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Essential toolkit: colorectal cancer

Keep your learning up to date with our series of monthly toolkits to help support nurses in delivering recovery cancer care.

Keep your learning up to date with our series of monthly toolkits to help support nurses in delivering recovery cancer care

Welcome to the first in a series of monthly toolkits that support nurses in delivering recovery packages in important cancer fields. Written by Cancer Nursing Partnership experts, each article will cover the essential facts about living with and beyond cancer, alongside a clinical revision guide to keep your learning up-to-date.

Other topics to be covered in the toolkit include head and neck cancer, bone marrow transplantation, lymphoma, lung cancer and urological cancer.

Disease prevalence

There are 34,025 new cases of colorectal cancer diagnosed in England every year (PHE 2016). Incidence rates in the UK for this cancer increase sharply from age 50 with almost six in ten cases diagnosed in people of 70 years and over (Cancer

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Keep your learning up to date with our series of monthly toolkits to help support nurses in delivering recovery cancer care

Welcome to the first in a series of monthly toolkits that support nurses in delivering recovery packages in important cancer fields. Written by Cancer Nursing Partnership experts, each article will cover the essential facts about living with and beyond cancer, alongside a clinical revision guide to keep your learning up-to-date.

Other topics to be covered in the toolkit include head and neck cancer, bone marrow transplantation, lymphoma, lung cancer and urological cancer.

Disease prevalence

There are 34,025 new cases of colorectal cancer diagnosed in England every year (PHE 2016). Incidence rates in the UK for this cancer increase sharply from age 50 with almost six in ten cases diagnosed in people of 70 years and over (Cancer Research UK (CRUK) 2017).

Rates for colorectal cancer increase greatly in patients over 50 years old. Picture: Alamy

The majority of patients are diagnosed with disease that is localised and can be treated with curative intent (Miller et al 2016). Five-year survival rates are improving following introduction of the national bowel cancer screening programme and improved treatment availability (Ouakrim et al 2015).

Risk factors

Some colorectal cancer risk factors, such as genetics and age, cannot be avoided. Others, such as obesity, smoking, diet and other lifestyle choices, may be addressed to significantly reduce the risk of developing colorectal cancer.

The factors which lead to increased risk for colorectal cancer include alcohol, X-ray, gamma-radiation, processed meat, body fat and smoking, while factors that decrease risk include physical activity and dietary fibre in foods (CRUK 2017).

Diagnosis

In addition to a physical examination, the following tests may be used to diagnose colorectal cancer: flexible sigmoidoscopy, colonoscopy and CT colonography. If a diagnosis of colorectal cancer is confirmed, further staging investigations will be carried out to help plan treatment. In all cases, a CT scan of the chest, abdomen and pelvis is needed to assess for metastatic disease, which might be most commonly detected in the liver or lungs. A magnetic resonance imaging (MRI) scan of the pelvis will also be requested for people with rectal cancer to provide a detailed image of the organs surrounding this final section of the large bowel.

Treatment

Treatment depends on the stage and location of the cancer, as well as the health and preferences of the patient (Schmoll 2012). Treatment decision-making can often be complex, particularly if the disease has advanced locally and/or distant disease is detected and should be guided by recommendations from the lower gastrointestinal (GI) multidisciplinary team and then discussed in detail with the patient to take into account their fitness and particular wishes. The majority of patients with early stage (stage I and II) colon cancer undergo surgery alone.

If histology results indicate nearby lymph nodes and/or blood vessel invasion (stage III disease), chemotherapy is likely to be advocated to lower the risk of cancer recurrence (Chau and Cunningham 2002).

The Cancer Nursing Partnership comprises 18 organisations representing more than 22,000 nurses in supporting the delivery of recovery packages to people living with and beyond cancer in the UK.

The recovery package, which is recognised in the NHS England Five Year Forward View and the Cancer Taskforce Strategy, has four main elements: holistic needs assessment and care planning; treatment summary; cancer care review; and health and well-being events.

