Colorectal Cancer and Anal Cancer. Learning Objectives. The learner will be able to: Identify key demographic data for colorectal and anal cancer. Describe the treatment options for patients with colon and anal cancer. Describe nursing implications related to treatment.
Learning Objectives The learner will be able to: • Identify key demographic data for colorectal and anal cancer. • Describe the treatment options for patients with colon and anal cancer. • Describe nursing implications related to treatment.
Colorectal Cancer (CRC): Incidence and Mortality 2012 • Excluding skin cancers, colorectal cancer is the third most common diagnosed cancer in both men and women in the United States • Estimated new cases in 2014: • 96,830 colon cancer • 40,000 rectal cancer • The death rate from colorectal cancer has been dropping for more than 20 years d/t screening and early detection with better cure.
CRC Risk Factors • The overall lifetime risk of developing colorectal cancer is about 1 in 20 (5%) • Nonmodifiable Risk Factors: • Age • History • CRC, polyp • Inflammatory bowel disease (IBD) • Family history of CRC • Familial adenomatous polyposis (FAP) or hereditary nonpolyposis colon cancer (HNPCC) • Diabetes • Race or ethnic background African Americans, Ashkenazi Jews
CRC Risk Factors • Modifiable: • Diet: High in red or processed meat, low in fruits and vegetables • Obesity • Physical inactivity • Heavy alcohol consumption • Possibly smoking
CRC Prevention • Regular screening • Maintain a healthy weight. • Adopt a physically active lifestyle. • Consume a healthy diet with emphasis on plant sources. • Limit consumption of alcoholic beverages. • Consume the recommended levels of calcium, primarily through food sources • Avoid tobacco products
CRC Screening and Staging • Image courtesy the National Cancer Institute
Signs and Symptoms of CRC • Early CRC produces few symptoms, so it is paramount to stress screening. • Later CRC • Change in bowel habits • Blood in stool • Crampy lower abdominal pain • Anemia and fatigue
American Joint Committee Staging System for CRC • Primary tumor • TX: Primary tumor cannot be assessed. • T0: No evidence of primary tumor • Tis: Carcinoma in situ; intraepithelial or invasion of lamina propria • T1: Tumor invades submucosa. • T2: Tumor invades muscularispropria. • T3: Tumor invades through muscularispropria into the pericolorectal tissues. • T4a: Tumor penetrates to the surface of the visceral peritoneum. • T4B: Tumor directly invades or is adherent to other organs or structures.
American Joint Committee Staging System for CRC • Regional lymph nodes • NX: Regional lymph nodes cannot be assessed. • N0: No regional lymph node metastasis • N1: Metastasis in 13 regional lymph nodes • N1a: Metastasis in 1 regional lymph node • N1b: Metastasis in 23 regional lymph nodes • N1c: Tumor deposit(s) in the subserosa, mesentery, or nonperitonealizedpericolic or perirectal tissues without regional nodal metastasis. • N2: Metastasis in 4 or more regional lymph nodes • N2a: Metastasis in 46 regional lymph nodes • N2b: Metastasis in 7 or more regional lymph nodes
American Joint Committee Staging System for CRC • Distant metastasis (M) • MX: Distant metastasis cannot be assessed. • M0: No distant metastasis • M1a: Distant metastasis confined to one organ or site • M1b: Metastasis in more than one organ/site or the peritoneum
American Joint Committee Staging System for CRC • Stage 0: Tis • Stage I: T1, T2, N0, M0 • Stage IIA, IIB, IIC: T3, T4, N0, M0 • Stage IIIA, IIIB, IIIC: T1-T4, N1-2, M0 • Stage IVA, IVB: Metastatic disease
Management of CRC • Stage 0: Surgery • Stage I: Surgery • Stage II: Surgery • Stage II with high-risk features: Surgery + adjuvant chemotherapy • Stage III: Surgery + adjuvant chemotherapy • Stage IV: • Surgery of resectable disease, including metastasis if possible • Systemic therapy with chemotherapy and/or biotherapy
Factors Determining CRC Treatment • Stage • Histology • Tumor genetics • Performance status • Patient preference
Surgical Management of CRC • En bloc colectomy with removal of at least 12 lymph nodes • Laparascopic colectomy provided absence of: • Lesions in rectum or transverse colon • Advanced local or metastatic disease • Acute bowel obstruction or perforation • For obstruction, resection with diversion or stent placement followed by colectomy • Resection of hepatic or pulmonary metastatic disease if feasible
Management of Rectal Cancer • Sphincter-sparing transanal resection • Neoadjuvant chemotherapy and radiotherapy can be used to make a patient a candidate for sphincter-sparing surgery. • Transabdominal surgery (APR, LAR), which may require an ostomy if not a candidate for sphincter-sparing surgery • Patients who require an ostomy should be seen by an enterostomal therapist preop.
