COLORECTAL CANCER

 less formally known as bowel cancer

 a cancer characterized by neoplasia in the colon, rectum, or vermiform appendix.
 ETIOLOGY: (unknown) Yet in spite of the high incidence of colon cancer, we still
do not have a sound basis for delineating the causes and mechanism of colon
carcinoma growth, nor do we have a means of curing the disease in every case.
 Almost all colon cancer starts in glands in the lining of the colon and rectum.
There is no single cause of colon cancer. Nearly all colon cancers begin as
noncancerous (benign) polyps, which slowly develop into cancer.

RISK FACTORS
 Age. The risk of developing colorectal cancer increases as we age. The disease is more
common in people over 50, and the chance of getting colorectal cancer increases with
each decade. However, colorectal cancer has also been known to develop in younger
people.

 Gender. The risk overall are equal, but women have a higher risk for colon cancer, while
men are more likely to develop rectal cancer.

 Polyps. Polyps are non-cancerous growths on the inner wall of the colon or rectum.
While they are fairly common in people over 50, one type of polyp, referred to as an
adenoma, increases the risk of developing colorectal cancer. Adenomas are non-
cancerous polyps that are considered precursors, or the first step toward colon and
rectal cancer.

 Personal history. Research shows that women who have a history of ovarian, uterine,
or breast cancer have a somewhat increased risk of developing colorectal cancer.
Also, a person who already has had colorectal cancer may develop the disease a
second time. In addition, people who have chronic inflammatory conditions of the colon,
such as ulcerative colitis or Crohn's disease, also are at higher risk of developing
colorectal cancer.

 Family history. Parents, siblings, and children of a person who has had colorectal
cancer are somewhat more likely to develop colorectal cancer themselves.
A family history of familial polyposis, adenomatous polyps, or hereditary polyp
syndrome also increases the risk as does a syndrome known as hereditary non-
polyposis colon cancer, or HNPCC. This latter syndrome also increases the risk for other
cancers as well.

 Diet. A diet high in fat and calories and low in fiber may be linked to a greater risk of
developing colorectal cancer.

 Lifestyle factors. You may be at increased risk for developing colorectal cancer if you
drink alcohol, smoke, don't get enough exercise, and if you are overweight.

 Diabetes. People with diabetes have a 30-40% increased risk of developing colon
cancer.

SYMPTOMS
*Many cases of colon cancer is asymptomatic, however, the following symptoms may indicate
colon cancer:
 Abdominal pain and tenderness in the lower abdomen
 Weight loss with no known reason
 Change in the frequency of bowel movements
 Diarrhea, constipation, or feeling that the bowel does not empty completely
 Bright red or very dark blood in the stool
 Stools that are narrower than usual
 General stomach discomfort like frequent gas pains, bloating, fullness and/or cramps
 Constant fatigue
 Vomiting
SCREENING TESTS
 Barium Enema
 Sigmoidoscopy- visualization of the sigmoid colon and rectum
 Colonoscopy – best screening test for colon cancer

If your doctor learns that you do have colorectal cancer, more tests will be done to see if the
cancer has spread. CT or MRI scans of the abdomen, pelvic area, chest, or brain may be used
to stage the cancer. Sometimes, PET scans are also used.

Blood tests to detect tumor markers, including carcinoembryonic antigen (CEA) and CA 19-9,
may help your physician follow you during and after treatment.

COLORECTAL CANCER STAGING

Stage TNM stage TNM stage criteria for

colorectal cancer
Stage 0 Tis N0 M0 Tis: Tumor confined to
mucosa; cancer-in-situ
Stage I T1 N0 M0 T1: Tumor invades
submucosa
Stage I T2 N0 M0 T2: Tumor invades muscularis
propria
Stage II-A T3 N0 M0 T3: Tumor invades subserosa
or beyond (without other
organs involved)
Stage II-B T4 N0 M0 T4: Tumor invades adjacent
organs or perforates the
visceral peritoneum
Stage III-A T1-2 N1 M0 N1: Metastasis to 1 to 3
regional lymph nodes. T1 or
T2.
Stage III-B T3-4 N1 M0 N1: Metastasis to 1 to 3
regional lymph nodes. T3 or
T4.
Stage III-C any T, N2 M0 N2: Metastasis to 4 or more
regional lymph nodes. Any T.
Stage IV any T, any N, M1 M1: Distant metastases
present. Any T, any N.
POSSIBLE COMPLICATIONS
 Blockage of the colon (Intestinal Obstruction): blockage in the intestine that does not
allow food or stool to pass through the intestine.
 Gastrointestinal Bleeding
 Anemia : when the polyps bleed it can result in anemia, which is a lack of red
blood cells and/or hemoglobin
 Cancer recurrence: when colon cancer comes back after it has gone into remission
 Cancer spreading to other organs or tissues (metastasis) this is when the colon cancer
spreads to other parts of the body and organs, most often the liver, the lungs, bones and
the brain
 Development of a second primary colorectal cancer

COLLABORATIVE MANAGEMENT
Treatment depends partly on the stage of the cancer. In general, treatments may include:
 Surgery (most often a colectomy) to remove cancer cells
 Chemotherapy to kill cancer cells
 Radiation therapy to destroy cancerous tissue

 SURGERY
Stage 0 colon cancer may be treated by removing the cancer cells, often during a colonoscopy.
For stages I, II, and III cancer, more extensive surgery is needed to remove the part of the colon
that is cancerous.

Generally, large bowel resection is surgery to remove all or part of your large bowel. This
surgery is also called colectomy. The large bowel is also called the large intestine or colon.

Removal of the entire colon and the rectum is called a proctocolectomy.

Removal of part or all of the colon but not the rectum is called subtotal colectomy.

