Colorectal Cancer for students lab notes.ppt

Cancer
• Cancer is a disease in which the cells of a tissue undergo
uncontrolled proliferation.
• Cancerous cells divide repeatedly out of control even though
they are not needed, they crowd out other normal cells and
function abnormally. They can also destroy the correct
functioning of major organs.
• Cancer can spread from the original site and cause
secondary tumours. This is called metastasis. They interfere
with neighbouring cells and can block blood vessels, the gut,
glands, and other parts of the body.

Definition
• Colorectal cancer is the cancer of the large intestine(colon
and rectum).
• Cancers that start in the cells that line the inside of the colon
(the longest part of the large intestine) and rectum (the last
few inches of the large intestine before the anus) are called
colorectal cancers.
• The colon and rectum form the large intestine (large bowel),
which is the last portion of the digestive system.

Cause
• This condition is somehow idiopathic.
• Most cases of colorectal cancer begin as small, non-
cancerous clumps of cells called adenomatous polyps.
Overtime, some of these polyps become colorectal cancers.
• Colorectal cancer usually begins as a non-cancerous polyp
that can, overtime, become a cancerous tumor.
• There’s no specific cause of colorectal cancer but it has risk
factors.

Risk Factors
Polyps
Cigarette smoking
Age (older)
Family history(individuals with Gardner’s syndrome)
Obesity
Inflammatory bowel disease like Crohn’s disease or Ulcerative colitis
Exposure to radiation
Diabetes
Lack of physical activity
Previous colon cancer
High-fat, high-protein (with high intake of beef ), low-fiber diet
Genital cancer or breast cancer (in women)

Risk factors cont’
• Family history: Some conditions such as familial adenomatous polyps
(FAP) and Lynch syndrome (a genetic condition that predisposes
certain families to colon cancer, even when polyps are not present)
occur in certain families and may make an individual more likely to
develop cancer of the colon or the rectum.
• History of colorectal cancer: Even when colorectal cancer has been
completely removed, new cancers may still develop in other areas of
the colon and the rectum. The incidence of recurrence is every 10
years.
• Recurrent intestinal polyps: These are polyps that increase the risk of
colorectal cancer, especially if they are large and there are many of
them.

• Inflammatory bowel disease: Chronic ulcerative colitis, a condition in
which the colon is inflamed over a long period of time and causes
ulcers in the lining, can increase the risk of colon cancer.
• Age: About 90% of colorectal cancers are found in people over the
age of 50.
• Diet: Eating foods that are high in fat and low in fiber may increase
the risk of colorectal cancer. It is estimated that diet accounts for
35%–45% of disease incidence.
• Physical inactivity: A sedentary lifestyle and not enough physical
activity has been reported to be associated with a higher risk of
colorectal cancer.

• Gender factors: Women have a 38% higher risk of having upper-colon
cancer than men.
• Smoking: There is strong evidence that smoking increases the risk of
colorectal cancer, possibly causing 12% of all colorectal cancer
deaths. The frequency, amount, and duration of smoking over a
lifetime are positively correlated with colon cancer. The more a
person smokes over a long period of time, the greater the incidence
of colon cancer.
• Ethnicity: Black, non-Hispanic people may have as much as a 24%
increased risk in upper-colon cancer than other groups.

• Co-morbid illnesses: The presence of serious, life-threatening
diseases like congestive heart failure, peptic ulcer, and diabetes
mellitus may contribute up to a 28% increase in risk of colorectal
cancer.

Stages of Colorectal Cancer
• Colorectal cancer staging describes the size of the tumour, how far it has
grown into the colon or rectum wall, and whether the cancer has spread to
lymph nodes or other places in the body past the place where it began to
grow. Colorectal cancer has five(5) stages:
Stage 0– Cancer cells are located only in the inner lining of the
colon or rectum. Typically, this is confined to the surface of a
polyp(a growth that protrudes from a mucous membrane). It is
also known as carcinoma in situ.
Stage 1– Cancer cells have spread from the inner lining into the
middle layers of the muscular wall of the colon or rectum.

