• Day before surgery can be an intimidating and confusing time
• Patients who do well the day before surgery describe being active with others
• Contrary to popular opinion, the days before surgery should be an active time with good hearty meals
• Exercising beforehand can set back atrophy by not allowing it to get a head start
• Remember the details of your instructions before surgery

The day before surgery can be an intimidating and confusing time. Anxiety about the outcome of the operation and long-term survival can be alleviated by knowing facts about surgery and tips patients have found useful in preparing.

First, stay active and eat well right up until the night before surgery. Unless you’re having colon surgery which often requires a bowel prep and an extra day of a restricted diet before surgery, go ahead and beef up! Contrary to popular opinion, the days before surgery should be an active time with good hearty meals. I tell many patients to treat themselves to a delicious meal in the days leading up to surgery and, depending on the operation, even the night before surgery. You won’t be eating much after the operation for a couple days at least, so to minimize the period of going without nutrition, its good to get some good calories in the system. Nutrition is also known to strengthen your immune system, which sometimes needs to work well during your recovery.

Along the same lines, stay fit. Go ahead and go to the gym and get some good exercise before surgery. The days after surgery are like being an astronaut in that your muscles get weak from lack of use (called atrophy). Exercising beforehand can set back atrophy by not allowing it to get a head start.

Here are some more facts that are good to ease fears. The data on surgery demonstrate that the operation itself is very standardized. In my field of pancreas surgery for example, nearly every experienced pancreas surgeon in the world performs essentially the same operation with minimal variation. Many patients are also worried about general anesthesia, perhaps based on scary movies or public legends of the olden days, but general anesthesia today has a major complication rate of only about 1 in 100,000. Anesthesia is very safe in the modern era, and its safety profile in medicine is among the best of any medical intervention.

Patients who do well the day before surgery describe being active with others. As a general note on patients that I see who are depressed and anxious, the more someone has a community, the less likely they are to experience depression or anxiety. Movies, performances, getting together with friends, and family gatherings are some of the activities patients find helpful in making the day before surgery a pleasant experience. Often times patients describe a great experience surrounding themselves with positive friends—people who are optimistic and enjoy life.

Finally, remember the details of your instructions before surgery: Nothing to eat or drink by mouth 8 hours before your scheduled surgery time, and bring your most recent CAT scan with you if your surgeon does not already have it.



Blog Highlights:

• The decision-making for cancers of the rectum can be more complex than any other cancer
• Decisions about the initial treatment are often very complicated and require the treatment plan and care by oncologists of different specialties including surgery, medical oncology, and radiation oncology
• The patient has an important role in the treatment plan because their perception of “quality of life ” is important in deciding the extent of operation that they will accept
• Below are 12 important questions that you will need to go over with your doctors to determine the right treatment plan

The list of questions below should make it clear that the management of rectal cancer is very complex and should be performed by doctors who are very experienced and specialized in the treatment of these specific types of cancer. It is a real challenge for the doctors and for the patient to determine the right treatment that removes the cancer while preserving the function of surrounding organs and minimizing the number of complications that can be very debilitating after the treatment.

