Rectal Cancer 101

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• Speaker(s): Mary Mulkerin, RN, OCN

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The information and services provided by Fight Colorectal Cancer are for general informational purposes only. The information and services are not intended to be substitutes for professional medical advice, diagnoses or treatment.

If you are ill, or suspect that you are ill, see a doctor immediately. In an emergency, call 911 or go to the nearest emergency room.

Fight Colorectal Cancer never recommends or endorses any specific physicians, products or treatments for any condition.

Speaker:Mary Mulkerin, RN, OCN is the Gastrointestinal Oncology Nurse Coordinator at University of Wisconsin Carbone Cancer Center, coordinating multi-disciplinary patient care and leading a Gilda’s Club support group. She obtained her BSN from the University of Wisconsin-Madison and has practiced in Oncology for the last 31years. She is currently completing her MS in Nursing Education at Edgewood College to pursue her research interests in survivorship and patient and staff education, in addition to developing a patient education app that would make patient’s management of their care more accessible and user-friendly.

MARY MULKERIN, RN, BSN, OCNUNIVERSITY OF WISCONSIN CARBONE CANCER CENTER

MAY 25, 2016

Rectal Cancer 101

Objectives

Discuss:Prevalence, risk factors and diagnosis of

rectal cancerStaging of rectal cancerTypes of treatment and treatment by stageSurvivorshipFuture research

Rectal Cancer

Malignant (cancer cells) form in the tissues of the rectum

The rectum is about 6 inches – temporary storehouse for feces

CoccyxTumorRectum

Bladder

Image retrieved from: aibolita.com

Prevalence

Colorectal Cancer (CRC) – 3rd most common diagnosed cancer

39,220 new cases per year – slightly more prevalent in men than women

About 5% or 1 in 20 people of the general population

90% of cases are diagnosed over age 50Rates are decreasing over time There are more than 1 million CRC survivors!

American Cancer Society, 2016

Increased Prevalence in Younger Adults

Incidence increasing in people under age 40Between 1984-2005, rate increased by 3.8% -

doubled Approximately 18% rectal cancer cases are in

people <50, 11% for colon cancerOf these, 20% are caused by familial

syndromesCause unknown, but possibly related to

lifestyle behaviors and environmental factors

Malik, M., 2016

Who’s at risk?

Age 40 or olderCertain hereditary conditions Having a parent, sibling, or child with a

history of colorectal cancerBehavioral risk factorsPersonal history of:

Colorectal cancer Polyps Cancer of the ovary, endometrium or breast

Cleveland Clinic, 2016

Symptoms

Change in bowel habits Diarrhea/Constipation Narrow stools Feeling like the bowel does not empty completely

Blood in the stoolAbdominal discomfortChange in appetiteUnintentional weight lossFatigueAnemia

Cleveland Clinic, 2016

Detection

Physical exam and historyDigital rectal examProctoscopyColonoscopyBiopsy Carcinoembryonic antigen (CEA) – tumor

marker

Cleveland Clinic, 2016

Factors Affecting Prognosis and Treatment

Stage of the cancerWhether the tumor has spread into or

through the bowel wallWhere the cancer is located in the rectumWhether the bowel is blocked or has a hole in

itWhether all of the tumor can be removed by

surgeryGeneral health of the personNew diagnosis vs. recurrence

Cleveland Clinic, 2016

Determining Cancer Stage

Chest x-ray

CT scan

MRI (magnetic resonance imaging)

Endoscopic ultrasound (EUS)

PET scan

Cleveland Clinic, 2016

How Does Cancer Spread?

Through tissue – cancer invades the surrounding normal tissue

Through the lymph system – cancer invades the lymph nodes then travels

Through the blood – Capillaries and veins are invaded by cancer

Metastasis – cancer cells spread from the primary tumor and form another tumor in another site

Cleveland Clinic, 2016

Stages of Rectal Cancer

Standard Treatment of Rectal Cancer

Surgery

Radiation Therapy

Chemotherapy

Targeted Therapy

Cleveland Clinic, 2016

Surgery

Surgery is the most common treatment for all stages

Radiation therapy or chemotherapy may be given before surgery – neoadjuvant therapy

After surgery, chemotherapy or radiation may be given – adjuvant therapy

Cleveland Clinic, 2016

Types of Surgery

Type of surgery depends on the stage and overall health of the person

Types Polypectomy Cryosurgery Local excision - TAMIS Resection Radiofrequency ablation Pelvic exenteration

Cleveland Clinic, 2016

Surgical Resection

Low Anterior Resection (LAR) – Tumor is in the upper part of the rectum. May have a temporary ostomy.

