Colorectal (bowel) cancer pathway

Bowel cancer is a general term for cancer that starts in the large bowel or intestine. The large bowel is the last part of the gastrointestinal tract (tube from the mouth to the anus) and of the digestive system (organs that extract nutrients and absorb energy from food). Water is absorbed here and the body’s solid waste material is stored as faeces before exiting the body.

Cancer can start within different parts of the large bowel.

Colon cancer

Cancer that starts in the main part of the large bowel and the final part of the digestive tract.

Rectal cancer

Cancer that starts in the rectum which is the lower end of the large bowel.

Anal cancer

Cancer that starts in the anal canal or anus which is the five-centimetre-long end section of the large bowel through which solid waste exits the body.

See separate pathway for anal cancer.

What to expect

This information describes the care you can expect from an initial concern about colon or rectal cancer and for every step afterwards
– your cancer pathway.

For more information about the different types of bowel cancer:

Bowel Cancer UK

NHS

Needing immediate support

Macmillan support line 0808 808 0000 (8am-8pm, 7 days a week)

Directory of Services

COVID-19 update

Please note that aspects of the cancer pathway may have changed due to the COVID-19 pandemic and these changes are highlighted throughout the pathway. If you have any concerns or questions, always speak to your GP or cancer care team.

The aim of the COVID-19 guidance is to:

  • minimise your risk by reducing investigation and visits to hospital
  • reassure you if you have low risk symptoms that you will be investigated within a safe time frame in line with national guidance
  • identify if you are at a higher risk and make sure you are investigated quickly and receive urgent surgery if required.

People you could meet on your pathway

Consultant Surgeon

A doctor who is trained to perform types of surgery, in this case they specialise in surgery of the bowel. Your colorectal (bowel) surgeon is usually the first person you will see and specialises in the diagnosis of bowel cancer as well as treatment.

Consultant Oncologist

A doctor who specialises in the diagnosis and treatment of cancer.

Consultant Radiologist

A doctor who carries out investigations to diagnose diseases using medical imaging, such as X-rays, computed tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, positron emission tomography (PET) and ultrasound. They also perform biopsies if needed.

Clinical Nurse Specialist

A nurse who has specialised in a specific cancer site, in this case bowel cancers, and who is able to offer expert advice and information about diagnosis, treatments, ongoing care and follow up.

Cancer Support Worker

A non-clinical support worker who is part of the cancer care team and provides one-to-one support for patients and ongoing information about cancer and cancer services.

Initial investigation and referral

Most bowel cancers develop from pre-cancerous growths, these are called polyps, however not all polyps will develop into a cancer. Polyps do not usually cause symptoms so most people will not know they even have them.  

You are more at risk of getting bowel cancer if you:  

  • are 50 years old or over – bowel cancer risk increases with age but it can affect people at ANY age
  • have a family history of bowel cancer
  • have a genetic condition which is linked to bowel cancer
  • have polyps (non-cancerous growths) in your bowel
  • have a longstanding inflammatory bowel disease, for example Ulcerative colitis and Crohn’s disease 
  • have type 2 diabetes
  • have an unhealthy lifestyle, for example poor diet, drinking alcohol, smoking and lack of physical activity and exercise.

Symptoms of bowel cancer include:

  • bleeding from your bottom and/or blood in your faeces (poo)
  • a persistent and unexplained change in bowel habit 
  • pain or a lump in your tummy 
  • weight loss with no explanation 
  • extreme tiredness for no obvious reason.

If you are concerned about any of these symptoms, always visit your GP. There is no need to be embarrassed, they are used to seeing patients who have bowel problems.

For more information about what to expect when you visit your GP
NHS
Bowel Cancer UK

COVID-19 update

If you have symptoms that you are worried may be cancer, it is important to still seek advice from your GP surgery. Your symptoms do not mean you have cancer and could be caused by a number of common conditions but it is always best to get checked.

