Colorectal Cancer and Anal Cancer

1. Colorectal Cancer and Anal Cancer

2. 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.

3. 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.

4. 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

5. CRC Risk Factors • Modifiable: • Diet: High in red or processed meat, low in fruits and vegetables • Obesity • Physical inactivity • Heavy alcohol consumption • Possibly smoking

6. 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

7. ACS CRC Screening for Average-Risk Asymptomatic Age 50+

8. CRC Screening and Staging • Image courtesy the National Cancer Institute

9. 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

10. 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.

11. 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 13 regional lymph nodes • N1a: Metastasis in 1 regional lymph node • N1b: Metastasis in 23 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 46 regional lymph nodes • N2b: Metastasis in 7 or more regional lymph nodes

12. 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

13. 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

14. 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

15. Factors Determining CRC Treatment • Stage • Histology • Tumor genetics • Performance status • Patient preference

16. 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

17. 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.

18. 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

19. 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.

20. 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

21. 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).

22. 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.

23. 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

24. 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 (2h2d) or with subsequent cycles • Usually resolves within 14 d

25. 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.

26. 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

27. Neuropathy Manifestations • Persistent sensory neuropathy • Paresthesias • Dysesthesias • Hypoesthesias

28. EGFR Skin Toxicity • Rash that occurs 810 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.

29. 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

30. 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.

31. 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.

32. 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. 2536).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. 215234).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.

33. 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. 6383).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. 193213).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. 149174). Pittsburgh, PA: Oncology Nursing Society.

34. 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. 119134). 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

35. References (cont.) Samuel-O’Garro, L., & Suozzo, S.H. (2007). Symptom management in gastrointestinal cancers. In J. Griffen-Sobel (Ed.), Gastrointestinal cancers (pp. 7588). 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. 3855). 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. 6272). 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.