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02.08 Colorectal Cancer (colon rectal cancer)

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Overview

  1. Cancer of colon and rectum share:
    1. Causes
    2. Screening
    3. Incidence
    4. Symptoms
  2. Surgery is the definitive treatment
    1. Can vastly alter the flow of GI tract
    2. Subsequent surgeries common

Nursing Points

General

  1. Colon Cancer
    1. Cancer of large intestine
    2. Surgery is the only cure
    3. 5-year survival 64%
  2. Rectal Cancer
    1. Cancer of connector between intestine and anus
    2. Treatment will include surgery and chemotherapy
    3. Radiation also possible
    4. 5-year survival 67%
  3. Other Colorectal Cancers
    1. Anal
      1. HPV related
    2. Appendiceal
      1. High mortality
  4. Risk Factors
    1. Modifiable
      1. Sedentary lifestyle
      2. Waist circumference
      3. Smoking
      4. Alcohol use
      5. Diet
    2. Non-modifiable
      1. Age
      2. Family history
      3. Sex

Assessment

  1. Colonoscopy Screening
    1. Average risk
      1. Begin age 45
      2. Every 10 years until age 75
    2. Increased risk
      1. Abdominal cancer history
      2. History of IBS or other GI syndromes
      3. History of abdominal radiation
      4. Begin age 45, or earlier as determined by MD
        1. Frequency of subsequent exams patient-specific
        2. Consider risk factors and personal history
    3. Screening alternatives
      1. Stool tests
      2. Sigmoidoscopy
      3. Virtual Colonoscopy
      4. Any abnormal results require follow-up colonoscopy
  2. Symptoms
    1. Colon Cancer
      1. Asymptomatic in early stages
      2. Colonoscopy helps to catch early
      3. Late stage
        1. Abdominal tenderness
        2. Rectal bleeding
        3. Ascites
    2. Rectal Cancer
      1. Bleeding in 60% of patients
      2. Change in bowel movements
        1. diarrhea
        2. malformed stool
        3. fullness in rectum/anus
        4. feeling of incomplete BM
  3. Diagnostics
    1. Colon Cancer
      1. Colonoscopy
      2. Abdominal CT
      3. CEA level
        1. perform baseline at diagnosis
        2. use to monitor disease progression
      4. Liver and kidney function
    2. Rectal Cancer
      1. Digital Rectal Exam (DRE)
      2. Rigid Proctoscopy
        1. Assess sphincter involvement
        2. Helps determine level of continence expected after surgery
      3. CT
      4. Stool Testing
        1. Occult stool
        2. Stool DNA
      5. CEA level
        1. perform baseline at diagnosis
        2. use to monitor disease progression
      6. Liver and kidney function

Therapeutic Management

  1. Surgery is First Line
    1. No cure without surgical removal
    2. Depends on tumor location
      1. Recovery differs depending on area of resection
      2. Many require colostomy or ileostomy
      3. Sometimes reversible
  2. Chemotherapy
    1. Some breakthrough treatments in last decade
    2. Needed for any patient with metastatic disease
  3. Radiation
    1. Not indicated for colon cancer
    2. Some benefit for rectal cancer
      1. Conservative resections to preserve continence
      2. Supplement surgical removal of tumor
      3. Radiate remaining cancer cells to prevent growth
      4. Bladder irritation common
  4. Nutrition
    1. Alteration in GI tract
      1. Changes absorption of nutrients
      2. Dumping syndrome
      3. Short gut syndrome
    2. Recurrent bowel obstructions
      1. Surgical adhesions
      2. Scar tissue
      3. Tumor burden
    3. Supplemental nutrition as needed
      1. Protein supplements
      2. Vitamin supplements
      3. Tube feeding
      4. Total Parenteral Nutrition (TPN)

Nursing Concepts

  1. Elimination
    1. Some require colostomy, ileostomy as a result
    2. Rectal cancer surgery may reduce continence
    3. Changes in stool character common
  2. Gastrointestinal/Liver Metabolism
    1. Surgery alters the route of GI tract
    2. Absorption of nutrients and fluids often changes
  3. Nutrition
    1. Diet is a risk factor
    2. Altered nutrition during surgery and chemotherapy is common