Bowel Screening

Screening is where people with no symptoms are invited to complete a test which looks for blood in their poo. If you are invited to take a test, it’s important to do it. Detecting cancer earlier makes it easier to treat and could save your life.

If you are between 60-74 and registered with a GP, you will receive an NHS screening test in the post every two years. This is called a Faecal Immunochemical Test (FIT) test and is a kit you use to collect small samples of poo. Screening can detect tiny amounts of blood in the poo which cannot usually be seen.  

For more information about screening
NHS

Suspected cancer

If you have any of the symptoms described, your GP will discuss your symptoms and probably do a rectal examination. This is when your doctor puts a gloved finger in your rectum (back passage) to feel for any lumps or swelling.

If you have symptoms that don’t meet the criteria for an urgent referral to the hospital but your GP is thinks your symptoms may suggest cancer, you may be offered a FIT test to see if you have blood in your poo. This is the same test as the one used in the bowel cancer screening programme. 

It is important to know that even if you have previously had a negative bowel cancer screening test result, you must still complete the FIT test again if your GP asks you to because the FIT test your GP will do is measured differently.

If the FIT test is negative, the chances of you having cancer are very small but your GP may still refer you to the hospital. However, you must contact your GP if your symptoms worsen. 

If the GP FIT test is positive or if your GP suspects bowel cancer, the next step of the pathway is a referral to the hospital for some blood tests to be carried out within two weeks. This is called a fast track referral.

COVID-19 update

During the COVID-19 pandemic fast track referrals are still essential but they may be managed differently.

For more information about fast track referrals during the COVID-19 pandemic download a fast track referrals leaflet:

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There are different ways you could get to the fast track referral stage. It could be: 

  • via bowel screening as explained earlier
  • because you had an emergency hospital appointment due to bowel obstruction and needed further tests afterwards
  • attended the iron deficiency anaemia clinic and needed further testing afterwards.

When the hospital receives the fast track referral from your GP, they may send you a FIT test to see if you have blood in your poo.  It is important that you collect your stool sample and return this in the post as quickly as possible. 

You would not be sent this FIT test if:

  • you have already carried out a FIT test for your GP
  • you have visual bleeding from your bottom.

Following referral, you will have the further diagnostic tests you need.

COVID-19 update

Your referral will still be reviewed by the colorectal team at the hospital.

If you have not experienced bleeding from the back passage but have been referred to the colorectal team to exclude cancer with other symptoms. For example, changes in bowel habit, abdominal pain, weight loss, iron-deficiency anaemia (the blood lacks adequate healthy red blood cells) and palpable mass (a lump you can feel). You may be offered a faecal immunochemical test (FIT) if this has not already been completed by your GP. The use of the FIT test in the cancer pathway may vary depending on individual patient symptoms and hospitals.

You will have an appointment with a member of the colorectal team (probably a telephone) and they will make an assessment based on your described symptoms and FIT test. 

If you need a test or to be seen in person, this will be explained to you and any decisions will be made taking your overall health and safety into consideration.

It is understandable that you may be worried about going into hospital where patients with COVID-19 are being cared for but please be reassured that your safety is a priority. Hospital areas dealing with non-COVID-19 issues are kept separate from those dealing with COVID-19 positive patients and this is carefully managed for your safety.

Testing for colon cancer

You may be seen by a consultant or you may have an endoscopy or CT scan first.  

Endoscopy

A long, thin, flexible tube (endoscope) which has a light and camera at one end is used to look inside the body. There are lots of different kinds of endoscopy but usually you will have a flexible sigmoidoscopy or colonoscopy to look inside your bowel. 

For more information about endoscopy
Bowel Cancer UK

COVID-19 update

Colonoscopy services have restarted. If your FIT test is negative, your colonoscopy may be deferred until a safer time. This decision will be made taking your overall health and safety into consideration. 

CT scan or computerised tomography scan

This type of scan uses x-rays and a computer to create images of the inside of the body.

Testing for rectal cancer

Rectal examination

When your consultant puts a gloved finger in your rectum (back passage) to feel for any lumps or swelling.

