Helping Patients Combat Colon Cancer

By Janice C. Colwell, RN, CWOCN, MS, FAAN, and Barbara Gordon, RN, OCN, MSN

Nursing2009,

April 2009 2.3 ANCC contact hours Online: www.nursingcenter.com

© 2009 by Lippincott Williams & Wilkins. All world rights reserved.

Statistics regarding colon cancer  148,810 people in the U.S. received diagnosis of colon cancer in 2008  Estimated 49,960 died of the disease  Third most frequently diagnosed cancer in the U.S.

Cancer of the GI tract defined  Cancers of colon and rectum are

colorectal cancer

 Cancer below small intestine and above rectum is

colon cancer

(includes ascending, transverse, descending, sigmoid colon) 

Rectal cancer

affects last 6 inches of GI tract

A look at the colon and rectum The colon has four sections:  The

ascending colon

starts with the cecum, where the small bowel attaches to the colon on the right side of the lower abdomen and moves upward  The

transverse colon

crosses from the right to the left side in the upper abdomen

A look at the colon and rectum  The

descending colon

continues downward on the left side of the abdomen  The

sigmoid colon

has an “S” shape  The highest incidence of colon cancer is in the sigmoid and ascending colon. The

rectum

is the final 6 inches of the digestive tract

Focus on colon cancer  Deaths from colon cancer have decreased over the last 30 years  Possibly due to earlier diagnosis, thorough screening  Better treatments

Who’s at risk?

 Equal among men and women  Increases with age; 90% of people diagnosed are over age 50  Additional risks include family history of adenoma polyps or colorectal cancer, inflammatory bowel disease

Modifiable risk factors  Cigarette smoking  Obesity  Diet high in red and processed meats, low in fruits and vegetables  Adult-onset diabetes  Limited physical activity

How colon cancer develops  A series of events leads to colon cancer  Changes in DNA oncogenes speed up cell division and turn off tumor suppressor genes  Adenomatous polyps cause most colon cancers; early polyp removal via colonoscopy is recommended

Location and stage determine symptoms   

Ascending colon

- tumors can be large before obstructing flow - anemia may be first sign of tumor

Transverse or descending colon

- tumor may cause obstruction of solid stool - patient may have cramping and constipation

Sigmoid colon

- blood through the rectum, bowel changes, narrow stool

Screening for trouble  Highly curable with early detection  5-year survival rate is 90% if detected early  U. S. Preventive Service Task Force (USPSTF) screening guidelines suggest that adults age 50 to 75 at average risk with no signs and symptoms can choose one of the following options

USPSTF guidelines 

Average risk

patients may choose: - colonoscopy every 10 years - sigmoidoscopy every 5 years with high sensitivity fecal occult blood test every 3 years - FOBT annually  People with

known risk

factors should have a colonoscopy at age 40 or earlier

USPSTF screening guidelines  If high risk, should have colonoscopy earlier  No routine screening for adults age 76 to 85 except in special circumstances; mortality benefit declines after age 75  Screening adults over age 85 isn’t recommended; risks outweigh benefits

Additional tests  Complete blood cell count can identify anemia  Chemistry panel to determine advanced disease; elevated liver enzymes may indicate metastasis to the liver  Carcinoembryonic antigen (CEA) can detect tumor recurrence after resection  CT can screen for metastasis to other organs

Surgery  Best possible chance for cure  Aims at resecting tumor and preventing recurrence  80% of patients have potentially curative surgery

Surgery  Standard surgical treatment is colectomy  Lymph nodes will be removed for biopsy

Staging for colon cancer

TNM staging system



T

(tumor): extent of the primary tumor through the colon layers 

N

(nodes): the absence or presence of metastasis to lymph nodes and number of nodes involved 

M

(metastasis): absence or presence of distant metastasis

Adjuvant therapy  Systematic treatment to help reduce risk of recurrence and increase chance of cure  Chemotherapy is principal method; generally started 6 to 7 weeks after surgery  Adjuvant chemotherapy in stage III improves long-term survival

Recommended therapies  National Comprehensive Cancer Network recommends one of the following therapies: - 5-FU/leucovorin/oxaliplatin - capecitabine - 5FU/leucovorin - participation in a clinical trial or - observation for resected stage III and IV disease

Targeted therapy  Also known as biological therapy  Designed to stop cancer cell growth  May be used alone or with chemotherapy

Targeted therapy  Monoclonal antibodies are a type of targeted therapy  Antibodies - cetuximab and panitumumab (target epidermal growth factor) and bevacizumab (targets vascular endothelial growth factor) have been effective against metastatic disease

Long-term follow-up  So far, no standard for surveillance in patients who have surgically resected colon cancer  Follow-up care most likely includes: - history and physical every 3 to 6 months for 2 years, then every 6 months for 5 years - stage II or higher may have serum CEA every 3 to 6 months for 5 years - annual CT of chest, abdomen, pelvis for 3 years if patient has high risk of recurrence

Teaching your patient what to expect  Offer support for diagnosis and treatments the patient will undergo  Encourage patient in managing the disease and adhering to treatment plan  Educate patient regarding what to expect

Teaching your patient what to expect  Advise patient to follow a low-residue diet for 6 weeks after surgery  Instruct patient that he may need to use fiber supplements

Managing the effects of chemotherapy 

Appetite changes

- suggest drinking fluids between meals - eat food at room temperature - light exercise to stimulate appetite - eat nutritious snacks high in calories and protein

Managing the effects of chemotherapy 

Mucositis

- swish ice chips in mouth 5 minutes prior and for 30 minutes with chemotherapy treatments - remove dentures - gently brush teeth - rinse with salt water/baking soda solution - avoid spicy foods and foods requiring excessive chewing

Managing the effects of chemotherapy 

Fatigue

- plan naps if possible - some fatigue is normal - alert healthcare provider if symptoms of fatigue persist despite rest or experiences shortness of breath

Managing the effects of chemotherapy 

Finger and toe numbness

- hand-foot syndrome: skin on hands and feet appears red and peels - can be painful - advise patient not to handle cold items (iced beverages/frozen foods)