CASE SCENARIO

Rajesh is a 64-year-old man who comes to his

primary care provider’s (PCP’s) office for an
yearly examination. He initially reports having no
new health problems; however, on further
questioning, he admits to having developed some
fatigue, abdominal bloating, and intermittent
constipation. His nurse practitioner completes
the examination, which includes a normal rectal
exam with a stool positive for guaiac. Diagnostic
studies include a CBC with differential, chem 14, and
carcinoembryonic antigen (CEA). 1
 SEMINAR ON
EVIDENCE BASED
PRACTICES IN
COLON CANCER
PRESENTED
BY:
Anupam Sisodia 2
 CONTENT
• Introduction
• Colon cancer
Anatomy & physiology
Epidemiology
Risk factors
Types
Pathophysiology
Stages
Diagnostics
Treatment
Prevention
• Case Vignette 3
 INTRODUCTION

 Colo Rectal Cancer(CRC) is also known as

colon or rectal or bowel cancer.
 3rd most common diagnosed
 2nd deadliest malignancy
 Multifactorial disease
 March is CRC awareness month
4
PARTS OF COLON AND RECTUM

5
LAYER OF BOWEL WALL

6
REGIONAL LYMPH NODES

7
 COLORECTAL CANCER

Adenocarcinoma makes upto 95% of CRC

Hereditary CRC- Familial adenomatous polyps(FAP),
Hereditary non polyposis colorectal cancer HNPCC

Surgical resection is standard treatment

Neoadjuvant therapy is standard for high risk patients

8
 EPIDEMIOLOGY
Overall age-standardized rates for Colorectal Cancers (2004 – 2014) per 100, 000 persons.

2004- 2005 2006- 2008 2009- 2011 2012- 2014 Trend (% Change)
India 5.8 (5.5 – 6.0) 6.0 (5.8 – 6.2) 6.3 (6.1 – 6.6) 6.9 (6.6 – 7.3) ↑ 20.6 %

© 2020 American Society of Clinical Oncology

In 2020, more than 1.9 million new cases of colorectal cancer and more than 930 000 deaths due to colorectal
cancer were estimated to have occurred worldwide. Large geographical variations in incidence and mortality
rates were observed. The incidence rates were highest in Europe and Australia and New Zealand, and the
mortality rates were highest in Eastern Europe.

By 2040 the burden of colorectal cancer will increase to 3.2 million new cases per year (an increase of 63%)
and 1.6 million deaths per year (an increase of 73%).
© 2023 WHO
9
CRC incidence among persons younger than 50 years decreased slightly
between 1975–1979 and 1990. However, among persons 20–49 years
old, CRC incidence increased from 8.3/100,000 persons in 1990–1994
to 11.4/100,000 persons in 2010–2013; incidence rates in younger
adults were similar for whites and blacks.
©Clinical gastroenterology and hepatology Vol 15 June 2017
10
EPIDEMIOLOGY (Contd.)

11
© 2019 𝑊𝐻𝑂
© 2021, Cancers
12
Identified 155 high-confidence effector genes functionally linked to
CRC risk, many of which had no previously established role in CRC.
These have multiple different functions and specifically indicate that
variation in normal colorectal homeostasis, proliferation, cell adhesion,
migration, immunity and microbial interactions determines CRC risk.
Crosstissue analyses indicated that over a third of effector genes most
probably act outside the colonic mucosa.
13
PATHOPHYSIOLOGY
ADENOCARCINOMA

14
15
 MAJOR PATHWAYS IN CRC

Mundade, Rasika & Imperiale, Thomas & Prabhu, Lakshmi & Loehrer, Patrick & Lu, Tao. (2014). Genetic pathways,
16
prevention, and treatment of sporadic colorectal cancer. Oncoscience. 1. 400-6. 10.18632/oncoscience.59.
SPREAD AND METASTIZES
PATHWAYS
LOCAL INVASION
LYMPHATIC METASTATIS
HEMATOGENOUS METASTASIS
IMPLANTATION AND METASTASIS

17
 TYPES OF CRC

Familial
Carcinoids
Adenocarcinoma colorectal
tumor
cancer (FCC)

