Colorectal Cancer

1. Colorectal Cancer Lewis, pp. 1035-1046 Concept 3, pp. 141-148 CSC pp. 691-696

2. Colorectal Cancer—statistics • Third (ACS) leading cause of death from cancer • Most are adenocarcinoma • Approximately 70-75% occur in colon; 25-30% in rectum with ½ occurring in the rectosigmoid area • Over ¾ of cancers come from polyps that spread into mucosal lining and into lymph system and then to liver*,lungs, bone, brain • More common in men than women • Mortality rates highest among blacks

3. Colorectal Cancer—Risk Factors • >50 y.o. • PMH or FH • Hx polyps, polyposis, or inflammatory bowel disease • Obesity • Inactivity • Smoking • ETOH • Diet high in animal fat

4. Manifestations • Maybe none for 5-15 years • Hematochezia or melena • Abdominal pain/cramping • Weakness, anemia, weight loss • Change in bowel habits • Change in stool caliber • Fullness in lower abdomen or rectum or palpable mass

5. Complications • Intestinal obstruction (pain, vomiting, distention, unusual bowel sounds, no stool) • Anemia from blood loss • Perforation with peritonitis (sudden pain, distention, fever, sepsis) • Fistula formation

6. Diagnostics • Colonoscopy is gold standard—polyps or tumors may be seen, but bx is confirmation • Hemoccult or guaiac (FOB) • CBC • Coag studies • Liver functions • CEA—initial and to monitor treatment and recurrence • CT or MRI

7. Collaborative Care: Surgery • Treatment depends on TNM classification • Polypectomy during colonoscopy for in-situ • Colon resection (right or left hemicolectomy) with end-to-end anastomosis with lymph removal (lap procedures increase recovery time) • Abdominal-perineal resection (rectal) with ostomy; lower abdominal resection (rectosigmoid) without ostomy to preserve anal sphincter • If metastasized, surgery may be palliative to control bleeding or obstructive sx

8. Chemo and Radiation Therapy • Several options in pharmacology book. Treatment is highly individualized. • Chemo for + lymph nodes using a triple combo of 5-FU, leucovorin and usually one other drug • If triple is not an option, then Xeloda • Biologic and targeted therapies slow/prevent tumor growth by stopping vessel formation or inhibiting growth factors in tumor • Radiation as adjuvant or for metastasis to reduce tumor size & provide symptomatic relief

9. Nursing Management: History • Colon, breast, ovarian cancer, familial or hereditary polyposis, inflammatory bowel dz, meds affecting bowel function • High-fat, low-fiber diet • Weakness, fatigue, anorexia, wt loss, N/V • Bowel changes: urgency, bleeding, mucoid, black, gas, decrease in caliber, pain

10. Nursing Management: Objective Data • Pallor, cachexia, lymphadenopathy • Abd mass, distention, ascites, hepatomegaly • Hemoccult + stools, anemia • + DRE, + scopes, + radiography

11. Nursing Management: Preop Care • Preop teaching—may need ostomy teaching by wound care or ostomy care nurse, preferably • Need info about bowel prep procedure • Bowel cleansing and or antibiotics to decrease contamination

12. Postop Nursing Management • If reanastamosis is done, then postop care is routine abdominal surgery. Incision may be large, but closed with staples. Remember to check incision, dressing, and drainage. • Lap procedures will only have small midline incision and lap sites covered with Tegaderm • Pt may have NGT or TPN. May be NPO, ice chips, or clear liqs depending on type of surgery

13. Surgical Nsg Care cont’d • Monitor for infection in any skin break • Provide adequate pain control and give prophylacticly • Monitor for signals of readiness to resume oral intake • If abdominal-perineal surgery is done for extensive metastasis, care of both an abdominal and an open perineal wound and drain management is necessary. • Ostomy care if indicated • Probs with sexual dysfunction

14. Patient Education • For screening: • FOB q yr • Patients > 50 to have routine colonoscopy; 45 in blacks—repeat q 10 y unless + hx; flex sig q 5y • Teaching regarding colonoscopy prep • Teach patients how to recognize early warning signs • For postop: • Home instruction on sitz baths, wound & ostomy care • Don’t forget psychosocial issues & grief mgmt

