Care pathway for a bowel cancer patient

After the surgeon’s appointment, your treatment will be discussed at a meeting attended by surgeons, radiologists, an oncologist and the coordinating nurse. We plan your treatment on the basis of the examinations performed. It will be confirmed at this meeting whether surgery is the primary option or whether you will be referred to the Comprehensive Cancer Center for chemotherapy. If we make any changes to the plan, we will let you know. We will notify you of the date of the operation well ahead of time, and you will be given the time when to arrive at the hospital on the weekday preceding the day of the operation. 

Colon cancer is primarily treated surgically, but sometimes we begin with chemotherapy. Colon cancer surgery is performed at Jorvi Hospital. You will be notified of the examination times and outpatient clinic appointment time by letter. At the outpatient clinic appointment preceding the operation, you will meet the surgeon, who will review the examination results with you and advise you of the treatment plan.

You will be notified of the examination times and a further outpatient clinic appointment time by letter. At this appointment, you will meet an anesthesiologist or a nurse. The purpose of the anesthesia appointment is to devise an anesthesia regime suitable for you, meaning general anesthesia and pain management. The operation itself will be performed under general anesthesia. We often also administer an epidural anesthetic to alleviate postoperative pain. The anesthesiologist ensures that your health is as good as possible in view of the operation and recovery. 

The nurse will meet you after the surgeon’s appointment. 

The nurse will discuss your treatment plan with you and advise you on how to prepare for the operation. The nurse will review the details on your medical history form with you, including your medication, height, weight, blood pressure, support stockings, and anesthesia information. You will be given instructions on how to prepare for the operation and possibly instructions on how to void your bowels. 

We will also discuss postoperative pain management at the appointment and select a pain rating scale to use for assessing pain after the operation. Because nutrition is of great importance for recovery from surgery, we will also assess the risk of malnutrition at this point. The nurse will also give you information on postoperative recovery. 

You will prepare for the operation at home as instructed and arrive at Jorvi Hospital in the morning of the day of the operation. We will prepare you for the operation, and you will meet the physician. The operating room staff will bring you to the operating room. 

The operation may be performed as open surgery or keyhole surgery. In the operation, we will remove the portion of the colon where the tumor is located, including the mesentery and lymph nodes. In a colon cancer operation, a colostomy is generally not required. Postoperative monitoring is performed in the recovery room. You should be mobile as soon as possible to speed up your recovery. You may be able to sit up or stand up in the recovery room and have something to drink. When your condition allows, you will be transferred to Ward K7 or K6 for further recovery. You will be assisted in recovery by the nurses on the ward and a physiotherapist if necessary. 

The outpatient clinic nurse will generally come to see you on the ward before you are discharged and will also call you one week after discharge. You can be discharged if you are getting enough nutrition, your bowel movements have become normal, you are able to urinate, and your pain management is sufficient using painkillers taken by mouth. After the operation, you will need to have subcutaneous injections of blood thinning medication at home.

The physician will report the findings on the quality of the removed tumor to you by phone within about two weeks of your discharge. You will have a follow-up appointment at the Surgery Outpatient Clinic about one month after the operation. Any further treatment will be provided at the Comprehensive Cancer Center, depending on the quality of the tumor and the metastatic examinations performed. 

Based on the examinations performed, we will plan your treatment at a meeting attended by surgeons, a radiologist, a pathologist, an oncologist, and the coordinating nurse. We plan your treatment on the basis of the examinations performed. The choice of treatment depends on the type of tumor, local spreading, and metastases if any. Radiation therapy or a combination of radiation therapy and chemotherapy may be administered before the operation if necessary. On the day after the meeting, the nurse will contact you to confirm the treatment plan. 

Colostomy

If necessary and appropriate, a temporary or permanent colostomy may be made. If your tumor is very close to the anus, we will have to remove the entire rectum and anus and close off the anus (end colostomy). 

Before the operation and after the operation (2 to 3 weeks), you will be given an appointment with a colostomy nurse. You may bring family members to the appointment if you wish. At this appointment, we will discuss the colostomy and how it works, how it has to be treated, how colostomy dressings are used, and how the colostomy will affect your everyday life (nutrition, exercise and other pastimes). 

