• Stage I. Cancer has formed in the innermost layer of the rectum and has spread to the next layer. Cancer may have spread to the muscle layer.  
• Stage II. One of the following
  • IIA. Cancer has spread through the muscle layer and to the outermost layer of the rectum
  • IIB. Cancer has spread through the outermost layer of the rectum but not to nearby organs.
  • IIC. Cancer has spread through the outermost layer of the rectum and to nearby organs.
• Stage III. One of the following:
  • IIIA.  Cancer may have spread through the two innermost layers and may have spread to the muscle layer. Cancer has spread to at least one but no more than three nearby lymph nodes or cancer cells have formed in tissues near lymph nodes. Or cancer has spread through the two innermost layers of the rectum. Cancer has spread to at least four, but no more than six nearby lymph nodes.
  • IIIB. Cancer has spread through the muscle layers to the outermost layer or has spread through the outermost layer but not to other organs. Cancer has spread to at least one but no more than three nearby lymph nodes, or cancer cells have been found in tissues near the lymph nodes. Or cancer has spread to the muscle layer of the rectum wall, or to the outermost layer. Cancer has spread to least four but no more than six nearby lymph nodes. Or, cancer has spread through the two innermost layers of the rectum and may have spread to the muscle layer. Cancer has spread to seven or more nearby lymph nodes.
  • IIIC. Cancer has spread through the outermost layer of the rectum but not to nearby organs. Cancer has spread to at least four but no more than six lymph nodes. Or, cancer has spread through the muscle layer into the outermost layer of the rectum, or has spread through the outermost layer but has not spread to nearby organs. Cancer has spread to seven or more lymph nodes. Or, cancer has spread through the outermost layer of the rectum and has spread to nearby organs. Cancer has spread to one or more lymph nodes of cancer cells have formed in the tissues near the lymph nodes.

• Stage IV. The cancer has spread (metastasized) from where it started to lymph nodes, nearby organs and distant parts of the body.
  • IVA. Cancer may have spread through the rectum wall and to nearby organs or lymph nodes. Cancer has spread to one organ that is not near the rectum or to a distant lymph node.
  • IVB. Cancer may have spread through the rectum wall and may have spread to nearby organs or lymph nodes. Cancer has spread to more than one organ that is not near the rectum or into the lining of the abdominal wall.

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Surgery is the most common treatment for all stages of rectal cancer. Unlike colon cancer, the rectum resides within the bony pelvis. Because of this, the treatment of rectal cancer differs from colon cancer substantially. The type of procedure recommended, and the addition of chemotherapy and radiation may be possible depending on the stage of the rectal cancer. It is very important to correctly stage, determine both local and distant spread, of rectal cancer before proceeding with surgery or other treatments.

Rectal cancer is divided into early and late or “advanced” stage.  Early stage rectal cancers are those that have not spread to the lymph nodes and are confined to the inner layer of the rectal wall.  Late stage rectal cancers have either spread through the wall of the rectum into the fat surrounding the rectum (mesorectum) or involve lymph nodes in the mesorectum. 

Early rectal cancer

If a rectal cancer is early, then several options may be open to the patient.  Some very small early rectal cancers can be removed through the anus through:

• Traditional open approach.
• Transanal endoscopic microsurgery (TEM)
• Endoscopic mucosal resection (EMR) 

This is called “local excision.” Typically, these cancers must be removed entirely with no tumor left behind. They must be “good risk” nonaggressive cancers to be treated with local excision and they may need additional chemotherapy and radiation added to the surgery to ensure optimal results. 

Small early stage rectal cancers that are located higher in the rectum must be taken out along with part or all of the rectum through an abdominal incision, either laparoscopically or in an open fashion. Consultation between the surgeon or gastroenterologist, the oncologist, and the radiation oncologist is typically made prior to making a final decision on treatment.

Late rectal cancer

Late or advanced stage rectal cancer simply refers to the fact that the tumor invades through the rectal wall or involves perirectal lymph nodes. Surgeons almost always pre-treat advanced rectal cancer with a combination of chemotherapy and radiation given simultaneously in order to reduce the size of the tumor and help prevent recurrence of the cancer in the area of the pelvis. 

Following radiation and chemotherapy, surgery to remove both the rectum and the surrounding lymph nodes is required. This can be done either laparoscopically or in an open fashion, and typically requires an abdominal incision.  The type of gastrointestinal reconstruction and need for a colostomy or ileostomy bag is based on the distance of the tumor from the anal sphincter muscle as well as individual patient characteristics.  

Resection

“Resection” refers to the removal of tissue.  If the cancer has spread into the wall of the rectum, the section of the rectum with the cancer and nearby healthy tissue is removed. Sometimes, the tissue between the rectum and the abdominal wall is also removed. The lymph nodes near the rectum are removed and checked under a microscope for signs of cancer.

Pelvic Exenteration

If the cancer has spread to other organs near the rectum, removal of the lower colon, rectum and bladder is possible. In addition, in women the uterus, cervix, vagina, ovaries and nearby lymph nodes may require removal. In men, the prostate may be removed. Colostomy or ileostomy for stool and urostomy for urine are created for urine and stool to flow from the body into a collection bag.