Blood tests

You will have blood tests to check for low blood cells (anaemia) and to check your liver and kidney function.

 

You may also have one or more of the following tests

Colonoscopy

To check inside your bowel.

Virtual colonoscopy or CT colonography

To produce pictures of the inside of the colon or rectum.

Sigmoidoscopy or flexible sigmoidoscopy

A procedure which allows your consultant to look inside your colon using a flexible tube with a light.

 
You may find it helpful to bring a family member or friend with you to your appointment.

COVID-19 update

Please check with the hospital to see if you can take someone with you. If it is possible, they will usually be expected to wait outside.

Please be reassured all hospitals are working hard to make sure it is safe to attend the hospital if you are advised to. Your test areas will be separated from areas where patients with COVID-19 are being treated. If you still feel unsure or concerned about attending hospital, please contact your cancer care team or your GP.

Diagnosis and staging

If you are diagnosed with bowel cancer, your consultant will speak to you about staging.

Staging of a cancer describes the location of the tumour and whether it has spread to other parts of the body. Your cancer will be graded by assessing how aggressive the cells look under a microscope. This will give an idea of how quickly your cancer could grow or spread and will assist with choosing the best treatment choices for you.  

Colon cancer

To work out the stage of your colon cancer you will be offered a CT scan.

For more information about staging
Bowel Cancer UK

Rectal cancer

If you have rectal cancer, further tests may include

CT scan or computerised tomography scan

A scan which uses x-rays and a computer to create images of the inside of the body.

Magnetic resonance imaging scan or MRI

A scan which uses strong magnetic fields and radio waves to produce a detailed image of the inside of the body.

Endorectal Ultrasound Scan (ERUS)

A test to find tumours in the rectum and, if found, to provide information about the size, location and how deeply the tumour is growing into the rectal wall. Lymph nodes close to the tumour will also be checked to see if the cancer has spread. 

Positron Emission Tomography (PET)-CT scan

This is a combination of a CT scan and a PET scan which gives detailed information about your cancer. The CT takes a series of x-rays from around your body and creates a three-dimensional picture. The PET scan uses a mildly radioactive drug to show up areas of your body where cells are more active than normal.

The results of these tests will help your consultant find out about the staging and grading of your cancer.

COVID-19 update

If further testing is required your cancer care team will discuss the next steps with you. If you have any concerns or questions, please contact your cancer care team.

Treatment

Treatment will depend on various factors including the location of the cancer in the bowel and whether it has spread to another part of the body.  

The best course of treatment for you will be discussed within a team of specialists called a multidisciplinary team (MDT).  

Multidisciplinary team

A multidisciplinary team (MDT) is a group of health care professionals who are from one or more clinical disciplines who make decisions together regarding the recommended treatment for individual patients.  

Your clinical nurse specialist or consultant will go through the different treatments and the side effects they may have.

For questions to ask during your consultation
Bowel Cancer UK

Colon and rectal cancer

If you have rectal cancer, you may have treatment before surgery which could be chemotherapy or radiotherapy, or both. Not everyone will have treatment before surgery.

Treatments

Surgery

The most common treatment for colon and rectal cancer. However, this will depend on the staging, where the cancer is within the part of the bowel and if it has spread to other parts of the body. It will also depend on your general health.

For more information about types of surgery, preparing for surgery and after surgery
Bowel Cancer UK

After Surgery

It is important that you allow time to recover following surgery and follow steps to getting back on your feet.

For information about after surgery
Bowel Cancer UK

Chemotherapy

The use of anti-cancer drugs to destroy cancer cells. Chemotherapy may be used after surgery or sometimes as your main treatment if the cancer has spread. 

 

COVID-19 update

If further testing is required your cancer care team will discuss the next steps with you. If you have any concerns or questions, please contact your cancer care team.

For colon cancer you may also have

Targeted therapy or immunotherapy drugs

These interfere with the way cancer cells signal or interact with each other and stops them from growing and dividing. May be used with chemotherapy.

