Abramson Cancer Center

Some risk factors for 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 programs at the Abramson Cancer Center or the Joan Karnell Cancer Center at Pennsylvania Hospital.

Intestinal Cancer Risk Factors

There are different kinds of risk factors for small intestine cancer.

• Gastrointestinal syndromes. Having Lynch syndrome or familial adenomatous polyposis (FAP) increases the risk of intestinal cancer.
• Smoking. Smoking has been linked to an increased risk of developing small intestine cancer.
• A high-fat diet. Studies show that people whose diets are high in fat may be at an increased risk for developing intestinal cancer.
• Crohn’s disease. People with this condition in which the gastrointestinal tract is inflamed over a long period of time are at higher risk of developing intestinal cancer.
• Celiac disease. This digestive disease in which the body has an immune response to a protein called gluten can lead to an increased risk for small intestine cancer as well as small bowel lymphomas.

Small Intestine Cancer Prevention

Most risk factors for intestinal cancer cannot be prevented. However, there are preventive measures people can take to decrease the risk of developing cancer.

• Quit smoking. Quitting smoking or chewing tobacco can decrease 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.
• Eating a low-fat diet. Eating a diet rich in fruits and vegetables, and high in fiber may decrease the risk of intestinal cancer.

Small Intestine Cancer Risk Assessment

Penn Medicine offers programs for patients who want to determine their risk of developing gastrointestinal cancer through:

• Abramson Cancer Center
• The Joan Karnell Cancer Center at Pennsylvania Hospital

These programs offer knowledge about the presence of genetic risk factors for cancer and provide patients with important, sometimes life-saving options.

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• Adenocarcinoma
• Gastrointestinal stromal tumor
• Carcinoid tumors
• Lymphoma
• Sarcoma
  • Leiomyosarcoma

Adenocarcinoma

The most common type of intestinal cancer, adenocarcinoma, begins in the lining of the small intestine and usually develops in the duodenum.

Carcinoid tumors

Also known as neuroendocrine tumors, these tumors are slow growing and usually occur in the ileum.

Lymphoma

Lymphoma is cancer that starts in the lymph tissue of the small bowel and usually occurs in the jejunum. Lymphomas are typically non-Hodgkin’s lymphoma, but they can also be Hodgkin’s lymphomas. Occasionally, T-cell lymphomas can develop with long-standing celiac disease.

Sarcoma

Sarcomas in the small intestine begin in the muscle wall and usually occur in the ileum.

Leiomyosarcoma

The most common subtype of sarcoma in the small intestine.

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Because intestinal cancer is so rare, it can be difficult to diagnose. Its symptoms are usually nonspecific:

• Crampy abdominal pain
• Blood mixed in the stools
• Iron deficiency anemia
• Dark/tarry/black stools 
• Weight loss without trying
• Diarrhea
• Jaundice, or a yellowish tint to the skin and whites of eyes.

While these symptoms could be caused by a number of medical conditions, if symptoms such as these are severe, worsening, or persistent, medical attention should be sought so that a timely and accurate diagnosis can be made. Anytime blood is seen in the stool or the stool is black, medical attention should be sought.

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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 treatment.

The “staging diagnosis” depends on the type of cancer and the staging system the doctor is using, but in general there are four stages of intestinal cancer:

• Stage I. Cancer contained within the small bowel lining or spread into the muscle wall, but not yet involving the lymph nodes or other parts of the body
• Stage II. Cancer spread through the muscle wall, possibly involving other nearby organs (such as the pancreas)
• Stage III. Cancer spread to nearby lymph nodes.
• Stage IV. The cancer has spread (metastasized) from where it started to other organs, such as the liver, bones or lungs.

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After being diagnosed with small intestine 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 small intestine 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 treating patients with gastrointestinal 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.

Many treatment options including standard treatments and clinical trials are available for those with small intestine cancer.

A clinical trial is a study meant to help improve current treatments or obtain information about new treatments.  Patients at Penn Medicine can benefit from participating in clinical trials that take place at Penn. Patients interested in learning more about clinical trials should speak with someone on their treatment team.

Oncology 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 Patient Navigation specialists at the Abramson Cancer Center.

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Currently, there are no standard intestinal cancer screening recommendations for the general public like there mammograms for breast cancer and colonoscopy for colon cancer.

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When physicians suspect intestinal cancer, they may order several tests to make a diagnosis.

