Colorectal cancer, which is also commonly known as colon cancer is the second leading cause of cancer related deaths in the US. According to statistics retrieved from the centers for disease control, approximately 100,000 new cases of colon cancer are detected every year. The incidence of colon cancer is observed more commonly in patients that belong to higher socioeconomic background. Furthermore, colon cancer is most commonly detected in patients who are 50 years or older (CDC.gov). It was observed that approximately 49000 deaths occur annually on account of colon cancer. The death rate for colon cancer has been falling annually according to the data published by the national cancer institute (NCI.gov)
Colorectal cancer or colon cancer is the cancer where tumor cells are formed or transformed in the colon or rectum tissue. Colon cancer occurs in the ascending, transverse, descending and sigmoid colon, the rectum and the cecum. The most type of colon cancer is usually the adenocarcinoma. Most kinds of colon cancers in general and adenocarcinomas in particular progress slowly and do not present symptoms for five to six years after tumor initiation (NCI.gov).
There a number of risk factors associated with the incidence of colon cancer. These include some modifiable risk factors such as consumption of diet rich in fat and poor in fiber, smoking, drinking alcohol, sedentary lifestyle and being overweight. Modification of these factors can reduce the risk for colon cancer. However, there are various risk factors that are also responsible for higher incidence of colon cancer that are not modifiable (Cappell, 2005). Some of the non-modifiable risk factors for colon cancer include age, history of polyps occurrence, family history of colon cancer, history of inflammatory bowel disease, type 2 diabetes to name a few. People who have history of benign polyps in their colon can transform to malignant kind of cells resulting in adenocarcinoma. Patients who have a history of adenomatous polyposis or Gardner’s syndrome, which are responsible for occurrence of polyps in colon and rectum are also associated with increased risk for colon carcinoma. Colon cancer is the most well understood cancer in regards to molecular genetics of the cancer. Most of the identified colon cancers are moderately differentiated adenocarcinomas. Adenomatous and hyperplastic are the two most common histologic types of colon cancer (Cappell, 2005). The symptoms of colon cancer are usually observed after the cancer has progressed and include change in bowel pattern, blood in stool, unexplained weight loss, bloating and abdominal pain, nausea, shortness of breath, abdominal discomfort and vomiting (Cleveland Clinic foundation, 2009). The symptoms described above can elicit performance of one or more screening diagnostic test by the health care provider. Fecal occult blood test (FOBT) is performed to detect presence of blood in the fecal material. There are two modes of FOBT that either use chemical guaiac or immunohistochemical detection method to identify hemoglobin presence in fecal blood. It has been shown that performance of FOBT every two year can lower the death associated with colon cancer by 15-30%, especially in adults who are between 50-80 years (ACS.gov). Double contrast barium enema is performed by giving a barium enema to the patient followed by introduction of air. The barium enema and air help to outline colon and rectum and provide information of cancerous growth in the X-ray images. Sigmoidoscopy, is a detection technique that makes use of a lighted instrument known as the sigmoidscope that can detect precancerous or cancerous growth in rectum and lower colon can remove the growth or perform biopsy. Colonoscopy can also detect and remove precancerous or cancerous growth from the rectum or the entire colon by using a lighted instrument called the colonoscope. The colonoscope can detect tumors in the upper part of the colon that can be missed by sigmoidoscopy. Colonoscopy is more invasive and usually requires sedation. Colonoscopy and sigmoidoscopy can help reduce the cancer related deaths in adults who are older than 50 years (American Cancer Society, 2013). As opposed to traditional colonoscopy, virtual colonoscopy is performed by taking multiple X-ray images of colon and rectum. These detailed images are used to detect the presence of cancerous or precancerous growth. In addition to these screening tests, many physicians use digital rectal exam to detect for abnormal area in lower part of rectum (Cappell, 2005).
The progression of colon cancer is well defined and understood. In the stage 0, the cancer is localized and has not traveled beyond the colon lining. The stage 1 colon cancer has been described to have grown through the numerous intestinal layers but not spread beyond the muscular layer of colon. The stage 2 of colon cancer is described as having spread beyond the muscular layer of the colon tissue and spread into the nearby tissue. The colon cancer does not reach to lymph nodes in the stage 2. Stage 3 is an advanced stage of colon cancer. The cancer progresses to lymph nodes, however is restricted to the colon and not spread to other organs in the body (ACS.gov). The stage 4 is characterized by metastasis of the cancerous cells to other organs such as lungs, liver or brain. When the disease metastasizes the treatment strategy is to simply relieving pain and preventing the complications of the disease as opposed to curing the cancer. (The Cleveland Clinic foundation, 2012).