Here are 12 important questions that you will need to go over with your doctors:
1. What is the best way to stage the extent of the rectal cancer and, in addition, assess any spread to regional lymph glands or distant sites? Endoscopic ultrasound or MRI are the standard to assess the depth of invasion into the rectal wall and lymph nodes. CT scans for the liver and lungs.
2. Which type of surgical specialty should do my surgery (surgical oncologist, general surgeon, or colorectal surgeon)?
3. For the surgeon, how many operations for rectal cancer do you do each year? Should be a minimum of 12 per year.
4. Can the rectum be removed while sparing the anus so that a permanent colostomy is not necessary? Again, for the surgeon, are you trained to do “intersphincteric resections”, and how many have you done?
5. Should I have “minimally invasive” surgery, such as laparoscopic surgery or robotic surgery? Whereas minimally invasive approaches to colon cancer have been found to be as “safe” as an open operation, the same is yet to be determined for rectal cancer. The studies are ongoing. Minimally invasive approaches to rectal cancer is very new and should only be done as part of a clinical trial by surgeons with experience with minimally invasive procedures for the rectum.
6. If the cancer is small and does not invade very far into the rectal wall, is it possible to have a local excision only? (Be very careful with this! There is a lot of controversy over local excision. Local excision has a higher chance of recurring!)
7. Should chemotherapy and/or radiation therapy be given prior to surgery?
8. How much of adjacent pelvic organs need to be sacrificed in order to adequately treat the cancer?
9. Should molecular markers be obtained to help determine the type of chemotherapy which should be given?
10. What would be the side effects of radiation therapy to the pelvis and anus?
11. What are the long-term side effects of these complex treatments with regard to anal sphincter function (i.e. incontinence of stool or soiling) urination, fertility, and sexual function?
12. Do I have distant disease, or spread of cancer to the liver or lungs? If so, should I have systemic chemotherapy prior to an operation on the rectum? If you do have spread to the liver, make sure you are evaluated immediately by a surgeon who has significant experience with liver surgery, and especially liver surgery for colon or rectal cancer which has spread to the liver. These surgeons are usually found at a tertiary care facility or academic medical center. See a liver surgeon before starting chemotherapy!

When cancers of the rectum first present, the decisions about the initial treatment are often very complicated and require the treatment plan and care by oncologists of different specialties including surgery, medical oncology, and radiation oncology. In fact, the decision-making for cancers of the rectum can be more complex than any other cancer. The patient has an important role in the treatment plan because their perception of “quality of life ” is important in deciding the extent of operation that they will accept. Other factors that have a major role include:

• Depth of invasion of the cancer into the rectal wall or invasion into adjacent organs
• Spread of cancer to lymph nodes
• Spread of cancer to distant organs, like the liver or lungs,
• Distance of the lower end of the cancer from the anal sphincter muscles, and
• Size of the pelvis (men have a smaller and narrower pelvis than women)

Doctors usually make a distinction between the rectum and colon even though they are both part of the large bowel or intestine. In general, the rectum is the end of the large bowel and is situated inside the pelvis. The colon makes up the majority of the large bowel, which is located outside the pelvis. Given the anatomical differences between the colon and rectum, the treatment of their respective cancers is also different.

Cancers of the colon, which occur outside the pelvis, can grow to a large size but usually do not invade surrounding organs. The surgery is fairly straightforward and the surgical excision can take a wide margin or berth of normal tissue, including lymph nodes, without causing many side effects. By taking a margin of normal tissue, the surgeon can assure that all tumor is removed, including any disease that is microscopic. Depending on the pathology, which is determined after the colon cancer is removed, chemotherapy may be given after the operation.

In contrast, cancer arising in the rectum is growing in a small space confined by the pelvic bones, surrounded by organs such as the bladder, prostate in men or the uterus or vagina in women. Cancers growing low in the rectum can be especially difficult because they may be close to the anal sphincter muscles, which make it difficult to get an adequate margin of normal tissue. If the cancer is too low, the anus and anal sphincters may have to be removed as well in order to safely remove all the cancer and reduce the chance of having a recurrence. If the anus and anal sphincter muscles are removed, a permanent colostomy is required, whereby the end of the colon is brought out through the lower abdominal wall and attached to the skin to create a new channel for feces to leave the body into a colostomy bag.

Chemotherapy and radiation therapy may be given prior to an operation depending on:

• Distance of the tumor from the anus
• Depth of invasion of the cancer into the rectal wall or invasion into adjacent organs, or
• Spread of cancer to the surrounding lymph nodes

Chemotherapy and radiation given before the operation may shrink the tumor enough to allow an operation to save the sphincter muscles. In addition, chemoradiation therapy before an operation has been found to be more tolerable than after an operation and reduce the risk of having a recurrence in the pelvis. There are procedures (i.e. intersphincteric resection) that can be done to save the sphincter muscles as well, but these are not safe in every situation and are technically very challenging. These are specialized procedures and should only be done by surgeons with experience using these techniques.