Patient Education

  1. Screening recommendations
    1. Understand personal risk
    2. Understand familial risk
    3. Colonoscopy
      1. Most MD prefer
      2. Uncomfortable preparation
      3. So important for detecting early
      4. Early detection = more survival
  2. Dietary changes
    1. Prevention
      1. Less red meat
      2. More vegetables
      3. Decrease alcohol usage
    2. During Treatment
      1. Optimize protein intake
      2. Watch intake/output closely
      3. Prevent dehydration
  3. Family history
    1. Genetic component is strong
    2. Abnormal Coloscopy may change screening recommendations for immediate family

Reference Links

Video Transcript

Hey there, you guys have gotten Meg again and today we are going to talk all about colorectal cancers, which is actually one of the topics that I am most passionate about because GI cancers in general are sort of my jam. So let’s go ahead and get started.

The thing to know about colorectal cancer is that even though the colon and the rectum are connected organs, we actually do treat them differently. So we’ll talk a little bit about the differences. Some things I have in common though, I’m going to be these things we have listed here. So the causes and survival rates for colon and rectal cancer are pretty similar. In general, we’ve got about a 66% five year survival. So what that means is 66% of the patients that are diagnosed with colorectal cancer are still living five years after diagnosis. Of course, this right is going to go up the earlier stages that we’re looking at. So it’s very important that we catch it early when we talk about treating colorectal cancer.

Surgical intervention is going to be our primary way. So our patients might get chemo or radiation as well, but we know that if a patient is diagnosed with colorectal cancer, they’re going to be getting some sort of surgery screening recommendations. So we’re talking about colonoscopy, everyone’s favorite procedure. For a person with average risk, we’re going to start that at 45 years old. And then nutritional impact. So not only is diet a risk factor, um, but because we’re going in surgically and removing part of the patient’s GI tract, it can also have a nutritional impact. So we’ll talk about nutrition as well. So I talked about how colon and rectal cancer are different. So let’s start there. The thing to know about colon cancer is that it is a symptomatic in early stages that differs from rectal cancer. And that about 60% of our patients with rectal cancer have some sort of bleeding in their stool. Um, they’re also going to see probably some differences in stool character, which makes sense because if we have a tumor in the patient’s rectum, which is where our body is forming that stool to be expelled from our body, there’s going to be either diarrhea or just a malformed stool with both. Remember, surgery is our primary treatment. However, with colon cancer, um, radiation is not an option, whereas with rectal cancer, radiation is more common. So let’s think about that. If we have a patient with cancer in the transverse colon. Right here this is incredibly risky to do radiation because radiation is supposed to be a targeted therapy. But because the transverse colon is so near to all of these important organs, so our stomach or our gallbladder, our liver, which is highly vascular, it is very risky to do radiation in that area. But when we talk about the rectum, which is down here, the two most common side effects that we get with radiation and the rectal region is diarrhea and then actually bladder irritation. But there are far fewer vital organs in the area of the rectum. So radiation is generally more of an option because it’s safer.

When we talk about colon cancer, the scope that we’re going to be doing is going to be a colonoscopy. Now with rectal cancer, the patient’s also going to get a colonoscopy, but they’re also going to get what we call a rigid Proctorio scopy. So product oscopy is a scope of the rectum. Similarly, rectal surgery is called a proctectomy. So just keep that in mind. We’ll talk about that in a minute. What a rigid [inaudible] scopy does is it is looking specifically at the sphincter because the, the challenge with rectal con rectal cancer is maintaining that patient’s continent. So their ability to pass stool constantly. So we’re looking for sphincter involvement and this is going to give us an idea of whether or not we can preserve that continence or not. So now let’s talk about some things that colon and rectal cancer have in common and that is our risk factors. First, we have a diet. We do know that a diet high in red meat, alcohol as well as a sedentary lifestyle of and smoking are risk factors for both. In general, these are going to be risk factors for all of our GI cancers and most cancers in general. The other big component that they share in common is going to be this family history. So there are several genetic disorders that cause colorectal cancers as well as some benign colorectal disorders and diseases. Then also, of course, a history of colorectal cancer is highly significant and calculating a patient’s risk of getting colorectal cancer. This is incredibly important because in my years as being a GI oncology nurse, we have seen the average age of a patient with colorectal cancer come down. The youngest patient that I’ve actually treated for colorectal cancer was only 21 years old. This has made the news and recent years because we are trying to figure out exactly why that is. Um, it’s probably environmental, but we also know that family history is huge in risk for colorectal cancers. And then of course we have chronic conditions. So I want you to think about IBD. So that is crones as small as IBS. So the key word here is inflammatory. So when we talk about inflammation, we have irritation, we have cells regenerating quicker trying to heal, and any time we have cells regenerating, the increased for cancer goes up. So any sort of chronic bowel conditions in general are gonna elevate that patient’s risk. And then I want to talk about polyps. We’ll talk more about some of the interventions that we can do in a colonoscopy on the next slide. But I do want to talk about this picture here. So here we have the inside of a patient’s colon. This right here is cancer. And then you can see we have a couple of polyps here as well as maybe a Pall up over here that’s not highlighted. If a physician were to see polyps like this on exam, this one, they would probably biopsy. This is one because it looks highly vascular and maybe was even bleeding at some point. We have the ability to sometimes resect these areas on colonoscopy and biopsy. Now the thing about, um, polyps on a colonoscopy is most of the time they’re benign. But we do know that if a patient has multiple, multiple polyps, they are at an elevated risk for cancer because the patient’s body is showing us that it has a history of creating abnormal growths in the patient’s colon. So it is important to know as a patient has a history of polyps.

