Care and Management of Colorectal Cancer Student Name

Care and Management of Colorectal Cancer Student Name
Institutional Affiliation
Care and Management of Colorectal Cancer
Introduction
Colorectal cancer refers to cancer which occurs in the rectum or colon, and sometimes it is referred to as colon cancer. Notably, colon is the large bowel or large intestine while rectum is the passageway which connects the colon to the anus (Journy, Lee, Harbron, McHugh, Pearce, & de González, 2017). Colon cancer is an example of a long term condition; a long term condition is one which at present cannot be cured. It can only be managed and controlled through different therapies and medication. Other examples of long term conditions include heart disease, diabetes, and chronic obstructive pulmonary disease. One of the effective ways of managing colon cancer is through holistic nursing care which is offered by nurses.  
Research in this study was conducted through a systematic review. Before searching literature for this project, a strategy was put in place in order to ensure that the most appropriate and relevant sources are gathered and that these sources are of the highest possible quality (Ciria, Ocaña, Gomez-Luque, Cipriani, Halls, Fretland, & Edwin, 2020). A clear search strategy was created by formulating an answerable question by using the search terms in a framework such as PICO. The primary question used for this project is ‘What is the pathophysiology of colorectal cancer and what is the role of holistic nursing care in managing the condition?’ Rewording the question was done to make it easier to search for literature was useful and enable the researcher to use key terms in their research. This is why PICO was selected, because it is an effective tool. The acronym PICO stands for ‘Population’, ‘Intervention’, ‘Comparator’ and ‘Outcome’. Due to the size of the project and the different themes that are being discussed, a range of search terms were used within the PICO framework in order to ensure that the literature search returns a variety of appropriate sources. The search terms used include colorectal, holistic, pathophysiology, comorbidity, and disease progression. 
Portfolio Entry 1
The Pathophysiology of Colorectal Cancer
Colorectal cancer is caused by a stepwise accumulation of genetic defects as well as clonal proliferation arising from mutation in colonic epithelia cells in a rather ademocarcinma transformation sequence of the normal colonic mucosa; this results from a protuberant growth referred to as adenoma or polyp, which is shown in the Fig. 1 below, before progressing to adenocarcinoma (Lemoine, Sugarbaker, & Van der Speeten, 2017). The tumour suppressor gene of the adenomatous polyposis colon (APC) undergoes mutations, and these are some of the most common forms of genetic defects which are observed in sporadic colorectal cancer; they account for approximately 80% of all the genetic defects leading to colorectal cancer. The protein product associated with the APC gene which does not undergo mutation prevents cases of accumulation of a β-catenin protein, nuclear translocation of the same, as well as gene transcription from being inappropriately activated (Dulai, Sandborn, & Gupta, 2016). This is achieved through the canonical Wnt pathway which promotes cell proliferation. 
The genetic mutations in the colonic mucosa epithelium are caused by a plethora of carcinogens such as smoke and tobacco. Poor intake of folate among heavy alcoholics as well as its interference with absorption due to the alcohol content can also contribute to genetic defects due to synthesis of folatemediated DNA, methylation of DNA, and different repair processes in the body (Andersen, Svenningsen, Knudsen, Hansen, Holmskov, Stensballe, & Vogel, 2015). The high levels of different insulin-like growth factors have a proliferative influence on colonocytes during hyperinsulinemia, causing inflammation which leads to a high colon cancer risk among individuals with obesity. Further, literature shows that reliable findings have shown that there is a positive relationship between consumption of processed and red meat and colorectal cancer, but dietary fibers have a protective effect. Available evidence that supports the fact that such dietary components as folate, vitamin D, fruits, fish, selenium, and vegetables have a protective effect against colorectal cancer is suggestive despite being limited. However, something interesting is that colonic microbiota have been established to have a crucial role in the mediation of the effect of diet on colorectal cancer. According to the figure below, dietary fibres have a protective influence.  Fig. 1: Microbiotal metabolities and dietary factors which mediate the risk of colorectal cancer.
Symptoms of Colorectal
Some of the most common signs and symptoms of colorectal cancer include the following; 
i. Bowel habits change persistently, including constipation, diarrhoea or the consistency of stool. ii. Blood in stool or rectal bleeding (Liu, Ren, Wang, Chen, Gong, Bai, & Qian, 2015).
iii. Such persistent abdominal comfort as gas, cramps, or pain. 
iv. Feeling that the bowel is not emptying completely. 
v. Fatigue or general body weakness (Landman & Quevrain, 2016). 
vi. Unexplained, drastic weight loss. 
Many people who have colorectal cancer may not experience or show any signs or symptoms during the early stages of the condition. Once the signs and symptoms appear, they vary in accordance with the size of the cancer and the location in one’s large intestine. However, it is advisable for one to be on the outlook of these changes in their body and seek medical if they feel they may have colorectal cancer. The condition is easier to manage during the early stages than during its last stages. As such, frequent screening is recommended for people with these signs and symptoms. 
Portfolio Entry 2
Disease progression and comorbidity
Understanding the progression of colorectal cancer is important as it enables one to understand how the condition is staged. Once one has been diagnosed with the condition, one of the first things that the doctor seeks to establish is the stage of the cancer (Huang & Yu, 2015). The stage is the extent of the cancer or the extent to which it has spread. Staging colorectal cancer also helps in determining the most appropriate treatment approach. 
