COLORECTAL CANCER (CRC) Cancer of the colon/rectum; worlds major health problem; 3rd most common site of new

w cancer cases (USA) Disease of western cultures; 2nd leading cause of cancer death (M/F) 95% adenocarcinomas (tumors arising from the glandular epithelial tissues of the colon Develops a multistep process resulting in a number of molecular changes such as: Loss of key tumor suppressor genes Activation of certain oncogenes that alter colonic mucosa forms polyps transformed into malignant tumors Arise from adenomatous polyps presenting a visible protrusion from a mucosal surface of the bowel Incidence of CRC 3rd most common malignancy (after PCA & lung CA in men; after BRCA & lung CA in women) Americans _ 6% lifetime risk for development of CRC Rare before 30 but with age; median age @ diagnosis: 67 CA of the rectum: common in men Anal Cas: 4% of CRC Both black men & women: with high risk from CRC than the whites Tumors: found in different areas of the colon about 2/3 within the rectosigmoidal region Ascending colon & cecum, 22% Transverse colon, 11% Descending colon, 6% Sigmoid colon, 25% Rectum, 30% CRC metastasize by Direct extension Spreading through the blood or lymph CRC may spread locally into 4 layers of the bowel wall & into the neighboring organs Enlarges into the lumen of the bowel Spread through the lymphatic or circulatory system The circulatory system is entered directly from the primary tumor through The blood vessels in the bowel or Via the lymphatics Metastasis to the liver develops in 15-30% even the surgical resection of the tumor, lungs, brain, bones & adrenal glands Peritoneal seeding during surgical resection of the tumor occurs when: The tumor is excised Cancer cells break off from the tumor to the peritoneal cavity Complications related to high growth of tumor locally or through metastatic spread: Bowel obstruction or perforation with resultant peritonitis Abscess formation Fistula formation to the urinary bladder or vagina Growing tumor in lumen: gradually obstruct intestine & blocks it completely Tumors beyond the bowel wall: may cause pressure on neighboring organs (uterus, urinary bladder & ureters) Etiology Risk factors Increasing age Familial history of colon cancer or polyps Previous colon cancer or adenomatous polyps High consumption of alcohol Cigarette smoking Obesity CELLULAR ABERRATIONS- NCM 106 COLORECTAL CANCER ACC, AY MVBerango, RN, MAN/Lecturer 20122013,1ST Sem

 History of gastrectomy History of inflammatory bowel disease High fat, high protein (with intake of beef), low fiber diet Genital cancer (endometrial Ca, ovarian Ca) or BRCA (women) Personal Factors Age_ 95% diagnosed in persons 50 With previous diagnosis & treatment for CRC (risk of developing second primary CRC); often @ the site of surgical anastomosis With ademotous polyps (need for required follow-up with colonoscopy Dietary Factors bowel transit time Foods with chemical mutagens_ bowel transit time thus bowel exposure to carcinogens fat diet (animal fat from red meat bile acid secretion & anaerobic bacteria) Fried or broiled meats & fish Large amount of refined carbohydrates lacking in fiber Foods that Affect a Persons Risk to CRC What to AVOID Consumables Red meat Fruits & vegetables (cruciferous veggies, e.g. broccoli, cabbage, Animal fat cauliflower, Brussels sprouts) Fatty foods Whole grain products Fried meats & fish Adequate fluids (specially water) Refined CHOs (concentrated Baked or poached fish or poultry sweets) Genetic considerations Individuals with 1st degree relatives diagnosed with CRC (with 3-fold risk) Familial adenomatous polyposis (FAP)_ autosomal dominant inherited genetic disorder (1%) Result of 1 or more mutations in the adenomatous polyposis coligene (APC) FAP develops in 10-15 years with 100% chance becoming malignant New treatment approach: COX-2 drug therapy (as alternative to invasive surgical procedures) assisted with cardiovascular events, e.g. MI & stroke HNPCRC (Hereditary Non-Polyposis CRC)_ autosomal dominant disorder accounting 10% of all CRC Caused by gene mutations Individual with these mutations have 80% chance to develop CRC @ an average of 45 years High incidence of endometrial, ovarian, stomach & ureteral cancers Gerontologic Considerations Men: only incidence of Prostate CA & lung CA exceeds that of CRC Women: only incidence of BRCA exceeds that of CRC Signs & symptoms Fatigue, due to anemia Early stages: minor changes in bowel patterns & occasional bleeding Later symptoms: abdominal pain, obstruction, tenesmus, rectal bleeding Staging of CRC 1. Dukes Classification_Modified Staging System Class A_ tumor: limited to muscular mucosa & submucosa Class B1_ tumor: extends into mucosa Class B2_ tumor: extends through the entire bowel wall into serosa or pericolic fat, no nodal involvement Class C1_positive nodes; tumors: limited to bowel wall Class C2_ positive nodes; tumors: extends through the entire bowel wall CELLULAR ABERRATIONS- NCM 106 COLORECTAL CANCER ACC, AY MVBerango, RN, MAN/Lecturer 20122013,1ST Sem