So with that, let’s talk more about colorectal cancer screening. Um, colonoscopy. It is our diagnostic tool of choice. So there are some other options that are less invasive, um, such as a stool DNA test, a virtual colonoscopy, which we do with a CT. and then a sigmoidoscopy, which is just basically a shorter, um, colonoscopy where, um, a sigmoidoscopy stops at the sigmoid colon, which is right about there. So we’re missing all of this space right here. So the thing to know about colonoscopy is to be Frank. Um, the bowel preparation for colonoscopy is brutal. I’ve had to do it twice personally and I can say that it is completely ruined. The lemon-lime flavored Gatorade for me. It’s just in general, not a good time. What we have patients do is we have them drink enormous amounts of laxatives until their Stoll runs clear. Um, so you can imagine, once one patient and a group of friends have their colonoscopy and they tell their friends about it, it becomes a barrier to getting all those friends to want to come and do their colonoscopy. So this is really a big education piece with our patients stressing to them why it’s important they go through this. So, um, it is our best tool for screening these patients. And for any patient with average risk, we’re going to start at age 45. Now, average risk means they don’t have any or they have just a few of the risk factors that we talked about on the last slide. Increased risk. That area is a little more gray. We don’t have a hard and fast rule there. It’s going to be very patient specific, especially when we’re talking about a family history of colon cancer. So for example, my mom had a colonoscopy last year and she had a number of polyps on her last colonoscopy. And because we also have a family history of colon cancer, her doctor recommended that I as her daughter start getting my routine colonoscopy every three to five years starting at age 30. Thanks mom. Then from that they also determined that my mom’s next colonoscopy should be in five years instead of in 10 years and she’ll get annual stool tests as well just to be safe. So do you see how these guidelines are just incredibly patient specific when we’re talking about increased risk? It also depends as well on doctor discretion.

So in colonoscopy, say we have a tumor or even just a polyp on our colonoscopy, these little scissors right here allow us to resect smaller tumors and polyps as well as biopsy. So inter procedure biopsy of polyps is common. You can biopsy pretty much as many polyps as you want on colonoscopy. The other screening tool we have is CEA. We treat this very similarly to the way that we use PSA levels and prostate cancer. Once we are working up a patient for colon cancer and we’re going to draw a CEA level, which is a blood test. And while there is a normal range, that patient’s baseline CEA level becomes their normal for the rest of their treatment continuum because theoretically if we go in and we surgically remove the patient’s colon cancer and we give them some colon or excuse me, chemotherapy to treat it, those CEA levels should go down. If the CEA levels continue to go up, we know that perhaps the patient has metastatic disease we weren’t aware of. Perhaps the chemotherapy isn’t the right chemotherapy for them. There could be a recurrence or there could have been a couple cancer cells left during surgery. They are now causing problems so that CEA level becomes very patient specific once we get that baseline during diagnosis or workup. Okay, so let’s remember, surgery is going to be our first line measure for treating colorectal cancer. Once we’ve done that colonoscopy, once we have our CEA level, we’re going to decide what sort of surgery this patient needs. So to understand that you really need to know the anatomy of the colon. So down here the ilium connects to the cecum. It goes through ending at the colon, the transverse colon down through the day, sending through the sigmoid and then exits the body through the rectum and anus. So we know the more time that bowel contents spend in the colon, the more formed and solid they get. And that is why when we talk about a patient having, so the descending colon is actually on our left side and the ascending colon is on the right, a patient with right-sided colon cancer or a right-sided colectomy. Typically their outcomes are worse than those of similar patients with a left sided colectomy or a descending colon collected me. The reason for that is because if we’re taking away this piece of the colon right here, we’re shortening the colon enough that we are taking away some of the opportunity for the body to absorb last minute nutrients to form the stool and to, to reabsorb some of the fluids or the water in the colon, which is what the Colon’s job is.