Staging of colorectal cancer is basically done based on a system that was established by the American Joint Committee on Cancer, referred to as the TNM staging system. The factors that are considered in the system include the following;
Primary tumour (T); this refers to the size of the original tumour and whether or not cancer has progressed into the colon wall or spread to the surrounding areas (Peng, Bai, Shao, Shen, Li, & Huang, 2018). 
Regional lymph nodes (N); refers to whether or not cancer cells have progressed and spread to the surrounding lymph nodes (Cavazzoni, Bugiantella, Graziosi, Franceschini, & Donini, 2013). 
Distant metastases (M); refers to whether or not colorectal cancer has spread from the large intestine to other body parts like the liver and lungs. 
Classification of Cancer Stages
Based on the categories described above, cancer is further classified further and assigned a letter or a number that indicates its extent. The assignments are usually based on the structure of the large intestines, and the progress it has made through the colon wall. The different stages of the condition are described below. Stage 0; the earliest type of colorectal cancer, and it implies that it has not progressed beyond the mucosa (the innermost colon layer). It is easily manageable at this stage.
Stage 1; this indicates that colorectal cancer has progressed to the inner layer of the large intestine (the mucosa) and entered the next layer (the submucosa). However, its spread has not yet reached the lymph nodes. 
Stage 2; the disease at this stage has progressed more than in stage 1, and it has also grown beyond submucosa and mucosa. It is classified further into 2A, 2B, and 2C. 2A stage; colorectal cancer has no yet spread to the nearby tissues or lymph nodes but it has reached the colon’s outer layers, although it is yet to grow completely.  
2B stage; it has progressed to the visceral peritoneum and the outer layer of the colon, but not yet to the lymph nodes. 
2C stage; it has not yet reached lymph nodes, but it has grown through the colon’s layer and also to the nearby structures or organs. Stage 3
This is also further classified to stage 3A, 3B, and 3C.
3A stage; the tumour has growth through the colon’s muscular layers and has reached the nearby lymph nodes. It has not spread to distant organs or nodes. 3B stage; tumour has growth through the colon’s outermost layers and penetrated the viscera peritoneum and invaded other structures or organs, and has progressed to 1-3 lymph nodes. It may also fail to penetrate through the outer layers but be found in 4 or more lymph nodes. 
3C stage; the tumour has at this stage grown past the muscular layers and 1-4 nearby lymph nodes have cancer, but it is yet to spread to distant sites. The tumor has grown beyond the muscular layers and cancer is found in four or more nearby lymph nodes, but not distant sites.
Stage 4
Stage 4 colorectal cancer is further classified into 2.
4A stage; it indicates that the cancer has spread to a distant site like the lungs or liver. 
4B stage; this is the most advanced level of colorectal cancer and it shows that the cancer has spread to at least two distant sites such as the liver and lungs. 
Low-grade and high-grade
Besides the staging of colorectal cancer, it is also classified as either high-grade or low-grade. Once a pathologist has examined cancer cells using a microscope, they then assign it a number ranging between 1 and 4 depending on much they appear like healthy cells. A lower grade implies that the cells look more abnormal. Although it varies, low-grade cancers grow slower compared to high-grade cancers. The prognoisis also appears better for individuals whose colorectal cancer is low-grade. 
Nursing Care and Treatment 
Surgery is the mainstay treatment for colon cancer, and it involves a broad range of such procedures as radical dissection, local excision, liver resections, laparascopic procedures, as well as bypass operations. The primary aim of such procedures is to ensure the cancer is removed cleanly and ensuring there I an adequate margin of tissue surrounding it and minimize collateral damage as much as possible. 
Colorectal cancer surgery basically involves a segmental colonic resection; for instance, for a cancer that is located in the cecum or ascending large intestine, a hemicolectomy is performed. The surgical procedures involved in rectal cancer include the following; 
 Anterior resection of the rectum.
 Total Mesorectal Excision (TME), which involves resection of the lower anterior. 
 Abdominoperineal excision; excision conducted on the rectum and anal canal, forming a permanent stoma. This is common for cancers lying very low within the rectum. 
Colorectal cancers can be managed during the early stages, by a special surgical team. However, cancers which are locally advanced need attention from the multidisciplinary team. Optimal treatment of such cancers involves radiotherapy and/without chemotherapy before surgery so as to improve the likelihood of cure. Combining the TME and preoperative radiotherapy surgery has helped in cutting the risk of a colorectal cancer reoccurring locally, reducing the rates from 30% to below 10%. 
Radiotherapy
Radiotherapy is used for treating colorectal cancer by primarily reducing the incidence of the local recurrence. The procedure is performed as a course of treatment that is conducted for a week (short course) or over a period of five weeks (long course). The procedure may or may not involve chemotherapy. It is mainly given before surgery is performed, but it can also be given afterwards if the histological examinations conducted on the resected bowel show that the patient is at a high risk of local recurrence, such as when there is proof of a tumor the margin of the circumferential resection. 
Radiotherapy is associated with such side-effects as altered bowel, sore skin, impaired sexual function, and bladder function impairment. Fatigue is also common during the period of treatment and also for several weeks after the treatment. As such, patients are required to expect all these side-effects and should seek specialist assistance if the side-effects persist. 
Chemotherapy
Chemotherapy is conducted with the purpose of shrinking the size of the tumor, reducing the likelihood of metastasis, or slowing down the growth of the tumor. It can be performed following a surgery (adjuvant), prior ...