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Radiation oncologists at Penn Medicine are recognized for techniques that target radiation precisely to the disease site while sparing nearby tissue.

Radiation therapy may be given to patients with rectal cancer before surgery to shrink the tumor and make it easier to remove.

Proton therapy is currently used to treat recurrent tumors in the digestive tract. Penn Medicine is the only facility in the country treating gastrointestinal cancers in this way.

Radiation therapy uses high-energy radiation to kill cancer cells. A radiation therapy schedule usually consists of a specific number of treatments given over an extended period of time. In many cases, radiation therapy is capable of killing all of the cancer cells.

Three-dimensional Conformal Radiation Therapy

The imaging technology used by radiation oncologists at Penn Medicine helps shape the radiation treatment beam to the shape of the tumor. Conformal radiation therapy gives doctors more control when treating tumors.

Special computers use CT imaging scans to create 3D maps of the location of the cancer in the body. The system permits the delivery of radiation from several directions, and the beams can then be shaped, or conformed, to match the shape of the cancer. Conformal radiation therapy limits radiation exposure to nearby healthy tissue as well as the tissue in the beam's path.

Intensity-modulated Radiation Therapy (IMRT)

This advanced type of radiation therapy uses a computer-controlled device, called a linear accelerator, to deliver precise doses of radiation to tumors or specific areas within the tumors. Radiation therapy, including IMRT, stops cancer cells from dividing and growing, thus slowing or stopping tumor growth. In many cases, radiation therapy is capable of killing all of the cancer cells.

Using 3-D computed tomography (CT) images of the gallbladder along with computerized dose calculations, IMRT allows for the radiation dose to conform more precisely to the shape of the tumor by controlling, or modulating, the intensity of the radiation beam. The therapy allows higher radiation doses to be delivered to areas within the tumor while minimizing the dose to the surrounding area.

Volumetric-modulated Arc Therapy (VMAT)

Volumetric-modulated arc therapy (VMAT) is a type of specialized intensity modulated radiation therapy, or IMRT. VMAT delivers radiation by rotating the radiation machine, through one or more arcs while radiation is continuously delivered.

VMAT allows Penn radiation oncologists to treat complex cancers while minimizing exposure to surrounding healthy tissue. VMAT shortens radiation delivery time, and offers patient more comfort because it does not require patients to lie completely still for long periods of time.

Penn radiation oncologists use RapidArc™ radiotherapy technology to treat hard to reach tumors.

Proton Therapy

Penn Medicine is the only health care facility in the country that is using proton therapy to treat recurrent gastrointestinal tumors in clinical trials.

Penn Medicine's Roberts Proton Therapy Center is the largest and most advanced facility in the world for this precise form of cancer radiation. Patients have access to one of the most sophisticated weapons against cancer, seamlessly integrated with the full range of oncology services available at Penn Medicine. Proton therapy is external beam radiotherapy in which protons are directed at a tumor.

The radiation dose that is given through protons is very precise, and limits the exposure of normal tissues. This allows the radiation dose delivered to the tumor to be increased beyond conventional radiation. The result is a better chance for curing cancer with fewer harmful side effects.

Proton therapy, like all forms of radiation therapy, works by aiming the energized particles, in this case protons, onto the target tumor. The particles damage the DNA of cells, ultimately causing their death. Unlike X-rays, protons can be manipulated to release most of their energy only when they reach their target. With more energy reaching the cancerous cells, more damage is administered by each burst of radiation.

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Penn Medicine specializes in a team approach to treatment with interdisciplinary care and innovative approaches that use chemotherapy to target tumors prior to and after surgery.

Chemotherapy may be given to patients with rectal cancer before surgery to shrink the tumor and make it easier to remove.

Chemotherapy

Chemotherapy uses drugs to kill cancer cells. It is delivered through the bloodstream, targeting cancer cells throughout the body. Chemotherapy is usually delivered intravenously through a catheter, or orally by pill.

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Today, more and more people are surviving cancer. Clinical trials benefit patients with access to breakthrough therapies and treatments. These new advances in cancer treatment are occurring every day at Penn Medicine, giving patients hope that even greater discoveries lie ahead. Through clinical trials:

• Diagnosing cancer has become more precise.
• Radiation and surgical techniques have advanced.
• Medications are more successful.
• Combinations of medical, surgical and radiation therapy are improving treatment effectiveness and enhancing outcomes.
• Strategies to address the late effects of cancer and its treatment are improving quality of life.

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In addition to standard treatments and clinical trials, patients at Penn Medicine may wish to add additional therapies and treatments such as massage therapy, acupuncture and art therapy. These therapies do not have curative intent, and are designed to complement standard treatments, not take their place.

Integrative Medicine and Wellness Programs

At Penn Medicine, integrative medicine and wellness services can supplement traditional cancer treatments such as chemotherapy, surgery and radiation therapy. While conventional medicine plays a critical role in eradicating cancer, integrative medicine and wellness programs offer patients and their families ways to enhance the quality of their lives, minimize or reduce the side effects of cancer and cancer treatment, and promote healing and recovery.