Stages of Colorectal Cancer cont’
Stage 2– Cancer has spread to the outside surface of the
colon or rectum, and may involve nearby tissues but not the
lymph nodes.
Stage 3– Cancer involves the nearby lymph nodes.
Stage 4– Cancer has spread to other distant parts of the
body, such as the liver or lungs.

Signs & Symptoms
• Signs and symptoms of colorectal cancer vary depending on its location of the
tumour in the bowel, size and whether it has spread to other parts or not. The classic
warning signs include;
1.Worsening constipation
2.Blood in stool
3.Change in bowel habit
4.Anorexia
5.Weight loss
6.Vomiting
7.Anaemia
8.Rectal bleeding
9.Fatigue
10.Tenesmus
11.Abdominal pain

Diagnosis
• History taking
• Physical examination
• Proctosigmoidoscopy
• Colonoscopy
• Double contrast barium enema
• Fecal occult blood testing
• Others include chest x-ray and computed tomography scan
to see if the cancer has spread to lungs, lymph nodes, liver,
and other parts of the body.

Diagnosis cont’
• Carcinoembryonic antigen (CEA): describes a set of highly
related glycoprotein involved in cell adhesion. CEA is
normally produced in gastrointestinal tissue during fetal
development, but stops the production stops before birth.
However, serum levels are raised in some types of cancer
especially colorectal cancer.

Types Of Colorectal Cancer
1. Adenocarcinoma (most common type)
2. Leimyosarcoma
3. Lymphoma
4. Melanoma
5. Neuroendocrine tumors
Adenocarcinomas: are the most common type of colon cancer and
originate in glands. They account for about 90-95% of all colorectal
cancers, and have two subtypes; mucinous and signet ring cell.

Types Of Colorectal Cancer cont’
• Leiomyosarcoma: this type of colon cancer occurs in the smooth
muscle of the colon.
• Lymphomas: are rare and more likely to start in the rectum than in
the colon. However, lymphomas that start somewhere else in the
body are more likely to spread to the colon than to the rectum.
• Melanoma: is rare and results from a melanoma that started
somewhere else then spread to the colon or rectum.
• Neuroendocrine tumors: are divided into 2 main categories;
aggressive and indolent. Large and small cells neuroendocrine
tumors are considered aggressive, while carcinoid tumors are
considered indolent.

Medical Treatment
• Chemotherapy is the use of anti-cancer medicines (chemotherapy drugs) that are
typically given by injection, or sometimes as pills, to destroy cancer cells.Some of these
drugs include;
Eloxatin (oxaliplatin)
Fluorouracil (5-FU, Adrucil)
Folinic acid (Leucovorin)
Irinotecan (Camptosar, CPT-11)
Capecitabine (Xeloda) (this is an 5-FU in pill form)
Raltitrexed (Tomudex) (may be used instead of 5-FU for patients with advanced
colorectal cancer who are unable to tolerate 5-FU).
Leucovorin
Bevacizumab (Avastin)
Cetuximab (Erbitux)

Medical Treatment cont’
• While chemotherapy drugs work to destroy cancer cells and
prevent cancer cells from growing and spreading, they also
damage healthy cells just like radiation, and may cause side
effects.
• Damage to healthy cells is temporary and they will repair
themselves after the treatment stops.
• Some of the side effects one may experience include nausea,
vomiting, soreness in the mouth, loss of appetite, tiredness,
hair loss, diarrhea, neurotoxicity, an increased risk of
infection, and bleeding.

Medical Treatment cont’
Chemotherapy treatment may be given before or after surgery. It may
be used:
•1) Before surgery (neoadjuvant therapy) and sometimes combined
with radiation therapy to shrink a rectal tumour.
•2) After surgery to destroy any microscopic cancer cells left behind
and therefore to reduce the risk of the cancer coming back (adjuvant
therapy).
•3) To help slow down and control the cancer when the cancer has
spread to distant organs. This is also called “palliative chemotherapy”
where the goal is to control symptoms and extend life but, ultimately,
the cancer is not curable.