Advanced bowel cancer

Different treatment options may be available to you, it is possible to reach a cure if the cancer has only spread to the liver or the lungs. Surgery is sometimes possible and can either keep the cancer under control or cure.

Sometimes the options are palliative which means everything will be done to relieve your symptoms but usually this will not cure your cancer. You may still be able to have chemotherapy or biological therapies.

Your cancer care team will go through the treatment options which are best suited to you. If they think there are no treatment options for you, they will discuss this with you. If they think you are nearing the end of your life, they will discuss this with you too if you want to talk about it.

After treatment

You will have regular check-ups and your consultant will monitor your progress. You will have a care plan detailing your follow-up care based on the type of cancer and treatment you have had.

Treatment summary

Your GP will be sent a treatment summary from the hospital which summarises the:

  • diagnostic tests carried out
  • types of treatment you had
  • treatment plans from other involved health care professionals.

For more information about after treatment
Bowel Cancer UK

COVID-19 update

Due to the pandemic, your follow up appointment may be a telephone or virtual clinic to minimise hospital visits.

If bowel cancer returns

Your cancer care team should inform you of the signs and symptoms to look out for. You should always speak to your cancer care team if you are worried about your cancer returning or if you have any questions.

Bowel cancer that comes back following your treatment is called recurrent bowel cancer. The cancer can come back in the bowel close to the original site, this is called local recurrence, or in another part of the body which is called advanced or secondary cancer.  

Diagnosing recurrent bowel cancer

Following treatment your cancer care team will inform you of your follow-up plan. Your follow-up aims to pick up: 

  • non-cancerous growths (polyps) that have the potential to develop into a new cancer 
  • cancer that has come back in the bowel or another part of the body. 

If your cancer care team suspect your cancer has returned, you will have more tests to find out where it is. These tests may include scans, blood tests and a colonoscopy.  

If you have any concerns or new symptoms that you are worried about, do not wait for your next follow up appointment, speak to your GP or cancer care team straight away. 

For more information about recurrent bowel cancer
Bowel Cancer UK

Living with and beyond cancer

Emotional impact

How you cope with your diagnosis and treatment will be specific to you. You may expect to feel relief once your hospital-based treatment ends but this is not always the case and it can be a difficult and emotional time.

Following treatment, you may have time to reflect on the impact of your diagnosis. It is completely normal to have a mixture of emotions if you are living with or affected by cancer. There are a lot of support services available to help you through. It is important to remember you are not alone.

You may benefit from:

  • talking to friends and family
  • communicating with others in the same situation
  • talking therapies and counselling
  • moving forward courses
  • local support groups
  • health and wellbeing events.

For more information on dealing with your feelings and emotions
Bowel Cancer UK – Your emotions
Macmillan – Cancer and your emotions
Macmillan – Emotional help

 

Support groups
Directory of services

Online support – you can get support on the internet via online support groups, social networking sites, forums, chat rooms and blogs for people who are affected by cancer.
Bowel Cancer UK – Living well
Penny Brohn

For information about counselling services
British Association for Counselling and Psychotherapy

If you are feeling depressed or need to speak to someone immediately, please contact Samaritans 116 123  

If you are struggling with how you are feeling emotionally, it is important to speak to your GP or your cancer care team, they will be able to provide you information on the treatments and support available to you.  

Side effects and symptoms

You will most likely feel very tired and may also have some side effects or be coping with symptoms. Your body will need time to recover from treatment.

Long term side effects can include: 

  • tiredness
  • hernia 
  • nerve damage 
  • changes in bowel function 
  • changes in bladder function 
  • changes in sexual function

Side effects usually get better with time but they can continue for more than six months or develop years after treatment.

For more information about side effects
Bowel Cancer UK

For help with managing fatigue and sleep
Bowel Cancer UK 

For help with managing bowel habit changes
Bowel Cancer UK

Stoma

A stoma is where a section of bowel is brought out through an opening in your tummy. Your bowel movements are collected in a pouch or bag which is attached to the area around your stoma.  

