Keywords: Bowel cancer/Colorectal Nursing Practice cancer/Best practice Review ●This article has been double-blind Bowel cancer peer reviewed Survival from is significantly influenced by the stage of disease at the time of presentation, but treatment options for all patients are expanding Best practice in colorectal cancer care 5 key In this article... points Aetiology and risk factors for colorectal cancer Some 40,000 Diagnosis and staging investigations 1new cases of Treatment options and care during and after treatment colorectal cancer are dignosed in the UK every year Authors Claire Taylor is lecturer in » Descending colon: 5% (CRUK, 2011). Risk factors for gastrointestinal nursing, Florence Adenocarcinoma is the most common 2colorectal Nightingale School of Nursing, King’s type of bowel cancer and is the focus of cancer include a College London this article; leiomyosarcoma, lymphoma, high intake of meat Abstract Taylor C (2012) Best practice in melanoma and neuroendocrine tumours and fat, smoking, colorectal cancer care. Nursing Times; 108: are more rare. lack of exercise and 12, 22-25. Primarily a disease occurring in devel- high alcohol Nurses need up-to-date knowledge of oped countries with a western culture, the consumption colorectal cancer. This article provides an incidence of colorectal cancer may be sta- Most colorectal overview of the aetiology and risk factors bilising in some parts of the world. How- 3cancers for this disease, diagnostic and staging ever, in others, such as Japan, it is rapidly develop from investigations, treatment options and increasing (Haggar and Boushey, 2009) – benign polyps or future care. Managing colorectal cancer is this is likely to be associated with the “west- adenomas and so complex. Patients can have a range of ernisation” of the Japanese diet, which saw can be detected healthcare needs. Nurses play an a tenfold increase in the consumption of before they increasingly important role in informing, meat and dairy products between the 1950s become malignant supporting and coordinating care to and 1990s (Marchand, 1999). Accurate improve patients’ quality of life. 4staging of the Aetiology cancer will mean olorectal cancer is the third A high intake of meat and dietary fat can an appropriate most common cancer world- increase the risk of colorectal cancer. Other treatment plan can wide (World Cancer Research modifiable risk factors include smoking, be put together CFund, 2007); in the UK nearly high alcohol consumption, lack of phys- Colorectal 40,000 new cases are diagnosed each year, ical activity and a high body mass index. 5cancer equating to more than 100 people being Increasing evidence shows that lifestyle treatment diagnosed each day (Cancer Research UK, changes such as quitting smoking and includes surgery, 2011). This article reviews the prevalence losing excess weight can reduce the risk of radiotherapy and and aetiology of the disease and its diag- developing the disease (WCRF, 2007). chemotherapy nosis, treatment and management. Care is Some risk factors for colorectal cancer, overseen by a multidisciplinary team, however, cannot be modified; these which has the colorectal surgeon, patholo- include age and hereditary factors. gist, radiologist, oncologist and specialist Colorectal cancer is strongly linked to nurse as core members. advancing age – 86% of cases arise in people aged 60 years or more (CRUK, 2011). Three- Prevalence and incidence quarters of cancers occur by chance so, Prevalence of colorectal cancer is higher in although its high prevalence means many men than women, with an 11:10 ratio, and people will have a family member who is varies according to site as follows: affected, only 5-10% of cases are a result of » : 35%; recognised hereditary conditions. » Sigmoid: 20%; Examples of germline mutations include Colorectal cancer, also called colon cancer » Ascending colon: 20-25%; hereditary non-polyposis colorectal cancer or large bowel cancer, includes cancerous » Transverse colon: 5-10%; (HNPCC), which accounts for 5% of all growths in the colon, rectum and appendix