For more information on colostomy, visit the Health Village (Terveyskylä)

We perform rectal cancer operations at Meilahti Hospital. You will be invited to an appointment with the surgeon before the operation. At this appointment, we usually perform a sigmoidoscopy to inspect the rectum and the descending colon. 

For the sigmoidoscopy, we will instruct you to void your bowels with a laxative drink. Based on this examination, the surgeon can pinpoint the location and size of the tumor and plan the appropriate surgical procedure. We will take a biopsy of the tumor if necessary in connection with the sigmoidoscopy.  

The nurse will meet you after the surgeon’s appointment. 

The nurse will discuss your treatment plan with you and advise you on how to prepare for the operation. The nurse will review the details on your medical history form with you, including your medication, height, weight, blood pressure, support stockings, and anesthesia information. You will be given instructions on how to prepare for the operation and possibly instructions on how to void your bowels. 

We will also discuss postoperative pain management at the appointment and select a pain rating scale to use for assessing pain after the operation. Because nutrition is of great importance for recovery from surgery, we will also assess the risk of malnutrition at this point. The nurse will also give you information on postoperative recovery. 

In most cases, you will be admitted to the hospital on the day before the operation. You will meet the anesthesiologist, the operating surgeon, the ward nurse and a physiotherapist. You will need to void your bowels by drinking a laxative as instructed on the day before the operation. If required, we will install the epidural anesthetic device for pain management on the day before the operation. 

Depending on the location of the tumor, the operation involves removing part or all of the rectum, the rectal mesentery, and adjacent lymph nodes. The operation is performed as open surgery through a cut in the lower abdomen or as keyhole surgery. If we are able to preserve the lower part of the rectum, we join up the end of the colon to the lower part of the rectum. Sometimes we make a temporary colostomy to protect the join. If we need to remove the entire rectum and anus, we make a permanent end colostomy. 

From the operating room, you will be taken to the recovery room and then to Ward M14 at the Meilahti Tower Hospital. During your first days on the ward, you will receive intravenous fluids, painkillers and possibly antibiotics. We recommend that you get mobile as soon as possible after the operation to help you recover, assisted by a nurse, practical nurse, or physiotherapist. You can be discharged if you are getting enough nutrition, your bowel movements have become normal, and you are able to urinate. It is also important that you are getting sufficient pain management with painkillers taken by mouth and that you are able to inject yourself with the subcutaneous blood thinning medication needed after the operation. You must also be able to manage your colostomy when discharged. 

The nurse will review the wound care instructions and medication before you are discharged. You will also be given this information in writing. The length of your sick leave depends on the nature of the operation and the type of work you do. Sick leave is typically about three weeks after keyhole surgery and somewhat longer after open surgery.

We will book you a phone appointment about two weeks after your discharge, once the pathology results are ready. Further treatment will be decided upon on the basis of examinations performed. If the tumor was confined to the intestinal wall, then nothing more than monitoring will be required. If the tumor had spread to lymph nodes in the mesentery or to other locations in your body, you will be given a referral to an oncologist at the Comprehensive Cancer Center for consultation. The healing of the bowel join will be confirmed 6 to 8 weeks after surgery using either imaging with a contrast agent or by colonoscopy.

Radiation therapy reduces the risk of local recurrence of rectal cancer, and thus evaluating the need for radiation therapy is essential. Your treatment will be discussed at a meeting attended by a surgeon, a pathologist, an oncologist, the physician in charge of radiation therapy, and the coordinating nurse. In case of an elevated risk of local recurrence, we will administer radiation therapy on five days before the operation. Sometimes we have to reduce the size of the tumor before the operation by administering a combination of radiation therapy and chemotherapy. In this case, the preoperative treatment lasts about 5 weeks.

We will book an initial appointment with a physician for you at the Radiation Therapy Unit of the Comprehensive Cancer Center if radiation therapy or a combination of radiation therapy and chemotherapy is indicated before your rectal cancer operation. At the appointment, the radiation oncologist will evaluate your eligibility for radiation therapy or a combination of radiation therapy and chemotherapy, advise you of the benefits and potential disadvantages of the treatment, and explain how the radiation therapy will be delivered. 

