Colon cancer develops in the tissues of the colon; the cancer is usually adenocarcinomas meaning that this cancer begins on cells that produce mucus or other fluids. Rectal cancer on the other hand develops on the rectum tissues. The two cancers are broadly referred to as colorectal cancer. This report is prepared following a case study at the medical ward at the university hospital where a patient, Mrs. Arora Lane, aged 65 years was diagnosed with colorectal cancer.
The pathophysiology of colorectal cancer
Colorectal cancer in most of the cases is related to dysplastic adenomatous polyps. This type of a cancer has major effects on the lower section of digestive tract. Colorectal cancer is common to people who are in their 50 and above years, however, it may form in young people especially those who are from a family with a history of the cancer. The colorectal cancers form from growth of tissues that line the large intestine. Most the tissue growths are benign; however some of them may undergo mutations eventually becoming cancerous (Powell, 2001). Colorectal cancer develops gradually due to the stages involved during invasion of the tissues. The inner tissues are the first invaded while the others are invaded with time. Before the cancer forms in a way to be identified, a tumor forms beginning on the lining of the rectum or the colon as a polyp which is non-cancerous. With continued invasion on the tissues the tumor develops into a cancerous cell (Speechley & Rosenfield, 2001).
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In most cases, adenomatous polyps and the adenomas are the mainly polyps with the potential to develop into cancer. Other types of polyps such as hyperplastic and the inflammatory polyps are not pre-cancerous (Powell, 2001). However, the hyperplastic polyps growing in the ascending colon may develop into adenomatous polyps leading to cancer. Dysplasia is also pre-cancerous; it is commonly found in individuals with certain diseases such as the ulcerative colitis and causes inflammation of colon exposing it to the cancer (Ellis et al 2006).
Some of the early sign and symptoms of colorectal cancer include;
Bleeding from your rectum
Blood in your stool or in the toilet after you have a bowel movement
A change in the consistency of your stool (e.g. diarrhea or constipation lasting several weeks) (Escott-Stump, 2008).
Cramping pain in your lower stomach
A feeling of discomfort or an urge to have a bowel movement when there is no need to have one
Weakness or fatigue
Unintended weight loss
These signs and symptoms vary with individuals whereby only some may be observed form an individual. For instance, Mrs. Arora Lane in the case study, who was diagnosed with this cancer, had only two of the symptoms, which are used to diagnose her with colorectal cancer, drastic weight loss, and non-specific abdominal pain (Richards & Edwards, 2003). The patientââ‚¬â„¢s age (65), is one of her major predisposing factor. This is because people at the age of 50 and above are at a greater risk of developing this type of cancer. Besides age other factors that exposes one to the risk of developing colorectal cancer include, family history of the cancer, poor diet, lifestyle factors such as smoking and diseases such as diabetes (Wax, 2009).
Chemotherapy in treating colorectal cancer
Chemotherapy involves treatment using a combination of drugs to slow tumor growth and destroy cancer cells (Powell, 2001). This method of treatment is referred to as a systematic treatment due to the systematic mechanisms involved in destroying the cancer. Several studies indicate that administration of chemotherapy following surgery increases the survival rate of patients in certain severe stages of colorectal cancer (Lipscomb, 2005). Chemotherapy treatment is also known to aid relieve some of the major symptoms related to advanced colorectal cancer. The drugs can be taken orally or through intravenous injection, (Powell, 2001); these drugs are known to have hypersensitivity or allergic reactions. The reactions are caused by immune system responses occurring immediately or may occur hours or days after administration (Miskovitz & Betancourt, 2005).
This type of treatment is usually used in treatment of metastasis colorectal cancer usually as a first line treatment in destroying the metastasized cancer cells. Chemotherapy can also be administered before beginning of surgery that aims to shrink the tumors this is termed as neoadjuvant therapy. Chemotherapy is also used after a surgery (adjuvant therapy), or it may be used together with biological therapy (immunotherapy) or with radiation therapy (Casciato & Territo, 2008).
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The commonly used chemotherapy drugs in preventing reoccurrence after surgery or in shrinking tumors before surgery is done include drugs such as folfox (5-fluorouracil [5-FU], leucovorin, and oxaliplatin [Eloxatin) and FOFIRI (5-fluorouracil [5-FU], leucovorin, and irinotecan [Camptosar) (National Cancer Institute, 2009). There are chemotherapy drugs combinations which are standard in the treatment of metastasis colorectal cancers such include (5-fluorouracil [5-FU], leucovorin, and irinotecan [CPT11]); they are taken in intravenously. Colorectal cancer may also be treated with floxuridine (FUDRÂÂ®) which is taken in through the artery (intra-arterially), (Powell, 2001).
