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Colon cancer: A major case studyBy: Emily Macieiski, Dietetic Intern

+Introduction

Patient: J.W.

53 year-old Caucasian male

Height: 5’11”

Weight upon Admission February 19, 2014- 183 lbs (~83 kg) BMI: 26.42 kg/m2

Weight upon Discharge February 26, 2014- 178 lbs (~81 kg) BMI: 25.65 kg/m2

Admitting diagnosis: anemia and abdominal pain

Past Medical Hx: None

+Social history

Homeless

Used to fly planes, but turned down a pilot job d/t ailing health

Used to study to become a nurse

Has no health insurance

Not married

Brother visited during his stay

Does not smoke or drink alcohol

Food is a daily struggle

+GI tract

Stomach and small intestine make up first part Where food is processed for energy

Colon and rectum make up the last part Where solid waste is passed out of the body

Small intestine 20 ft & Large Intestine 5 ft

Rectum last 6 inches of the digestive system

Colon has 4 parts: ascending, transverse, sigmoid, descending

+Colon cancer

Third most common cancer (excluding skin) diagnosed in the U.S.

The risk of developing is 1 in 20 (5%)

Risk factors: > 50 years old Hx of colorectal polyps Hx of DM IBD (Crohn’s and Ulcerative Colitis) 1st degree relatives with the dx Eating a high-fat diet Red/processed meats Smoking/ heavy alcohol abuse Obesity Physical inactivity

+Colon cancer diagnosis

Begins when healthy cells that make up the lining of colon or rectum change and grow uncontrollably

They can form a mass/tumor and be benign or malignant

Colorectal cancer usually begins as a polyp Non-cancerous growth Most form a mound in wall of colon About 10% require a special dye to be seen during a colonoscopy

If metastasizes, cancer cells can develop new tumors

+Symptoms

Change in bowel habits: diarrhea, constipation

Pain without a bowel movement

Feeling like the bowel does not empty completely

Rectal bleeding

Dark/bloody stools

Cramping/abdominal pain

Weakness/fatigue

Unintended wt loss

+Tests to diagnose

Many develop symptoms after it has already developed

If symptoms occur, a doctor will do a physical exam and review medical hx

Blood tests: CBC, liver enzymes, or tumor markers (CEA)

Sometimes colorectal CA will bleed into large intestine or rectum Can cause anemia

Tests and procedures to detect: colonoscopy, biopsy, molecular testing of the tumor, CT scan, MRI,

ultrasound, chest x-ray, and PET scan.

+Treatment- Colon

Colon: Colectomy (sometimes called hemicolectomy, partial,

or segmental resection) removes part of the colon and nearby lymph nodes

Polypectomy removal of the polyp through a colonoscope

+Treatment- Rectal

Rectal: Polypectomy Transanal resection instrument is inserted thru the anus & cuts thru all

the layers of the rectum to remove any cancerous tissues Low anterior resections part of the rectum containing the tumor is

removed and then the colon attached to remaining rectum. Proctectomy entire rectum is removed and then the colon is attached to

the anus (colo-anal anastomosis) Abdominoperineal resection (APR) removal of anus, sphincter muscle,

and tissues. Pelvic exenteration rectum will be removed, along with the bladder,

prostate in men, or uterus in women, if the cancer has spread

+Radiation therapy

Radiation therapy Can be used with colon CA that has spread to the lining of the abdomen or

other organs For rectal CA, can be used before or after sx

Chemoradiation radiation given with chemo

Side Effects: skin irritation at the site of radiation; nausea; rectal irritation causing

diarrhea, painful bowel movements, or blood in the stool; bowel incontinence; bladder irritation; fatigue/tiredness

+Chemotherapy

Systemic uses drugs that are injected into a vein or given by mouth; travel to difference parts of the body

Regional drugs are injected directly into an artery leading to a part of the body containing a tumor; less side effects

Drugs: FOLFOX (a type of combination chemotherapy used to treat colorectal cancer) Camptosar (used when colon cancer has metastasized or returned) Avastin (used when colorectal cancer has spread, it starves tumors of blood

and oxygen) Erbitux (it helps to stop cancer cells from reproducing) Vectibix (used when colorectal cancer has spread despite chemotherapy)

Side Effects

+Stages

Stage 0: cancer cells found only in inner lining of colon/rectum

Stage I: grown through the mucosa and invaded mucosa layer

Stage 2A: grown into outermost layers of colon/rectum

Stage 2B: grown into the layers of the muscle to the visceral peritoneum

Stage 2C: spread through the wall of the colon/rectum and grown into or attached to nearby tissues or organs

+Stages Continued

Stage 3A: grown through the inner lining/the muscle layers of the intestine; 1-3 lymph nodes

Stage 3B: grown thru bowel wall or into surrounding organs; 1-3 lymph nodes

Stage 3C: 3-4 lymph nodes

Stage 4A: spread to one part of the body (such as liver/lungs)

Stage 4B: spread to more than one organ/set of lymph nodes

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+J.W.’s sx/procedures

2/19 GI consult. US showed mass in abdominal area.

