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Our human body has numerous functions to lead a happy life. The basic function includes respiration, digestion, elimination etc without which life cannot be successful. Of the various routes of elimination bowel elimination is one. There are various problems which affects the eliminatory functions like diarrhea, constipation, inflammatory bowel diseases, cancer etc.
Cancer is unregulated growth of immature cells. These cells divide and grow in uncontrollable manner which invades the nearby and distal organs through direct invasion, lymphatic channel or blood stream.
About 12.7 million people were diagnosed with cancer globally and caused death of 7.6 million people in 2008. It accounted for 13% of all death per year. The most common cancer includes carcinoma of lungs (1.4 million deaths), stomach cancer (740,000deaths), liver cancer (700,000deaths), colorectal cancer (610,000 deaths), and breast cancer (460,000 deaths) (World Health Organization, November 2009).
On an average 1 out of 9 males and 1 out of 8 in females gets Cancer in his/her life time (0-74yrs). Cancer is the second leading cause of mortality in US, accounting 1 in every 4 deaths. The expected death due to cancer in America by 2012 is about 577,190 thus 1,500 deaths per day and the five year survival rate for cancers diagnosed between 2001 and 2007 is 67% which rose from 49% during 1975-1977 (American cancer society- Cancer facts and figures 2012).
Colorectal cancer is a type of cancer (CRC) which results in uncontrolled cell growth in colon or rectum. It originates from the mucosal lining of colon or rectum if not treated it can grow into muscle layers then bowel wall and metastasize into other organ like liver, bone, lung and brain.
Globally Colo rectal cancer (CRC) ranks third commonly occurring cancers. In the year 2008 about 1.23 million new CRC patients were diagnosed in the world and it accounts mortality rate of approximately 608,000 patients during 2008 throughout the world. Since 1992 its incidence was raising about 1.7% per year (GLOBOCAN 2008).
In developed countries its incidence is more, (ie) about 60%. The countries which reported highest colo rectal cancer incidence are Australia/New Zealand and Western Europe, while lowest incidence is reported in Africa (except Southern Africa) and South-Central Asia, and are intermediate in Latin America. Incidence rates are substantially higher in men than in women.
It is the fourth most common cause of death from cancer, accounts about 8% among all cancer related deaths. While comparing the mortality rate due to Colo rectal cancer in both genders, mortality rate is lower in women than men(Age Specific Ratio is 1.4:1) (GLOBOCAN, 2008).
The mortality rates due to Colo rectal cancer is higher in Central and Eastern Europe (20.1 per 100,000 for male, 12.2 per 100,000 for female), while lower in Middle Africa (3.5 per 100,000 for male and 2.7 per 100,000 for female) (GLOBOCAN, 2008).
The estimated new colo rectal cancer patients in United States by 2012 is 103, 170 (colon); 40,290 (rectal) and the estimated death due to this disease is 51,690 (National Cancer Institute, 2011).
According to United States statistics, SEER (Surveillance Epidemiology and End Results) data 2012, the estimated median age at death due to colo rectal cancer for 2005-2009 was 74 years, while median age at diagnosis was 69 years. About 0.1% of patients were diagnosed below 20 years; 1.1% between 20 to 34; 4.0% between 35 to 44; 13.4% between 45 to 54; 20.4% between 55 to 64; 24.0% between 65 to 74; 25.0% between 75 to 84; and 12.0% above 85 years of age. The age-adjusted incidence rate was 46.3 per 100,000 men and women per year. These rates were based on cases diagnosed during the year 2005-2009 from 18 SEER geographic areas.
Centre for disease control (CDC) have taken an initiative to reduce the colo rectal cancer incidence and mortality in United States and started Colorectal Cancer Control Program (CRCCP) in 2007. Its main aim is to reduce colorectal cancer incidence and mortality rates among adults aged 50 years or older. To achieve this aim the strategies adapted includes, providing funds, screening programmes, conducting research and awareness programme to 25 states and tribes in United States.
In Asia many countries like China, Japan, South Korea, and Singapore, also have experienced an increase of about two to four times in the incidence of colorectal cancer during the past few decades. The reason behind this is interaction between factors like Changes in dietary habits, lifestyle and genetic characteristics of the Asian populations. But unfortunately most Asian populations are not aware of the growing problem of colorectal cancer. Thus more urgent work is needed to throw light upon the magnitude of the problem in Asia (Sung JJ et al., Asia Pacific Working Group on Colorectal Cancer).
According to Indian Council of Medical Research 2009 report, cancer cases is increasing annually, among men its rate will increase from 4.47 lakhs in 2008 to 5.34 lakhs by 2020. Among sites of cancer in almost all sites cancer is increasing, except esophagus, which will actually a dip from 23,573 fresh cases in 2008 to 20,642 cases in 2020.
