Colorectal Cancer

Dr. Belal Hijji, RN, PhD

February 6, 2012

2

Learning Outcomes

At the end of this lecture, students will be able to:

• Describe the incidence and trend of colorectal cancer in Saudi Arabia compared to the United States of America.

• Identify the risk factors for the development of colorectal cancer.

• Discuss the clinical picture of colorectal cancer along with the assessment and diagnostic evaluation.

• Discuss the medical management of a patient with colorectal cancer.

• Describe the nursing process as a framework for caring for a patient with colorectal cancer.

3Source: http://www.cancer.gov/cancertopics/wyntk/colon-and-rectal/page2

The colon and rectum

4

Incidence of Colorectal Ca in KSA Versus USAASR for colorectal cancer (1994-2003) in the Kingdom of Saudi Arabia and the United States of America

ASR for Incidence (KSA)ASR for Incidence (USA)

YearMalesFemalesALLMalesFemalesALL

19943.363.453.3840.8028.9033.41

19953.254.023.5639.2028.8032.63

19962.933.733.2540.7028.2033.01

19973.053.513.2241.9029.3034.06

19983.453.523.4841.0030.2034.14

19993.984.634.2640.6029.4033.59

20003.704.283.9539.7028.5032.82

20014.154.924.4839.1028.0032.24

20025.095.075.0738.2028.4032.11

20036.065.605.8436.9026.5030.49

Source: Ibrahim, E. et al. (2008). Past, Present and Future of Colorectal Cancer in theKingdom of Saudi Arabia. The Saudi Journal of Gastroenterology. 14(4): 178–182.

5

The age-standardized rate for colorectal cancer for males and females in the Kingdom of Saudi Arabia and the USA (1994-2003) .

Source: Ibrahim, E. et al. (2008). Past, Present and Future of Colorectal Cancer in theKingdom of Saudi Arabia. The Saudi Journal of Gastroenterology. 14(4): 178–182.

6

Predicted colorectal cancer burden in the Kingdom of Saudi Arabia, up to 2030

YearMalesFemales

No. of patients

%Changes from 2005

No. of patients

%Changes from 2005

2005680-537-

20108813069730

20151,1928093170

20201,7921701,397160

20303,1713702,538370

Source: Ibrahim, E. et al. (2008). Past, Present and Future of Colorectal Cancer in theKingdom of Saudi Arabia. The Saudi Journal of Gastroenterology. 14(4): 178–182.

7

Risk Factors For Colorectal Cancer

• Increasing age (highest in people older than 85 years).

• Family history.

• Previous colon cancer.

• High consumption of alcohol.

• Cigarette smoking.

• Obesity and history of gastrectomy.

• History of inflammatory bowel disease.

• High fat, high protein, low fiber diet.

• Genital cancer or breast cancer.

8

Clinical Manifestations

• Three factors greatly determine the signs and symptoms experienced by a patient with colorectal cancer. These are:– Location of tumor.

– Stage of disease.

– Function of the affected intestinal part.

• Most commonly, patients have change in bowel habits and passage of stool with blood. Other clinical manifestations include unexplained anemia, anorexia, weight loss, and fatigue.

• Right-sided lesions are associated with:– Abdominal pain and melena.

9

Clinical Manifestations (Continued…)

• Left-sided lesions, causing obstruction, are associated with:– Abdominal pain and cramping.

– Narrowing stools and constipation.

– Distention and bright red blood in stool.

• Rectal lesions are associated with:– Ineffective, painful straining at stool.

– Rectal pain.

– A feeling of incomplete evacuation after a bowel movement.

– Alternating constipation and diarrhea.

– Bloody stools.

10

Assessment and Diagnostic Findings

• Abdominal and rectal examination.

• Stool for occult blood.

• Barium enema.

• Proctosigmoidescopy. Most important

• Colonoscopy.

• Carcinoembryonic antigen may be useful

11

Medical Management of a Patient With Colorectal Cancer

• If there is intestinal obstruction, patients are treated with IV fluids and nasogastric suction. Blood transfusion if there is significant blood loss.

