colorectal cancer

colorectal cancer (CRC) is most common in which gender?

men but is also affects women

which race has the highest mortality rate from CRC?

african american men and women

risk for CRC increases with…

age

people with the highest risk for CRC have…

a first degree relative with CRC or they have IBD

what gene is involved in the development of CRC?

an abnormal KRAS gene

name three hereditary forms of CRC that account for 5-10% of cases

• FAP

• hereditary nonpolyposis colorectal cancer (HNPCC) syndrome or lynch’s syndrome

name three factors that decrease the risk of CRC

• physical exercise

• diet high in fruit, veg, grains

• long term NSAID use

what is the most common type of CRC?

adenocarcinoma (85% from adenomatous polyps)

how does the tumor spread?

spreads through walls of the colon into the musculature, eventually gaining access to the regional lymph nodes and vascular system

what are the most common sites of metastasis?

• regional lymph nodes

• liver

• lungs

• bones

• brains

why is the liver a common site for metastasis?

venous blood from colon flows into the portal vein and inferior rectal vein

early disease manifestations of CRC include

• nonspecific (anorexia, weight loss)

• weakness and fatigue possible from iron deficiency anemia d/t GI bleed

advanced disease manifestations of CRC include

• abd tenderness

• abd distention

• rectal pain

• palpable abdominal mass

• hepatomegaly

• ascites

what bowel symptoms may the patient present?

• rectal bleeding

• alternating constipation and diarrhea

• change in stool caliber (narrow, ribbon like)

• incomplete evacuation sensation

• obstruction

right sided lesions are more likely to…

bleed and cause diarrhea

left sided tumors are usually associated with…

change in bowel habits and could present with a bowel obstruction

what signs and symptoms may present from a transverse colon tumor?

• pain

• obstruction

• change in bowel habits

• anemia

what signs and symptoms may present from an ascending colon tumor?

• pain

• mass

• change in bowel habits

• anemia

what signs and symptoms may present from a descending colon tumor?

• pain

• change in bowel habits

• bright red blood in stool

• obstruction

what signs and symptoms may present from a rectal tumor?

• blood in stool

• change in bowel habits

• rectal discomfort

what diagnostic studies will be performed?

• individual and FMHx

• colonoscopy (gold standard q10 years)

• flexible sigmoidoscopy (q5 yrs)

• double contrast barium enema (q5 years)

• CT colonography (q5 years)

• tissue biopsy

• CBC (anemia)

• LFTs (may be normal even if metastasis has occurred)

• abd CT/MRI

• Carcinoembryonic antigen (CEA)

what does a CEA tell you?

its a glycoprotein SOMETIMES produced by colorectal cancer cells that may be used to monitor for disease recurrence after surgery/chemo

other than colon carcinomas, what else with elevate CEA levels?

• gastric, pancreatic, lung, breast, thyroid carcinomas

• IBD, pancreatitis, cirrhosis, COPD, smokers

prognosis worsens with…

• depth and size of tumor

• lymph node involvement

• metastasis

what are the surgical goals?

1. complete tumor resection

2. thorough abd exploration

3. removal of all lymph nodes that drain the area

4. bowel continuity restoriation

5. prevention of surgical complications

when is a polypectomy performed?

during colonoscopy to resect colorectal cancer in situ

what surgical therapy is used for stage I cancer?

• remove tumor and at least 5 cm of surrounding intestine

• cancer free ends sewn together and nearby lymph nodes

• laparoscopic surgery may be used esp for left colon

what surgical therapy is used for low risk stage II cancer?

wide resection and reanastomosis

what therapy is used for high risk stage II cancer?

wide resection, reanastomosis, chemotherapy

what therapy is used for stage III cancer?

radiation and chemotherapy may be performed before surgery to reduce tumor size.

what therapy is used for stage IV cancer?

• palliative surgery

• chemo

• radiation

• pain relief

name three reasons for a temporary colostomy

1. perforation

2. perionities

3. hemodynamic instability

what are the three surgical options for rectal cancer?

• local excision

• abdominal perineal resection (APR) with permanent colostomy

• low anterior resection (LAR) to preserve sphincter fxn

APR healing includes

perineal wound may be closed around drain or left open with packing to heal by granulatio

describe an LAR

• removal of rectum and connecting the colon to anal

• temp ostomy used to divert stool for healing for about 8-12 wks

what is a colonic J pouch?

a J shaped pouch formed by folding the distal colon back on itself to replace the rectum as a stool reservoir

a temp ostomy will be used to allow the sutures to heal

what is an coloplasty?

splitting the side of a section of colon a short distance proximal to the anus, stretching the colon transversely to make it wider

what clinical manifestations may occur from sphincter sparing procedures?

• urgency

• frequency (esp after meals)

s/s will improve as pouch stretches.

what is the purpose of chemotherapy?

• shrinks tumor before surgery

• adjuvant Tx after stage III and high risk stage II colon resections

• palliative Tx for unresectable CRC

how do angiogenesis inhibitors work?

they inhibit blood supply to tumors (Avastin & Zaltrap)

how do multikinase inhibitors work?

blocks enzymes that promote cancer growth and blocks epidermal growth factor receptors

what is radiation used for?

• adjuvant Tx to surgery and chemo

• palliative Tx for metastasis (reduce size, symptom relief)

what should you assess for?

• previous breast/ovarian cancer

• familial polyposis

• villous adenoma

• adenomatous polyps

• IBD

• meds

• weakness/fatigue

• change in bowel habits

• high cal, high fat, low fiber diet

• inc flatus

• incomplete evacuation feeling

• diarrhea/constipation

• fear/anxiety

• ineffective coping

what nursing management should you provide?

• encourage CRC screening for 50+

• ID high risk

• discuss early screening

• fear and lack of knowledge is a barrier to prevention

pre-op colonoscopy care

• low residue/full liquid diet day before procedure

• split dose bowel cleansing

  • evening before, drink 2 L of PEG lavage

  • second dose begin 4-6 hours before procedure

• start split dose regimen early morning day of procedure

• mag citrate, bisacodyl tabs, suppositories to remove bulk of stool before lavage

• stool should be clear or clear yellow

post op care

• sterile dressing change

• drain care

• pt and cg ostomy teaching

• assess drainage amount, color, consistency

• assess wound bleeding, drainage, odor

• monitor suture line

• pain control

• sexual dysfxn edu