In India Colorectal Cancer is the sixth most prevalent cancer, with about 41,535 patients in 2011. If the disease is diagnosed earlier it is easy to treat, but if it is diagnosed in advanced stage treatment is largely unsuccessful. (Eastern Society for Medical Oncology, ESMO 2012).
In Mumbai colorectal cancer ranks ninth among males and its truncated rate is 6.1.Most Common Sites of Cancer in Different Religious Groups by gender, shows among Christian males rectal cancer stands rank 4, cases affected includes 15 and their CR is 6.1. (Cancer incidence and mortality in greater Mumbai 2006, Mumbai cancer registry, National Cancer Registry Project, Report on the Leading Cancer Sites in 2006).
Table 1.1.1 (a): Colon and rectal cancer - Cumulative Rate (%) and Life Time Risk (LTR) of Greater Mumbai, 2006
In Delhi truncated incidence rates (TCR) of colon cancer was 5.5 per 100,000 populations for males, among females this rate is 4.6 per 100,000 populations. Number of colorectal Cancer death by five year age group and percentages for males and Females during 2002 was: colon13 (2.0%), rectum14 (2.1%), colon 8(1.7%), and rectum 5(1.1%) (Delhi cancer registry's-cancer incidence and mortality: Report on leading sites of cancer by world truncated incidence rates 2002 & 2003).
The status of in southern parts of India is, cancers of colon and rectum ranked fifth among men and sixth among women during 2006-2008. The annual number of cases was higher in men in the ratio of 742 women to 1000 men. It constituted 6% and 4% of all cancers in men and women respectively. Recto sigmoid and rectum together constituted 53% while colon accounted for 47% (MMTR-2010).
The peak incidence occurred in the age group of 65-69 years among men and 70-74 years among women. A significantly increasing trend in the incidence of cancer of the colon was forthcoming during 1982-2008 with an average annual change in ASR of 5.4% among men and 4% among women. The corresponding figures for rectal cancers were 3.6% and 3.2% respectively. (Madras Metropolitan Tumor Registry (MMTR) 2010 (National cancer registry program, Indian council of medical research, Cancer Institute (W.I.A)-Chennai, India).
The five year survival and follow up in Cancer Institute, Adyar, during the year 2002-2003 for rectum cancer was that 81.9% came for follow up and 46% survival rate was seen.
India is moving from underdeveloped to developing nation. Due to this move many changes have taken place in life style practices like increase in sedentary workers, in dietary practices increase use of fast foods , increased environmental pollution etc these changes are putting our country to increased colo rectal cancer incidence.
1.2 NEED FOR THE STUDY
Colo rectal cancer is one of the most common types of internal cancer. Colon cancer originates in the epithelial lining of the colon or rectum and can occur anywhere in the large intestine.
As age increases the risk of getting colorectal cancer increases, with more than 90% of cases occurring in persons aged 50 years or older Other risk factors of this disease includes inflammatory bowel disease, past history or family history of colorectal cancer or colorectal adenoma, and certain hereditary syndromes. Certain lifestyle factors also contribute to colorectal cancer risk like decreased regular physical activity, reduced fruit and vegetable intake, diet with low fiber content and high-fat content, obesity, alcohol consumption, and tobacco use. Reduction of mortality from colorectal cancer largely depends on early diagnosis and removal of precancerous colorectal polyps, detecting of CRC in early stage and treating the cancer in initial stages. Colorectal cancer can be prevented by removing precancerous polyps or growth in most of the cases. Four tests are recommended for colorectal cancer screening. Fecal occult blood test, sigmoidoscopy, colonoscopy, barium enema and digital rectal examination. (Division of cancer prevention and control, Center for Disease Control and prevention).
Signs and symptoms of CRC includes, change in bowel habits, blood or mucus in stools, abdominal or rectal pain, weight loss, anemia, obstruction etc.
Dr. V.M Katoch, ICMR director general said TOI (Times of India) in 2009 "cancer becoming a huge burden in India which needs emergency attention. CRC is following the pattern of west: Cancer of the colon (11,236 cases in 2008 to13, 420 in 2020) and rectum (11,738 cases in 2008 to 14,019 new cases in 2020)".
These datas projection shows that burden will worsen over a couple of years. Thus to reduce the future incidence of CRC it is vital to adopt a healthy life style and to avoid those unhealthy lifestyle practices. To understand the above mentioned healthy and unhealthy lifestyle practices, it is necessary to explore the risk factors of CRC.
Certain cancers are preventable which includes breast, cervical, colorectal, skin, lung, prostrate and testicular cancer are called preventable cancers because by eliminating the risk factors (eg. smoking, red meat etc) and by adapting those protective factors (eg. exercise, high fiber diet etc). We can prevent CRC.
