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Colorectal cancer: facts for primary care nurses

Claire Jagot
Press and PR Officer
Colon Cancer Concern
7 Rickett Street
London SW6 1RU
E:claireJ@coloncancer.org.uk

Every year, 35,000 people are diagnosed with colorectal cancer and around 16,000 of this number will die.(1) Putting it another way: one in 20 of us will develop colon cancer at some point in our lifetimes, so isn't it surprising that more isn't known about this disease?
Colorectal cancer - also called bowel or colon cancer - can develop in any part of the colon or rectum and tends to arise from nonmalignant growths called adenomas. In some cases, adenomas increase in size and undergo changes to become cancer or malignant.(2)
Five-year survival rates for colorectal cancer are still only 40%, yet this is a disease that is highly treatable when caught in its early stages. This is why early diagnosis is crucial, and one of the areas where the nurse's role is of paramount importance.

Being at risk
The exact cause of colorectal cancer is unknown, but there are several factors that might make someone more at risk:

  • The disease can develop in men and women of any age, but it tends to affect people of late middle age. In the UK, around 75% of cases occur in people over the age of 55.
  • In the UK, about 5% of all people who are diagnosed with colorectal cancer have a family predisposition to the disease. The two major identifiers of family risk are familial adenomatous polyposis (a fairly rare condition where the mucosa of the colon is covered with polyps) and hereditary nonpolyposis colorectal cancer.(3)
  • People who have a long history of inflammatory bowel disease, such as Crohn's or ulcerative ­colitis, or those who have had previous polyps removed, may be at increased risk.
  • Diets high in fat and low in vegetables, combined with an inactive lifestyle, can increase the risk of developing the disease.

What are the symptoms?
Colorectal cancer has a very slow onset and may not always show early symptoms. Common symptoms include:(4)

  • A persistent change in bowel habit over a period of four to six weeks.
  • Bleeding from the bottom without any reason in people over the age of 55.
  • Extreme tiredness without an obvious cause (anaemia).
  • Unexplained pain and/or lump in the abdomen.

All of these symptoms can be the result of many other digestive disorders that are not life-threatening, hence colorectal cancer can be difficult to diagnose. It is very important for symptoms to be investigated properly to allow correct diagnosis and treatment.

Diagnosis
There are several ways to diagnose colon cancer in individuals. The test used most often depends on the symptoms the person is experiencing. The main tests used in the diagnosis of colorectal cancer are:

  • Faecal occult blood test (FOBT): a procedure carried out in the home that involves taking a stool sample and sending it to be checked for blood that is not otherwise visible.
  • Flexible sigmoidoscopy (flexi-sig): a small camera is inserted into the rectum to investigate the lower part of the colon and through which polyps can be removed.
  • Colonoscopy: similar to the flexi-sig, although it investigates the whole of the colon and can again remove polyps if present.
  • Barium enema: a test whereby a white liquid, given in the form of an enema, coats the lining of the colon, which is then X-rayed to show up any abnormalities.
  • Ultrasound and computed tomography (CT) scans: also used in the further investigation of the disease, usually for staging the cancer rather than the diagnosis.

Screening
In October 2004, the government announced the launch of the National Bowel Cancer Screening Programme. This will be rolled out in April 2006 - starting with an 18-month trial period of two screening options - FOBT and flexi-sig. Pilot studies have been carried out to assess the effectiveness of these diagnostic tests and extra funding is being invested in the run up to the rollout.

Treatment for colorectal cancer
Treatment options for colorectal cancer very much depend on the stage of the cancer at diagnosis, where it is, if it has spread and any medical history.
The main form of treatment for colorectal cancer is surgery - about 80% of patients will undergo surgery. The surgeon will remove the portion of the colon or rectum containing the cancer, together with a healthy margin of tissue on either side of the tumour and the surrounding lymph nodes. This helps reduce the chances of the disease spreading or recurring.
Additional treatment of chemotherapy and radiotherapy will depend upon how far advanced the cancer is at diagnosis. Radiotherapy is used more commonly to treat cancer of the rectum and can be given before and/or following surgery.
The most common chemotherapy for the treatment of colorectal cancer has for many years been 5-fluorouracil (5-FU), although there are increasing numbers of other chemotherapeutic agents used in the treatment of the disease, particularly in its advanced stages. These include oxaliplatin, irinotecan and capecitabine (an oral form of 5-FU). There are also new biological agents, cetuximab (Erbitux; Merck) and bevacizumab (Avastin; Genentech), which are currently being trialled in combination with the chemotherapy drugs. Colon Cancer Concern (CCC) is campaigning for the availability of these drugs to all patients who would benefit from them, either in combination treatment or as monotherapy.