The physicians at Penn Medicine are knowledgeable and supportive of complementary cancer treatments. The cancer team works with patients and families to integrate these supportive programs into the overall care plan, while ensuring the safety and health of patients.

The Abramson Cancer Center’s range of integrative supportive services is designed to help patients cope with the cancer experience and improve their overall sense of well-being. Services include:

• Acupuncture
• Diet and nutrition
• Mindfulness-based stress reduction therapy
• Reiki therapy
• Yoga
• Exercise and rehabilitation

The Joan Karnell Cancer Center at Pennsylvania Hospital offers a variety of supportive care programs for patients and families, from diagnosis through survivorship. These programs are available at no cost to the patients treated at Pennsylvania Hospital, and some are open to patients treated elsewhere. These services include social work counseling, nutrition counseling, psychological counseling and spiritual counseling.

The Cancer Appetite and Rehabilitation Clinic focuses on patients with loss of appetite and weight as well as deconditioning.

The Supportive Care Clinic helps to manage cancer related symptoms and goals of care.

Integrative support programs include:

• Music therapy
• Art therapy
• Shiatsu massage
• Mindfulness meditation

Support groups and educational programs are available at Pennsylvania Hospital throughout the year.

Palliative Care

Palliative care provides medical and non-medical interventions to ease the symptoms of cancer and its treatment. Palliative care includes physicial, emotional and spiritual care that can enhance the quality of life for cancer patients.

Palliative care can be used to complement traditional cancer therapies, or to improve quality of life when curative therapies are no longer an option.

Palliative care is an approach to patient care that can be integrated with curative therapies at any point from diagnosis to survivorship or end-of-life care.

Palliative care services include palliative chemotherapy, radiation therapy and surgery as well as psychological counseling, art therapy and support groups for patients and families. The goals of palliative care are to enhance the quality of life for cancer patients and their families, and provide emotional and spiritual support to enhance personal growth.

Palliative care services are offered at Pennsylvania Hospital, and at the Hospital of the University of Pennsylvania.  

Penn Home Care and Hospice Services

Penn Home Care and Hospice Services offer a full range of home health care needs by partnering three top-level home health care services under one roof:

• Penn Wissahickon Hospice
• Penn Care at Home
• Penn Home Infusion Therapy

Penn Home Care and Hospice Services offer an array of specialized therapies and medications for patients with cancer and cancer-related conditions.

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At the end of treatment, rectal cancer patients should schedule a survivorship visit with their oncologist and nurse practitioner. At this time, patients are provided with a summary of the treatment received as well as a plan for follow-up care.

Long-term cancer survivors should speak to their oncologist and nurse practitioner about scheduling a one-time survivorship-focused consultation with a nurse practitioner or physician. Annual or more frequent follow-up appointments are also available.

Penn cancer providers work one-on-one with patients to develop survivorship care plans. Since every cancer is unique, the plans are tailored to the patients. 

The survivorship care plan includes information on:

• Potential long-term or late side effects of cancer treatment, the symptoms and treatment.
• Recommendations for cancer screening for disease recurrence or a new cancer.
• Psychosocial effects, including relationships and sexuality.
• Planning follow-up visits.

A survivorship care plan encourages patients to review the information with their health care team and become active participants in their follow-up care.

Penn also offers rectal cancer patients a number of support programs and groups to enhance their survivorship care plans.

Patient navigation Specialists

Every step of cancer treatment; from a cancer diagnosis, to surgery and treatment to forming a survivorship plan; comes with different needs and issues that should be addressed.

Oncology Navigation Specialists at the Abramson Cancer Center are available to make a patient’s experience as seamless as possible. As experts in navigating complex health care situations, Oncology Navigation Specialists serve as a consistent point of contact and a reliable source for advice, support and direction for patients and families. They can help in a variety of ways including; provide emotional support, identify resources, and ensure access to information, support services, educational programs and community resources.

Learn more about Oncology Navigation Specialists at the Abramson Cancer Center.

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Penn Medicine's Living Well After Cancer™ Program is a nationally recognized program that focuses on issues facing cancer survivors. In 2007, the Abramson Cancer Center was designated a LIVESTRONG™ Survivorship Center of Excellence Network.  The Abramson Cancer Center is only one of eight LIVESTRONG centers in the United States, and is the only LIVESTRONG Survivorship Center of Excellence in the Philadelphia region. The program focuses on survivorship, a distinct phase of care.

Prescription for Living: The Cancer Survivorship Program at the Joan Karnell Cancer Center at Pennsylvania Hospital, provides patients with a summary of important information about specific cancer diagnoses and treatments, as well as follow-up information and steps to take towards recovery, supportive care and education to help patients adjust to their lives as cancer survivors.

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Penn offers cancer patients support programs and groups to enhance their survivorship care plans.

The Abramson Cancer Center and the Joan Karnell Cancer Center at Pennsylvania Hospital offer materials and host a wide range of activities that provide education and support to address key areas of concern including survivorship for cancer patients and their loved ones.

Focus On: Gastrointestinal Cancers is a day-long conference that addresses issues for patients with gastrointestinal cancer, as well as their loved ones.

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