Colorectal

Cancer
Holistic Group:
Abeer Manea, Andrin Antony,
Annamma Varghese, Bency Abraham,
Jenitha Selvam, Neena Chacko
June 15, 2017
Outline
01 Description of colorectal cancer

02 Epidemiology

03 Risk factors, prevention, and screenings

04 Sings and symptoms

05 Diagnosis and treatment

Outline

06 Social and cultural factors influencing cancer treatment

07 New evidence and research for screening, treatment, and prevention

08 Nursing role in taking care for patients with colorectal cancer

09 Research,local resources in Qatar and Gulf region for support

 Video
https://www.youtube.com/watch?v=vEtZh2Zi9TU
 Colorectal Cancer
Colorectal Cancer(CRC) also known as bowel cancer.
Colorectal cancer is the cancer affecting colon, rectum and caecum.
Colon and rectal cancers are combined in the term colorectal cancer.
Colorectal cancer is 3 rd. leading cause of death from cancer in both men
and women, and is the leading cause of death from cancer in men and
women combined..
Colon and rectal cancers may share similar cellular path of carcinogenesis,
they are two separate disease.
Colon cancer is, in most cases, a preventable and curable disease.
Colon cancer may be silent until it reaches an advanced stage, screening
and early detection have become the primary method for reducing morbidity
and mortality.
(Wilkes, 2011)
 Pathophysiology
o Cancer is an uncontrolled division of abnormal cells,
which invade other tissues.
o These cells can travel to other parts of the body
through blood and lymphatic system.
o A glandular cells, located at the inner lining of the
colon and rectum, produce mucus to lubricate the
colorectal area.
o These cells then form an adenoma polyp and gradually
increases in size, which leads to adenocarcinoma.
o Almost 96% of the CRC are adenocarcinoma
( Colorectal cancer facts and figures, 2014).

(Bener, Moore, Ali, & El Ayoubi, 2010)

Polyps in the Colon

(Wilkes, 2011)
 Epidemiology
Colorectal cancer is third leading cancer in Qatar, both men
and women, around 61 cases in year
In 2010, the incidence of CRC in Qatar- 9%.
Qatar In 2014, the incidence of CRC in Qatar- 10% (Cancer
Strategy, 2014).
In 2015, there were 79 cancer related deaths among
Qataries, accounting for 30% of all deaths, breast cancer
19%, lung cancer 16.46%, and colorectal cancer- 12.66%
among Qatar population.

In 2010, in Middle East Countries such as, Saudi Arabia 12%,

Middle East Kuwait 8.4%, and in Bahrain 7.9% (Bener, Moore, Ali, & El
Ayoubi, 2010).

International Colorectal cancer is the 3rd most common cancer in men and
2nd in women.
 Risk factors
Risk factor of colorectal cancer can be broadly classified as
1. Environmental risk factors 03 04
Diet:
Total calories- Obesity and total calorie intake are independent risk factor for colorectal cancer.
Meat, fat, and protein:
Ingestion of red meat
Fried, barbecued, and processed meat.
High protein intake may augment carcinogenic
Fatty components of red meat may be tumour promoters

(Wilkes, 2011)
(Libutti, Saltz, & Tepper, 2008)
 Life style
o Physical inactivity
o Sedentary life style
o Alcohol consumption
o Prolonged cigarette smoking
o Occupational exposure to asbestos, acrylonitrile, ethyl acrylate, synthesis fibers,
halogens, printing materials, and fuel oils.
Drugs:
Steroidal anti-inflammatory drugs: use of aspirin and anti-inflammatory drugs
(NSAIDS),incidence of both colorectal cancer and adenomas.

(Wilkes, 2011)
(Libutti, Saltz, & Tepper, 2008)
2. Genetic risk factors:
o related to inherited germ line mutations(such as familial adenomatous
polyposis (FAP) with mutation adenomatous polyposis coloni (APC) gene,or
hereditary non-polyposis colon cancer(HNPCC),related to mutation in the MMR
gene, or inherited risk by a first- degree relative having colon cancer.
3. Socioeconomic factors:
o Generally, cancer incidence and mortality rates have been higher in
economically advantaged countries due to consumption of a high fat and high
red meat diet, lack of physical activity with resulting obesity.