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colorectal cancers, and familial adenoma- (if the suspected position of tous polyposis (FAP), which accounts for 1% Table 1. Symptoms the cancer is within 60cm of the anus so it (Burgess, 2005). Individuals diagnosed with associated with can be visualised) and blood tests. Further a previous colorectal cancer or with long- colorectal cancer examination of the bowel may involve a standing ulcerative colitis are also at Site of Symptoms (or with a increased risk of developing the disease and cancer computerised tomography (CT) scanner), need endoscopic surveillance (Triantafil- Right side l Anaemia or more rarely, a barium enema; tissue biop- lidis et al, 2009). l Diarrhoea sies are usually taken from any polyps seen. l Palpable right iliac fossa Histological confirmation of the diag- Genetic risk factors mass nosis is generally sought before the patient A multistep pathway of genetic events is is informed. Receiving a cancer diagnosis Transverse There may be a mix of left involved in the development of most color- is generally distressing and life-changing colon and right symptoms ectal cancers. The classic polyp-cancer (Taylor, 2001), and should be communi- sequence (Vogelstein et al, 1988) details Left side l Alteration in bowel habit cated sensitively (Department of Health, how alterations in a number of identified l Spurious diarrhoea Social Services and Public Safety, 2003). genes, such as the APC and p53, cause a l Obstruction Support and information are essential and small polyp in the bowel to progress over l Blood mixed with stool should be offered throughout the patient’s many years into a cancer. It is the accumu- Rectal l Bleeding journey. lation of several gene errors that appears l Passage of mucus critical in this process. l Tenesmus (constantly Staging and survival More recently, a second molecular feeling the need to empty Two systems are used to convey the ana- pathway has been identified called the the bowels) tomical extent of a colorectal cancer: Dukes’ microsatellite instability pathway, in l Change in bowel habit classification (Dukes and Bussey, 1958); and which only a short segment of the chromo- l Urgency the tumor, node, metastasis (TNM) clinical some becomes unstable and resulting defi- l Palpable rectal mass classification (Sobin et al, 2009). ciencies in the DNA cause an accumula- l Rectal pain Dukes’ staging uses A-D classification: tion of changes in the cells of the mucosal » A – excellent chance of the cancer not lining of the bowel. This pathway accounts there is a good chance of detecting and recurring and no further treatment; for 15% of colorectal cancers, is associated treating them before they become malig- » B and C – further treatment required; with HNPCC and can be recognised by nant. Polyps are known to bleed so the » D – the disease is advanced and right-sided colon cancers that are poorly National Bowel Screening Programme metastatic disease has been found. differentiated or mucinous (Bellizzi and involves a faecal occult blood test designed The TNM system is more widely used Frankel, 2009). to screen for blood in the bowel motions. A and offers a detailed classification of can- In most cases of FAP, the responsible positive result does not diagnose cancer cers, the three letters representing tumour, gene mutation (or fault) is identified to be but will determine whether a colonoscopy nodes and metastases to assess the extent the APC tumour suppressor gene. This is required. Screening is offered every two of the tumour’s local spread, involvement genetic condition leads to the develop- years to all men and women aged 60-75 in regional lymph nodes and presence of ment of more than 100 adenomatous years; those aged over 75 can request a any metastases to distant organs. Fig 1 polyps in the colon which, if left untreated, testing kit. shows how the tumour is classified in the will develop into colorectal cancer (Lal and The overwhelming majority of patients TNM system. Gallinger, 2000). If a patient’s family his- with symptoms associated with colorectal Accurate staging of colorectal cancer tory of colorectal cancer appears signifi- cancer present initially to their GP. Those allows an appropriate treatment plan to be cant, advice should be sought from a with highly suspicious and persistent made. The multidisciplinary team must genetic counsellor, who can take a family symptoms can be referred to a hospital spe- establish whether there is any local and history to establish individual risk. Signifi- cialist urgently under the two-week wait distant spread when deciding whether cant criteria are: referral system. treatment can be curative or should be » Early onset of colorectal cancer (under Two symptoms shown to have a high palliative. 