Colorectal Cancer

Colorectal Cancer • • •

Third most common form of cancer Second leading cause of cancer-related deaths 85% of colorectal cancers arise from adenomatous polyps

Etiology and Pathophysiology • More common in men • Adenocarcinoma is most common type • Most arise from adenomatous polyps • Tumors spread through the walls of the intestine into musculature into the lymphatic and vascular system Risk factors 1. Family or personal history of colorectal cancer 2. Increased age (the older you get the more high risk) 3. Colorectal polyps 4. Inflammatory bowel disease (IBD) 5. Lifestyle factors • Obesity • Smoking • Alcohol • Large amounts of red meat >7 servings per week Dietary factors: a) High fat such as granola, peanut, croissant and whole milk, cream cheese, sour cream b) Red meat c) Increase fiber to prevent colon cancer • Brand muffin, skin milk, broccoli, stir fry, cauliflower, Most common sites of metastasis 1. Regional lymph nodes 2. Liver 3. Lungs 4. Peritoneum Clinical Manifestations • Usually nonspecific, do not appear until advanced • Symptoms include 1. Hematochezia: passage of blood through rectum 2. Melena: black, tarry stools 3. Abdominal pain 4. Changes in bowel habits 5. Weakness 6. Anemia 7. Weight loss 8. Rectal bleeding (common in left sided) • Most often with left-sided lesions • Cancer on the right side different symptoms from those on the left side of the colon Left-sided lesions

Right-sided lesions

Rectal bleeding Alternating constipation and diarrhea Narrow, ribbonlike stools Sensation of incomplete evacuation

Usually asymptomatic Vague abdominal discomfort Abdominal pain Iron-deficiency anemia Occult bleeding (blood not visible in the naked eye)

Diagnostic Studies • Family history • Physical examination: tumor is large, it can be palpated • Digital rectal examination: large percentage of colorectal cancer = can be palpated • Colonoscopy a) Gold standard b) Entire colon is examined c) Biopsies can be obtained d) Polyps can be immediately removed and sent to laboratory for examination e) Colonoscopy and tissue biopsies confirm diagnosis • Fecal occult blood tests a) Cancerous tumors bleed intermittently into colon (don’t bleed continuously) b) Used to detect very small quantities of blood c) Does not detect nonbleeding tumors d) Guaiac-based tests (FOBT) e) Avoid NSAIDs, vitamin C, citrus juices, red meat for 3 days before test f) In text, it requires six samples from three consecutive bowel movements. In practice, 3 samples from different bowel movement. • Stool DNA test a) DNA markers are shed from premalignant adenomas and cancer cells in stool and not degraded b) Stools collected and analyzed c) Not yet sensitive enough to replace other screening methods • Additional laboratory studies must be done a) CBC especially if there is blood loss • Carcinoembryonic antigen (CEA) a) Complex glycoprotein b) Produced by 90% of colorectal cancers c) Helpful in monitoring disease recurrence d) We want ↓CEA in blood • It tells us that the cell is in immature state. They cannot function as mature cell • CEA (Carcinoembryonic Antigen): colon cancer ------ The treatment is effective if we see a DROP (↓) of CEA level. Cells are now in a mature state and function as colon cells. • Can also be used or drawn after a year or 2 to check for recurrence meaning. No immature colon cells and no cancer activity. • CT scan or MRI a) Helpful in detecting metastasis in vital organs b) Liver metastases c) Retroperitoneal and pelvic disease d) Depth of penetration of tumor in bowel wall Collaborative Care • Prognosis and treatment correlate with pathologic staging of the disease a) TNM system is used o Preferred classification system o Duke’s classification using TNM system specific for colon CA • Surgical therapy a) Polypectomy (removed polyp) during a colonoscopy used to resect colorectal cancer b) If cancer is localized, tumor can be resected (taken out) with healthy tissue and cancer-free ends sewn together (anastamos) o Lymph nodes removed • Chemotherapy and radiation therapy (often in conjunction with the surgery) a) If cancer has spread to lymph nodes or nearby tissue, then we use chemotherapy. We want to kill all the cancers cells that spread to the other parts of the body (systemic). b) Once cancer has spread to distant sites, surgery is palliative • Surgical goals: a) Complete resection of tumor o Site of cancer dictates site of resection. Removed all tumor and part of the healthy tissue as well in case there are cells that invaded healthy tissue.