Remember, an informed and educated patient will usually get better care and have a treatment that best fits their risk tolerance to the different types of treatment side effects and recurrence rates.

This tool, known as a nomogram, can be used to predict the probability of being disease-free from colon cancer five to ten years following complete resection (surgical removal of all cancerous tissue). It is designed to help patients and physicians make decisions on further treatment and plan long-term follow-up.

The colorectal cancer nomogram is based on a database of 1,320 patients with nonmetastatic colon cancer treated at Memorial Sloan-Kettering Cancer Center. It provides a more accurate picture of the five- or ten-year risk of recurrence than older assessment tools, such as the staging system of the American Joint Committee on Cancer (AJCC).

This predictive tool may also be used by researchers to help design and evaluate clinical trials.

Who Is This Tool For?
This tool can be used to predict probability of being disease-free from colon cancer after surgery, assuming that all of the primary cancer was completely removed during the original surgery. The nomogram is for patients who have localized colon cancer that shows no evidence of metastasis, or spread beyond the colon, before or at the time of surgery. This means that only patients with tumors found in the colon — between the pouch that forms the first part of the large intestine (known as the cecum) and the S-shaped section of the colon that connects to the rectum (the rectosigmoid, or sigmoid, colon) — should use this tool. Patients using this nomogram may or may not have had chemotherapy.

The tool should be used by physicians. Patients should use this tool only in consultation with their physicians.

To use this tool, click here.

A diagnosis of cancer can be scary, and understanding a treatment plan confusing. To gain more information, it is sometimes wise to seek a second opinion or advice from another qualified cancer specialist or group of specialists before or even after you begin treatment.

If you are asked to consider alternatives, such as surgery or radiation or chemotherapy or hormone therapy, you might want to hear from each type of oncologist who gives that treatment. It’s all right to look at all your options. A second opinion could save your life or better protect your quality of life.

Options for getting a second opinion:

- Talk to a cancer specialist in another specialty or medical group.

- Ask that your case be presented to a tumor board or tumor conference at your hospital.

- Ask to get a second opinion on your pathology reading, especially if there is any controversy in making a complete diagnosis.

- Seek the advice of a renowned cancer expert usually in a comprehensive cancer center especially if your situation is complicated or uncommon.

For more information, see our companion website: www.patientresource.net. Here’s some of the content from patientresource.net that you may find useful:

Getting a second opinion involves asking another cancer specialist or group of specialists to review your medical records and confirm your doctor’s diagnosis and treatment plan. Other specialists can confirm your pathology report and stage of cancer and might suggest changes or alternatives to the proposed treatment plan. They can also answer any additional questions you may have. There is often collective wisdom gained from the experience and opinions of different oncology specialists who are experts in your type of cancer.

There are lots of reasons for seeking a second opinion. Some doctors may favor one treatment approach, while others might suggest a different combination of treatments. Doctors in each oncology specialty bring different training and perspectives to cancer treatment planning. Another doctor’s opinion may change the diagnosis or reveal a treatment your first doctor was not aware of. You need to hear arguments for all of your treatment options. A second opinion is also a way to make sure your pathology diagnosis and staging are accurate, and that you are aware of clinical trials that you might want to consider.

If you are asked to consider alternatives, such as surgery, radiation, chemotherapy or hormone therapy, you might want to hear from each type of oncologist who provides that treatment. It’s all right to look at all your options; a second opinion could save your life or better protect your quality of life. Most doctors welcome another doctor’s opinion.

Second opinions are also valuable if you live in a small town or rural area where there may not be as many oncology specialists, especially if you have an uncommon type of cancer or might need a highly specialized or complicated type of care. If so, you may want to get an opinion from specialists at a larger medical center or comprehensive cancer center with particular expertise in treating your type of cancer.