50 years) in a first-degree relative; predictive value for cancer when they Radiological diagnostic techniques are » Three or more relatives diagnosed with present together are rectal bleeding and used for both local and distant staging; the an associated cancer (colorectal cancer, change in bowel habit – towards increased most common are endo-anal ultrasound, or cancer of the endometrium, small looseness or increased stool frequency – CT, magnetic resonance imaging and posi- intestine, ureter or renal pelvis); and particularly if they persist over six weeks tron emission tomography scans. The nodal » A diagnosis of colorectal cancer in two (Hamilton and Sharp, 2004). However, the status of a tumour may be indicated before or more successive generations. two-week referral system has a poor cancer treatment but will be verified after surgical Genetic testing may be undertaken detection rate (under 10%) as the symp- resection and histological examination of using a blood sample from an affected toms suggestive of colorectal cancer are the lymph nodes; 20-30% of patients will family member to identify whether they diverse (Table 1) and few are unique; for have metastatic disease at time of presenta- carry known mutated genes such as MLH1, example, rectal bleeding may be caused by tion, with , peritoneal and lung metas- MSH2 or MSH6. haemorrhoids (Rai and Kelly, 2007). tases being the main sites (Mella et al, 1997). Establishing a diagnosis involves taking Local staging of a rectal cancer is par- Early detection and diagnosis a full medical history and conducting a ticularly important; this determines its As most cases of colorectal cancer develop physical examination including anorectal circumferential location, height from the slowly from adenomas or benign polyps, assessment, which may include a anal verge, whether any resection margins Alamy

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Fig 1. How ‘T’ in TNM consideration by the multidisciplinary The side-effects of radiotherapy include relates to local team; optimal treatment is likely to involve sore skin, altered bowel and bladder func- spread through bowel radiotherapy with or without chemo- tion and impaired sexual function. Fatigue therapy before surgery, to increase the like- is common during treatment and for some wall Tis* T T T T 1 2 3 4 lihood of cure (Hassan and Cima, 2007). The weeks afterwards. Patients should be pre- combination of preoperative radiotherapy pared to expect all of these side-effects in Mucosa and TME surgery has cut the risk of a rectal the short term and be offered specialist Muscularis mucosa cancer recurring locally from 30% to less help if the effects persist. Submucosa than 10% (Sebag-Montefiore et al, 2009). Technological advances in radiation, Increasingly, patients having multi- when used in combination with new cyto- Muscularis propria modal treatment will have a temporary toxic drugs, offer hope to patients with stoma formed to rest the bowel until treat- unresectable rectal cancer (Glynne-Jones Subserosa ment is completed, which can take several et al, 2007). These tumours can be “down- Serosa months. Patients who may need formation staged” by such treatments and, in up to of a stoma must be referred to a specialist 80% of cases, may become resectable Extension to an adjacent organ stoma care nurse, who advise and can offer (Braendengen et al, 2005). *Tis: The cancer is in the earliest stage (in situ) practical support. Complication rates depend on the Chemotherapy extent of disease, treatment required, skill Chemotherapy is used to reduce the likeli- may be threatened and if the cancer of the surgeon and the health of the indi- hood of metastasis, shrink tumour size involves any other organs in the pelvis. vidual. Emergency patients have more or slow tumour growth. It can be used Survival in colorectal cancer depends postoperative complications and a higher after surgery (adjuvant), before surgery largely on the stage of disease at diagnosis, risk of perioperative death (10-20%) than (neoadjuvant), or as the primary therapy and typically ranges from a 90% five-year elective patients (5%) because of their less (palliative). survival rate for people with cancers robust health (Leung et al, 2011). Approxi- Chemotherapeutic drugs have side- detected at the localised stage to 10% for mately 15% of diagnosed cases of colorectal effects and are given in treatment cycles to those diagnosed with distant metastatic cancer present as an emergency, princi- cause maximum cancer cell death while cancer; overall this equates to 53% of those pally with an obstruction or a bowel perfo- minimising adverse effects. Common diagnosed with colorectal cancer living for ration (John et al, 2011). side-effects include