As usual, my wife and her family have come to me to make a decision about a major medical issue. My sister in law's boy friend has been diagnosed with bowel cancer stage III. He's known about it for over a year but can't make a decision what to do about it. Probably a year ago his prognosis would probably been stage II and a fairly good survivability rate. Researching this, at stage II and surgery ++ the 5 year prognosis was 90%, at stage III it's down to 50%.

I'm not comfortable at making these kind of life/death decisions but they want me to tell them the best course of action. Obviously if left untreated I would assume his life expectancy would be rather short. Guess what they want from me is to decide whether to do the surgery +chemo +radiotheraphy. He put off the decision probably out of fear and not understanding what it means, or perhaps the doctors not really telling him what it meant.

I've read many places very mixed statements about chemo and it has only a small effect on longevity but with a lot of discomfort. He is in Chon Buri so not sure what hospitals and treatment is available there and how successful treatment for this in Thailand is.

He will definitely die if he does not get the recommended treatment and has a better than 50% chance of surviving if he does. Actually the latest literature shows a 60-70% survival rate for stage III depending on the extent of lymph node involvement.

I think the real question here is why, given that it may save his life and he will definitely otherwise die (and I am assuming he is relatively young) he is asking the question at all. Need to find out what exactly is on his mind that leads him to consider doing nothing, i.e. does he clearly understand what will happen in the absence of treatment? Does he somehow think that the surgery itself is very dangerous(not true)? Has he been told he will require a permenent colostomy? Or what?

Assuming that by bowel cancer you mean colon, surgery + chemotherapy is the indicated treatment. Radiation is used for rectal cancer but not AFAIK commonly used in cancer of the colon.

Response to chemo, altho it varies by the type of tumor, is better nowadays than it used to be. In some cases chemo post-surgery effects complete cure. http://www.medscape.com/viewarticle/587852. There is no debate about the value of chemo for stage III, the ongoing debate is whether or nto it is worthwhile in stage II.

The Thai government hospital system can provide chemotherapy, although he may have to travel to a regional hospital for it. Not sure which hospital in that region it would be, but they have provincial hospitals with thsi caapcity serving a cluster of provinces throughout the country.

If you can tell me exactly where the tumor is located and the type (would be in the pathology report) I can give more precise info on prognosis and treatments, but it will not change the basic equation which is certain death on one hand and chance of cure on the other.

There may be a cost issue as I know chemo can be expensive, even at a government hospital, as the preferred (at least for lung cancer) drugs are imported. Cost was estimated at over 100k per month and actual cost at cancer hospital in Bangkok I believe is a bit under 80k per month. A cheaper alternative would have been about 40k per month. Proper testing also seems to be expensive and not done in a timely manner at normal first line hospitals.

Believe most Thai believe the word 'cancer' equals death and they seem to have valid reasons for such pessimism. Years ago I wondered why the wife went pale when I had a skin cancer that had to be removed. In most cases they will not even use the word.

The currently preferred chemo regimen for cancer of the colon is fluorouracil plus either leucovorin or levamisole. Not sure about levamisole but the other two are available in local generic.

Mum and sister have had it, both had surgery before any chemo. Mum was stage 3 sis stage 2. Mum died sister was fine after surgery but could not take the chemo for long. Can't understand why he has not had surgery already.