2/20 EGD/colonoscopy with small bowel biopsy; rectal polypectomy Post-op diagnosis: diverticulosis, mass in colon, rectal polyp Mid to proximal transverse colon mass most likely cancer

2/21 Right hemicolectomy Post-op diagnosis: proximal transverse colon CA Await pathology results Oncology consult

2/24Pathology results showed stage 3B colon CA

+Medications

Cefotan- antibiotic

Heparin- anticoagulant

Zofran- antiemetic/antinauseant

Sennagen- laxative/stimulant

Venofer- antianemic to treat iron deficiency

Protonix- antigerd

Decadron- corticosteroid, anti-inflammatory, immunosuppressant

Lantus

Humalog- diabetic

Toradol- pain

+Important Labs

HgA1c: 9.0%- 2/21

Glucose: 358 mg/dl- 2/21

Serum albumin: 2.3 gm/dl- 2/21

H/H: 5.6 gm/dl/22.3%- 2/21

CRP: 9.37 mg/dl

+Dietary treatment

J.W. was NPO on 2/19

Advanced to full liquids on 2/22 Glucerna shake TID

Regular diet on 2/24 Recommended to switch to Diabetic High left Dear Doctor note

Estimated needs: 25-30 kcal/kg 2,075-2,490 kcals/day Protein: 1.0-1.2 g/kg 86-100 grams PRO/day

Needs increased once confirmed he had stage 3B colon CA 30-35 kcal/kg 2,430- 2,835 kcals/day Protein: 1.2-1.5 g/kg 97- 122 grams PRO/day

+Dietary treatment continued

The Diabetic high diet was recommended d/t his newly dx DM and for his increased needs

J.W. was also constipated since 2/20, which delayed his discharge

He lost 5 lbs during his stay of 1 week. NPO x 3 days.

He consumed 100% of most meals and drank every Glucerna that was sent to him

Glucerna coupons provided

Academy of Nutrition and Dietetics handouts: Carbohydrate Counting for People with Diabetes, Fat Content of Foods List, and Fiber Content of Foods List provided.

+Nutritional guidelines

Low-fat, high-fiber diet to prevent future polyps Limit fiber post sx until bowels

return to normal

Rich in vegetables (cruciferous), fruits, whole grains

Consume less red meat

intake of poultry, fish, beans, and tofu

Omit trans fatty acids

unsaturated fats- salmon, flaxseed, canola and olive oils

Tobacco and alcohol are discouraged

Drinking 6-8 glasses water/day & exercise 30 min, 5 days/wk

Fish oil can help inflammation

Multi-vitamin- especially folic acid, vitamins B6 and D3

Dairy products encouraged for calcium and vitamin D

+Nutrition diagnosis and Goals

Unintended weight loss related to malabsorption as evidenced by 75 pounds weight loss (29%) over 6 months.

Altered nutrition-related lab values related to newly diagnosed DM as evidenced by HgA1c of 9.0%.

Increased calorie and protein needs related to newly diagnosed colon cancer stage IIIB as evidenced by biopsy results.

Altered GI function related to changes in motility as evidenced by constipation x 5 days.

Goal- Provide adequate kcal and protein to meet estimated needs

Pt will maintain po intake of 75% or more of meals, including supplement

Prevent further wt loss, maintain lean body mass

Improvement with blood sugars

Start solid foods by day 5-7

+Prognosis

MD set him up with free class at Diabetes Wellness Center in April

Free meter and glucose test strips

Sent home with Metformin

Port to be placed for chemo in a few weeks

J.W. is very intelligent and driven

Will be staying with family friends in Mason

His stage of colon cancer hasn’t spread to other organs yet

Doctors have a lot of faith in him

+References

"Colorectal Cancer." Welcome to the Johns Hopkins Colon Cancer Center. N.p., 2001-2014. Web. 21 Apr. 2014.

Mahan, L. Kathleen., and Sylvia Escott-Stump. "Medical Nutrition Therapy in Cardiovascular Disease." Krause's Food, Nutrition, & Diet Therapy. 11th ed. Philadelphia: Saunders, 2004. 730-731. Print.

Pronsky ZM, Crowe JP. Food Medication Interactions. 17th edition. Birchrunville, PA: Food-Medication Interactions; 2012

"Colon Cancer Treatment." Treatment for Colon Cancer. N.p., 2014. Web. 21 Apr. 2014.

"Colorectal Cancer." University of Maryland Medical Center. N.p., 2014. Web. 21 Apr. 2014.

+References

"Colorectal Cancer." Cancer.net. American Society of Clinical Oncology, 2014. Web. 21 Apr. 2014. http://www.cancer.net/sites/cancer.net/files/asco_answers_guide_colorectal.pdf

"Colon Cancer Nutrition." EMedTV: Health Information Brought To Life. Clinaero, Inc, 2006-2014. Web. 21 Apr. 2014.

"Colorectal Cancer." American Cancer Society, 2013. Web. 21 Apr. 2014. <http://www.cancer.org/acs/groups/cid/documents/webcontent/003096-pdf.pdf>.

Escott-Stump, Sylvia. "Colorectal Cancer." Nutrition and Diagnosis- Related Care. 7th ed. Philadelphia: Lippincott Williams and Wilkins, 2012. 759-62. Print.

"SuperTracker." ChooseMyPlate.gov. United States Department of Agriculture, 2014. Web. 21 Apr. 2014.