sore mouth five years or more (CRUK, 2011). Survival Nurses have an important role in pre- (mucositis), nausea and vomiting, diar- rates in the UK are increasing but do not paring patients for surgery, with particular rhoea, hair thinning and neutropenia. match those of many European countries emphasis on providing information about Additional side-effects are specific to par- (Hayne et al, 2001). what the treatment involves, its risks and ticular drugs; for example hand-foot syn- benefits, and whether there are alterna- drome is associated with capecitabine and Treatment and nursing care tives (Association of Coloproctology of numbness or tingling in the hands or feet Surgery remains the mainstay treatment Great Britain and Ireland, 2007). In many (peripheral neuropathy) with oxaliplatin. for colorectal cancer, encompassing a centres, nurses run pre-assessment clinics Individual reactions differ but tend to be range of procedures including local exci- and manage patients’ expectations of their cumulative so it is important that these sion, radical dissection, bypass opera- rehabilitation if they enter an enhanced symptoms are monitored. tions, laparascopic procedures and liver recovery programme. These programmes resections. If there is no metastatic dis- include surgical and rehabilitative modifi- Liver treatments ease, surgery will be performed with cura- cations to traditional practice, and are A small percentage of patients with meta- tive intent and according to oncological designed to reduce surgical trauma and static liver disease are offered combina- principles. The aim is to cleanly remove limit the stress response. Early re-estab- tions of therapy; this involves chemo- the cancer with an adequate margin of lishment of oral nutrition and hydration, therapy followed by bowel and liver tissue around it (en-bloc resection), while and mobilisation on the day of surgery surgery and are offered with the hope of minimising collateral damage. have been shown to hasten recovery, typi- achieving cure. Colon cancer surgery principally cally enabling hospital discharge within Those who undergo a curative resection involves a segmental colonic resection; for five days of surgery (King et al, 2006). of liver metastases now have a greater than example, for a cancer in the cecum or 50% chance of surviving five years (Sim- ascending colon this will be a right hemi- Radiotherapy monds et al, 2006). An expanding range of . Surgical procedures for rectal Radiotherapy is used to treat rectal cancer, other modalities can also be used instead cancer include: primarily to reduce the incidence of local of, or in conjunction with, surgery; these » Anterior resection of the rectum; recurrence, and is delivered as a course of include radio frequency ablation, cryoab- » Total mesorectal excision (TME), that treatment over a week (short course) or, lation and chemoembolisation. is, lower anterior resection); or more commonly, over five weeks (long » Abdominoperineal excision – excision course), with or without chemotherapy. It Palliative treatments of the rectum and with is most likely to be given before surgery, Patients diagnosed with advanced disease formation of a permanent stoma – for although it can be given afterwards if histo- need to know not only that the appropriate cancers very low in the rectum. logical examination of the resected bowel support is available but also that their Early-stage rectal cancers can be man- indicates a high risk of local recurrence, for cancer is potentially treatable. Surgery, aged by a specialist surgical team, but those example if there is evidence of a tumour at radiotherapy and chemotherapy are gener- that are locally advanced require the circumferential resection margin. ally offered in the palliative setting to those

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epidemiology: incidence, mortality, survival, who are fit and willing, to improve their improve treatment outcomes while and risk factors. Clinics in Colon and Rectal Surgery; quality of life. However, these treatments sparing patients the toxicity and cost asso- 22: 4, 191-198. are likely to involve side-effects and a bal- ciated with approaches that prove ineffec- Hamilton W, Sharp D (2004) Diagnosis of colorectal cancer in primary care: the evidence ance must often be struck between cancer tive against their particular cancer type. base for guidelines. Family Practice; 21: 1, 99-106. control and maintenance of quality of life. There is also the promise of chemopreven- Hassan I, Cima RR (2007) Quality