India's rapid urbanization is characteristic of a country changing status from a "developing" to a "developed" country. Alcoholism, smoking, reductions in physical activity, increasing obesity etc generally follow this transition, especially as urbanization occurs. Hence, it is necessary to identify if there is any link between these changes and colorectal cancer.
Zhao, Z., et al (2012) conducted a case control study from 1999-2003 at Canada to assess interaction between alcohol drinking and obesity in relation to CRC. Cases (702) and controls (717) were selected, then self administered questionnaire assessing health and life style variables was given result pictures reveals that among obese individuals (BMI> 30), alcohol was associated with higher risk of CRC (OR-2.2, 95% CI: 1.2 -4) relative to non alcoholic category also concludes that among obese individuals 3 or more types of alcoholic drinks were associated with 3.4 fold higher risk of CRC relative to non drinkers.
Indian dietary habits are rapidly been changing as Western diet. Diet rich in vegetables, greens etc are now vanishing and passion towards processed foods like KFC, burger etc are booming.
During the year 2011, 400 cases of CRC were diagnosed in Rajiv Gandhi Hospital; among this 50 percent were in advanced stage. Hence to diagnose the clients earlier awareness among the people should be improved which helps the people to seek the medical care earlier and can be treated completely. Hence "early detection" calls for finding out the risk factors of CRC.
As per the proverb, "prevention is better than cure" the prevention strategies are crucial in colorectal cancer eradication. This approach offers a great public health concern and also an inexpensive long term method of cancer control.
National Cancer Control Programme (started in 1975-1976 in India) has laid down 3 major objectives:
Primary prevention of cancers by health education
Secondary prevention by screening
These objectives are applicable for reducing colorectal cancer burden also. All these lines of prevention can be done only after finding out the risk factors involved in causing colorectal cancer. Hence identifying those risk factors involved is the base line for all.
Primary prevention of CRC aims at bringing awareness to the community about all the risk factors identified to cause CRC through individual and/or mass education programmes.
In secondary prevention colorectal screening activities (colonoscopy, feacal occult blood test, etc) will be carried, routinely for all individuals who cross 50 years of age and before that for those who are at high risk for acquiring the disease, again these high risk groups can be identified only if the risk factors of CRC are known. It calls for performing this study.
In addition to the above prevention strategies primordial prevention can also be initiated once we identify those risk factors which are involved in causation of CRC. By educating the public to adopt healthy behavior right from their childhood period
(eg. Preventing junk foods, exercise etc).
Hence we need to detect the disease earlier. If we need to detect it earlier, we have to identify the risk factors that lead to the disease.
Identification of risk factors of CRC helps in health promotion by health education to the public which then result in environmental modification (eg. Pollution control, dietary interventions (eg. Intake of high fiber diet), lifestyle and behavioral change (e.g. Avoidance of smoking) etc thus the countries huge future CRC incidence will be reduced easily by identifying risk factors with low cost.
The Researcher have taken care of many patients with Colo rectal cancer during her clinical experience among them many were in colostomy, among patients with colostomy, patient or their family members or both were hesitant to involve in colostomy care as it is very distressing both physically also psychologically. This created an enthusiasm within the researcher to create some sort of awareness among the public to reduce future CRC patients incidence.
Also the Researcher being specialized in oncology nursing felt that to reduce the cancer burdens of future India this initiative will be very helpful.
1.3 STATEMENT OF THE PROBLEM
A case control study to identify the risk factors for colorectal cancer in selected settings, Chennai.
To find the association of the case and control groups into various factors such as clinical variability, genetic, environmental, dietary and life style factors and to identify significant risk factors of colo rectal cancer among the groups.
1.5 OPERATIONAL DEFINITIONS
Case refers to patients who are medically diagnosed with colo rectal cancer
Control refers to patients with any disease other than cancer.
IDENTIFICATION OF RISK FACTORS:
It refers to assessment of susceptible factors which may increase the chance of developing colorectal cancer among adults. The factors includes,
Life style factors
Colorectal cancer is the cancer diagnosed in colon or rectum.
1.6 RESEARCH HYPOTHESIS
H1: There is significant risk factor for colo rectal cancer among case and control group
The study is delimited to a period of 4 weeks
1.8 CONCEPTUAL FRAMEWORK
Conceptual models are made up of concepts, which are words describing mental images of phenomena and propositions which are essential for nurses to integrate data into logical thinking and decision making in practice.
Researcher adopted the conceptual frame work based on Betty Neumans system model, which is to identify the risk factors of colo rectal cancer.
