COLORECTAL CANCER

Definition - Colon cancer is a type of cancer that begins in the large intestine (colon) and rectum. The
colon is the final part of the digestive tract.

Colon cancer typically affects older adults, though it can happen at any age. It usually begins as small,
noncancerous (benign) clumps of cells called polyps that form on the inside of the colon. Over time
some of these polyps can become colon cancers.

The incidence increases with age (the incidence is highest for

people older than 85 years of age) and is higher for people with a family history of colon cancer and
those with IBD or polyps. The exact cause of colon and rectal cancer is still unknown,

RISK FACTOR

 Increasing age

 Family history of colon cancer or polyps

 Previous colon cancer or adenomatous polyps

 History of inflammatory bowel disease

 High-fat, high-protein (with high intake of beef ), low-fiber diet

 Genital cancer or breast cancer (in women

• Pathophysiology

• Cancer of the colon and rectum is predominantly (95%) adenocarcinoma (ie, arising from the
epithelial lining of the intestine).

• A major causative factor is lack of fiber in the diet, which prolongs fecal transit time and in turn
prolongs exposure to possible carcinogens

• It may start as a benign polyp but may become malignant, invade and destroy normal tissues,
and extend into surrounding structures.

• Cancer cells may break away from the primary tumor and spread to other parts of the body
(most often to the liver)

• Stage 0 Colon Cancer

• When abnormal cells are found in the wall, or mucosa, of the colon, it is considered stage 0
colon cancer. This is also called carcinoma in situ.
 • Stage I Colon Cancer

• Cancer which has invaded the mucosa and the submucosa is considered stage I colon cancer.
The submucosa is the underlining of the large intestine and it lies beneath the mucosa. In stage I
colon cancer, malignant cells may have also affected the deeper muscle layer of the colon wall,
but have not invaded any areas outside of the colon.

• Stage II Colon Cancer

• When cancer has spread past the colon wall, but has not affected the lymph nodes, it is
considered stage II colon cancer. This condition is subdivided into three stages.

• Stage IIA Cancer has spread to the serosa, or outer colon wall, but not beyond that outer barrier.

• Stage IIB Cancer has spread past the serosa but has not affected nearby organs.

• Stage IIC Cancer has affected the serosa and the nearby organs.

Stage III Colon Cancer

• Cancer that has spread past the lining of the colon and has affected the lymph nodes is
considered stage III colon cancer. In this stage, even though the lymph nodes are affected, the
cancer has not yet affected other organs in the body. This stage is further divided into three
categories: IIIA, IIIB and IIIC

• Stage IV Colon Cancer

• In stage IV colon cancer, the cancer has spread to other organs in the body through the blood
and lymph nodes.

Clinical Manifestations

 The symptoms are greatly determined by the location of the cancer, the stage of the disease,
and the function of the intestinal segment in which it is located.

 A persistent change in your bowel habits, including diarrhea or constipation or a change in the
consistency of your stool

• The passage of blood in the stools is the second most common symptom.

• unexplained anemia, anorexia, weight loss, and

• fatigue.

• The symptoms most commonly associated with right-sided lesions are dull abdominal pain

• .
 • The symptoms most commonly associated with left-sided lesions are those associated with
obstruction (ie, abdominal pain and cramping, narrowing stools, constipation, and distention),
as well as bright red blood in the stool.

• Symptoms associated with rectal lesions are tenesmus (ie, ineffective, painful straining at stool),

• Rectal pain, the feeling of incomplete evacuation after a bowel movement,

• alternating constipation and diarrhea, and bloody stool

• Medical Management

• intravenous fluids and nasogastric suction. analgesics

• If there has been significant bleeding, blood component therapy may be required.

• supportive therapy, and adjuvant therapy.

• adjuvant therapy—chemotherapy,

• radiation therapy,

• immunotherapy,

ADJUVANT THERAPY

• The standard adjuvant therapy administered to patients with Dukes’ class C colon cancer is the
5-fluorouracil plus levamisole regimen . Patients with Dukes’ class B or C rectal cancer are given
5-fluorouracil and high doses of pelvic irradiation.Mitomycin is also used.

