Interventions for Clients Interventions for Clients with Colorectal Cancerwith Colorectal Cancer

What is Colorectal Cancer?What is Colorectal Cancer? Third most common type of cancer Third most common type of cancer

and second most frequent cause of and second most frequent cause of cancer-related deathcancer-related death

A disease in which normal cells in A disease in which normal cells in the lining of the colon or rectum the lining of the colon or rectum begin to change, grow without begin to change, grow without control, and no longer diecontrol, and no longer die

Usually begins as a noncancerous Usually begins as a noncancerous polyp that can, over time, become a polyp that can, over time, become a cancerous tumorcancerous tumor

What is the Function of the What is the Function of the Colon and Rectum?Colon and Rectum?

The colon and rectum The colon and rectum comprise the large comprise the large intestine (large intestine (large bowel)bowel)

The primary function The primary function of the large bowel is of the large bowel is to turn liquid stool to turn liquid stool into formed fecal into formed fecal mattermatter

What Are the Risk FactorsWhat Are the Risk Factors for Colorectal Cancer? for Colorectal Cancer?

Polyps (a noncancerous or precancerous Polyps (a noncancerous or precancerous growth associated with aging)growth associated with aging)

AgeAge Inflammatory bowel disease (IBD)Inflammatory bowel disease (IBD)Diet high in saturated fats, such as red meatDiet high in saturated fats, such as red meatPersonal or family history of cancerPersonal or family history of cancerObesityObesitySmokingSmokingOtherOther

Hereditary Colorectal Cancer Hereditary Colorectal Cancer Syndromes: HNPCCSyndromes: HNPCC

Hereditary non-polyposis colorectal cancer (HNPCC), Hereditary non-polyposis colorectal cancer (HNPCC), sometimes called Lynch syndrome, accounts for sometimes called Lynch syndrome, accounts for approximately 5% to 10% of all colorectal cancer casesapproximately 5% to 10% of all colorectal cancer cases

The risk of colorectal cancer in families with HNPCC is The risk of colorectal cancer in families with HNPCC is 70% to 90%, which is several times the risk of the 70% to 90%, which is several times the risk of the general populationgeneral population

People with HNPCC are diagnosed with colorectal People with HNPCC are diagnosed with colorectal cancer at an average age of 45cancer at an average age of 45

Genetic testing for the most common HNPCC genes is Genetic testing for the most common HNPCC genes is available; measures can be taken to prevent available; measures can be taken to prevent development of colorectal cancer development of colorectal cancer

Hereditary Colorectal Cancer Hereditary Colorectal Cancer Syndromes: FAP Syndromes: FAP

Familial adenomatous polyposis (FAP) accounts for 1% of Familial adenomatous polyposis (FAP) accounts for 1% of colorectal cancer casescolorectal cancer cases

People with FAP typically develop hundreds to thousands People with FAP typically develop hundreds to thousands of colon polyps (small growths); the polyps are initially of colon polyps (small growths); the polyps are initially benign (noncancerous), but there is nearly a 100% chance benign (noncancerous), but there is nearly a 100% chance that the polyps will develop into cancer if left untreatedthat the polyps will develop into cancer if left untreated

Colorectal cancer usually occurs by age 40 in people with Colorectal cancer usually occurs by age 40 in people with FAP FAP

Mutations (changes) in the APC gene cause FAP; genetic Mutations (changes) in the APC gene cause FAP; genetic testing is availabletesting is available

Yearly screening for polyps is recommendedYearly screening for polyps is recommended Attenuated familial adenomatous polyposis Attenuated familial adenomatous polyposis (AFAP) is related to FAP; people have fewer(AFAP) is related to FAP; people have fewer polypspolyps

Hereditary Colorectal Cancer Hereditary Colorectal Cancer SyndromesSyndromes

Several other less common Several other less common syndromes can increase a syndromes can increase a person’s risk of colorectal person’s risk of colorectal cancercancer

Talk with your doctor about Talk with your doctor about finding a genetic counselor if finding a genetic counselor if you have a history of you have a history of colorectal cancer in your colorectal cancer in your family and family members family and family members developed cancer before age developed cancer before age 5050

Colorectal Cancer and Early Colorectal Cancer and Early DetectionDetection

Colorectal cancer can be prevented through Colorectal cancer can be prevented through regular screening and the removal of polyps regular screening and the removal of polyps

Early diagnosis means a better chance of Early diagnosis means a better chance of successful treatmentsuccessful treatment

Screening should begin at age 50 for all Screening should begin at age 50 for all “average risk” individuals or sooner if you have “average risk” individuals or sooner if you have a family history of colorectal cancer, symptoms, a family history of colorectal cancer, symptoms, or a personal history of inflammatory bowel or a personal history of inflammatory bowel diseasedisease

Screening Methods for Screening Methods for Colorectal CancerColorectal Cancer

Colonoscopy (currently the best way to Colonoscopy (currently the best way to prevent and detect colorectal cancer) prevent and detect colorectal cancer)

Virtual colonographyVirtual colonography SigmoidoscopySigmoidoscopy Fcal occult blood testFcal occult blood test Double contrast barium enemaDouble contrast barium enema Digital rectal examination Digital rectal examination

What Are the Symptoms ofWhat Are the Symptoms ofColorectal Cancer?Colorectal Cancer?