Chemotherapy action involves the destruction of rapidly dividing cells and in this process it may destroy healthy dividing cells in the body such as the cells of the gastrointestinal track, bone marrow or the mouth, thus it results to several side effects (DelbrÃÂ¼ck, 2007). The side effects related to these chemotherapy drugs include diarrhea, nausea, enteritis (inflammation of the intestine), vomiting, mucositis, neutropenia (low white blood cell count), and alopecia (hair loss). (American Society of Clinical Oncology, 1998).These side effects however depend with an individual or the type of chemotherapy drug used. For instance, the alopecia is not common and may be experienced by few individuals in the treatment. The side effects however resolve after the chemotherapy treatment is completed or treatment such as anti-nausea drugs can be used to reduce the side effects (American Society of Clinical Oncology, 1998).
Other treatment options for colorectal cancers are radiation therapy and surgery. (Radiological society of North America, 2010).Surgery is common in all the stages of the cancer where it is used together with the two other methods. Colectomy is term that refers to the removal of a colon, after the removal, the remaining parts of the bowel is joined; this is referred to as anastomosis (Radiological society of North America. 2010). If the cancer has developed on the ascending colon, a right colectomy is done. Right or left colectomy is called hemicolectomy and it involves partial removal of the colon during treatment in surgery. Radiation therapy involves the use of x-rays or any high energy rays to destroy the cancer and may be used together with chemotherapy or surgery (Radiological society of North America, 2010).
Biological treatment can also be used whereby the body is made to actively fight the cancer using materials introduced to the body in order to boost the body defense mechanism or to restore its natural one. This method of treatment is at times referred to as immunotherapy or biological response modifier therapy (Jacoby & Youngson, 2004).
The digestive system and colorectal cancer
The digestive system is sometimes termed as the gastrointestinal tract or the GI. It begins from the mouth, pharynx, and esophagus ending in the anus. Generally, it comprises of the mouth, tongue and the salivary glands, esophagus, the stomach, pancreas, liver and gallbladder, the small intestine and the large Intestine and the anus (Martinez, 2005).
The rectum and the colon form part of the large intestines. Characteristically, the colon forms the first upper 6 feet of the large intestine while the rectum forms the last lower five to seven inches of the large intestine located just over the anal canal. The six feet of the colon are divided into four sections; the ascending colon, transverse colon, the descending colon and the sigmoid colon (Martinez, 2005). The ascending colon is the first part of the colon; the transverse colon follows the ascending colon and is found going across the left side of the body it joins with the descending colon this goes downwards to the left of the abdomen. The sigmoid colon forms the last section of the colon; it is sigmoid in shape and joins with the rectum leading to the anus (Martinez, 2005).
The first stage of digestion of food takes place in the mouth where it is mechanically broken down by the teeth. In the stomach the food is broken down further preparing it for further digestion. The food in the stomach is reduced into smaller elements by enzymes and acids such as the hydrochloric acids.
This food is then moved down into the small intestine which is about five meters in length. The small intestine is formed of the duodenum, jejunum and ileum. It removes nutrients out of the food from the stomach and transports them into the bloodstream. The rest of remain of the food left is passed on to the large intestines (Martinez, 2005). The colon has the function of extracting water (fluids) from the food coming from the small intestines after the nutrients are absorbed into the body. The colon also serves to store solid waste temporary before they are moved to the rectum then to the anus for excretion (Bub, et al 2003). All the parts of the large intestine are prone to cancer but the most common parts affected are the rectum, descending and the sigmoid colons. The lining of these parts is made up of layers of tissues. When colorectal cancer is developing, it begins from the innermost layer and with time it gets to all the layers, the severity of the cancer is defined by the degree of invasion in these layers of tissues (Martinez, 2005).
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The chances of developing cancer of the colon and the rectum are usually enhanced by poor diets. Studies show that intake of low-fiber and high-fat presents higher chances of developing colorectal cancer than intake of high fiber and low-fat diets (Powell, 2001). This indicates the role diet in controlling the onset of the cancer. In most cases, two-thirds of the cancer occurs in the colon while about one-third occurs in the rectum, this difference can be explained by the role the systems play in storage and fermentation of the food materials (Larson, 2005).