Radiotherapy
• During radiation therapy, high doses of a special type of energy
(radiation) are aimed at the area where the cancer is growing and
destroys cells, making it impossible for them to grow and divide.
• Radiation therapy destroys cancer cells, which grow uncontrollably,
but it also can damage healthy cells nearby. Healthy cells are able to
repair themselves after the therapy is complete.
• There are two types of radiation therapy that can be used:
1.External beam radiation therapy
2.Brachytherapy

Radiotherapy cont’
• In external beam radiation, the beam of radiation is directed at
the tumour.
• In brachytherapy, radioactive material is placed inside the
tumour, making it possible to treat the cancer in a very focused
manner.
• Side effects that may be experienced after radiation are a feeling
of being more tired than usual, occasionally diarrhea, and
perhaps changes to the skin such as redness or tenderness in the
area of the body where the treatment was applied.
• These side effects are temporary and will usually go away when
the treatment period is over and the normal cells have had the
chance to repair themselves, usually within one to two weeks

Surgical Treatment
• Surgery is the primary treatment for most colon and rectal cancers.
• It may be curative or palliative.
• It may be curative when detected early.
• The type of surgery recommended depends on the location and size
of the tumor.

Surgical Treatment cont’
Surgical procedures include the following:
oSegmental resection with anastomosis (that is, removal of the tumor
and portions of the bowel on either side of the growth, as well as the
blood vessels and lymphatic nodes)
oAbdominoperineal resection with permanent sigmoid colostomy (that
is, removal of the tumor and a portion of the sigmoid and all of the
rectum and anal sphincter)
oTemporary colostomy followed by segmental resection and
anastomosis and subsequent reanastomosis of the colostomy, allowing
initial bowel decompression and bowel preparation before resection

Surgical Treatment cont’
oPermanent colostomy or ileostomy for palliation of unresectable
obstructing lesions
oConstruction of a coloanal reservoir called a colonic J pouch is
performed in two steps. A temporary loop ileostomy is constructed to
divert intestinal flow, and the newly constructed J pouch (made from
6 to 10 cm of colon) is reattached to the anal stump. About 3 months
after the initial stage, the ileostomy is reversed, and intestinal
continuity is restored. The anal sphincter and therefore continence
are preserved.

Nursing Management
Pre-operative Nursing management
• Allay anxiety in patient who is to undergo a colorectal surgery by
educating him/her on the condition. Explain the need for surgery as
well as pre and post-operative care activities and assure him of support
from the staff, especially if a colostomy is to be done.
• Pass nasogastric tube to decompress.
• Put patient on nil per os.
• Monitor and record input and output.
• Monitor serum electrolyte levels. This can help you detect
hypokalaemia and hyponatraemia that occur with gastrointestinal fluid
loss so as to intervene as soon as possible.

Pre-op cont’
• Administer prescribed intravenous fluids.
• Check and record baseline vital signs(temperature, pulse rate,
respiratory rate, and blood pressure) and report any abnormalities.
• Assist patient to sign consent form.
• Give patient laxatives or enema to empty the bowel a day before
surgery.
• Administer prescribed antibiotics( such as sulfonamides, neomycin,
cephalexin) a day before surgery to reduce intestinal bacteria.

Pre-op cont’
• Assess for signs of hypovolaemia( tachycardia, hypotension, decrease
pulse), and assess hydration status( skin turgor, mucous membrane;
dry or not, concentrated urine) and report if any.
• Pass a urinary catheter to drain urine from the bladder and prevent
trauma during the surgery

Post-operative Nursing Management
• Monitoring vital signs (temperature, pulse rate, respiratory rate, and
blood pressure) every 15 minutes for the first hour, every 30 minutes
for the next hour and every 4 hours for the rest of his stay at the
hospital.
• Nothing should be given by mouth until normal colon function has
resumed. This is determined by assessing for the return of flatus and
bowel movements.
• Lung sounds are monitored for response to coughing and deep
breathing and early ambulation.
• Dressings are observed for drainage. Large amounts of drainage or
bleeding are reported. If a drain is inserted in the perineal wound,
moderate amounts of serosanguineous (light pink) drainage are
expected. If the patient has an ostomy, it is monitored.