A change in bowel habits: diarrhea, constipation, or a A change in bowel habits: diarrhea, constipation, or a feeling that the bowel does not empty completelyfeeling that the bowel does not empty completely

Bright red or dark blood in the stoolBright red or dark blood in the stool

Stools that appear narrower or thinner than usualStools that appear narrower or thinner than usual

Discomfort in the abdomen, including frequent gas Discomfort in the abdomen, including frequent gas pains, bloating, fullness, and crampspains, bloating, fullness, and cramps

Unexplained weight loss, constant tiredness, or Unexplained weight loss, constant tiredness, or unexplained anemia (iron deficiency)unexplained anemia (iron deficiency)

How is Colorectal Cancer How is Colorectal Cancer Evaluated?Evaluated?

Diagnosis is confirmed with a biopsyDiagnosis is confirmed with a biopsy

Stage of disease is confirmed by Stage of disease is confirmed by pathologists and imaging tests, such pathologists and imaging tests, such as computerized tomography (CT or as computerized tomography (CT or CAT) scansCAT) scans

Endoscopic ultrasound and magnetic Endoscopic ultrasound and magnetic resonance imaging (MRI) may also resonance imaging (MRI) may also be used to stage rectal cancerbe used to stage rectal cancer

Cancer Treatment: SurgeryCancer Treatment: Surgery Foundation of curative therapyFoundation of curative therapy

The tumor, along with the The tumor, along with the adjacent healthy colon or adjacent healthy colon or rectum and lymph nodes, is rectum and lymph nodes, is typically removed to offer the typically removed to offer the best chance for curebest chance for cure

May require temporary or May require temporary or (rarely) permanent colostomy (rarely) permanent colostomy (surgical opening in abdomen (surgical opening in abdomen that provides a place for waste that provides a place for waste to exit the body)to exit the body)

Cancer Treatment: Cancer Treatment: ChemotherapyChemotherapy

Drugs used to kill cancer cellsDrugs used to kill cancer cells

Typical medications include fluorouracil Typical medications include fluorouracil (5-FU), oxaliplatin (Eloxatin), irinotecan (5-FU), oxaliplatin (Eloxatin), irinotecan (Camptosar), and capecitabine (Xeloda)(Camptosar), and capecitabine (Xeloda)

A combination of medications is often A combination of medications is often used used

Types of ChemotherapyTypes of Chemotherapy Adjuvant chemotherapy is given after Adjuvant chemotherapy is given after

surgery to maximize a patient’s chance surgery to maximize a patient’s chance for cure for cure

Neoadjuvant chemotherapyNeoadjuvant chemotherapy is given is given before surgerybefore surgery

Palliative chemotherapy is given to Palliative chemotherapy is given to patients whose cancer cannot be patients whose cancer cannot be removed to delay or reverse cancer-removed to delay or reverse cancer-related symptoms and substantially related symptoms and substantially improve quality and length of lifeimprove quality and length of life

Cancer Treatment: Radiation Cancer Treatment: Radiation TherapyTherapy

The use of high-energy x-rays or other The use of high-energy x-rays or other particles to destroy cancer cellparticles to destroy cancer cell

Used to treat rectal cancer, either before or Used to treat rectal cancer, either before or after surgeryafter surgery

Different methods of deliveryDifferent methods of delivery

External-beam: outside the bodyExternal-beam: outside the body

Intraoperative: one dose during surgeryIntraoperative: one dose during surgery

New Therapies: New Therapies: Antiangiogenesis TherapyAntiangiogenesis Therapy

““Starves” the tumor by disrupting its blood Starves” the tumor by disrupting its blood supplysupply

This therapy is given along with This therapy is given along with chemotherapychemotherapy

Bevacizumab (Avastin) was approved by Bevacizumab (Avastin) was approved by the U.S. Food and Drug Administration the U.S. Food and Drug Administration (FDA) in 2004 for the treatment of stage IV (FDA) in 2004 for the treatment of stage IV colorectal cancercolorectal cancer