The intent of the Neumans model depicts an open system in which person and their environment are in dynamic interaction. Basic core structure is composed of five interacting variables: genetic, environment, dietary and life style factors. These variables are unique to the individual but with a range of response and are common to all human beings. The model shows the individual as an open system in the basic core structure which is surrounded by concentric rings.
BASIC CORE STUCTURE
The basic core structure of this model denotes the components of physiological, socio cultural developmental and spiritual factors of the client which helps to function and to achieve stability in relation to the stressors experienced.
In case group the basic core structure of this model represent the individual aged 25-80 years, varying with their physiological, psychological, socio-cultural, developmental and spiritual factors and was diagnosed to have colo rectal cancer.
In control group the basic core structure of this model represent the individual aged 25-80 years, varying with their physiological, psychological, socio-cultural, developmental and spiritual factors and was not diagnosed to have colo rectal cancer.
The forces that produce tensions, alterations or potential problems causing instability within the clients system are called Stressors.
For case group the various stressors acting against the 3 circles are Diabetes Mellitus, pollution, asbestos exposure, dye exposure, metal exposure, night shift, constipation, intake of meat and meat products, preserved foods, grilled meat and fried foods, genetic factors like colo rectal polyps, colorectal cancer and other cancers.
Control group may or may not have the above mentioned stressors.
LINE OF RESISTANCE
Line of resistance are the broken line, it acts only when the normal line of defense is affected by many stressor thus causes alteration in the normal health pattern. The line of resistance helps to facilitate coping and to overcome the stressors which affects the individual.
The line of resistance of this model in case group involves, all the signs and symptoms of colo rectal cancer like diarrhea or constipation, malena, thin caliber of stool, pain, anorexia, anemia, weight loss etc.
The line of resistance of this model in control group involves absence of signs and symptoms of colo rectal cancer.
NORMAL LINE OF DEFENSE
Normal line of defense is that which acts in coordination with wellness state. It is the reaction exhibited by the client when exposed to stress. It is the base level determinants of wellness within the continuum of health.
The normal line of defense in this model involves, for case group the patient and the family goes to health care support due to the presence of signs and symptoms, to a certain extent patient tries to cope up with it.
For control group, patient does not seek the health care support.
FLEXIBLE LINE OF DEFENCE
Flexible line of defense involves the body's coping mechanism which helps to adapt to the situations that causes disequilibrium in the clients system.
Flexible line of defence in case group is, patient body is not able to adjust to the stressors and progress toward the process of carcinogenesis.
Flexible line of defence in control group is, body's immune mechanism which tries to neutralize the stressors and the disease origin will be eliminated.
DEGREE OF REACTION
Degree of reactions are the outcomes and produced results of stressors and actions of the lines resistance of client. It may be of positive or negative which depends on degree of reaction the client exhibits to adjust and adapt with the stressor.
The degree of reaction in this model includes, for case group the patient develops cancer of colon or rectum.
For control group, patient does not develop colo rectal cancer.
Primary prevention involves foreseeing the end result of a particular situation and thus preventing its ill effects as much as possible. It mainly aims at strengthening the capacity of a person thus helping to achieve and maintain an optimum level of functioning while interacting with the environment.
Primary prevention in this model includes identification of risk factors of colo rectal cancer and creating awareness among public regarding risk factors and thus eliminating the risk factors, which enables them to eliminate those ill practices and adapt healthy practices.
Secondary prevention focuses on helping alleviate the actual existing ill effects of an action which altered the balance of health. It aims to reduce and eliminate the influences form environmental which produce a dis equilibrium in the stability of the client.
Secondary prevention in this model includes regular screening programmes like colonoscopy, feacal occult blood etc.
Tertiary prevention primarily focuses on rehabilitation, which facilitate strengthening of person after getting exposed to stressors. It aims to prevent future regression and recurrence of the disease.
It involves rehabilitation of patient and family members on coping mechanism with disease ex. Educating Colostomy care, dietary education etc.
A state of returning back to previous healthy status. In this model it involves, the interventions helps the client system for the modification of modifiable risk factors.
It is therefore evident that this conceptual frame work which is based on Betty Neuman's System model is appropriate to this study.
1.9 OUTLINE OF THE REPORT
CHAPTER I : Dealt with the back ground of the study, need for the study, statement of the problem, objectives, operational definitions, hypotheses, delimitations and conceptual frame work.
CHAPTER II : Focuses on review of literature related to the present study.
CHAPTER III : Enumerates the methodology of the study.
CHAPTER IV : Presents the data analysis and data interpretation.
CHAPTER V : Deals with the discussion of the study
CHAPTER VI : Gives the summary, conclusion, implications, recommendations and limitations of the study.
The study report ends with selected Bibliography and Appendices.