If you have a stoma, it will either be temporary or it can be permanent. If you have a temporary stoma, you will have a further operation to reverse it.  

There are two types of stoma:  

  • colostomy 
  • ileostomy

For more information about stomas
Bowel Cancer UK
Colostomy UK
IA Support

For further information about diet and eating with a colostomy or ileostomy
Bowel Cancer UK

Changes to your appearance and body image

Cancer and treatment for cancer can change how you feel about your body. You may have scarring, weight loss or physical discomfort which may lower your body confidence. Always talk to someone as this can help with coping. You could talk to a family member, friend or you could ask for your clinical nurse specialist for help. 

If you have had a stoma, you may feel strong emotions about the changes to your body and adapting to your new body will take time and support from your clinical nurse specialist. 

For further information about body image
Bowel Cancer UK

Information about stomas
Colostomy UK
IA Support

Relationships and sex

Bowel cancer and the treatment for cancer can affect your emotions and relationships which can then lead to issues with intimacy and sex. 

Discussing your worries with your partner and being open about the effects of treatment on your sex life can be helpful to you both and may help you to cope better. There are also professionals who can help with becoming sexually active or starting a new relationship. 

Often people find it embarrassing to talk about their sex lives but if you have any concerns or questions,  your cancer care team are used to talking openly about sexual matters. 

For more information about relationships and sex
Bowel Cancer UK

Maintaining a healthy lifestyle

Following your treatment, there are many things you can do that may help to reduce the risk of lung cancer recurrence and prevent other health conditions.

You can take care of yourself by:

  • Stopping smoking
    Your cancer care team and your GP can help as well as the national stopping-smoking service.
    NHS
    Livewell Dorset
  • Managing tiredness
    Your clinical nurse specialist can discuss this with you and perhaps how family and friends could support you with day to day tasks.
  • Getting more active
    SafeFit
  • Eating well and maintaining a healthy weight
    NHS
  • Sticking to sensible drinking guidelines
    Drinkaware
  • Reducing stress

For more information on taking care of yourself
Macmillan – Lifestyle and wellbeing after treatment
Macmillan – In your area
Macmillan – Online community

You can get in contact with your GP for further information regarding maintaining a healthy lifestyle and they will be able to offer you advice and support.

For further information on your follow-up care, please speak to your cancer care team.

For additional information on after treatment
Bowel Cancer UK – After surgery
Bowel Cancer UK – After treatment

Talking about cancer

It can be difficult to tell people you have cancer, however talking to your closest friends and family can make you feel more supported and reassured that the feelings you may be experiencing are normal. 

Everyone you tell may have a different reaction and it is important to be prepared for this. Some will be keen to support you but this may not always be the case as some people may find the conversation difficult and uncomfortable. This may be through lack of experience, fearing your reaction or they may go into denial.

For videos of people talking about their own experiences and coping with people’s reactions
healthtalk

It can also help to talk to people who also have cancer as they may have a better understanding of what you are going through.  

For more information on talking about cancer
Macmillan Cancer Support

Complementary therapies

Complementary therapies can be used alongside conventional bowel cancer treatments. These are not the same as alternative therapies which are used instead of conventional treatments, such as chemotherapy or radiotherapy.

Complementary therapies can give you comfort and help you feel more relaxed after treatment and diagnosis. Types of complementary therapies can include:

  • activities that improve mindfulness
  • acupuncture
  • acupressure and shiatsu
  • aromatherapy
  • healing and energy therapies
  • herbal therapies
  • hypnotherapy
  • massage
  • meditation
  • mindfulness
  • reflexology
  • special ‘cancer diets’ and dietary supplements
  • yoga, Tai Chi and Chi Gung.

You can discuss what complementary therapies are available to you with your cancer care team.

For more information about complementary therapies
Macmillan Cancer Support

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