• Radiation therapy is used before, during, and after surgery to shrink the tumor, to achieve
better results from surgery, significant relief from symptoms.

• Intracavity and implantable mdevices are used to deliver radiation to the site.

Targeted drug therapy

• Targeted drug treatments focus on specific abnormalities present within cancer cells. By
blocking these abnormalities, targeted drug treatments can cause cancer cells to die. Targeted
therapy works by targeting the cancer's specific genes, proteins, or the tissue .

Targeted drugs are usually combined with chemotherapy. Targeted drugs are typically reserved for
people with advanced colon cancer. Eg ; aflibercept, bevacizumab

Immunotherapy

• Immunotherapy is a drug treatment that uses your immune system to fight cancer.
Eg nivolumab, avelumab

Surgical management

• Removing polyps during a colonoscopy (polypectomy). If your cancer is small, localized,

completely contained within a polyp and in a very early stage, your doctor may be able to
remove it completely during a colonoscopy.

• Endoscopic mucosal resection. Larger polyps might be removed during colonoscopy using
special tools to remove the polyp and a small amount of the inner lining of the colon in a
procedure called an endoscopic mucosal resection.

• Minimally invasive surgery (laparoscopic surgery). Polyps that can't be removed during a
colonoscopy may be removed using laparoscopic surgery. In this procedure, your surgeon
performs the operation through several small incisions in your abdominal wall, inserting
instruments with attached cameras that display your colon on a video monitor. The surgeon
may also take samples from lymph nodes in the area where the cancer is located.

Partial colectomy. During this procedure, the surgeon removes the part of your colon that contains the
cancer, along with a margin of normal tissue on either side of the cancer. Your surgeon is often able to
reconnect the healthy portions of your colon or rectum. This procedure can commonly be done by a
minimally invasive approach (laparoscopy).

• Temporary colostomy - followed by segmental resection and anastomosis and subsequent

reanastomosis of the colostomy, allowing initial bowel decompression

• Permanent colostomy or ileostomy for palliation of unresectable obstructing lesions

Nursing management

• The nurse completes a health history to obtain information about fatigue, abdominal or rectal
pain (eg, location, frequency, duration, association with eating or defecation), past and present
elimination patterns, and characteristics of stool (eg, color, odor, consistency, presence of blood
or mucus).

• Assessment includes auscultating the abdomen for bowel sounds and palpating the abdomen
for areas of tenderness, distention, and solid masses. Stool specimens are inspected for
character and presence of blood.

• If the patient’s condition permits, the nurse recommends a diet high in calories, protein, and
carbohydrates and low in residue for several days before surgery to provide adequate nutrition
and minimize cramping by decreasing excessive peristalsis.

• A full-liquid diet may be prescribed 24 to 48 hours before surgery to decrease bulk. If the patient
is hospitalized in the days preceding surgery, PN may be required to replace depleted nutrients,
vitamins, and minerals. Insome instances, PN may be given at home before surgery.
 • Antibiotics such as sulfonamides, neomycin, and cephalexin are administered the day before
surgery to reduce intestinal bacteria. The bowel is cleansed with laxatives, enemas, or colonic
irrigations the evening before and the morning of surgery. For the patient who is very ill and
hospitalized,

• the nurse measures and records intake and output, including vomitus, to provide an accurate
record of fluid balance. The patient’s intake of oral food and fluids may be restricted to prevent
vomiting

Nursing diagnosis

• Imbalanced nutrition, less than body requirements, related to nausea and anorexia

• Risk for deficient fluid volume related to vomiting and dehydration

• Anxiety related to impending surgery and the diagnosis of cancer

• Risk for ineffective therapeutic regimen management related

to knowledge deficit concerning the diagnosis, the surgical procedure, and self-care after discharge

• Impaired skin integrity related to the surgical incisions (abdominal and perianal), the formation of a
stoma, and frequent fecal contamination of peristomal skin

• Disturbed body image related to colostomy