After the appointment, the clinic nurse will book you appointments for the radiation therapy dosage planning session and for your first radiation therapy appointment. If necessary, we will also book an appointment for chemotherapy guidance with a nurse if the combination treatment is being administered. During the radiation therapy and chemotherapy period, we will monitor blood tests and estimate the progress of the treatment at appointments with the radiation oncologist. 

A radiographer will give you instructions for the dosage planning examinations, or radiation simulation. To aid us in planning your radiation therapy, we perform a computer based simulation and sometimes also an MRI scan. This examination is performed with you in the same position that you will have during the actual radiation therapy. At the end of the examination, we mark your skin with three tattooed points that will help us align you in the exact same position on each visit. 

The radiographer will show you around the radiation therapy unit and will explain the progress of the treatment and its side effects. The radiographer will book your first radiation therapy appointment and explain your laboratory visits and any other examinations that may be needed. At this appointment, you will also be advised of the travel allowance and social security system of Kela, and you will be given contact details for a social worker.

At your first radiation therapy appointment, you will be given a timetable for your visits. We will also inform you of the side effects of radiation therapy and how you should care for yourself at home. You can talk about things on your mind at any radiation therapy appointment. 

Side effects include irritation of the skin or mucous membranes, and possibly diarrhea. In case of any problems, you can contact the radiographers working on your radiation therapy unit. If you develop a fever of more than 38 °C or severe stomach symptoms during the radiation therapy period, please call your radiation therapy unit before your next visit. The radiographer will contact a physician if necessary. 

If you need to take a break from radiation therapy appointments because of illness, we will need to add appointments to the end of the period so that the planned number of appointments will be completed.

We plan the number of radiation therapy appointments individually, and we perform radiation therapy on every weekday. Although the radiation therapy itself only lasts about 15 minutes, you should allow plenty of time for each visit. We will review your further treatment at your last appointment. If you have any questions after your radiation therapy is completed, you may contact the radiographers working on your radiation therapy unit for a period of one month thereafter. 

We will answer any questions you may have at the Surgical Outpatient Clinic before you meet the oncologist for the first time at the Comprehensive Cancer Center. For chemotherapy, we will prepare an individual treatment plan based on the most recent research data and on international and national care recommendations. 

Treatment planning is a collaborative effort. Before your appointment with the oncologist, input will already have been given by the pathologist, radiologist, surgeon, and oncologist. Other specialists may sometimes be needed, and close cooperation between them will continue throughout your treatment in order to ensure the best possible outcome. 

We will prepare the required statements for applying to Kela for long-term benefits at your first appointment with the oncologist. Before your first treatment session, you will review your treatment plan and the side effects of chemotherapy with a nurse. You will be given instructions in writing on all aspects of your treatment. 

For every patient, we evaluate the need for postoperative adjuvant therapy. The purpose of adjuvant therapy is to reduce the risk of your cancer recurring. We consider multiple factors when making the treatment decision, including the biology of the tumor. The most important factors are the possible existence of lymph node metastases and how deep in the intestinal wall the tumor is. 
 
Adjuvant therapy lasts for 3 to 6 months, depending on the characteristics of your disease. Adjuvant therapy usually consists of a cytotoxic drug administered by mouth (capecitabine), sometimes with added intravenous medication (oxaliplatin). 

Postoperative chemotherapy is administered on the day ward of the Comprehensive Cancer Center. You will be treated by a nurse, generally your primary nurse. Your primary nurse’s contact details will be given to you at your first appointment. You can also contact your primary nurse using the Noona app, to which you will be given a client account. 

Adjuvant therapy usually consists of a cytotoxic drug administered by mouth (capecitabine), sometimes with added intravenous medication (oxaliplatin).  

We will instruct you to take premedication one hour before beginning the chemotherapy. The chemotherapy lasts for 1 to 4 hours each time, and the sessions are every 1 to 3 weeks. During the treatment, the nurse will monitor your condition, see to your needs, and consult other professionals as required: a physician, a social worker, or a clinical dietitian.

The aim is that you should be able to live your life as normally as possible despite the chemotherapy. It usually takes about 3 to 7 days to recover from each treatment session, and then you will feel better. Gentle exercise and outdoor activities are recommended if you feel well enough. 
 