Proctectomy with colo-anal anastomosis – Tumor is in the mid to lower third. Entire rectum removed and colon is attached to the anus

Abdominoperineal resection (APR) – Tumor is in the lower rectum. Permanent ostomy American Cancer Society, 2016

Radiation Therapy

High-energy x-rays or other types of radiation is used to kill cancer cells

2 types of radiation: External beam Internal radiation – uses needles seeds, wires or

cathetersType of treatment chosen and length of

treatment depends on stage

Cleveland Clinic, 2016

Chemotherapy – Anti-Cancer Drugs

Chemotherapy is give at different times during treatment – before or after surgery and for stage IV cancer

Chemotherapy is given is different ways:Systemic chemotherapy – IV or orallyRegional chemotherapy – given directly

into an artery that leads to a part of the body with a tumor. Examples: Hepatic artery infusion, Chemoembolization

American Cancer Society, 2016

Embolization

Substances are injected into the hepatic artery to try and block or reduce the blood flow to cancer cells in the liver

3 main types of embolization:Arterial embolizationChemoembolization (TACE) Radioembolization

American Cancer Society, 2016

Targeted Therapy

Drugs that attack specific genes or proteins in a cancer

Often have different and less severe side effects

May be given alone or with chemotherapyExamples:

Drugs that target blood vessel formation Drugs that target Epidermal Growth Factor

Receptor – Test tumor for KRAS Mutation/Molecular Profiling

Kinase inhibitors – block signals to the cancer cell’s control center American Cancer Society, 2016

Treatment of Rectal Cancer by Stage

Stage 0 – Removal of the polyp onlyStage I

Local excision Resection Resection with radiation therapy and

chemotherapy usually before surgery but may be after

Stage II Resection plus chemotherapy and radiation Resection with or without chemotherapy after

surgeryCleveland Clinic, 2016

Treatment of Rectal Cancer by Stage

Stage III Resection plus chemotherapy and radiation usually before surgery Resection with or without chemotherapy after surgery

Stage IV and Recurrent Rectal Cancer Resection with or without chemoradiation before surgery Resection or pelvic exenteration as palliation Palliative radiation and/or chemotherapy Chemotherapy with or without targeted therapy Placement of a rectal stent/diverting ostomy Tumor Molecular Profiling

Cleveland Clinic, 2016

Treatment of Rectal Cancer by Stage

Treatment of liver metastasis Cryosurgery of Radiofrequency Ablation Chemoembolization or systemic chemotherapy Internal radiation therapy Surgery to remove the tumor

Treatment of lung metastasis Cryosurgery or Radiofrequency Ablation Surgery

Cleveland Clinic, 2016

Living as a Rectal Cancer Survivor

A cancer survivor is anyone who has been diagnosed with cancer – from the time of diagnosis and for the balance of his or her life

Survivorship Care Plan Treatment summary Suggested schedule for follow-up exams and tests Long-term effects from treatment – management

and when to call the doctor Surveillance for recurrence and secondary

cancers Healthy lifestyle suggestions

American Cancer Society, 2016

Survivorship

Follow-up Doctor visits Colonoscopy CT Scans or other imaging CEA

Some side effects linger after treatment or may develop months or years later

American Cancer Society, 2016

Long-Term Treatment Effects

Fatigue Keep a diary for 1 week and use the diary to plan your

schedule Make a daily schedule with rest breaks Keep naps to < 30 minutes Be active 3 Ps: Prioritize, Plan and Pace

NeuropathyTake practical steps to make your environment safer May take months or years to improve Full recovery sometimes is not possible

Long Term Treatment Effects

Changes in bowel function Imodium, Stool bulking agents Pelvic floor exercises Diet

Phantom rectal sensation/pain – common, resolves spontaneously in most cases Ice packs/warm baths Anti-depressant medications Pelvic floor exercises, yoga Relaxation techniques

Emotional Challenges

Sense of reliefSadness, sense of

lossWorry, irritability and

anxietyFear of recurrenceUnexpected

emotionsLosing the “safety

net”

Role changesChanges in social

supportChanges in

relationships with family, friends & coworkers

Unmet expectations about returning to normal, “new normal”

Additional Concerns

Changes in sexual function

Infertility

Returning to work

Financial issues

Genetic counseling

Lowering Risk of Recurrence

Healthy weightBeing activeEating a healthy dietAspirinAlcoholQuitting smoking

American Cancer Society, 2016

What’s New in Rectal Cancer Research

Prospect Clinical Trial – awaiting data analysis. 4 months of IV chemotherapy is given prior to surgery instead of chemotherapy and radiation

TNT – Total neoadjuvant therapy. IV chemotherapy followed by chemotherapy and radiation, then surgery. No further treatment after surgery. Traditionally, only 68% of patients complete all of their adjuvant therapy

References

American Cancer Society. (2016). Retrieved from http://www.cancer.org/cancer/colonandrectumcancer/detailed guide

Cleveland Clinic. (2016). Retrieved from http://my.clevelandclinic.org/health/diseases_conditions/hic-colorectal-cancer

Malik, M., (2015). Rising rates of sporadic colorectal cancer in young adults: a possible environmental link. Retrieved from http://am.asco.org/rising-rates-sporadic-colorectal-cancer-young adults-possible-environmental-link

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