of life after Nurses may act as patient advocates, tion for colorectal cancer, preventing rectal resection and multimodality therapy. Journal of Surgical Oncology; 96: 8, 684-692. helping to clarify goals of treatment and the development of benign or malignant Hayne D et al (2001) Current trends in colorectal establish patients’ future priorities and tumours, which may be targeted at cancer: site, incidence, mortality and survival in preferences. There should be regular intermediate risk populations (Cooper et England and Wales. Clinical Oncology (Royal College of Radiologists); 13: 448-452. assessment of individual patients’ needs, al, 2010). John SKP et al (2011) Symptoms and signs in provision of information and support, patients with colorectal cancer. Colorectal Disease; symptom control and liaison between the Conclusion 13: 17-25. King PM et al (2006) Randomized clinical trial relevant agencies such as the oncology Colorectal cancer is one of the most comparing laparoscopic and open surgery for multidisplinary team, the specialist pallia- common cancers in the UK and the second colorectal cancer within an enhanced recovery tive care team, district nurses, the GP and leading cause of cancer mortality. In the programme. British Journal of Surgery; 93: 3, 300-308. social services, as appropriate last two decades major advances have Knowles G et al (2007) Developing and piloting a occurred in its treatment. By enhancing nurse-led model of follow-up in the Role of the specialist nurse and also often integrating surgical, radio- multidisciplinary management of colorectal cancer. European Journal of Oncology Nursing; 11: 3, Clinical nurse specialists play a vital role in therapy and chemotherapy treatments, we 212-223. delivering a high-quality continuous care are successfully addressing two distinct Lal G, Gallinger S (2000) Familial adenomatous to patients from the point of diagnosis, problems of this disease: local recurrence polyposis. Seminars in Surgical Oncology; 18: 314-323. Leung E et al (2011) Risk-adjusted scoring systems through to and beyond treatment (National and risk of metastases. in colorectal surgery. International Journal of Cancer Action Team, 2010). Patients see Colorectal cancer nurses may be Surgery; 9: 2, 130-135. cancer specialists as their primary source required to provide: emotional support at Marchand L (1999) Combined influence of genetic and dietary factors on colorectal cancer incidence of information (Sahay, 2000); a CNS with time of diagnosis; information and sup- in Japanese Americans. Journal of the National specific expertise in colorectal cancer and port through treatment decision making; Cancer Intsitute Mongraph; 26: 101-105. excellent communication skills should be preparation for treatment; ongoing assess- Mella J et al (1997) Population-based audit of colorectal cancer management in two UK health available to fulfil this role. CNSs act as key ment and care during and after treatment; regions. Colorectal Cancer Working Group, Royal workers, often becoming the main point of and survivorship care for those living College of Surgeons of England Clinical contact not only for patients but also beyond treatment. Many different health Epidemiology and Audit Unit. British Journal of between multidisciplinary team members professionals will be involved in an indi- Surgery; 84: 12, 1731-1736. National Cancer Action Team (2010) Quality in to promote the transfer of up-to-date and vidual’s care; nurses play a vital part in Nursing. Excellence in Cancer Care: The comprehensive patient information. helping to coordinate care and keep the Contribution of the Clinical Nurse Specialist. National Cancer Action Team, Part of the National Specialist nurses are also well placed to patient central to decision making. NT Cancer Programme. tinyurl.com/NCAT-CNS- provide the individualised post-treatment contribution care that promotes cancer survivorship. References National Cancer Survivorship Initiative (2011) Many run follow-up clinics and regularly Association of Coloproctology of Great Britain Consequences of Cancer Treatment. tinyurl.com/ and Ireland (2007) Guidelines for the Management NCSI-consequences assess patients’ holistic care needs, estab- of Colorectal Cancer. tinyurl.com/ACGBI-Guideline Rai S, Kelly MJ (2007) Prioritization of colorectal lish their end-of-treatment care plans and Bellizzi AM, Frankel WL (2009) Colorectal cancer referrals: a review of the 2-week wait referral planning future care. 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