Colorectal Cancer
Revised 11/6/21
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Colorectal Cancer
 Of cancers that affect both men and women
 2nd leading cause of cancer-related deaths
 3rd most common form of cancer
 More common in men
 Highest mortality rates among African
American men and women
 Risk of disease increases with age
 Recent increase in young men
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Incidence of Cancer
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Risk factors
 No single risk factor accounts for most
cases of CRC
 Highest risk
 First-degree relatives (~ 1/3 of cases ) w/ CRC
 IBD
 (FYI) ~ 30% to 50% - abnormal KRAS gene
(oncogene)
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What factors ↓ the risk of CRC?
 Physical exercise
 Diet high in fruits, vegetables, and grains
 Long-term use of NSAIDS
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Adenocarcinoma
- most common type
 About 85% arise from adenomatous polyps
 Tumors spread /metastasize  colon walls
 musculature  lymphatic & blood
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Colon Cancer
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Assessment Cues
 Bowel symptoms
 Rectal bleeding is most common
 Alternating constipation and diarrhea
 Change in stool caliber
 Narrow, ribbonlike
 Sensation of incomplete evacuation
 Obstruction
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Why is this a problem??
 Insidious onset
 Symptoms often do not appear until
disease is in advanced stages…
 Change in bowel habits
 Unexplained weight loss
 Vague abdominal pain
 Weakness and fatigue
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Most common sites of metastasis
 Regional lymph nodes
 Liver
 Lungs
 Bones
 Brain
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Diagnostic Studies
 Colonoscopy - First @ age 45
 “Gold standard”
 Entire colon is examined
 Biopsy samples – sent to lab
 Polyps can be immediately removed - to
lab
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Diagnostic Studies – Know this***
 Individual and family history
 Regular screening for polyps and cancer
from ages 45 to 75 years of age
 Colonoscopy every 10 years
 Flexible sigmoidoscopy every 5 years
 Double-contrast barium enema every 5 years
 CT colonography every 5 years
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Diagnostic Studies
 Persons at risk need earlier and more
frequent screening
 Those with first-degree relative in whom
CRC was diagnosed before age 60
 Those with two first-degree relatives with
CRC
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Diagnostic Studies
 Annual screening
 FOBT = fecal occult blood test (high sensitivity)
or
 FIT = Fecal immunochemical test
 Test for blood in the stool
 Must be done frequently to catch intermittent
bleeding common with tumors
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Diagnostic Studies
 Tissue biopsies confirm diagnosis
 Additional laboratory studies are then
needed
 CBC to check for anemia
 Liver function tests
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Nursing Management
Nursing Assessment
 Medications
 Weakness or fatigue
 Change in bowel habits
 High-calorie, high-fat, low-fiber diet
 Increased flatus
 Feelings of incomplete evacuation
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Diagnostic Studies
 Carcinoembryonic antigen (CEA)
 Complex glycoprotein
 Sometimes produced by colorectal cancer
cells
 May be used to monitor for disease
recurrence after surgery or chemotherapy
 NOT a good screening tool because of a large
number of false positives
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Diagnostic Studies
 CT scan or MRI of the abdomen
 Helpful in detecting
 Liver metastases
 Retroperitoneal and pelvic disease
 Depth of penetration of tumor in bowel wall
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Prognosis & Treatment depend on Stage
 Correlate with pathologic
staging of disease
 TNM system
 Prognosis worsens with
 Greater size and
depth of tumor
 Lymph node
involvement
 Metastasis
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Surgical therapy
 Polypectomy during colonoscopy is used
to resect colorectal cancer in situ
 Successful when
 Resected margin of polyp is free of cancer
 Cancer is well differentiated
 No lymphatic or blood vessel involvement is
apparent
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Colon Resection
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Surgical goals
1. Complete resection of tumor
2. Thorough exploration of abdomen
3. Removal of all lymph nodes that drain
the area
4. Restoration of bowel continuity
5. Prevention of surgical complications
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Chemotherapy
 Shrink a tumor before surgery
 Adjuvant treatment after colon resection
- stage III and high-risk stage II tumors
 Palliative treatment - nonresectable
colorectal cancer