For those with rectal cancer, surgery to remove part or the entire rectum is the most common treatment although it may be possible to resect very early stage cancers by local excision (NBOCA 2015). Radiotherapy is not indicated in colon cancer but it has an established role, usually prior to surgery, for more locally-advanced stages of rectal cancer (T3-T4) before or after chemotherapy. From a surgical and pathologic standpoint achieving a clear circumferential radial margin is critically important, and when this deep, lateral margin is threatened, radiotherapy is certainly indicated to try to downstage the tumour. Radiotherapy can play a role in rectal cancer in the palliative setting to improve symptom control.

A permanent stoma, usually a colostomy, may be required when resecting a very low rectal cancer. However, if the rectal tumour is more than 20mm above the anal verge it should be possible to safely resect it and still rejoin the bowel. During surgery, a temporary stoma (an ileostomy) will often be formed to protect the anastomosis (bowel join) and allow healing.

There are many treatment options for those with metastatic disease (stage IV) including liver and lung resections, localised ablation and embolisation therapies, in addition to systemic therapies: palliative chemotherapy and biological therapy.

Disease recurrence may be treated by surgery and in a small number of cases, after a complete curative resection can be achieved. Palliative treatment for incurable colorectal cancer may include a combination of approaches including, for example, surgery to form a defunctioning stoma or debulk disease commonly to relieve pain, obstructive symptoms or to manage fistulae. The treatment plan will again be dependent on individual patient disease status, fitness and patient wishes.

Key issues for nurses

In general, colorectal cancer is a disease where people can expect to live many years once their treatment is over, but the key early diagnosis. If diagnosed early, more than 90% of bowel cancer cases can be treated successfully.

For more information on how the Cancer Nursing Partnership can support your services, email cnp@macmillan.org.uk

The more advanced the disease is at presentation, the more likely that a multimodal treatment regime – will be required. An estimated one third of those diagnosed with rectal cancer will receive pelvic radiotherapy, and two-thirds of people with colorectal cancer will receive chemotherapy. This brings with it a risk of longer-term consequences that can appear months to years after treatment: in particular alterations in bowel, urinary and sexual function.

All patients should be informed of how to lead a healthier way of life to ameliorate several common consequences of cancer and its treatment, as well as improving overall survival and reducing the probability of relapse.

Essential facts covering late effects specific to colorectal cancer

While many people living with and beyond colorectal cancer develop acute consequences from cancer treatment, a much smaller percentage will experience late effects that become apparent after treatment has ended. A late effect could be a symptom such as GI bleeding or a change in cardiac function, which can be attributed to their previous oncological treatments and may arise many years later.

These effects may be physical, psychological, social or spiritual in nature (See table 1).

Table 1. Common physical consequences of treatment

Surgery

Chemotherapy

Radiotherapy

Abdominal or rectal pain

Gastrointestinal effects

Gastrointestinal effects

Changes to bowel function

Peripheral neuropathy

Infertility

Hernia development

Cognitive impairment

Menopausal symptoms

Sexual changes

Cardiac consequences

Sexual changes

Urinary symptoms

Fertility

Urinary symptoms

Fatigue

Fatigue

Bone health

Source: (Macmillan Cancer Support, 2016)

The first national cancer survey for patient reported outcome measures (PROMs) indicated that 21,802 respondents with colorectal cancer often reported the following four ‘frequently occurring challenges’ in the first three years of diagnosis (Glaser et al 2015):

  • The emotional consequences of being diagnosed and treated for cancer.
  • Unpleasant physical side effects of treatment.
  • On-going social and financial difficulties.
  • Long-term and age-related illnesses that could exacerbate, or be exacerbated by, problems associated with cancer treatment.

It is, therefore, important to conduct a holistic needs assessment (HNA), which is one of the four interventions constituting the recovery package. A review of HNA data across one large London trust over one year (April 2014 to March 2015) indicates the following top ten reported concerns of people completing colorectal cancer treatment:

  1. Worry, anxiety or fear
  2. Information needs
  3. Fatigue
  4. Constipation or diarrhoea
  5. Making plans
  6. Pain
  7. Sleep problems
  8. Tingling in hands and feet
  9. Work or education
  10. Other medical condition

By gaining a good baseline understanding of an individual’s concerns on treatment completion, nursing can plan an individual’s care and then support delivery of their on going health and social care. In doing so, an individual should be encouraged to self-manage as much as possible to build their skills and confidence in coping with future challenges.