(Wilkes, 2011)
(Libutti, Saltz, & Tepper, 2008)
 Age: Sporadic colorectal cancer increases dramatically above the age of 45 to 50 years.
There is further enhancement of risk affected prior to the age of 60.
Gender: Incidence rate less for women than men.
Race and Ethnic group: Although dietary and life style factors are of paramount
importance in low incident regions of the world, especially Asia and Africa, however there
are certain trends along racial and ethnic line. Inherited mutations in the DNA mismatch
repair genes may be more common among African Americans, in part accounting for
anatomic variation in colon cancer between races in the United States.
Obesity
Inflammatory bowel disease (IBD)
Micronutrient deficiency
Qatar- Risk factors for cancer among the Qatar populations are smoking, obesity, physical
inactivity, and unhealthy diet.(National cancer strategy in Qatar 2011)

(Wilkes, 2011)
(Libutti, Saltz, & Tepper, 2008)
 Prevention
Two type of prevention: are recognized for colorectal cancer:
Primary prevention
Minimizing external risk factors such as
obesity
Improving areas that are likely to be
protective such as, diet ,micronutrients,
exercise
Factors that may minimize polyp formation
such as aspirin ( if the benefit outweigh risk
of side effects).
80% of colon cancers can be prevented by
dietary changes.
Secondary prevention
The identification and modification of risk
factors following development of a colonic
polyp,
Involves surgical removal of suspicious
adenomatous or
Malignant polyps to prevent the
development of colon cancer.
(Wilkes, 2011)
 Dietary fiber : To protect the colonic
and rectal carcinogens through
increasing the transit rate of fecal
material containing carcinogens.
Primary Daily dietary recommendations for fiber
intake are 20 to 30 gram per day or
Prevention more, especially wheat bran and eating
at least 5 fruits and vegetables each
day.
Vegetable and fruits: A protective effect
of vegetables and fruits against
colorectal cancer, with raw, green and
cruciferous vegetables.

Calcium has been historically implicated as having a

protective effect.
Exercise: Study shows decreased risk of development of
adenoma in individuals who exercised vigorously . Weight
reduction to appropriate weight for height .
Micronutrients such as folate, calcium and vitamin D in the
diet.
Taking a baby aspirin or NSAIDs daily if at risk and
appropriate.

(Wilkes, 2011))
 Secondary Prevention and Screening
Removing premalignant polyps, there by evolution of colon cancer in most cases.
Polyps commonly form in the colon or rectums an individual ages, with risk increasing beyond 50 years of age.
A primary screening goal is to identify polyps before they become malignant.
Digital rectal examinations are simple but can detect abnormalities only up to 7 cm from anal verge, and not useful for
colon cancer screening.
Often polyps bleed as they enlarge, bleeding can be identified by fecal occult blood test (FOBT).
FOBT-annually
Flexible Sigmoidoscopy-every 5 years
Colonoscopy every 10 years
Double contrast barium enema every 5 years
CT colonography ( virtual colonoscopy, CTC) every 5 years, or MRI
Fecal immune chemical test(FIT) annually or stool DNA test (s DNA) frequency unknown.

(Wilkes, 2011))
 Secondary Prevention and Screening
Biopsy. colonoscopy is required for
Person with an inherited risk for FSIG,DCBE,OR CTC, if polyps are
colorectal cancer such as family less than 6 mm .
history of FAP should begin Laboratory test for gene mutation: to
screening by colonoscopy between screen individuals at increased risk
the age of 10 & 12. for developing colorectal cancer as a
Individual with 1 or more first- result of inherited mutations.
degree relatives who developed Genetic analysis of population at risk
colon cancer before the age of 55 and early identification of the
should have annual FOBT, and a colorectal malignancy.
colonoscopy or double contrast
barium enema every 5 years starting
10 years before the age of onset in
the relatives.
Person with lower level of risk
,should have standard screening at
the age 50.
If examination is positive, a
(Wilkes, 2011)
 Signs and Symptoms Unique to the Colorectal
Cancer

Clinical manifestation in the colon vary Signs are Iron deficiency anaemia-
depending on location . Symptoms includes those of anaemia
Tumor in the cecum or ascending or right (such as fatigue , weakness , shortness
colon, occurs in 54% of patients. of breath and exercise intolerance )