Gastrointestinal
stromal tumors Lymphomas
(GIST)

18
ADENOCARCINOM
A

19
Gastrointestinal
Carcinoid
stomal tumor
tumors
(GIST)

20
Leiomyosarcoma

21
MELANOMA

22
 TYPES OF CRC Contd.

GENETIC MUTATION CRC

Juvenile Peutz-
Jeghers Turcot
polyposis
syndrome syndrome
coli
(PJS)
23
 Peutz- Jeghers
syndrome (PJS)

24
 TYPES OF CRC Contd.

Hereditary CRC

Hereditary
nonpolyposis
Familial adenomatous
colorectal cancer
polyposis (FAP)
(HNPCC)/ Lynch
syndrome
25
 FAMILIAL
LYNCH ADENOMATOUS POLYPS
SYNDROME

26
27
 STAGING OF CRC
• Stage 0 - Indicates carcinoma in situ. Tis, N0,
M0.
• Stage I - Localized cancer. T1-T2, N0, M0.
• Stage II - Locally advanced cancer, early
stages. T2-T4, N0, M0.
• Stage III - Locally advanced cancer, late
stages. T1-T4, N1-N3, M0.
• Stage IV - Metastatic cancer. T1-T4, N1-N3,
M1
28
https://youtu.be/MvH1uEO6GQw
29
CLINICAL MANIFESTATIONS
Hematochezia
Blood in stool-dark brown/black
Intestinal obstruction
Reduced stool caliber
Iron deficiency anemia
Abdominal pain and bloating
Unexplained sudden weight lost

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CLINICAL MANIFESTATIONS contd.

Locally advanced disease

Tenesmus
Rectal urgency
Inadequate emptying
Urinary symptoms
Buttock and perineal pain
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 SIGNS AND SYMPTOMS
Right side Colon Left side Colon Transverse
Anemia/ easy cancer colon
fatiguability Pain abdomen Large bowel
obstruction
Asthenia Altered Bowel
Habits due to Pain abdomen
Anorexia obstructive nature
of growth Melena
Palpable mass in
Right Iliac Fossa Palpable lump

Locally advanced Distension of

features(duodenal/rig abdomen
ht ureter/iliopsoas
involvement)
Bleeding Per Rectal
32
 DIAGNOSIS

Emergency admission
with intestinal
Asymptomatic
Suspicious symptoms obstruction,
individuals discovered
and/or signs perforation, or rarely,
by routine screening
an acute
gastrointestinal bleed

33
 DIAGNOSIS FOR CRC
• Physical examination/ History taking/ Digital rectal
examination

• Tumor markers––there are no specific tumor markers for CRC

but currently, CEA (carcinoembryonic antigen) and CA19–9
(carbohydrate Antigen 19–9)
• X-ray––X-ray examination after barium enema can find signs
of filling defect and mucosal destruction at the tumor site.
Gas-barium double-contrast acts on the detection of colon
cancer with small lesion, but it is not suitable for patients
with intestinal obstruction.
• Ultrasound––ultrasonography has a certain effect on the 34
 DIAGNOSIS FOR CRC

• Computed tomography (CT)––CT is of great diagnostic value

for displaying the size of lesions, the relationship with
adjacent tissues and organs, abdominal lymph nodes, and
other conditions, which can assist in clinical staging;
• Nuclear magnetic resonance (NMR)––similar to CT, but
higher tissue resolution than CT examination.
• Positron emission computed tomography (PET/CT)––it
provides information on the anatomical site and metabolic
characteristics of the tumor, and has great guidance for the
diagnosis, preoperative staging, and recurrence assessment
of CRC
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 DIAGNOSIS FOR CRC
(staging investigations)
• Transrectal Ultrasound(TRUS) is a highly accurate preoperative staging tool for
early rectal cancer. In other words, it shows high accuracy in determining the
depth of wall penetration and high percent accuracy in assessing regional
lymph nodes.
• CE-MRI pelvis :
-For patients with rectal cancer.
-To see the tumor extent, locoregional structures (growth extent ,mesorectal
fascia, lymph nodes, sphincter).
-Mesorectal fascia – Threatened – If growth is less than 1mm from mesorectal
fascia
-Free- more than 1mm from MRF.
• CECT Abdomen+Pelvis+Chest:- To detect the loco regional extent of primary
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 DIAGNOSIS FOR CRC