Expert view

Claire Taylor, Macmillan nurse consultant in colorectal cancer, London North West Healthcare NHS Trust and visiting lecturer, King's College, London

Since the majority of people living with and beyond colorectal cancer will be more than 65 years old, they are likely to be managing at least one other long-term condition, which might exacerbate cancer-related problems (Glaser et al 2015) and lead to a worsening in health and well-being compared to age-matched controls (Elliot et al 2011, Khan et al 2011, Denlinger 2009).

A holistic approach can help identify any correlation between concerns; physical consequences such as chronic fatigue and altered GI function may create difficulties in returning to work, socialising and resuming leisure activities and associated mood disturbance. Time may be needed to uncover more sensitive emotional consequences such as body image changes and sexual and relationship issues, which may occur in this patient group.

Offering a health and well-being event is strongly advocated since we know that one third of all people who completed colorectal cancer treatment have difficulty engaging in leisure activities and vigorous exercise (Elliott et al 2011). The combination of information on the benefits of physical activity, demonstration and peer support may provide a teachable moment for initiating lifestyle change. Furthermore, specific nutritional advice in the context of ‘eating well’ is particularly well received by this patient group as they often experience changes in their weight and bowel function (including stoma formation) after treatment.

Receipt of all aspects of the recovery package hopefully yields immediate benefits for an individual’s health and well-being as well as supporting improvements in their subsequent after care. Ultimately we should all strive to help people live as well as possible for as long as possible.

References

  • Denlinger CS, Barsevick AM (2009) The challenges of colorectal cancer survivorship. Journal of the National Comprehensive Cancer Network. 7, 883-93.
  • Elliott J, Fallows A, Staetsky L et al (2011) The health and well-being of cancer survivors in the UK: findings from a population‐based survey. British Journal of Cancer. 105, 1, 11‐20.
  • Glaser A, Fraser L, Corner J et al (2013) Patient Reported Outcomes of cancer survivors in England 1-5 years after diagnosis: a cross sectional survey. BMJ Open. doi: 10.1136/bmjopen-2021-002317
  • Khan N F, Mant D, Carpenter L et al (2011) Long-­term health outcomes in a British cohort of breast, colorectal and prostate cancer survivors: a database study. British Journal of Cancer. 105, 1,29-37. doi:10.1038/bjc.2011.420.
  • Macmillan Cancer Support (2016) Managing the long term consequences of colorectal and anal cancer. www.macmillan.org.uk/documents/aboutus/health_professionals/consequences...
  • CRUK (2017) Bowel cancer statistics Cancer Research UK. www.cancerresearchuk.org/health-professional/cancerstatistics/statistics...
  • Chau I and Cunningham D (2002) Chemotherapy in colorectal cancer: new options and new challenges. British Medical Bulletin. 64, 1, 159-180.
  • Miller KD, Siegel RL, Lin CC et al (2016) Cancer treatment and survivorship statistics. CA: A Cancer Journal for Clinicians. 66, 271–289.
  • Mitry E, Bouvier AM, Esteve J et al (2005) Improvement in colorectal cancer survival: A population based study. European Journal of Cancer. 41, 15, 2297-2303.
  • National Bowel Cancer Audit Report 2015 Provisional Findings. digital.nhs.uk/catalogue/PUB17761/nati-clin-audi-supp-prog-bowe-canc-prov-2015.pdf.
  • Ouakrim A, Pizot D, Boniol C et al (2015) Trends in colorectal cancer mortality in Europe: retrospective analysis of the WHO mortality database. BMJ. 351h4970
  • Schmoll H J, Van Cutsem E, Stein A (2012) ESMO Consensus Guidelines for management of patients with colon and rectal cancer. A personalized approach to clinical decision making. Annals of Oncology. 23, 10, 2479-2516.

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