2. LEARNING OBJECTIVES:
By the end of the session, you should be able to:
Explain its epidemiology
Describe Risk factors
Explain its Screening & prevention
List Stages of the disease
Explain Sign and symptoms
Explain its treatment protocols
Side effects/complications
Prognosis
3. INTRODUCTION:
Cancer of the colon & rectum:
is the second most common cancer after the lung cancer in the
western world.
It contributes considerably to morbidity and mortality.
Until the last decade treatment has been limited to excisional
surgery.
A through understanding of the disease and the options available
for management are therefore more necessary than ever.
4. COLORECTAL CANCER (CLORECTAL NEOPLASM):
Definition:
Neoplasm:
means new growth(benign & Malignant).
Colorectal Neoplasms:
encompass both cancerous and benign growths colon & rectum
(including benign colorectal polyps).
Colorectal Cancer;
describes Malignant growth of tumor that begins from the inner wall
of the colon or rectum.
Can involve the anal canal.
5. The incidence of colorectal cancer varies between and within the
countries suggesting environmental factors.
it is common in western world but rare in Asia & Africa; the difference
among racial & groups within different areas of country suggesting
genetic or cultural factors.
The incidence is greatest among males (M= 37.4 per 100,000 vs. F= 29.9
per 100,000)
Life style play very important role in etiology of cancer
EPIDEMIOLOGY:
6. The 3rd most common malignancy worldwide ( ≥ 1.2 million new cases
annually) (ACS, 2016; NCI, 2019);
1st – Breast Ca= 12.5%
2nd- Lung Ca=12.2%
3rd –Colorectal=10.7%
the 2nd leading cause of cancer death in USA.
Highest incidence rates in economically developed countries
EPIDEMIOLOGY..
7. According to data from National Cancer Institutes (NCI,2023);
NEW CA CASES,2023
Breast Ca= 300,590 (15%)
Prostate Ca= 288,300 (15%
Lung & Bronchus Ca= 238,340 (12
%)
Colorectal Ca= 153,020 (8%)
Others= 978,060 (50%)
CANCER DEATHS, 2023
Lung & Bronchus Ca=127,070 (21%)
Colon & Rectum Ca= 52,550 (9%)
Pancreas= 50,550 (8%)
Breast Ca=43,700(7%)
Others= 335,950 (55%)
8. CANCER INCIDENCE
21%
9%
8%
7%
55%
CANCER DEATHS (NCI, 2023
Lung CA Colorectal CA Pancreas CA Breast CA Others
15%
15%
12%
8%
50%
CANCER CASES (NCI, 2023
Breast CA Prostate CA Lung % Bronchus Colorectal CA Others
9. COLORECTAL CA…
PATHOPYSIOLOGY:
The formation of colorectal CA is a multistep process.
Begins with an abnormal growth of tissue known as a polyp (precursors to
the disease) originating from the innermost wall of the colon.
Transformation from polyp to malignant disease after years through
process
After transformation, cancer begins to spread through the wall of
colon/rectum.
Then invade blood, L.Ns, or other organs directly.
95% are adenocarcinoma (glandular tissue).
12. Specific Sites For Colorectal Carcinoma (NCI, 2023)
Ascending colon:22%
Transverse colon:11%
Descending colon: 6%
Sigmoid colon:55%
13. The exact cause of the colorectal cancer is unknown.
Risk Factors:
Age
Diet
Polyps
Personal Medical History
Family Medical History
Genetic factors
Inflammatory bowel disease
Irradiation
ETIOLOGY:
14. Risk Factors For Colon CA
AGE:
more likely to occur as people get older (Age >50 (90% of patients)
However, can occur at younger ages, even, in rare cases, in the teens
DIET:
diets that are high in fat and calories and low in fiber.
