SINGAPORE — When she was diagnosed with colorectal cancer, Ms Luo S H initially refused treatment because she could not accept the idea of living with a stoma for life.

Cancer survivors living with a stoma lose control of their bowel movements after having a surgically created opening on the surface of the abdomen that diverts the flow of faeces, which is collected in a pouch.

“I felt that I was too young to have a permanent stoma,” said Ms Luo, who is in her 30s and works in sales. “I care about what people think, how the stoma bag would look on me, and had the perception that I would smell bad.”

After her oncologist at the Singapore General Hospital (SGH) told Ms Luo that patients who underwent surgery could still lead a good life, and after learning more about living with a stoma, she underwent surgery in November.

Colorectal cancer is the most common cancer in Singapore, with five people here diagnosed each day.

Rates of the cancer have risen in the past few decades.

But about one in 20 patients seen at SGH may refuse proposed surgery due to the anxiety or fear of living with a stoma, said Dr Ronnie Mathew, a consultant at the department of colorectal surgery.

Patients under the age of 55 make up about 15 to 20 per cent of colorectal cancer cases here and SGH sees about 700 colorectal cancer cases each year.

The refusal to seek treatment could also be due to a lack of understanding or perceived difficulty in managing a stoma, as well as aesthetic, social and personal reasons, said Dr Mathew.

Eventually, about 85 to 90 per cent of the cases seen at SGH do undergo surgery, of which a quarter require a stoma that is either temporary or permanent, he said.

In most of the cases, a stoma is a temporary measure — done essentially to divert the passage of stools away from a section of the bowel that has been newly joined (after a diseased portion is removed), thereby reducing side effects from possible complications.

It can be closed six weeks to several months later, said Dr Mathew.

But surgery that compromises the anal sphincter — the muscle controlling continence — would require a permanent colostomy, said oncologist Wong Seng Weng, medical director of The Cancer Centre of Singapore Medical Group.

Patients may find this hard to accept as it has a “huge impact on the quality of the patients’ lives, regardless of age or sex”, said Dr Wong.

NEWER TREATMENT TECHNIQUES

However, recent advances in treatment techniques have spared more patients from having a permanent stoma. Dr Wong estimated they make up about 5 per cent of all colorectal cancer cases.

At SGH, permanent stomas are created in less than 10 per cent of rectal surgeries, a figure that is considerably lower than the 20 to 25 per cent risk in other parts of the world, said Dr Mathew.

For one, chemotherapy and radiotherapy are now used to shrink the cancer before surgery to preserve the anal canal and its muscles.

Modern surgical techniques, including robotic surgery, are also used in technically challenging cases, said Dr Wong.

Surgery offers the best chance of a curative treatment, especially if the disease is diagnosed early and is localised with no other disease spread elsewhere in the body, said Dr Mathew.

“Generally, chemotherapy/radiotherapy alone is not sufficient for the treatment of colorectal cancers although some recent data suggests that chemo-radiotherapy may make rectal cancer disappear in a small proportion of cases. However, the evidence also suggests there is a one in three chance of the cancer returning in this group,” he said.

While living with a stoma requires drastic lifestyle changes, the experts said it is possible to continue living an active life. “The contemporary stoma bags are designed with ease of change in mind. With appropriate counselling and guidance, patients with a permanent stoma can lead a fairly normal life,” said Dr Wong.

Support, counselling and education play an important role. Hospitals like SGH, as well as the Singapore Cancer Society (SCS), run patient support groups that address these concerns. SCS’ patient ambassadors, who are cancer survivors, share practical tips such as on day-to-day stoma care to help patients adapt to their condition.

Patients at SGH may also be introduced to an “ostomate” (a person who has undergone the surgery) to understand what it is like to live with a stoma.

“After that, most patients will feel more relieved and prepared for the operation,” said SGH’s senior nurse clinician Ong Choo Eng.

Ms Luo took two months to come around and undergoing surgery and nearly lost her life in the interim, with episodes of heavy bleeding that required blood transfusions.

She has now gradually eased back into a routine of work and exercise.

She wears looser clothing to conceal the stoma bag, which is worn slightly below the belly button, and avoids certain foods like cabbage and carbonated drinks that would cause the bag to bloat easily.

To keep the pouch flat and well-concealed under her clothes, she drains the bag every half to one hour.

“(Living with a stoma) is not as bad as I thought it was. But I’m still worried about the day when I’d have to tell a prospective partner about my stoma. In Asia, there’s still a stigma attached to it,” she said.