So for rectal cancer, um, we’re also probably going to do a sigmoidoscopy to determine what level we need to be making the excision. And then remember, we also have that proc toss to me where we’re trying to preserve continents. So in general, when we’re talking about a colon surgery, it’s going to be a partial colectomy. Now we can also do a full colectomy, but that has been a put the patient at risk of short gut syndrome, which can be life limiting. And we also know that if a patient gets a total colectomy, they’re going to have a colostomy for the rest of their life. And then we have a proctectomy. So remember proctectomy that is going to be the rectum or if we have, um, a rectal cancer or a colon cancer that involves both the colon and the rectum, we’re going to have what’s called a colo proctectomy. So lots of ectomies. Those are my jam. I am a surgical oncology nurse.

So then I talked a little bit about short gut syndrome, but what I want you to know is that short gut syndrome is sort of what, um, to the colon what dumping syndrome is to the stomach. So we’re taking away so much of the gut that it is completely altering the way that the body of processes bowel contents and it’s life-limiting to the point that patients typically live the rest of their life on TPN, which is total parenteral nutrition. So we want to preserve as much of the colon as we can, but we don’t want to be too conservative and leave cancer cells behind. That is the true difficulty of surgical oncology. And then of course we have other considerations. Chemotherapy patients with colon and rectal cancer are typically going to get some sort of chemotherapy if they are past stage one radiation. Remember we are only doing on rectal cancer patients. Nutrition is important for both sets of patients because remember diet is all risk and then often because we’re a moving part of the patient’s gut, we’re altering their nutrition as well. And then finally more surgery. Now, more surgery is not necessarily a bad thing because sometimes we can reverse colossal means and that is absolutely wonderful for patients. They’re able to expel bowel contents, continental again, which is very important for them. It completely changes their life. So it’s wonderful when we can do that. And then on the flip side, of course, um, a patient could have surgical complications, they could have recurrence or we could just need to go into that belly and take a second look. So more surgery is definitely not uncommon for our patients with colorectal cancers.

And now it’s time for our priority nursing concepts for our patients with colorectal cancer. So first we have elimination because remember that a lot of patients end up with a colostomy as a result of the surgery we do to remove the cancer. Sometimes we’re able to reverse that and sometimes we’re not. And the patient lives the rest of their life with an ostomy. Also, remember that sometimes changes in elimination are the first sign that something is wrong in our patient’s gut. Next we have gastrointestinal and hopefully this one is obvious because we’re talking about one of the biggest organs in the GI tract. And then finally we have nutrition because not only is poor nutrition a risk factor, the patients who undergo treatment for colorectal cancer often have some sort of alteration in their nutrition as a result.

So let’s review the key points that you need to remember about colorectal cancer. Remember, even though colon and rectal cancer have a lot of similarities, there are some important differences as well. Next, we have screening. This is vitally important to catch and colorectal cancers early because the earlier we treat, treat it and catch it, the higher likelihood we have of treating for a cure. Next surgery, this is our first line treatment for these patients and though some patients might get chemotherapy or radiation, pretty much all of our patients get surgery. Next, we have nutrition, so this is always paramount in the oncology population in general, but colorectal cancer patients, even more so because we’re dealing with their GI tract and then finally, always, always, always survivorship. All oncology patients are survivors at the time of diagnosis, so knowing that we want to empower our patients to take great care of themselves, we want to meet their needs, we want to continue to support and prepare them for their life after colorectal cancer.

Okay. That’s all for our lesson on colorectal cancer. I know that was a big one, but it’s one of the topics that I’m most passionate about. Remember, early screening is the best screening, so don’t be afraid of your colonoscopy now. Go out and be your best selves today, and as always, happy nursing.

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