Class D_ advanced & metastasis to liver, lungs, bone 2. TNM (Tumor, Nodal involvement, Metastasis) Classification Size, invasion depth & surface spread Extent of nodal involvement Presence or absence of metastasis Health Promotion and Illness Prevention 1. Client with family members with hereditary CRC: must have gene testing for FAP or HNPCC 2. Everyone: modify diet to fat, refined CHOs, fiber foods 3. NSAIDs 4. Regular exercises, daily multivitamins, female hormonal therapy (oral contraceptives) 5. Regular CRC screening for men & women over 50: those with personal or familial history of disease must begin screening earlier & more frequently Screening Recommendations for Men & Women Age 50 & above @ Average Risk for CRC Procedure Interval Post Comments Screening Choice of one of the following: Fecal Occult Blood @ 50 years old Procedure: 2 samples from 3 consecutive BM Test (FOBT) Every year obtained @ home; tested by doctor or nurse Or Flexible Sigmoidoscopy Every 5 years FOBT + Flexible Sigmoidoscopy Double-contrast barium enema Or Colonoscopy FOBT every year; Flex. Sig. every 5 years Every 5 years Procedure for FOBT as above. Combination is preferred over either test above.

Every 10 years

Collaborative Management Assessment History 1. Obtain clients dietary history, major risk factors (personal history: breast, ovarian/endometrial CA; ulcerative colitis; Crohns disease; familial polyposis/adenomas and familial history e.g. CRC) 2. Assess clients participation in age-specific screening guidelines 3. Ask: changes in bowel habits (diarrhea, constipation; with symptoms of blood in stool) 4. Report on: fatigue (r/t anemias); abdominal fullness, pain or weight loss (advanced sign of disease) Physical Assessment/Clinical Manifestations 1. Signs of CRC: depend on location of tumor 2. Common signs: rectal bleeding, anemia, change in stool (mahogany-colored/bright red); gross blood: not detected with tumor of right side of colon but tumors @ left side of colon & rectum 3. Tumors from transverse & descending colon obstruction (growth impedes stool passage), gas pain, cramping/including evacuation rectosigmoid colon_ hematochezia (passage of red blood via rectum), straining to pass stools, narrowing of stools, dull pain right -sided tumors: grow large without disrupting bowel patterns or appearance (stool consistency, more liquid in this part of colon); blooded & ulcerate intermittently (stools: dark/mahogany colored); mass, palpable @ LRQ; anemia secondary to blood loss 4. Abdominal examination obvious distention/masses CELLULAR ABERRATIONS- NCM 106 COLORECTAL CANCER ACC, AY MVBerango, RN, MAN/Lecturer 20122013,1ST Sem