Palpable mass in the right

lower quadrant on physical
Melena examination
Weight loss

Anorexia Vague, dull pain or aching

(Wilkes, 2011)
 Transverse colon
Is the site of water absorption
where the faecal material
begins to become formed and
firm.
Signs and symptom of a
malignant lesion in the
transverse colon include gas
A change in bowel habit.
Abdominal cramping
Partial or complete obstruction
Possible perforation of the
bowel
And blood in the stool
Descending or sigmoid colon
Others
About 36% of colon cancer Early signs symptoms
found in this area
may include vague
A lesion may partially occlude
abdominal pain, flatulence
the lumen, causing a change in
minor change in the bowel
bowel habits as well as change
movement with or without
in calibre of stool , so the stool
rectal bleeding.
become pencil like or ribbon like
Late Signs and symptoms
and narrow
of cancer include , severe
Partial obstruction of the bowel
pain anorexia , weight
lumen can cause, cramps,
loss , sacral or sciatic pain
flatulence , constipation ,
, jaundice , pruritis ,
alternating with diarrhea.
ascites , hepatomegaly
Abdominal pain, bright red blood
and renal impairment .
on stooling
A feeling of incomplete stooling
and obstructive symptoms such
as nausea , vomiting , melena
may occur if bowel perforation.
(Wilkes, 2011))
How Cancer is Diagnosed and Treated?
A definitive biopsy often
done via colonoscopy
Complete blood count
Electrolytes
Level is drawn once a MRI to further explore
diagnosis of colon cancer
is made
CT scan of chest,
abdomen and pelvis to
evaluate metastasis in the
lungs , liver and extra
colonic tissues
Renal and liver function
studies
Coagulation assays
A baseline
carcinoembryonic
antigen(CEA)
questionable areas found
on CT or to evaluate
recurrence
PET Scan for whole body
evaluation and highlight
active tumors within the
body
Bone scan to identify
bone metastasis (Wilkes, 2011)
(Libutti, Saltz, & Tepper, 2008)
 Treatment Options
Surgical excision: Main stay of curative Rx
Specific procedure depends on the anatomic location of the cancer, but typically
involves hemi-colectomy
Surgical resection of affected bowel with clear margins, along with the adjacent
mesentery and at least 12 regional nodes
For rectal tumors, total mesolectal excision with a distal surgical margin of at least 2 cm
is recommended
For tumors that are located within 6 cm of the anal verge, or involve the anal sphincter,
wide surgical resection with abdominal-perineal resection and permanent colostomy is
recommended
Local excision, for palliative treatment or simple polyp removal
Radiation therapy:
Postoperative radiation, with or without chemotherapy, significantly reduces local
recurrence rates
(Wilkes, 2011)
(Libutti, Saltz, & Tepper, 2008)
 Treatment Options
Common regimen incorporates in fusional 5-fluorouracil (5-FU) as a radio sensitizer to boost the
efficacy of pelvic radiation
Administered as 45 to 55 Gy over 5 weeks
Repeated as needed
Systemic Chemotherapy
5-FU has been the mainstay of systemic chemotherapy for CRC
Capecitabine was approved in 2001 as first-line therapy for metastatic CRC
Irinotecan (Camptosar), Oxaliplatin (Eloxatin), Bevacizumab, Cetuximab
Electrocoagulation
Mostly palliative treatment for rectal carcinomas
Curative for small subset of patients
Two major molecular targeted therapies have been approved for use in advanced colon and
rectal cancers. bevacizumab and cetuximab both monoclonal antibiotics ,in combination with
chemotherapy
(Wilkes, 2011)
(Libutti, Saltz, & Tepper, 2008)
Cultural and Social Beliefs
Cancer is a punishment from God

Lack of education about cancer in relation to age and lifestyle

Cancer might be a result of Evil eye

Spiritually cancer is to test your patience

Undergoing the treatment will cause suffering

(Daher, 2012)
 New Evidence for Screening
Cologuard
Is a new alternative test for colonoscopy, a stool test, which detect
cancerous and precancerous genetic marker.
o Cologuard analysis a stool specimen for DNA changes and evidence of
blood.
o Cologuard does not require any preparation, dietary or medication
restriction.
o Recommended for under the age of 50.
o An option for anyone who refuses colonoscopy and is at risk for
colonoscopy.

(Cancer Treatment Centers of America, 2016)

 New Evidence for Screening
Fecal immune chemical test

o Use as an early screening for colorectal cancer.

o An option for elderly people who have no history of colorectal cancer and not
suffering from irritable bowel syndrome.
o Uses antibodies to detect blood in the stool.
o Help to detect early signs of malignancy.