SCREENING TESTS

• Guaiac Fecal Occult Blood Test (gFOBT)

• Faecal Immunochemical Test (FIT)
• Flexible Sigmoidoscopy (FS)
• Colonoscopy
• Faecal DNA
• Computed Tomographic Colonography (CTC)

37
Virtual Colonoscopy/ CT Colonoscopy
colonography
38
 39
©2022 NEJM
TREATMENT FOR CRC

40
 Surgery for
Colon Carcinoma

Open Laparoscopic Robotics

41
 Diagram showing different colon and rectal resections performed depending on tumour location
(Illustration by Scott Holmes, CMI, printed with permission from Baylor College of Medicine,
https://www.bcm.edu/healthcare/care-centers/general-surgery/procedures/colon-resection).

Kilian G M Brown et al. BMJ 2019;366:bmj.l4561

42
©2019 by British Medical Journal Publishing Group
Polypectomy Local Excision
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 IMMUNOTHERAPY FOR CRC
Immunotherapy is the use of medicines to boost a person's own immune system to recognize
and destroy cancer cells more effectively.
o Pembrolizumab (Keytruda)
o Nivolumab (Opdivo)
o Avelumab (Bavencio)
o Ipilimumab (Yervoy)
o Bevacizumab (Blincyto)

CHEMOTHERAPY FOR CRC

Chemotherapy (chemo) uses anti-cancer drugs that are given into a vein (IV) or taken by
mouth (as pills). Some chemo drugs such as:-
Cisplatin 5-Fluorouracil (5-FU) Gemcitabine
Chemotherapy is given in cycles with each period of treatment followed by a rest period to
allow the body time to recover. Chemo cycles generally last a few weeks. 44
45
46
Colorectal cancer (CRC) is the third most common malignant tumor in the world and
the second leading cause of cancer-related deaths, with the liver as the most common site
of distant metastasis. The prognosis of CRC with liver metastasis is poor, and most
patients cannot undergo surgery. In addition, conventional antitumor approaches such
as chemotherapy, radiotherapy, targeted therapy, and surgery result in unsatisfactory
outcomes. In recent years, immunotherapy has shown good prospects in the treatment
of assorted tumors by enhancing the host's antitumor immune function, and it may
become a new effective treatment for liver metastasis of CRC. However, challenges
remain in applying immunotherapy to CRC with liver metastasis. This review examines
how the microenvironment and immunosuppressive landscape of the liver favor tumor
progression. It also highlights the latest research advances in immunotherapy for
colorectal liver metastasis and identifies immunotherapy as a treatment regimen with a
47
promising future in clinical applications.
 Standard and conventional CRC treatments include surgical expurgation for resectable CRC and
radiotherapy, chemotherapy, immunotherapy, and their combinational regimen for non-resectable CRC.
Despite these tactics, nearly half of patients develop incurable recurring CRC. Cancer cells resist the
effects of chemotherapeutic drugs in a variety of ways, including drug inactivation, drug influx and efflux
modifications, and ATP-binding cassette transporter overexpression. These constraints necessitate the
development of new target-specific therapeutic strategies. Emerging therapeutic approaches, such as
targeted immune boosting therapies, non-coding RNA-based therapies, probiotics, natural products,
oncolytic viral therapies, and biomarker-driven therapies, have shown promising results in preclinical and
clinical studies. We tethered the entire evolutionary trends in the development of CRC treatments in this
review and discussed the potential of new therapies and how they might be used in conjunction with
conventional treatments as well as their advantages and drawbacks as future medicines.

48
 Mr. Padmender Singh Negi

• Chief Complaints
• Condition on admission of patient was poor. He was
having abdominal pain (feeling more in right side)
since 2 days, diarrhea (4-5 times/day), feeling
nauseous, restlessness, fever on & off, upset
stomach.