visible peristaltic waves with high pitched or tingling bowel sounds (partial bowel obstruction from tumor) total absence of sounds after 5 full minutes listening (complete bowel obstruction) 5. Palpation & percussion _ determine liver/spleen enlargement /masses along colon 6. Digital rectal examination_ to palpate rectum & lower sigmoid colon for masses Psychological Assessment 1. Coping with diagnosis_ fear & anxiety r/t possible loss of health insurance, excessive cost of genetic listing, treatment, pain, possible disfigurement & death 2. If cancer is of genetic origin: anxiety for immediate family members Laboratory Assessment 1. Hemoglobin/hematocrit: (due to intermittent bleeding assisted with tumors) 2. Liver function test: (metastasis) 3. FOBT: positive for bleeding in GIT False positive result may be due to certain foods, drugs, or vitamins taken before the test 48 hours before the stool exam: avoid meat, peroxidase-containing foods (horse radish, beets); meds (ASA, VITAMIN C) Assess for anti-inflammatory drugs; discontinue before test 4. Carcinoembryonic antigen (CEA *octofetal antigen+_ in 70% people with CRC For monitoring effectiveness of treatment & identify disease recurrence Radiographic Assessment 1. Double-contrast barium enema_ better visualization of polyps small lesions; demonstrates an occlusion in the bowel where tumor decreases the size of lumen) 2. CT of abdomen, pelvis, lungs or liver_ aid to conform existence of masses & extent of disease 3. CXR or liver scan_ locate distant sites of metastasis Other Diagnostic Assessment 1. Sigmoidoscopy_ visualization of lower colon (polyps visualization & taking examples for biopsy) 2. Colonoscopy_ visualization of entire large bowel from rectum; ileocecal valve, definitive test for diagnosis of CRC Priority Nursing Diagnosis Anticipatory Grieving r/t diagnosis of potential terminal illness, a disturbance in body image, possible loss of fecal continence Priority collaborative problem: Potential for Metastasis o Let client demonstrate resolve feelings about loss, express spiritual beliefs about death, verbalize acceptance of loss, report decreased preoccupation with loss, seek social support, progress through stages of grief o Observe & identify: clients & familys current methods of coping, effective source of support used in past crises, clients & familys present perception of health problem, signs of anticipatory grief (crying, anger, withdrawal from usual relationships o Instruct about appearance & care of colostomy o Genetic counseling_ refer to genetics center for client with familial CRC; information on risks, costs, etc. on genetic tests POTENTIAL FOR METASTASIS Non-Surgical Management Type of therapy: based on pathologic staging of disease Dukes staging classification Radiation Therapy No improved overall survival rates for CRC Effective in providing local /regional control of disease As palliative measure: controls pain, hemorrhage, bowel obstruction/metastasis to the lungs in advanced disease Almost always part of treatment plan for rectal CA Drug Therapy Adjuvant chemotherapy post primary surgery: recommended for client with stage II (Dukes B2) or stage III (Dukes stage C) 4 CELLULAR ABERRATIONS- NCM 106 COLORECTAL CANCER ACC, AY MVBerango, RN, MAN/Lecturer 20122013,1ST Sem

Choice drug IV 5-fluorouracil (5-FU) with or without leucoverin (folinic acid) Side effects: diarrhea, mucositis, leucopenia, mouth ulcers, skin effects Oxoaplipthin (Eloxatin): new platinum analogous therapeutic agent combined with 5-FU & leucovorin with treatment-resistant CRC (FOLCOX regular) Dose-limiting toxicity: peripheral sensory neuropathy Initial treatment with advanced CRC Irinotecan (Camptosan , 97)_ approved 2nd line of treatment for metastatic (stage IV ?D_D) disease if it has recurred/ progressed post treatment of 5-FU dose-limiting toxicities: myelosuppression (bone marrow suppression pancytopenia (blood cells) & diarrhea given commonly with 5-FU (Saltz regimen) Bevacizumab (Avastin, 04)_ 1st antiangiogenesis medicine blood flow to growing cells Combination with other chemo agents Intrahepatic arterial chemo, often with 5-FU: given to clients with liver metastasis

CELLULAR ABERRATIONS- NCM 106 COLORECTAL CANCER ACC, AY MVBerango, RN, MAN/Lecturer 20122013,1ST Sem