(Cancer Treatment Centers of America, 2016)

 New Evidence of Treatment
Hyper-thermic intra-peritoneal chemotherapy (HIPEC) Chemotherapy

Different approaches are being tested in clinical

Surgery is done to remove as much of the
trials Including new chemo drug such as
cancer in the belly.
Trifluridine,Tipiracil and Cisplatin.
While still in operating room, the abdominal cavity is
bathed in heated chemotherapy drugs.
Combine drug such as Irinotecan and Oxaliplatin
This put the chemo directly in contact with cancer to improve the effectiveness .
cells, and the heat help the drugs work better.

Biological or genetic markers is useful in

predicting the sensitivity or resistance to
chemotherapy.

(American Cancer Society, 2017)

(Rodrigues., Longatto., & Martins,2016).
 New Evidence of Prevention
Immunotherapy

This is a treatment that uses the bodys own

immune system to fight cancer.

Vaccines
Researchers are studying several vaccines to
try to treat colorectal cancer or prevent it
coming after treatment.

At present vaccines are only available in clinical

trials

(American Cancer Society, 2017)

 Contribution of Nursing and other Healthcare Professions
The Multidisciplinary Team is a group of health professionals who are experts in
the diagnosis and treatment of colorectal cancer, multidisciplinary team is usually
made up of the following members:
Colorectal Surgeon
Oncologist
Clinical Nurse Specialist/Colorectal Nurse
A Clinical Nurse Specialist (CNS) is an expert nurse in caring for patients and
their careers who are living with colorectal cancer. She will provide you with
information, support and advice at all stages of your treatment. If you have had
surgery that affects how you feel about your image they can offer you information
and support to help you deal with this. They can also offer you emotional support
or refer you to another service, for example counseling.
Radiologist
Pathologist (South Eastern HSC Trust, 2010)
 Contribution of Nursing and other Healthcare Professions

Palliative Care Team

The Palliative Care Team is there to help with any emotional and spiritual needs
you have and to help manage pain or other symptoms you may have. Palliative
care is available to everyone affected by cancer and is especially important for
those people whose cancer cannot be cured.
Clinical Psychologist and UCF Counsellor
The Clinical Psychologist and the UCF Counsellor work as part of the cancer
services team. They provide psychological and emotional support to patients and
relatives who have been affected by cancer.
GP
GP is in charge of your care in the community and can bring together others to
help with any problems you may have. Your GP is available to discuss all aspects
of your care (South Eastern HSC Trust, 2010)
 Contribution of Nursing and other Healthcare Professions

Social Worker
Social Workers aim to help the patient, their family and careers to cope by
providing social care and support.
Dietician
Dieticians play an important role in managing dietary problems.
Physiotherapist
Physiotherapy aims to reduce some of the effects of cancer or its treatment.
Occupational Therapist
The occupational therapist aims to help you increase you independence and
quality of life.

(South Eastern HSC Trust, 2010)

 Local Resources In Qatar

Qatar National strategy supports,

1
Education and
Understanding Prevention
2 Early
3 Rapid and
Definitive
diagnosis
4 Treatment
5
Detection

(National Cancer Strategy, 2011)

 Local Resources In Qatar
Qatar National strategy supports,

6
Ongoing Care
Measuring
Performance
7 Workforce
8 Research
9 Treatment
5

(National Cancer Strategy, 2011)

 Local Resources In Qatar
Qatar cancer society gives,

Make Submission of
Awareness of Financial support recommendations
colorectal cancer to cancer patients projects on health
and provide the policy and a
and how to who are unable to necessary plans to
prevent it afford treatment comprehensive
fight all cancer national program to
types. fight cancer.

1 2 3 4

(Qatar Cancer Society, n.d)

 Local Resources In Qatar
Qatar cancer society gives,

To prevent and control CRC

Coordination Determine the size Prepare and Qatar has recognized national
between the of the problem, support research cancer society Maggies cancer
various including the and special caring centre managing
stakeholders incidence of the studies of cancer patients through MD approach
cancer disease and the and access to the introducing pathway
treatment and extent of its spread latest therapeutic coordinators for providing
follow-up and the number of means to cope secondary and tertiary care
emerging from deaths resulting with this disease. and developing national cancer
other countries. from it. research strategy
5 6 7 8

(Qatar Cancer Society, n.d)

(Brown, Kersh, Haondi & Darzi,2012)
Thank you
Any Question?
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