49
 History of Present Illness

• Patient was healthy 4-5 months back. Then, he started to

have episodes of vomiting and diarrhea 3 to 4 times in a
day. He went for check-up in nearby hospital where it was
conservatively managed. On evening of 2 February 2023, he
was having complains of severe abdominal pain and
frequent diarrheal episodes with melena. Later, he was
advised for higher reference and accordingly came to
Govind Ballabh Pant Hospital (GBPH), New Delhi. Here, after
1 month, he got admitted in Surgery Ward after undergoing
investigations as he was diagnosed with Adenocarcinoma of
Ascending Colon.
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 DIAGNOSTIC TESTS
• History Collection
It will help to identify the etiology of CRC and also
will help to get information on Genetic
abnormalities.
• Physical Examination
It will help to detect the swelling or lumps on the
abdomen.

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52
 Blood Test

 Complete blood count - It determines the count of

red blood cells, white blood cells and platelets. Low
CBC level can mean intestinal function is reduced.
 Liver function test – It helps identify the disruption
in liver and associated organ functions.
 Special blood test - The cancer can affect the levels
of certain chemicals in the blood such as high
levels of liver enzymes or high blood calcium, high
alpha feto proteins levels.
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58
The research team conducted a narrative review of studies involving the role of nurses at different levels of
colorectal cancer prevention, which included a variety of quantitative, qualitative, and mixed-method
studies. We searched PubMed, Scopus, Web of Science, Cochrane Reviews, Magiran, the Scientific
Information Database (SID), Noormags, and the Islamic Science Citation (ISC) databases from ab initio
until 2021. A total of 117 studies were reviewed.
Nurses' roles were classified into three levels of prevention. At the primary level, the most important role
related to educating people to prevent cancer and reduce risk factors. At the secondary level, the roles
consisted of genetic counseling, stool testing, sigmoidoscopy and colonoscopy, biopsy and screening test
follow-ups, and chemotherapy intervention, while at the tertiary level, their roles were made up of pre-and
post-operative care to prevent further complications, rehabilitation, and palliative care.
Nurses at various levels of prevention care also act as educators, coordinators, performers of screening
tests, follow-up, and provision of palliative and end-of-life care.

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 NURSING
MANAGEMENT
60
 Case Scenario
• Mr. Ranjeet, is a 65-year-old retired railroad employee, husband, and father of
three grown children. For the past 3 months, Mr. Ranjeet has noticed small
amounts of blood in his stools and occasional mucus. He has a sensation of
pressure in the rectum, and notices that his stools are smaller in diameter, about
the size of a pencil. “After palpating a mass on digital examination of the rectum,
the physician orders a colonoscopy. " large sessile lesion is found in the rectum
and biopsied .The pathology report shows the lesion to be adencarcinoma. Mr.
Cunningham is scheduled for an abdominoper-inealresection and sigmoid
colostomy

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 NURSING DIAGNOSIS
• Pain related to surgical intervention

• Risk for impaired skin integrity (peristomal), related to

fecal drainage and pouch adhesion

• Risk for constipation/diarrhea, related to effects of

surgery on bowel function

• Risk for disturbed body image, related to colostomy

• Risk for sexual dysfunction, related to wide rectal 62

Ineffective tissue perfusion related to presence of growing cancer
cells causing compression of the blood vessels as evidenced by
increased blood pressure.
• Goal – To maintain an effective renal tissue perfusion with normal intake output.

 Assess the vital signs and monitor the weight daily.

 Monitor the intake and output along with electrolytes, BUN, CBC levels.
 Advise to drink adequate fluids around (1000 – 1200) ml/day so as to prevent
urinary retention.
 Assess for the need of catheterization.
 Administer oxygen therapy as advised (if needed).
 Administer antihypertensive, IV fluids and chemotherapeutic drugs as prescribed.
 Explain the client about the need of surgery or other treatment modalities.