High-Risk Factors for CRC Recurrence • Grade 3 or 4 histology • Lymphatic or vascular invasion • Presents with bowel obstruction • < 12 lymph nodes examined • Stage IIB or IIC: Large mass • Stage IIA with localized perforation or close, indeterminate, or positive margins
Adjuvant Therapy • Chemotherapeutic agents used in adjuvant therapy: • Fluorouracil (5-FU) and leucovorin • Oxaliplatin • Capecitabine • Use of other agents should only be in the setting of a clinical trial.
Metastatic Disease • Agents used in metastatic disease: • Chemotherapy • 5-FU and leucovorin • Oxaliplatin • Capecitabine • Irinotecan • Biotherapy (monoclonal antibodies) • Bevacizumab (vascular endothelial growth factor [VEGF] inhibitor) • Cetuximab (epidermal growth factor receptor [EGFR] inhibitor) • Panitumumab EGFR inhibitor
Toxicities of Chemotherapy • GI: Nausea, vomiting, mucositis, anorexia, and diarrhea may occur. • Myelosuppression • Neurotoxicity (acute and chronic) with oxaliplatin • Fatigue • Alopecia • Swelling and rashes, mouth sores • Hand-foot syndrome with infusional 5-FU and capecitabine • Hypersensitivity can occur with oxaliplatin later in therapy (dose #7 or later).
Toxicities of Biotherapy • Hypersensitivity may occur with monoclonal antibodies. • Acne-like rash, dry skin and swelling or pain in fingernails or toenails may occur with EGFR inhibitors. • Hypertension, bleeding, GI perforation, kidney damage, venous or arterial clots and delayed wound healing may occur with VEGF inhibitors.
Nursing Interventions • Myelosuppression: Education on prevention of infection, hand hygiene and administration of growth factors • GI: • Nausea/vomiting: Administer antiemetics, assess efficacy, education re: diet and fluids • Mucositis: Assess oral cavity, advise on oral care protocol. • Diarrhea: Education on how to use antidiarrheal agents, fluids, low-residue diet
Neuropathy Manifestations: Oxaliplatin • Acute: • Affects up to 90% of patients • Precipitated by cold exposure • Dysesthesias and paresthesias • Distal extremities • Tightness in back of throat • Muscle cramping • Jaw spasm • Early onset (2h2d) or with subsequent cycles • Usually resolves within 14 d
Acute Sensory Neuropathy • Preventing acute sensory neuropathy • Consider calcium gluconate and magnesium sulfate infusion pre- and post-oxaliplatin. • Consider prolonging infusion time. • Preventing cold dysesthesias • Avoid cold weather and dress properly. • Have someone warm up the car in cold weather. • Put on gloves before reaching into refrigerator. • Do not run air conditioner at high levels.
PharyngolaryngealDysesthesia • Severe reactions seen in 1%2% of first-line patients • Characterized by subjective sensations of dysphagia or dyspnea without any laryngospasm or bronchospasm (no stridor or wheezing) • Should be differentiated from hypersensitivity reaction
Neuropathy Manifestations • Persistent sensory neuropathy • Paresthesias • Dysesthesias • Hypoesthesias
EGFR Skin Toxicity • Rash that occurs 810 days after beginning EGFR therapy • Occurs on the upper 50% of the body • Rash looks like acne but is not and should not be treated with anti-acne medications. • Treatment recommendations have little evidence to support them and are based on expert opinion. • Recommendations include the use of sunscreen, topical antibiotics, topical steroids, systemic antibiotics, and moisturizers.
VEGF Toxicities • Monitor BP and report hypertension. • Educate about possibility of bleeding (nosebleeds or other). • Administration of bevacizumab is generally delayed until 28 days after major surgery. • Educate patient to report abdominal pain immediately to oncologist
CRC Survivorship • Colon cancer surveillance: • Routine good medical care and monitoring, including cancer screening, routine health care, and preventive care • Routine CEA monitoring and routine CT scanning are not recommended beyond five years. • Late sequelae of disease and treatment may include chronic diarrhea or incontinence. • Consider antidiarrheal agents, bulk-forming agents, diet manipulation, and protective undergarments.