HERE ARE SOME OF THE SURGERIES:

1. Wide segmental bowel resection of tumor, including regional lymph nodes and blood
vessels.
2. Transanal excision for small, localized, accessible tumors.
3. Low anterior resection for upper rectal tumors; possible temporary diversion loop
colostomy while rectal anastomosis heals; 2nd procedure for takedown of colostomy.
4. Colonic J-pouch is a new technique that may be offered for rectal tumors. Laparoscopic
procedures are controversial.
5. Abdominoperineal resection with permanent end colostomy for lower rectal tumors when
adequate margins cannot be obtained or anal sphincters are involved.
6. Temporary loop colostomy to decompress bowel and divert fecal stream, followed by
later bowel resection, anastomosis, and takedown of colostomy.
7. Diverting colostomy or ileostomy as palliation for obstructing, unresectable tumors.
8. Total proctocolectomy and possible ileal reservoir- anal anastomosis for patients with
familial adenomatous polyposis and CUC before cancer is confirmed.
9. More extensive surgery involving removal of other organs if cancer has spread (bladder,
uterus, small intestine)

 CHEMOTHERAPY
Almost all patients with stage III colon cancer should receive chemotherapy after surgery for
approximately 6 - 8 months. The chemotherapy drug 5-fluorouracil has been shown to increase
the chance of a cure in certain patients.

Chemotherapy is also used to improve symptoms and prolong survival in patients with stage IV
colon cancer.
 Irinotecan, oxaliplatin, capecitabine, and 5-fluorouracil are the three most commonly
used drugs.
 Monoclonal antibodies, including cetuximab (Erbitux), panitumumab (Vectibix),
bevacizumab (Avastin), and other drugs have been used alone or in combination with
chemotherapy.

You may receive just one type, or a combination of these drugs. Chemotherapy may be used as
adjuvant therapy to improve survival time. May be used for residual disease, recurrence of
disease, unresectable tumors and metastatic disease.

 RADIATION
Although radiation therapy is occasionally used in patients with colon cancer, it is usually used
in combination with chemotherapy for patients with stage III rectal cancer.

 Other Therapeutic Interventions

Blood replacement or other treatments if severe anemia exists.
For patients with stage IV disease that has spread to the liver, various treatments directed
specifically at the liver can be used. This may include:
 Burning the cancer (ablation)
 Delivering chemotherapy or radiation directly into the liver
 Freezing the cancer (cryotherapy)
 Surgery

NURSING MANAGEMENT
o Prepare the patient for surgery, as indicated.
o Provide comfort measures and reassurance for patients undergoing radiation therapy.
o Prepare the patient for the adverse effects of chemotherapy and take steps to minimize
this effects.
o Use strict aseptic technique when caring for I.V. catheters.
o Have the patient wash his hands before and after meals and after going to the bathroom.
o Listen to the patient’s fears and concerns, stay with him during periods of severe stress
and anxiety.
o Encourage the patient to identify actions and care measures that will promote his
comfort and relaxation.
o Monitor the patient’s bowel patterns.
o Monitors the patient’s diet modification, and assess the adequacy of his nutrition intake.
o Direct the patient to follow a high fiber diet.
o Caution him to take laxatives or an antidiarrheal medications only as prescribed by the
doctor.
o Inform the patient about screening and early detection.

Management of patient that is for surgery:

 Preoperative Management:
1. Preparing the client for surgery.
 Physical preparation – building the patient’s stamina and cleansing the bowel prior to
surgery
 Assess patient’s knowledge about the diagnosis, prognosis, surgical procedure, and
expected level of functioning after surgery.
 Assess patient’s anxiety level and coping mechanisms and suggest methods for reducing
anxiety such as deep breathing exercises.

 Intraoperative Management:
1. Maintenance of safety
 Maintains aseptic, controlled environment.
2. Effectively manages human resources, equipment, and supplies for individualized patient
care.
3. Transfer patient to operating room table.
4. Position the patient, exposing the surgical site.
5. Applies grounding device to patient.
6. Ensure that the sponge, needle, and instrument counts are correct.

 Postoperative Management:
1. Pain management during the immediate postoperative period, monitor for complications
such as leakage from the site of anastomosis, prolapse of the stoma, perforation, stoma
retraction, skin irritation, and pulmonary complications.
2. Maintaining optimal nutrition – The patient avoids foods that cause excessive odor and
gas, including foods in the cabbage family, eggs, fish, beans, and high-cellulose products
such as peanuts. Fluid intake of at least 2 L/day.
3. Providing wound care
 The nurse frequently examines the abdominal dressing during the first 24 hours after
surgery to detect signs of hemorrhage.
 Splint the abdominal incision during coughing and deep breathing to lessen tension on the
edges of the incision.
 Monitor vital signs to detect an infectious process.
 With colostomy – stoma is examined for swelling (slight edema from surgical manipulation
is normal), color (a healthy stoma is pink or red), discharge (small amount of oozing is
normal), and bleeding (an ABNORMAL sign)
4. Monitoring and managing complications
 Frequently assess the abdomen, including decreasing or changing bowel sounds and
increasing abdominal girth to detect bowel obstruction.
 Monitor hematocrit and haemoglobin levels and administer blood products as prescribed.
 For pulmonary complications – frequent activity (turning to sides every 2 hours), deep
breathing exercises, coughing, and early ambulation
5. Removing and applying the colostomy appliance – The colostomy begins to function
3 to 6 days after surgery.
 Advise patient to protect the periostomal skin by washing the area gently with a moist soft
cloth and a mild soap.
6. Irrigating the colostomy – to empty the colon of gas, mucus, and feces
7. Supporting a positive image – Help the patient overcome aversion to the stoma or fear of
self injury by providing care and teaching in an open, accepting manner and by
encouraging the patient to talk about his or her feelings about the stoma.