The cancer of the colon can result in a number of complications including bowel obstruction, bowel perforation, abscess formation, acute appendicitis, ischemic colitis and intussusception. Bowel obstruction is obstruction in the intestine that can affect digestion and obstruct removal of fecal matter. Bowel obstruction is mostly commonly observed in the small intestine and the colon. Advanced stage of cancer and surgery performed to remove both increase the risk for bowel obstruction. Surgery or less invasive stenting is performed to remove the obstruction. Acute appendicitis is another common complication associated with colon cancer. Interestingly, colon cancer has been discovered in many elderly patients at the surgery table, who present symptoms of appendicitis and appendiceal abscess. Intussusception occurs when one part of intestine invaginates into another part causing obstruction in the intestine. This invagination is similar to sliding action of collapsible telescope (Cappell, 2005).
The strategy suggested for colon cancer treatment is based on the stage of the colon cancer. The stage 0 does not have the tumor grown beyond the colon tissue and can be easily removed by surgery. The stage 1 is treated by partial colectomy wherein a section of colon is removed. It can also involve removal of nearby lymph nodes since the colon has spread to various layers of colon but not beyond that. Stage 2 which is characterized by tumor growing beyond various layers of colon to nearby tissue, but not into nearby lymph nodes. Surgery is performed to remove the cancer. Adjuvant chemotherapy can be recommended based on the grade of the tumor or if the tumor has obstructed the colon or created a perforation in the colon wall. The chemotherapeutic agents include antimetabolites such as 5-FU, capecitabine, and leucovorin as a drug that enhances the activity of 5FU (ACS.gov). Radiation therapy is also advised for stage 2 colon cancer if the entire tumor mass was not removed. The treatment for stage 3 cancer is generally similar to stage 2, where partial colectomy is performed followed by adjuvant chemotherapy or radiotherapy. The commonly used chemotherapeutic regimen includes FOLFOX, which is a combination of 5FU, leucovorin and oxaliplatin or CapeOx which is a combination of capecitabine and oxaliplatin (Cleveland Cancer foundation, 2012). Stage 4 colorectal cancer that has metastasized to other organs. Colon cancer most commonly metastasizes to liver, lining of the peritoneal cavity and lungs. Surgery cannot treat the stage 4 cancer, however if the tumor has only spread to nearby organs, complete removal of the tumor mass might be a viable strategy. However if the cancer has spread to various distant organs treatment with chemotherapy and other targeted therapy might be a useful option. Surgery, including diverting colostomy is often performed to remove blockage in the colon. Furthermore, radiation therapy is also utilized to alleviate symptom of pain. However it is key to explain to the patient that stage 4 colon cancer is difficult to cure and the treatment will only partially help with the symptoms of pain and abdominal problems. Surgery, chemo and radiation therapy, in addition to treating the cancer can also result in many undesired effects including nausea, vomiting, and infection at the surgery site, urinary retention, leakage from the site of surgery, diarrhea and loss of immune function. The patient, especially in stage 4 of cancer must be informed about the various risks and benefits associated with various treatment options. The patient must be advised to take precautions if possible to avoid getting exposed to various infections (Cleveland Cancer foundation, 20012).
Nurses can play a key role in caring for the patient during treatment. The patient has to be properly informed about pre and post-operative care including caring for the colostomy and nasogastric tube and keeping track of nutritional requirements after the surgery. The nurse should be able to recognize symptoms of malnutrition that can occur after chemotherapy. Parenteral route of feeding might be required when patients appear malnourished. The patients should be informed about the special precautions that are to be taken around the site of radiation therapy. The nurses should also inform about the potential side effects observed with the treatment options. The nurses can educate the patients about getting enough nutrition and some physical activity after chemotherapy and surgery (VanBeuge, 2009) Anxiety and feeling of powerlessness, pain, fatigue and knowledge deficit are also well documented in patients which should be given proper attention and care.
References
American Cancer Society. (2008). Colorectal cancer: What you need to know-now (2nd ed.). Atlanta: American Cancer Society.
American Cancer Society. (2013, September 30). What are the risk factors of colorectal cancer. Retrieved from http://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancer-risk-factors.
American Cancer Society. (2013). What’s new in colorectal cancer research
and treatment? Retrieved from http://www.cancer.org/cancer/
Cappell, M. S. (2005). The pathophysiology, clinical presentation and diagnosis of colon cancer and adenomatous polyps. The Medical Clinics of North America. Retrieved from http://www.med.upenn.edu/gastro/documents/MedClinNAcolonicpolyps.pdf
Centers for Disease Control and Prevention. (2013). Colorectal cancer screening guidelines. Retrieved from http://www.cdc.gov/cancer/colorectal/basic_info/screening/guidelines.htm
National Cancer Institute. (2013). Colon and rectal cancer. Retrieved from http://www.cancer.gov/cancertopics/types/colon-and-rectal
The Cleveland Clinic Foundation. (2009). Diseases and conditions colorectal overview.
Retrieved from http://my.clevelandclinic.org/disorders/colorectal_cancer/
hic_colorectal_cancer_-_overview_signs_symptoms_stages.aspx
VanBeuge, S. S. (2009). Colorectal cancer. Risk, screening and referral. Advance for Nurse Practitioners, 17(12), 19-22