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Chemotherapy: 5-FU

 5-Fluorouracil (5-FU) plus folinic acid
 Leucovorin is used alone or in combination
with oxaliplatin (Eloxatin) or irinotecan (CPT11)
 Eloxatin is preferred if patients can tolerate
side effects
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Targeted therapy
 Angiogenesis inhibitors inhibit the blood
supply to tumors
 Bevacizumab (Avastin)
 Ziv-aflibercept (Zaltrap)
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Nursing Actions
 Health Promotion
 Encourage all persons older than 45 to
have regular CRC screening
 Help identify those at high risk
 Discuss with patients how early screening
helps decrease mortality rates
 Realize that fear and lack of information
create barriers to prevention activities
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Nursing Actions (this is a review)
 Health Promotion
 Colonoscopy detects polyps only when
the bowel has been adequately prepared
 Provide teaching about bowel cleansing for
outpatient procedures
 Correctly administer cleansing preparations to
inpatients
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NOTE: Remaining slides are FYI
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Surgical therapy
 Site of cancer dictates site of resection
 Right or left hemicolectomy
 Stage I tumors
 Removal of tumor and at least 5 cm of
surrounding intestine and nearby lymph
nodes
 Cancer-free ends are sewn back together
 May be done laparoscopically
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Interprofessional Care
 Low-risk stage II tumors
 Wide resection and reanastomosis
 High-risk stage II tumors
 Same as for low-risk stage II tumors, plus
chemotherapy
 Stage III tumors
 Surgery and chemotherapy
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Interprofessional Care
 Stage IV tumors
 Indicates cancer has spread to distant
sites
 Surgery is palliative
 Chemotherapy and radiation used to
control the spread and provide pain relief
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Reasons for temporary colostomy
 Perforation
 Peritonitis
 Hemodynamic instability
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Three surgical options in rectal CA
 Local excision
 Abdominal-perineal resection (APR) with
a permanent colostomy
 Low anterior resection (LAR)
 to preserve sphincter function
 Anastomosis
 Temporary ileostomy or colostomy
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Abdominoperineal Resection (APR)
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(Review from IBD)
 Colonic J-pouch or coloplasty create an
alternative reservoir that replaces
rectum as a reservoir for stool
 The anal sphincters remain
 Temporary colostomy allows for healing
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Targeted therapy
 Multikinase inhibitors block several
enzymes that promote cancer growth
 Regorafenib (Stivarga)
 Block epidermal growth factor receptor
 Cetuximab (Erbitux)
 Panitumumab (Vectibix)
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Radiation therapy
 May be used
 As an adjuvant to surgery and chemotherapy
 As palliative therapy for metastasis
 To reduce tumor size
 To provide symptomatic relief
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Nursing Management
Nursing Diagnoses
 Diarrhea
 Constipation
 Fear
 Anxiety
 Ineffective coping
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Nursing Management
Nursing Implementation
 Acute Care
 There is no difference in surgical outcome
between those who undergo preoperative
cleansing and those who do not
 Post-op care is similar to care of patient
after a laparotomy
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Nursing Management
Nursing Implementation
 Acute Intervention
 Postoperative care
 Sterile dressing changes, care of drains, and
patient and caregiver teaching about stoma
 Management differs depending on type of
wound
 Type of management is individualized
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Nursing Management
Nursing Implementation
 Postoperative care
 Drainage must be assessed for amount, color,
and consistency
 Wound should be examined regularly
 Record bleeding, excessive drainage, and odor
 Monitor suture line for infection
 Help with pain control
 Be aware of phantom sensations
 Provide sexual dysfunction education
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Nursing Management
Nursing Implementation
 Ambulatory Care
 Psychologic support
 Managing changes that result from cancer
and cancer treatment
 Ostomy rehabilitation
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Nursing Management
Nursing Implementation
 Evaluation
 Expected Outcomes
 Minimal alteration in bowel elimination
patterns
 Optimal nutritional intake
 Relief of pain
 Quality of life appropriate to disease
progression
 Feelings of comfort and well-being
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