Increased fecal bile salt- post-cholecystectomy
selenium deficiency
high anaerobic bacterial count in feces
15. POLYP:
benign growths on the inner wall of the colon and rectum.
common in people over age 50.
the risk of malignant change in benign polyp depends:
Size and number of polyp
histological type
also presence of epithelial dysplasia increase the risk of cancer
Risk Factors For Colon CA
16. Personal Medical History:
women with a history of cancer of the ovary, uterus, or breast have
high chance of developing colorectal cancer.
Family Medical History:
relatives (parents, siblings, children) of a person who has had colorectal
cancer are some what more likely to develop this type of
cancer themselves
Risk Factors For Colon CA…
17. Genetic factors:
Play small but very important role in etiology of Colonic cancer
The 2 most common forms of hereditary (familial) syndromes
with increased risk of colorectal carcinoma includes:
1) Familial adenomatous polyposis (FAP)
2) Hereditary non-polyposis colorectal cancer (HNPCC):
Risk Factors For Colon CA…
18. 1.Familial adenomatous polyposis (FAP):
Accounts for 1% of colorectal cancer cases
People with FAP typically develop multiple colon polyps
the polyps are initially benign , but high chance to develop into cancer
if left untreated
Colorectal cancer usually occurs by age 40 in people with FAP
Yearly screening for polyps is recommended
Diagnosed by late teens or early 20s.
Total colostomy is recommended when detected.
Risk Factors For Colon CA…
19. 2. Hereditary non-polyposis colorectal cancer (HNPCC):
Sometimes called Lynch syndrome
Accounts for approximately 5% to 10% of all colorectal cancer cases
The risk of colorectal cancer in families with HNPCC is 70% to 90%,
People with HNPCC are diagnosed for colorectal cancer at an average
age of 45 years.
Genetic testing for the most common HNPCC genes is available;
To take measures to prevent development of colorectal cancer
Diagnosed in early age of onset as compared to FAP
Tend to be located primarily in the right-sided (proximal colon)
Risk Factors For Colon CA…
20. Inflammatory Bowel Disease (Ulcerative colitis & Crohn's
disease):
Patient with extensive colitis for long duration are at high risk of
developing colorectal cancer.
↑ 5- to 10-fold
Irradiation & immunosuppression:
Irradiation: is well known carcinogenic,
immunosuppression drugs: are increased risk of developing
colorectal cancer
Risk Factors For Colon CA…
21. CRC) Risk of Colorectal ) Cancer-----Graph on slide 21
22. Modifiable Factors:
Environmental factors/ life style
Obesity
Excessive alcohol
Law fruit & vegetable intake
Smoking:
more risk for rectal than Colon Ca
As compared to never smokes, the risk of colorectal Ca & mortality
in smokers were 18% and 25% higher respectively
Risk Factors For Colon CA…
23. STAGING:
TNM Staging System;
T: (tumor size), based on DEPTH (penetration); invasion
into mucosa
T1= Tumour invades the sub-mucosa
T2=Invades the muscularis propria
T3=Invade through the muscularis propria into sub-serosa
T4=Tumors invading or adhering other local
organs/structures/segments/ surface of visceral peritoneum
N: lymph node involvement;
N1=1-3 +ve lymph node
N2=≥ 4 or more +ve lymph node
M: distant metastasis;
M0=no other organs involved
M1=distant metastases are present
25. Clinical Manifestations:
The colorectal cancers have wide range of presentation which depend on (ACS,
2019):
Site of the tumor
Presence of complications (obstruction, perforation, hemorrhage)
The presence of metastasis
The most common presenting symptoms include:
change in bowel habits: Prolong constipation or diarrhea, pencil thin stool.
blood on the stools: the 2nd most common symptom.
unexplained anemia,
anorexia,
weight loss, and fatigue.
27. C/M…
Right Colon are manifested with:
dull abdominal pain and
melena (i.e., black, tarry stools).
Left Colon are manifested with:
those associated with obstruction (i.e., abdominal pain and cramping,
narrowing stools, constipation, distention, & bright red blood in the
stool).