Reducing the risks
There are several things that can be done to help reduce the risks of developing colorectal cancer. These include:

  • Encouraging people to get to know their bowel habits so that they are more aware of what is ­normal for them. They will then be able to identify unexplainable changes more easily.
  • Improving diet. The NHS Health Development Agency identifies that diet can be a contributing factor in the development of colorectal cancer.(5) Its recommendations to reduce this risk include eating more fruit and vegetables, eating more fibre, maintaining a healthy body weight, and not eating too much red or barbecued meat.
  • Encouraging people to become more active, because regular exercise is associated with reducing the risk of colorectal cancer.(5)
  • Encouraging people to give up smoking, since this, in combination with poor diet and limited exercise, is seen to increase the risk of developing colorectal cancer.

The role of primary care nurses
Colorectal cancer is more common than we'd like to believe, and public awareness is crucial, especially as the disease is very preventable when caught in its early stages. Primary care nurses play a pivotal part in reducing the number of deaths from this disease.
The increasing role of primary care nurses in health promotion,(6) raising awareness of disease and prevention in the healthy population instead of just looking after illness, makes them well placed to work with CCC to help it achieve its objective of raising awareness of colorectal cancer.
Primary care nurses can identify colorectal symptoms in their patients. It is vital that they have a good knowledge of the symptoms and risk factors surrounding colorectal cancer, so that they can adequately advise their patients who might have concerns. In addition, they need to be aware of the urgent referral guidelines for the disease and be able to identify patients who are at risk.
The guidelines for urgent referrals are as follows:(7)

  • Rectal bleeding and a persistent change in bowel habit for at least six weeks.
  • Persistent rectal bleeding without anal symptoms in patients over 65.
  • Recent changes of bowel habit to looser stools and/or increased frequency of defecation, ­persistent for more than six weeks.
  • Iron-deficiency anaemia without obvious cause.
  • An easily palpable abdominal or rectal mass.

Primary care nurses are also important influencers of other primary care workers, including GPs, and have a key role to play in raising awareness and encouraging best practice across the sector.

The role of Colon Cancer Concern
As the UK's leading colorectal cancer charity, CCC  has a huge responsibility in the fight against the second biggest cancer killer. The charity is involved in a broad spectrum of work, including:

  • Raising awareness of the disease among the public.
  • Educating healthcare professionals.
  • Providing information on all aspects of colorectal cancer, to both the public and medical experts alike.
  • Campaigning on behalf of the patients and carers we represent.

CCC can do none of the above in isolation, and as such works closely with healthcare professionals across all pillars of its activity. For example, the charity runs education programmes for colorectal nurse specialists, provides medical information to nurses, and works together with local nurse specialists as part of our national awareness-raising campaigns.
This collaboration between CCC and the healthcare community to raise awareness is of particular importance and relevance to nurses in the primary care field.
The charity works closely with these nurses, providing them with campaign literature so that they are themselves more aware of symptoms and prevention messages. With greater awareness levels among the population, primary care nurses are often the first port of call for people who do have concerns - and CCC works hard to ensure that they are supported in this as much as possible.

Conclusion
Recent research has indicated that 84% of the UK population would rather ignore their symptoms than act upon them by visiting their GP.(8) An increased understanding that early diagnosis increases the likelihood of cure is crucial. Encouraging people to act upon their symptoms has to be done in conjunction with healthcare professionals if it is going to be as effective as possible.
Primary care nurses are in a strong position to help achieve this and must not be overlooked when it comes to raising awareness of the prevention and symptoms of colorectal cancer.

References

  1. Cancer Research UK.Cancer Stats London Cancer Research UK;2003
  2. Colon Cancer Concern Concerned about...colorectal cancer?London CCC;2002
  3. Fordy C.Focuson treatment.Perspective 2001;Summer:2
  4. Colon Cancer Concern.could it be Bowel Cancer?London CCC;2004
  5. NHS Health Development Agency.Cancer Prevention London;Department of health 2000
  6. Swan E,The nurse's role in bowel awareness.Nurs Times2002;98(14):42
  7. NHS Executive .Referral guidelines for cancer London:DH;1999
  8. United European Gastroenterology Federation.IPSOS survey .Barcelona:UEGF;2003.

Resources
Colon Cancer Concern
The CCC infoline is staffed by specialist colorectal stoma and oncology nurses.It is open Monday to Friday,10am until 4pm
W:www.coloncancer.org.uk
Infoline:08708 50 60 50