Physical assessment of colorectal cancer to facilitate effective and efficient care of the patient
A complete physical examination and history enables the health provider to establish the causes of the identified symptoms and to plan properly fro the treatment that would follow.
In assessing for colorectal cancer, the physical assessment is used to determine whether the patient has a higher than normal chances of developing colorectal cancer or whether more tests are required to verify the presence of the cancer.
Higher than normal chances of developing colorectal cancer are associated with; history of the cancer, removal of polyps from the colon in the past, and a family history of relatives with who may have developed the cancer or polyps. Additionally, presence of diseases such as ulcerative colitis, or whether there have ever been radiation treatments on the abdomen or in the pelvis are other predisposing factors.
The subjective data is the first data that should be taken from the patient other information to be gathered from the patient may include; changes in the bowel habits, this could be whether diarrhea or constipation. Whether there blood in the stool, changes in weight in the recent past, any frequent experiences of fatigue and whether there is loss of food appetite (Tobias & Hochhauser, 2010). It is also important to ask the patient on the history of some of the symptoms and question regarding daily activities such as frequency of body exercises, whether the patient smokes, the type of diet often taken, and any current medication for instance, asking on the advances of the symptoms (Ganz & Horning, 2007).
The objective physical examination may include taking rectal examination and fecal occult blood test for the individual over 50. If the tests are positive, the tests are recommended to be done annually, taking of the body temperature and weight, measurement of the pulse rate, inspection of the abdomen for any signs such as presence of tumors, and liver enlargement. Auscultation of abdomen is used to reveal the status of the bowel (National cancer institute, 2009), whereby if there are high-pitched bowel sounds, there is possible partial obstruction of the bowel. Faint- pitched or absence of the sounds shows possibility of a complete obstruction of the bowel. Another physical examination that can be carried on the abdomen is a check on any distention or any other abnormality of the abdomen (Corman, 2005).
Palpation is used in identification of masses that may help to identify bowel perforation. An acute bowel perforation is characterized by a palpable mass, pain and fever while in a chronic bowel perforation, there are fistulae and no acute signs (National cancer institute, 2009). When the cancer develops on the sigmoid colon, a fistula is formed into the bladder and this is followed by urinary tract infections. A percussion and palpation on the right upper quadrant may provide information on a possible presence of liver metastases, which is a common metastatic region of colon cancer (Fisher, 2000).
Screening for colorectal cancer
The screening tests for colorectal cancer may include colonoscopy, rectal examination or proctoscopy (Powell, 2001). The screening tests usually aim to locate any precancerous polyps before they develop into cancers. Screening tests in early stages for any diseases is important for it helps to either prevent the advance of the disease to severity (Bayless & Diehl, 2005). A diagnostic test on the other hand is used after the disease is screen to identify the cause of the identified symptoms (Richards & Edwards, 2003).
Colonoscopy is a major screening test whereby the doctor looks at the inner lining of the colon and the rectum (The New England Journal of Medicine, 2010) using a tube referred to as a colonoscope. This test requires that the colon to be first cleaned and this requires the patient to keep using the bathroom. This may bring a lack of comfort to the patient and it also requires eating of little foods (Tresca, 2009). It is thus important for the care providers, who are usually the nurses, to have training on how to handle such patients since it has been reported that many nurses get angry or frustrated due to the difficulties presented by the patients. The situation may also withdraw the patient from the social activities due to embarrassment (Bruera & Portenoy, 2003). It is thus important for the care providers to give confidentiality to such patients as a requirement by the nursing and midwifery councilââ‚¬â„¢s code of professional conduct (Stokes, 2005). Primary care physicians are responsible in referring the patients to sub- specialists and a consistent follow up is required for them on the performance of the patient (Mitchell, 2010)
Colorectal cancer can be prevented or avoided; this is through avoiding the risk factors associated to it. For example, it is important to avoid habits such as those of smoking, avoid getting overweight, watching diet and regular exercising (Beck, et al 2009). It is also important to have knowledge of the increasing risk factors of the cancer such age, obesity, and a family history of the colorectal cancer. Handling a patient with colorectal cancer requires a good understanding of every detail of this type of cancer in order to offer effective and efficient care. It is such understanding that will enable satisfying services to the patient such as Mrs. Arora Lane (Yarbro, 2005).
Follow up care for patients are important especially after a colectomy since the patient experiences frequent bowel movements, which must be normalized. After treatment, it is also crucial to give the patient periodical checkups such as colonoscopy, physical exam, a CT scan, and blood test to prevent recurrence (Cedars-Sinai, 2010).