Rectal lesions are manifested with:
tenesmus,
rectal pain,
the feeling of incomplete evacuation after a bowel movement,
alternating constipation and diarrhea, and bloody stool
28. 1) Signs and symptoms
2) Entire Large bowel evaluation:
ENDOSCOPY:
Sigmoidoscopy:
performed in case of bleeding & mucus discharged from the rectum
To take biopsy for histological studies
rigid sigmoidoscopy: reach only the distal 30 cm of the colon,
flexible sigmoidoscopy: can reach up to 60 cm where 70% of tumor can detected.
colonoscopy:–Can visualize small lesions < 5mm
gold standard for colorectal screening
should be carried in all cases as in 3% of cases there will be synchronous tumor
DIAGNOSIS:
29.
30. Entire large Bowel Evaluation…
Ultrasound: Determines depth of tumor penetration, assessing L.Ns.
CT-scan: to assess metastasis, evaluate resectability.
plain X-ray: show signs of obstruction &dilated bowel
CXR: for lung metastasis
Barium enema: carcinoma of the colon, irregular, filling defect;
( apple core deformity)
MRI: has lower sensitivity and higher specificity than CT scan in T staging.
31. DIAGNOSIS…
BIOPSY (during colonoscopy):
Evaluation for cancerous changes of tissue samples removed during test
procedures
No body have cancer until the pathologist say so.
Blood tests: CBC, PT, PTT, Liver function test.
Fecal occult blood testing (FOBT);
To identify blood on the surface of stool
Many early-stage tumors do not bleed.
Digital Rectal Exam (DRE);
Can detect anorectal palpable mass
34. TREATMENT:
GOALS OF TREATMENT:
For Early Disease:
Remove cancer cells
Kill cancer cells
Keep the cancer cells from returning
For Advanced Disease:
Slow or stop the growth of cancer cells
Manage quality of life concerns
35. Treatment is defined by stage and type of cancer present
Depend on the location & extent of disease.
1) Surgery
2) Radiation
3) Chemotherapy
4) Adjuvant therapy
Curative therapy: for localized CA
Palliative therapy: for metastatic CA.
TREATMENT…
36. TREATMENT:
ADJUVANT THERAPY:
Is commonly used as a broad term encompassing all types of treatment
used in conjunction with surgery.
Two terms are commonly used in this context;
1.Neoadjuvant therapy:
any form of treatment the patient receives prior to definitive surgical
intervention
2.Adjuvant therapy:
Those treatments that are given following the definitive surgery
These are given with the aim of reducing the risk of survival of micro-
metastases after curative surgery has been undertaken.
37. COLORECTAL CA Rx…
1.SURGERY:
for stage- I, II, III:
Complete surgical resection of the primary tumor mass
For Selected patients with resectable metastases
If the distal margin clear of tumor is at least 1 cm,
sphincter-preserving surgery may be possible for patients with CAs in the middle and
lower portion of the rectum.
If not Candidate for sphincter-preserving surgery; Abdomino-perineal resection (APR) =
remove distal sigmoid, recto-sigmoid, rectum, anus.
Colostomy after colectomy; an accepted procedure for colon and rectal cancer.
38. COLORECTAL CA Rx…
SURGERY…
Stage I colon or rectal cancer are cured by surgical resection alone (no
need of adjuvant therapy).
Rectal CA is more difficult to resect with wide margins.
Local recurrence of rectal CA is more common compared to colon CA
If lies closer to the anal sphincter, so;
the risk of localized treatment failure &
recurrence at the initial site of disease is increased
40. 2. RADIATION THERAPY:
is usually reserved for rectal cancer
it will reduce the symptoms in metastasis disease,
Adjuvant XRT + chemotherapy are standard for stage II/III rectal CA
Neo- Adjuvant therapy before rectal surgery to:
Shrink the Tumour & make it resectable
prevent local recurrence in rectal CA.