63
Acute flank pain related to the presence of cancerous mass
or incision due to surgical procedure as evidenced by facial
expression and verbalization of pain.
• Goal – To relieve the patient from pain.
 Monitor the vital signs and pain score regularly.
 Assess the cause, precipitating factors, severity and quality of
pain.
 Provide side lying position on the unaffected area with extra
pillows to support the back.
 Provide diversional therapies in form of music or watching TV.
 Administer IV fluids, NSAIDs (Ibuprofen) as advised.
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Imbalanced nutrition less than body requirements related
to anorexia as evidenced by weight loss.
• Goal – To maintain normal nutritional status with dietary
compensation.
 Assess the vital signs and monitor the weight, BMI, I/O daily.
 Monitor the nutritional status and nutritional needs.
 Advise to take more fruits, vegetables, grains, starches and proteins in
diet.
 Advise to take sufficient fluids as advised.
 Advise dietary restrictions of sodium and phosphorus as per the
consultation of dietician.
 Administer dietary supplement with essential amino acids like
65
glutamine, L-Carnitine and L-arginine as prescribed.
 Ineffective thermoregulation related to increased basal metabolism
secondary to the presence of growing cancer cells or inflammation of the
surgical site as evidenced by increased body temperature.
Goal – To maintain an effective renal tissue perfusion with normal urine output.
 Assess the vital signs especially body temperature frequently.
 Monitor for raised ESR levels and urine culture studies.
 Advise to drink adequate fluids as per I/O chart.
 Provided cold compressors or tapid sponging as prescribed.
 Provide adequate ventilation and low environmental temperature.
 Provide aseptic care at the incision site by changing the dressings.
 Follow all moments of hand hygiene.
 Encourage the client to follow hygienic practices as well after teaching him/her.
 Administer antipyretics, antibiotics and NSAIDs as ordered.
66
 Anticipatory grieving related to the diagnosis of CRC secondary to the
evidence of growing cancer cells or surgery or long-term intervention as
evidenced by verbalization of their grief.
Goal – To help relieve anxiety and exhibit improvement in coping mechanism.
 Assess the level of anxiety and extend of grief.
 Maintain a good interpersonal relationship with the client and their families.
 Provide psychological support by explaining the available treatment protocols.
 Provide positive reinforcement on improvement in prognosis of the condition.
 Do not leave them alone and if possible allow them with their near ones.
 Encourage spiritual support by allowing them to do prayers by casting their
hope towards God.
 Provide group therapy and listen alternatively to their concerns.
 Administer anxiolytics or sedatives if prescribed.
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 Risk for fluid volume imbalance related to impaired glomerular
filtration secondary to the presence of growing cancer cells.
Goal – To maintain a normal fluid volume status.
 Assess the vital, weight and I/O daily.
 Assess the severity of edema & elevate the edematous extremities using
a pillow or folded linen.
 Monitor the urine output and adjust the intake based on the output and
insensible losses.
 Catheterize the client if needed as advised by following aseptic
techniques.
 Administer the IV fluids as prescribed and monitor for adequate
electrolyte imbalances.
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 Knowledge deficit related to home care management of the disease as evidenced
by unawareness of the client regarding their disease condition or its prognosis.
Goal – To help gain knowledge regarding the disease condition, prognosis and home care
management.
 Assess the client and significant other’s ability to understand instructions and their
language.
 Inform about adequate diet therapy and fluid intake as recommended.
 Advise to strictly avoid smoking and exposure to environmental chemicals.
 Educate about the disease condition and its treatment modalities.
 Educate about the drugs regarding its dose, frequency, usage and possible side effects.
 Advise on need for long duration treatment and to comply with the treatment
procedures.
 Educate by demonstrating about the surgical site care.
 Introduce the client to voluntary or governmental agencies for financial support.
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 CONCLUSION
• Colon cancer is a common malignancy
that causes a significant number of
deaths. The symptoms of colon cancer
are vague and, therefore, require
evaluation by health care professionals.
Through screening it is potentially
preventable and highly curable with
surgery alone when diagnosed at an
early stage.
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 Eat fresh seasonal fruits, beans
and green leafy vegetables

•Screening for cancers

should be done yearly or
every 2 yearly
nd

71