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.

3 Source: The colon and rectum

4 Incidence of Colorectal Ca in KSA Versus USA ASR for colorectal cancer ( ) in the Kingdom of Saudi Arabia and the United States of America ASR for Incidence (USA)ASR for Incidence (KSA) ALLFemalesMalesALLFemalesMalesYear Source: Ibrahim, E. et al. (2008). Past, Present and Future of Colorectal Cancer in the Kingdom 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 ( ). Source: Ibrahim, E. et al. (2008). Past, Present and Future of Colorectal Cancer in the Kingdom 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 FemalesMalesYear % Changes from 2005 No. of patients % Changes from 2005 No. of patients , , , , , Source: Ibrahim, E. et al. (2008). Past, Present and Future of Colorectal Cancer in the Kingdom 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 1 st 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.