COLORECTAL CA Rx…
41. COLORECTAL CA Rx…
3. CHEMOTHERAPY:
Adjuvant chemotherapy should be considered for stage II disease
with pts. at higher risk for relapse :
inadequate LN sampling,
bowel obstruction/ perforation of the bowel at presentation,
poorly differentiated tumors
perineural invasion, and T4 lesions.
42. COLORECTAL CA Rx…
CHEMOTHERAPY…
Adjuvant chemotherapy:
is standard therapy for patients with stage III colon cancer
decreases risk of cancer recurrence & death
Combined neo-adjuvant therapy + radiation therapy and surgery:
for patients with stage II or III rectal cancer
to decrease risk of local and distant disease recurrence.
44. Complications:
partial or complete bowel obstruction:
due to tumor growth.
perforation
Hemorrhage:
due to extension & ulceration to surrounding blood vessels
NB:- Each of these complications is treated surgically.
46. Prevention:
Several primary prevention strategies might thwart the onset
of colorectal cancer;
Avoid tobacco use
Physical activity, diet, and weight reduction strategies mirror those for
other cancers (Greenwald, 2015b).
take daily or alternate-day aspirin (dosage ≥75 mg) for 5 to 10 years for
adults between the ages of 50 and 59 who are also at risk for developing
cardiovascular disease and who have no contraindication to aspirin, as an
effective primary prevention strategy for both cardiovascular disease
and colorectal cancer (Chubak, Kamineni, Buist, et al., 2015).
To date, there is no expert consensus guideline that advocates routine
prescription of aspirin post-colorectal cancer diagnosis
47. Surgical Management…
• Possible surgical procedures include the following (note that only segmental resections with
anastomoses may be done by laparoscope):
Segmental resection with anastomosis (i.e., removal of the tumor and portions of the bowel on
either side of the growth, as well as the blood vessels and lymphatic nodes) (see Fig. 47-9)
Abdomino-perineal resection with permanent sigmoid colostomy (i.e., removal of the tumor
and a portion of the sigmoid and all of the rectum and anal sphincter, also called Miles resection)
(see Fig. 47- 10)
Temporary colostomy followed by segmental resection and anastomosis and subsequent re-
anastomosis of the colostomy, allowing initial bowel decompression and bowel preparation
before resection
Permanent colostomy or ileostomy for palliation of unresectable obstructing lesions
Construction of a colo-anal reservoir called a colonic J-pouch, which 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.
The colostomy can be created as a temporary or permanent fecal diversion.
- It allows the drainage or evacuation of colon contents to the outside of the body. The
consistency of the drainage is related to the placement of the colostomy, which is dictated by
the location of the tumor and the extent of invasion into surrounding tissues (see Fig. 47-7).
48. NURSING PROCESS FOR THE PATIENT WITH COLORECTAL CANCER:
1. PATIENT ASSESSMENT:
HEALTH HISTORY:
about the presence of fatigue, abdominal or rectal pain (e.g., location,
frequency, duration, association with eating or defecation), past and
present elimination patterns, and characteristics of stool (e.g., color,
odor, consistency, presence of blood or mucus).
a history of IBD or colorectal polyps,
a family history of colorectal disease, Lynch syndrome, or FAP, and
current medication therapy.
Assesses dietary patterns, including fat and fiber intake, as well as
amounts of alcohol consumed and history of smoking.
The nurse describes and documents a history of weight loss and
feelings of weakness and fatigue.
Assessment includes auscultation of the abdomen for bowel sounds and
palpation of the abdomen for areas of tenderness, distention, and solid
masses.
Stool specimens are inspected for character and presence of blood.