The most common side effects of chemotherapy are irritation of the mucous membranes in the mouth, diarrhea, fatigue and nausea. You must ensure that you drink enough fluids and have a diverse diet, that your bowel movements are regular, and that you maintain good oral hygiene. Alcohol should be avoided, and natural supplements are prohibited. 
 
Calcium and vitamin D or multivitamin products from the pharmacy may be used during the treatments. You should discuss any other vitamin supplements with your physician in advance. Your existing medications will continue as before, although if you are taking blood thinning medication, this may need to be adjusted. You should take medication to alleviate the side effects of chemotherapy (nausea, pain, indigestion, diarrhea) as needed, so that the treatment can progress as planned. 

You may be more vulnerable than usual to infections during the treatment. If you develop a fever of more than 38 °C or suddenly feel unwell in general, you must go to your local hospital emergency clinic, where you will be admitted without a referral. The Comprehensive Cancer Center has no emergency clinic. You can reach your primary nurse by phone during business hours as needed. 

In non-urgent cases, you may contact the HUS Comprehensive Cancer Center via the Noona mobile app during your treatment and monitoring period. Your primary nurse will respond to messages in the system within 1 to 2 days. 

Most bowel cancers can be cured permanently. For some patients, the cancer recurs or is found to be metastasized early on. A metastasized cancer is one that has caused remote tumors to appear in other internal organs or in the bones. Palliative care to alleviate the symptoms will be given alongside chemotherapy and will be continued once the chemotherapy is discontinued and symptomatic therapy is introduced. 

The Palliative Hub is an online service for patients with incurable illnesses and their family members. The Palliative Hub contains information on adult palliative care, terminal care, symptomatic care, and illnesses and forms of support. 

We prepare a monitoring program for each patient according to the tumor type and their general health. For colon cancer and rectal cancer, monitoring will be undertaken in specialist medical care for the first two years and then in basic medical care (health center / occupational health care). If there is an elevated risk of colon cancer recurring, monitoring may continue at the Surgery Outpatient Clinic for longer than 2 years. 

Colon cancer monitoring will continue at the Comprehensive Cancer Center based on the oncologist’s evaluation. The monitoring includes symptom surveys, clinical examinations, blood tests, colonoscopy, and in some cases imaging examinations. 

For rectal cancer, so that any recurrence may be detected as early as possible, the bowel join will be monitored by sigmoidoscopy at the Surgery Outpatient Clinic for 2 years. The monitoring also includes symptom surveys, clinical examinations, blood tests and in some cases imaging examinations. You will be prepared a customized monitoring program depending on your tumor type and your general health. 

Bowel cancer may metastasize into the liver, lungs, lymph nodes or peritoneal cavity. According to current medical knowledge, it is not possible to cure a metastasized bowel cancer permanently with medication. 

We can, however, slow the progress of the disease and alleviate its symptoms. Treatments are constantly being developed, and patient prognoses and treatment outcomes are thereby improving. Depending on the status of the disease, we treat metastasized cancers by combining various cytostatic drugs with targeted biologic drugs. The choice of treatment depends on the biological properties of the tumor, on its spread, and on the treatment objectives. 

Radiation therapy is required in case of a symptomatic tumor in the rectal area. Metastases may also be subjected to radiation therapy in some selected cases. We evaluate the potential for surgical treatment for every patient with metastasized bowel cancer. It is possible to cure some metastasized cancer patients permanently, if it is possible to remove the metastases surgically. Such cases typically involve metastases in the liver or lungs or, in some cases, in the peritoneum. 

Surgery and starting medication

A surgeon will review your case and prescribe the required further examinations. We will book you an appointment for a body CT scan to find the exact location of the tumor, whether it has spread to surrounding tissues, and whether it has metastasized. If the tumor is in the rectum, we will also perform an MRI scan that will yield detailed information about any local spreading in the pelvis minor. These examinations are performed at the HUS Imaging units. 

We will also take blood tests, for instance for a minor blood count (PVK), for carcinoembryonic antigen (CEA) and for kidney function (Krea). You may go to any HUS laboratory to have the blood tests taken.