New Therapies: Targeted New Therapies: Targeted TherapyTherapy

Treatment designed to target cancer Treatment designed to target cancer cells while minimizing damage to cells while minimizing damage to healthy cellshealthy cells

Cetuximab (Erbitux) was approved Cetuximab (Erbitux) was approved by the FDA in 2004 for the treatment by the FDA in 2004 for the treatment of advanced colorectal cancerof advanced colorectal cancer

Colorectal Cancer StagingColorectal Cancer Staging

Staging is a way of describing a cancer, such as Staging is a way of describing a cancer, such as the depth of the tumor and where it has spreadthe depth of the tumor and where it has spread

Staging is the most important tool doctors have Staging is the most important tool doctors have to determine a patient’s prognosis to determine a patient’s prognosis

Staging is described by the TNM system: the Staging is described by the TNM system: the size (the depth of penetration of the size (the depth of penetration of the TTumor umor into the wall of the bowel), whether cancer has into the wall of the bowel), whether cancer has spread to nearby lymph spread to nearby lymph NNodes, and whether odes, and whether the cancer has the cancer has MMetastasized (spread to organs etastasized (spread to organs such as the liver or lung)such as the liver or lung)

The type of treatment a person receives The type of treatment a person receives depends on the stage of the cancerdepends on the stage of the cancer

Stage Stage 00 Colorectal Cancer Colorectal Cancer

Known as “cancer in Known as “cancer in situ,” meaning the situ,” meaning the cancer is located in cancer is located in the mucosa (moist the mucosa (moist tissue lining the tissue lining the colon or rectum)colon or rectum)

Removal of the Removal of the polyp (polypectomy) polyp (polypectomy) is the usual is the usual treatmenttreatment

Stage I Colorectal CancerStage I Colorectal Cancer

The cancer has The cancer has grown through the grown through the mucosa and invaded mucosa and invaded the muscularis the muscularis (muscular coat)(muscular coat)

Treatment is surgery Treatment is surgery to remove the tumor to remove the tumor and some and some surrounding lymph surrounding lymph nodesnodes

Stage II Colorectal CancerStage II Colorectal CancerThe cancer has grown The cancer has grown

beyond the muscularis beyond the muscularis of of the colon or rectum but has the colon or rectum but has not spread to the lymph not spread to the lymph nodesnodes

Stage II colon cancer is Stage II colon cancer is treated with surgery and, in treated with surgery and, in some cases, chemotherapy some cases, chemotherapy after surgeryafter surgery

Stage II rectal cancer is Stage II rectal cancer is treated with surgery, treated with surgery, radiation therapy, and radiation therapy, and chemotherapychemotherapy

Stage III Colorectal CancerStage III Colorectal Cancer

The cancer has spread to The cancer has spread to the regional lymph nodes the regional lymph nodes (lymph nodes near the (lymph nodes near the colon and rectum)colon and rectum)

Stage III colon cancer is Stage III colon cancer is treated with surgery and treated with surgery and chemotherapychemotherapy

Stage III rectal cancer is Stage III rectal cancer is treated with surgery, treated with surgery, radiation therapy, and radiation therapy, and chemotherapychemotherapy

Stage IV Colorectal CancerStage IV Colorectal CancerThe cancer has spread The cancer has spread

outside of the colon or rectum outside of the colon or rectum to other areas of the bodyto other areas of the body

Stage IV cancer is treated Stage IV cancer is treated with chemotherapy. Surgery with chemotherapy. Surgery to remove the colon or rectal to remove the colon or rectal tumor may or may not be tumor may or may not be donedone

Additional surgery to remove Additional surgery to remove metastases may also be done metastases may also be done in carefully selected patientsin carefully selected patients

Coping With the Side Effects Coping With the Side Effects of Cancerof Cancer

and its Treatmentand its TreatmentSide effects are treatable; talk with Side effects are treatable; talk with the doctor or nursethe doctor or nurse

Fatigue is a common, treatable side Fatigue is a common, treatable side effecteffect

Pain is treatable; non-narcotic pain Pain is treatable; non-narcotic pain relievers are availablerelievers are available

Antiemetic drugs can reduce or Antiemetic drugs can reduce or prevent nausea and vomitingprevent nausea and vomiting

Follow-Up CareFollow-Up Care

Doctor’s visitsDoctor’s visitsSerial carcinoembryonic antigen (CEA) Serial carcinoembryonic antigen (CEA)

measurements are recommendedmeasurements are recommendedColonoscopy one year after removal of Colonoscopy one year after removal of

colorectal cancercolorectal cancerSurveillance colonoscopy every three Surveillance colonoscopy every three

to five years to identify new polyps to five years to identify new polyps and/or cancersand/or cancers