49. 2. NURSING DIAGNOSES:
1) Imbalanced nutrition: less than body requirements related to nausea and
anorexia
2) Risk for infection related to surgery on bowel and disruption of colonic bacteria
3) Risk for deficient fluid volume related to vomiting and dehydration Risk for
ineffective health management related to knowledge deficit concerning the
diagnosis, the surgical procedure, and self-care after discharge
4) Anxiety related to impending surgery and the diagnosis of cancer Impaired skin
integrity related to the surgical incisions (abdominal or perianal)
51. 3. PLANNING AND GOALS:
The major goals for the patient may include:
attainment of optimal level of nutrition;
prevention of infection;
maintenance of fluid balance;
reduction of anxiety;
learning about the diagnosis, surgical procedure, and self-care after
discharge;
maintenance of optimal tissue healing; and avoidance of complications.
52. 4. NURSING INTERVENTIONS:
Priorities for nursing care include:
preparing the patient physically for surgery
providing information about postoperative care
supporting the patient and family emotionally.
54. A. PROVIDING PREOPERATIVE CARE:
1.Maintaining Optimal Nutrition:
recommends a diet high in calories, protein, and carbohydrates and
low in residue for several days before surgery
A full or clear liquid diet may be prescribed for 24-48 hours
before surgery
If the patient is hospitalized in the days preceding surgery,
parenteral nutrition may be required to replace depleted nutrients,
vitamins, and minerals.
In some instances, parenteral nutrition is given at home before
surgery.
55. PREOPERATIVE CARE…
2.Preventing Infection:
cleanse the bowel with laxatives, enemas, or colonic irrigations before
surgery.
Some surgeons prescribe antibiotics such as kanamycin, ciprofloxacin,
neomycin, metronidazole, and cephalexin to be given orally the day
before surgery to reduce intestinal bacteria.
IV antibiotics such as Cefazolin and metronidazole are given
immediately before surgery
56. PREOPERATIVE CARE…
3.Maintaining Fluid Volume Balance:
I & O monitoring
Food & fluid may be restricted to prevent vomiting.
administers antiemetic agents as prescribed.
NPO.
An NG tube may be inserted to drain accumulated fluids and prevent distention.
monitor IV fluids and electrolytes.
Monitoring serum electrolyte levels can detect the hypokalemia and
hyponatremia due to GI fluid loss.
observes for signs of hypovolemia (e.g., tachycardia, hypotension, decreased
pulse volume)
57. PREOPERATIVE CARE…
4.Providing Preoperative Education:
Assesses the patient’s knowledge about the diagnosis, prognosis, surgical
procedure, and expected level of functioning after surgery.
5.Providing Emotional Support:
assess the patient’s anxiety level and coping mechanisms and suggest
methods for reducing anxiety, such as deep-breathing exercises and
visualizing a successful recovery from surgery and cancer.
projects a relaxed, professional, and empathetic attitude.
58. B. PROVIDING POSTOPERATIVE CARE
pain management.
monitors the patient for complications.
assesses the abdomen for returning peristalsis and the initial stool
characteristics.
help patients out of bed on the first postoperative day to prevent
atelectasis, VTE, and accelerate the return of peristalsis
Maintaining Optimal Nutrition
Providing Wound Care
Educating Patients About Self-Care:
59. 5. EVALUATION:
Expected Patient Outcomes May Include:
1. Consumes a healthy diet;
Avoids foods and fluids that cause diarrhea, constipation, and obstruction
Substitutes nonirritating foods and fluids for those that are restricted
2. Does not exhibit any signs or symptoms of infection;
Is afebrile
3. Maintains fluid balance;
Experiences no vomiting or diarrhea
Experiences no signs or symptoms of dehydration
4.Acquires information about diagnosis, surgical procedure,
preoperative preparation, and self-care after discharge;
Discusses the diagnosis, surgical procedure, and postoperative self care
Demonstrates techniques of ostomy care
60. Expected outcome…
5. Feels less anxious;
a. Expresses concerns and fears freely
b. Uses coping measures to manage stress
6. Maintains clean wound
7. Recovers without complications;
a. Regains normal bowel activity
b. Exhibits no signs and symptoms of perforation or bleeding
c. Identifies signs and symptoms that should be reported to the
health care provider