Post-op cont’
• Give prescribed intravenous fluids and monitor the patient for signs
of circulatory overload (acute dyspnoea,fatigue).
• Serve prescribed antibiotics.
• Serve prescribed analgesics to relieve pain.

Prognosis
• The death rate from colorectal cancer has been going down for the
past 20 years.
• This is due to advanced methods of early detection and improved
treatment modes.
• If colorectal cancer is detected at an early stage and is treated
appropriately, 92% of patients will survive five years or more.
However, only a third of colorectal cancers are found at that early
stage.
• Once the cancer has metastasized to nearby organs or lymph nodes,
the five-year survival rate plummets to 64%.

Prognosis cont’
• If the disease has metastasized to distant sites such as the liver or the
lung, the outlook is bleak, with only 7% of the patients surviving five
years after initial diagnosis.
• The American Cancer Society also notes that once colorectal cancer is
detected and removed, another occurrence is highly probable in 10
years.

Complications
• Tumor growth may cause partial or complete bowel obstruction.
• Extension of the tumor and ulceration into the surrounding blood
vessels results in hemorrhage.
• Perforation
• Abscess formation
• Peritonitis
• Sepsis
• Shock may occur.
• Strictures
• Paralytic ileus
• Wound dehiscence

Prevention
• Many colon and rectal cancers may be prevented by avoiding risk
factors and following screening guidelines.
• The number of colorectal cancer cases can be lowered and, by
detecting the disease at an earlier stage, the death rate can be
reduced.
• The American Cancer Society recommends that, beginning at age 50,
both men and women follow a screening schedule for the early
detection of colorectal cancer.

Prevention cont’
• One or more of the following tests should be performed: a yearly
fecal occult blood test and a digital rectal examination, a flexible
sigmoidoscopy every five years, a colonoscopy every five to 10 years
(depending on the patient’s risk factors), or a barium enema x ray
every five to 10 years.
• Proper diet and exercise go a long way in preventing colorectal
cancer.
• The American Cancer Society recommends eating at least five
servings of fruits and vegetables every day and six servings of food
from plant sources that contain fiber, such as breads, cereals, grain
products, rice, pasta, or beans.

Prevention cont’
• Reducing the consumption of high-fat, low-fiber foods such as red
meat and processed foods is also advised.
• Achieving and maintaining an ideal body weight are recommended,
and participating in at least 30 minutes of physical activity every day
is advocated.
• The addition of mineral supplements may also be helpful in
preventing colorectal cancer. Copper, selenium, and calcium seem to
be factors in colorectal cancer prevention. Eating foods rich in these
minerals is recommended.

Prevention cont’
• It is also recommended that individuals over 50 quit smoking as soon
as possible. Besides the risks of other forms of cancer, there seems to
be a correlation between the incidence of colorectal cancer and the
amount of tobacco smoked and for how long.
• It may not be possible to control risk factors such as a strong family
history of colorectal cancer. However, by getting information about
prevention and early detection, one can still beat the odds.
• People with a family history of colorectal cancer should start
screening at a younger age, and the tests should be done more
frequently.

Prevention cont’
• Certain genetic tests are now available that can help determine which
members of certain families have inherited a high risk for developing
colorectal cancer.

Reference
• Pontieri-Lewis, V. (2000). Colorectal cancer. MedSurg Nursing, 9(1),9–
15, 20.
• American Cancer Society. (2002). Cancer Facts and Figures
2002.Atlanta, Georgia: Author.
• Dest, V. M. (2000). Colorectal cancer. RN, 63(3), 54–59.

Colorectal Cancer for students lab notes.ppt

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Colorectal Cancer for students lab notes.ppt