Anal Cancer • Anal cancers constitute 1% of GI cancers. • They are usually associated with infection with human papilloma virus (HPV), a sexually transmitted virus. • Patients who are HIV-positive are two to six times more likely to develop anal cancer regardless of sexual history. • Presenting symptoms are rectal bleeding and the sensation of a mass. • Localized lesions can be treated with surgical excision. • Standard treatment is concurrent chemoradiotherapy. • Chemotherapeutic agents are fluorouracil and mitomycin.
References Adams, L.A., Cunningham, R.S., & Belansky, H. (2009). Anorexia. In L.H. Eaton & J.M. Tipton (Eds.), Putting evidence into practice: Improving oncology patient outcomes (pp. 2536).Pittsburgh, PA: Oncology Nursing Society. Aiello-Laws, L.B., Ameringer, S.W., & Eaton, L.H. (2009). Pain. In L.H. Eaton & J.M. Tipton (Eds.), Putting evidence into practice: Improving oncology patient outcomes (pp. 215234).Pittsburgh, PA: Oncology Nursing Society. American Cancer Society. (2014). Anal cancer. Retrieved from http://www.cancer.org/Cancer/AnalCancer/index American Cancer Society. (2014). Colon/rectum cancer. Retrieved from http://www.cancer.org/Cancer/ColonandRectumCancer/index American Joint Committee on Cancer. (2010). AJCC cancer staging manual (7th ed.). New York, NY: Springer. Eaton, L.H., & Tipton, J.M. (Eds.). (2009).Putting evidence into practice: Improving oncology patient outcomes. Pittsburgh, PA: Oncology Nursing Society.
References (cont.) Friend, P.J., Johnston, M.P., & Eaton, L.H. (2009). Chemotherapy-induced nausea and vomiting. In L.H. Eaton & J.M. Tipton (Eds.), Putting evidence into practice: Improving oncology patient outcomes (pp. 6383).Pittsburgh, PA: Oncology Nursing Society. Griffen-Sobel, J.P. (Ed.). (2007). Gastrointestinal cancers. Pittsburgh, PA: Oncology Nursing Society. Harris, D.J., Eilers, J.G., & Eaton, L.H. (2009). Mucositis. In L.H. Eaton & J.M. Tipton (Eds.), Putting evidence into practice: Improving oncology patient outcomes (pp. 193213).Pittsburgh, PA: Oncology Nursing Society. Mitchell, S.A., Beck, S.L., & Eaton, L.E. (2009). Fatigue. In L.H. Eaton & J.M. Tipton (Eds.), Putting evidence into practice: Improving oncology patient outcomes (pp. 149174). Pittsburgh, PA: Oncology Nursing Society.
References (cont.) Muehlbauer, P., Thorpe, D., & Belansky, H. (2009). Diarrhea. In L.H. Eaton & J.M. Tipton (Eds.), Putting evidence into practice: Improving oncology patient outcomes (pp. 119134). Pittsburgh, PA: Oncology Nursing Society. National Comprehensive Cancer Network. (2012a). NCCN Clinical Practice Guidelines in Oncology: Anal carcinoma [v. 2.2012]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/anal.pdf National Comprehensive Cancer Network. (2012b). NCCN Clinical Practice Guidelines in Oncology: Colon cancer [v.3.2012]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/colon.pdf National Comprehensive Cancer Network. (2012c). NCCN Clinical Practice Guidelines in Oncology: Rectal cancer [v.3.2012]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/rectal.pdf
References (cont.) Samuel-O’Garro, L., & Suozzo, S.H. (2007). Symptom management in gastrointestinal cancers. In J. Griffen-Sobel (Ed.), Gastrointestinal cancers (pp. 7588). Pittsburgh, PA: Oncology Nursing Society. Shields, S. (2011). Characteristics of cytotoxic agents. In M. Polovich, J.M. Whitford, & M. Olsen (Eds.), Chemotherapy and biotherapy guidelines and recommendations for practice (3rd ed., pp. 3855). Pittsburgh, PA: Oncology Nursing Society. Steinberg, M. (2011). Characteristics of targeted therapies. In M. Polovich, J.M. Whitford, & M. Olsen (Eds.), Chemotherapy and biotherapy guidelines and recommendations for practice (3rd ed., pp. 6272). Pittsburgh, PA: Oncology Nursing Society. Zitella, L., Gobel, B.H., & O’Leary, C. (2009). Prevention of infection. In L.H. Eaton & J.M. Tipton (Eds.), Putting evidence into practice: Improving oncology patient outcomes. Pittsburgh, PA: Oncology Nursing Society.