15. Ostomies (1039) • Ileostomy—small bowel; Colostomy—colon • Sigmoid (permanent) most common; double-barrel (temporary or permanent); transverse loop (temporary) • Continent pouch—total colectomy with reanastamosis at ileoanal area with formation of an ileoanal pouch (J-pouch, Kock pouch)

16. Prostate Cancer Lewis, pp. 1386-1391 Concept 3, pp. 169-175

17. Prostate Cancer • Most common cancer in men and • 2nd leading cause of death from cancer. 2/3 are over 65 y.o. • Almost 30,000 die each year. Interestingly, early dx leads to cure. • 5-year survival rate is 100%

18. Risk Factors • >50 y.o. • African American (twice as likely) • Family hx (father or brother twice as likely) • High fat diet, Vitamin A supplements, low intake of fruits and vegs • Vasectomy (more circulating testosterone)

19. Manifestations of Prostate Cancer • Asymptomatic at 1st • Dysuria, urgency, frequency, hesitancy, dribbling, nocturia, retention, interrupted stream, inability to urinate, hematuria, oliguria • Painful ejaculation, back, hip, leg pain and perineal or rectal discomfort and anemia, nausea, wt loss may be sx of metastasis

20. Complications • Metastasis to lymph nodes, bones, bladder, lungs, and liver • Bone mets are especially painful because of spinal cord compression and destruction of pelvic bone, femoral head, or lumbosacral spine. Pain control is important aspect of care.

21. Diagnostics • DRE reveals hard, nodular, asymetrical gland • PSA>4 (not all elevations are cancer). For screening and monitoring success of tx • CBC for anemia; elevated alkaline phosphatase indicates malignancy • Transrectal US; CT, MRI, bone scan, needle bx

22. Medical Management of Prostate Cancer • Depends on stage • Pharmacologic: androgen deprivation therapy or androgen antagonist therapy (estrogen) • Proscar (for BPH) may reduce risk; also black or cayenne pepper (capasazin) • External beam or brachytherapy (internal radiation with seed implants)—with or without surgery • Cryotherapy—liquid nitrogen placed into prostate

23. Surgical Management • Surgical tx includes radical prostatectomy (prostate, seminal vesicles, part of bladder neck and lymphs are removed) by one of three methods: suprapubic, retropubic, perineal—see p. 1389, Figure 55-5 • May also be done laproscopically and with nerve-sparing procedure • Orchiectomy may also be done if late stage

25. Complications • Urinary incontinence • Erectile dysfunction • Hemorrhage • Urinary retention • Infection • Dehiscence • DVT and PE

26. Nursing Management: Health Promotion • Teach importance of PSA and DRE beginning at age 50 and 45 for African Americans • If risk factors are present, screening may need to be done earlier • Teach symptoms of enlarged prostate and to seek help when it happens • Stress high success rate with early detection

27. Postop Nursing Management • Monitor for return of sensation from spinal anesthesia and protect from injury • Monitor 3-way Foley and CBI if used • Keep CBI running at rate that keeps urine pink without clots • Watch for hemorrhage • FF, keep strict I&O (subtract CBI) • Monitor surgical incision

28. Postop Nursing Care cont’d • After CBI is d/c, urine will be cranberry • Monitor for clots—call MD for irrigation order • Usually go home with cath; After cath is out, urine is racked (monitored by comparison samples) • Push fluids! Clots must be prevented • Expect bladder spasms and discomfort with first voiding which will be small • Give analgesics and also antispasmodics (if ordered), stool softeners • Emotional support

29. Patient/Family Education after Surgery • Catheter care and bag-switching • Kegel exercises • Wearing pad up to one year • Avoid intraabdominal pressure: Valsalva, lifting, long trips, strenuous activity, sitting or walking for long periods • Caffeine restriction, FF, urine will be cloudy • Watch for bright red bleeding, infection, decreased UOP, incision, calf tenderness • Management of ED—Viagra and penile implants