• Medical history and physical exam. A physician may examine the patient for general health, and to see if there are any signs of the disease.
• Lab tests. Basic blood tests to measure levels of proteins and enzymes in the blood, as well as liver function.
• 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.
  • Computed tomography (CT). A CT scan creates a three-dimensional X-ray of the inside of the body. A computer combines the images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium (dye) is used to provide better detail.
  • Magnetic resonance imaging (MRI). Magnetic fields are used to create detailed images of the body. A contrast medium may be injected into a vein to create a clearer picture.
  • Upper GI series with small intestine follow-through. A series of X-rays of the esophagus, stomach, and small bowel. The patient drinks a liquid that contains barium (a silver-white metallic compound). The liquid coats the esophagus, stomach, and small bowel. X-rays are taken at different times as the barium travels through the upper GI tract and small intestine.
  • Upper endoscopy. Endoscopy allows the doctor to see the lining of the upper digestive system with a thin, lighted, flexible tube called an endoscope. A patient may be sedated as the tube is inserted through the mouth, down the esophagus, and into the stomach and small intestine. If an abnormality is found, a biopsy is performed.
  • Capsule endoscopy: Capsule endoscopy allows the doctor to examine the lining of the small intestine. A small pill-sized video camera is swallowed. The camera captures thousands of images as it passes through the small intestine. These images are later reviewed by the doctor to evaluate for abnormalities in the small bowel.
  • Double balloon enteroscopy. This is an endoscopic technique for visualization of the entire small bowel. The small bowel is examined  by slowly advancing a flexible endoscope with a tube on it (about the thickness of a finger) throughout the small bowel. The endoscope may be inserted orally or rectally to give the physician the best access to the intestine. If an abnormality is found, a biopsy is performed.
  • Laparotomy. A procedure in which an incision is made into the wall of the abdomen to view the inside of the abdomen for signs of disease. Sometmes, a tissue sample is taken at the time of the procedure.
• Biopsy. A sample of the suspicious area is removed and viewed under a microscope. Penn Medicine surgeons perform several different types of biopsies based on the amount of tissue being removed. Some biopsies use a small forceps or a needle, while others require a small surgical procedure to remove more tissue.
  • Lymph node biopsy. The removal of all or part of a lymph node. The tissue is then checked for cancer.

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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 treatment.

The “staging diagnosis” depends on the type of cancer and the staging system the doctor is using, but in general there are four stages of intestinal cancer:

• Stage I. Cancer contained within the small bowel lining or spread into the muscle wall, but not yet involving the lymph nodes or other parts of the body
• Stage II. Cancer spread through the muscle wall, possibly involving other nearby organs (like the pancreas)
• Stage III. Cancer spread to nearby lymph nodes.
• Stage IV. The cancer has spread (metastasized) from where it started to other organs, such as the liver, bones or lungs.

Physicians also group small intestine cancer based on whether or not it can be surgically removed, or resected.  If the cancer can be surgically removed, the prognosis and outcome for a patient is improved.

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Surgery is the most common treatment for intestinal cancer.

Resection

When the tumor is resectable, radical surgery offers the best chance for cure.

Resection is surgery that removes all or part of an organ that contains cancer. Resection surgery may include the small intestine and nearby organs if the cancer has spread. Surgeons may remove the section of the small intestine that contains the cancer and join the cut ends of the small intestine together. This procedure is called an anastomosis. Surgeons may also remove affected lymph nodes during the procedure.

Surgical Bypass

When the tumor cannot be completely resected, a surgical bypass can relieve symptoms. This procedure reroutes the small intestine, allowing food to go around a tumor that cannot be removed.

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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.

Proton therapy at Penn Medicine is now being used to treat upper gastrointestinal cancers and recurrent tumors in the digestive tract. Penn Medicine is one of the only facilities 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.

3-D 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. Known as conformal radiation therapy, this technology gives doctors more control when treating tumors.

In conformal radiation, a special computer uses CT imaging scans to create 3-D 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)

As national leaders in radiation therapy, radiation oncologists at Penn Medicine are experts in the use of the latest therapies, including intensity-modulated radiation therapy (IMRT), to treat cancer.

This advanced type of radiotherapy 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 killing the cancer cells and preventing 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 patient along with computerized dose calculations, IMRT allows for the radiation dose to conform more precisely to the three-dimensional shape of the tumor by controlling; or modulating; the intensity of the radiation beam. The therapy allows higher radiation doses to be delivered to regions within the tumor while minimizing the dose to the surrounding area.

Proton Therapy

Penn Medicine is the only academic medical center in the country that is using proton therapy to treat recurrent gastrointestinal tumors in clinical trials. Also, radiation oncologists at Penn Medicine will soon use proton therapy to treat gastrointestinal cancers in the upper digestive tract.

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.

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.

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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 surgery.

Chemotherapy

Chemotherapy uses drugs to kill cancer cells. It is delivered through an intravenous catheter or a pill and targets cancer cells throughout the body. Depending on the stage of the tumor, chemotherapy may be given after surgery or in combination with radiation therapy.

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Today, more and more people are surviving cancer. Clinical trials, many of which are conducted at Penn Medicine benefit patients through breakthrough therapies and treatments. These new advances in cancer treatment are occurring every day, 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.

Biologic Therapy

Biologic therapy, also called targeted therapy, uses the patients' own immune system to target cancer cells. Substances made by the body or in a laboratory are used to boost, direct or restore the body's natural defenses against cancer, and are delivered orally by pill or intravenously.  This type of cancer treatment is also called immunotherapy.

Radiation Therapy with Radiosensitizers

Radiation therapy with radiosensitizers is currently being studied in clinical trials. Radiosensitizers are drugs that make tumor cells more sensitive to radiation therapy. Combining radiation therapy with radiosensitizers may kill more tumor cells.

Endoscopic stent placement

If the tumor is blocking the duodenum, a stent may be placed to bypass the blockage.

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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.

Cancer specialists 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.

The Supportive Care Clinic helps to manage cancer related symptoms. 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 physical, 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 and 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.

Oncology 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 Patient Navigation specialists at the Abramson Cancer Center.

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At the end of treatment, 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 intestinal 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 small intestine cancer patients a number of support programs and groups to enhance their survivorship care plans.

Oncology 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 patient 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 Medicine offers cancer patients support programs and groups to enhance their survivorship care plans.

The Abramson Cancer Center and Joan Karnell Cancer Center at Pennsylvania Hospital provide 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 for patients and their loved ones that addresses issues surrounding gastrointestinal cancers.

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