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b) Thorough exploration of abdomen: o Require surgical consent for exploratory/open up laparatomy to see any tumors that metastasis c) Removal of all lymph nodes that drain the area esp with breast cancer d) Restoration of bowel continuity: Re-anastamosis of ends of the colon together. Taken out tumor but restore continuity of the bowel. e) Prevention of surgical complications f) Optimal procedure: Bowel resection with reanastomosis of remaining segments a) ↓ Colonic bacteria to prevent infection and breakdown at site b) To prepare patient for surgery: decrease bacteria in the colon = because infection can can lead to PERITONITIS. c) Preoperative preparation (before colon surgery) a. Bowel cleansing agent (unless patient has bowel obstruction or perforation) i. Laxative: Go-lyte and Magnesium citrate ii. Give Oral antibiotics (NEOMYCIN) to sterilize their the bowel (opening the abdomen) NOTE: COLONSCOPY: a) Give laxative b) No antibiotic needed because we are not opening the colon Chemotherapy a) Positive lymph nodes at time of surgery b) Metastatic disease c) Used as an adjuvant (treatment in conjunction with) following colon resection d) As primary treatment for nonresectable colorectal cancer • Pt with nonresectable colon cancer may have debunking procedure and chemotherapy because we can’t completely removed the tumor because of where it is located. e) First-line treatment of metastatic colorectal cancer • 5-Fluorouracil (5-FU) plus leucovorin and irinotecan Biologic and targeted therapy a) Two monoclonal antibodies • Targets epidermal growth factor receptor: Cetuximab (Erbitux) • Targets vascular endothelial growth factor: Bevacizumab (Avastin) Radiation therapy a) May be used postop as an adjuvant to surgery and chemotherapy or as palliative for metastasis

Nursing Assessment a) Past health history: Certain types of cancer it will put you at higher risk for cancer. i. Previous breast or ovarian cancer ii. Familial polyposis iii. Villous adenoma iv. Adenomatous polyps v. Inflammatory bowel disease b) Medications: laxatives (lomotil) c) Weakness or fatigue d) Change in bowel habits (constipation or diarrhea) e) High-calorie, high-fat, low-fiber diet f) Increased flatus g) Feelings of incomplete evacuation Nursing diagnosis a) Alteration to and comfort r/t stomatitis if receiving chemotherapy b) Risk for infection ( decrease WBC r/t myelosuppression ) caused by chemotherapy c) Imbalance nutrition < than body requirement r/t diet restrictions and post op (NG tube) d) Impaired skin integrity r/t radiation e) Disturbed body image r/t colostomy f) Anxiety r/t diagnosis of cancer g) Ineffective coping h) Social isolation

Planning • Overall goals a) Normal bowel elimination patterns b) Quality of life appropriate to disease progression c) Relief of pain d) Feelings of comfort and well-being Implementation • Health promotion  American Cancer Society recommends starting at age 50 • Yearly fecal occult blood test or fecal immunochemical test • Double contrast enema every 5 years • Sigmoidoscopy every 5 years • Colonoscopy every 10 years a) Screening for high-risk patients should begin before age 50 and at more frequent intervals b) Colonoscopy only detects polyps when bowel has been adequately prepared c) Ingesting clear liquids for 24 hours before colonoscopy and using an oral preparation (NPO) required before colonoscopy •

Acute intervention • Preoperative care a) Provide information about prognosis and future screening b) Support dealing with diagnosis c) Inform of the extent of the surgical procedure and the amount of care necessary to facilitate healing d) Emotional support e) Taught side-to-side positioning because of perianal incision f) Teach on sitz bath positioning: provide comfort measure to clean perianal area and pain relief • Postoperative care a) Management differs depending on the type of wound b) Type of management is individualized c) If drains present, remain in place until drainage is < than 50 ml per 24 hours d) Drainage must be assessed for amount, color, consistency e) Wound should be examined regularly f) Record bleeding, excessive drainage, and odor g) Monitor suture line for infection h) Pain control : PCA

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Ambulatory and home care • Psychologic support • Chemotherapy • Perineal wound may not be completely healed before discharge a) Must be taught wound management

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Evaluation Expected outcomes 1. Minimal alterations in bowel elimination patterns 2. Relief of pain 3. Balanced nutritional intake 4. Quality of life appropriate to disease progression 5. Feelings of comfort and well-being