• Treatment of this disease depends on its stage and consists of surgical removal of tumor, supportive therapy, and adjuvant therapy. By adjuvant therapy we mean chemotherapy, radiotherapy, immunotherapy that a patient with non-metastasised colon cancer would receive. The standard adjuvant therapy is 5-fluorouracil and leucovorin calcium. Radiotherapy is used before, during, and after surgery to shrink the tumor and to reduce recurrence.

• Radiotherapy is also used for unresectable tumors for symptoms relief.

• Surgery is the primary treatment for most colorectal cancers.

12

Medical Management of a Patient With Colorectal Cancer (Continued…)

• Colostomy: This is a surgical creation of an opening into the colon. It could be temporary or permanent.

Permanent colostomy for rectal cancer

13

• Colostomy (Continued…):

Nursing Management of a Patient With Colorectal Cancer

Assessment

• Collect subjective data about:– Presence of fatigue.

– Abdominal or rectal pain.

– Past and present elimination pattern.

– Characteristics of stool.

– Family history and fat and fiber intake.

– Alcohol intake and smoking.

– Weight loss.

• Auscultate the abdomen for bowel sounds.

• Palpate the abdomen for distention and solid masses.

14

15

Nursing Management of a Patient With Colorectal Cancer (Continued…)

Nursing Diagnoses

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

• Risk for deficient fluid volume related to vomiting and dehydration.

• Anxiety related to cancer diagnosis and impending surgery.

• Impaired skin integrity related to surgical incisions.

• Disturbed body image related to colostomy.

16

Nursing Management of a Patient With Colorectal Cancer (Continued…)

Planning and goals

• Attainment of optimal nutrition.

• Maintenance of fluid and electrolyte balance.

• Reduction of anxiety.

• Attainment of optimal wound healing.

• Expressing feelings and concern about colostomy and the impact on self.

17

Nursing Management of a Patient With Colorectal Cancer (Continued…)

Nursing Interventions

• Patient Preparation for Surgery.• Build the patient’s stamina days before surgery.

• Cleanse the bowel the day before surgery.

• If possible, provide a diet high in calories, protein, and carbohydrate for several days before surgery.

• Provide full liquid diet if prescribed 24 to 48 hours before surgery to reduce bulk.

• Clean the bowel with laxatives and/ or enemas the evening before and the morning of surgery.

• Record intake and output to provide an accurate record of fluid balance.

18

Nursing Management of a Patient With Colorectal Cancer (Continued…)

Nursing Interventions

• Patient Preparation for Surgery (Continued…).• Insert nasogastric tube if ordered to drain accumulated fluids

and prevent abdominal distention.

• Monitor the patient for increasing abdominal distention, loss of bowel sounds, and pain or rigidity, which may indicate intestinal obstruction or perforation.

• Observe the patient for signs of hypovolemia (tachycardia, hypotension, decreased pulse volume).

• Assess hydration status.

19

Nursing Management of a Patient With Colorectal Cancer (Continued…)

Nursing Interventions (Continued…)

• Providing Emotional Support.• Assess the patient’s level of anxiety.

• Suggest methods for reducing anxiety such as deep breathing exercises and visualising a patient who successfully recovered from surgery and cancer.

• Provide factual information about the colostomy site to reduce the patient’s fear that everybody will be aware of the ostomy.

• Providing Postoperative Care.• Pain management.

• Abdominal assessment for bowel sounds.

• Mobilise the patient out of bed on the 1st day postop.

20

Nursing Management of a Patient With Colorectal Cancer (Continued…)

Nursing Interventions (Continued…)

• Maintaining Optimal Nutrition.• Teach patients undergoing surgery about the health benefits of

consuming healthy diet.

• Perform complete nutritional assessment to evaluate the nutritional status of the patient.

• Advise the patient on avoiding foods that cause excessive odor and gas such as foods in cabbage family, eggs, asparagus, fish, and beans.

• Help the patient identify any foods or fluids that may cause diarrhea including fruits, high fiber foods, soda, coffee, tea, or carbonated drinks.

• Advise a fluid intake of at least 2 L/ day

21

Nursing Management of a Patient With Colorectal Cancer (Continued…)

Nursing Interventions (Continued…)

• Supporting a Positive body Image.• Encourage the patient to verbalise feelings and concerns about

altered body image, and to discuss the surgery and the stoma if one was created.

• If applicable, teach the patient about colostomy care in an open, accepting manner and encourage him to talk about his feeling about the stoma.