Transcript Colon cancer: A major case study

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Colon cancer: A major
case study
By: Emily Macieiski, Dietetic Intern
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Introduction
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Patient: J.W.
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53 year-old Caucasian male
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Height: 5’11”
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Weight upon Admission February 19, 2014- 183 lbs (~83 kg)
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BMI: 26.42 kg/m2
Weight upon Discharge February 26, 2014- 178 lbs (~81 kg)
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BMI: 25.65 kg/m2
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Admitting diagnosis: anemia and abdominal pain
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Past Medical Hx: None
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Social history
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Homeless
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Used to fly planes, but turned down a pilot job d/t ailing health
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Used to study to become a nurse
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Has no health insurance
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Not married
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Brother visited during his stay
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Does not smoke or drink alcohol
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Food is a daily struggle
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GI tract
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Stomach and small intestine make up first part
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Where food is processed for energy
Colon and rectum make up the last part
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Where solid waste is passed out of the body
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Small intestine 20 ft & Large Intestine 5 ft
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Rectum last 6 inches of the digestive system
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Colon has 4 parts: ascending, transverse, sigmoid, descending
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Colon cancer
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Third most common cancer (excluding skin) diagnosed in the U.S.
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The risk of developing is 1 in 20 (5%)
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Risk factors:
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> 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
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Colon cancer diagnosis
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Begins when healthy cells that make up the lining of colon or rectum
change and grow uncontrollably
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They can form a mass/tumor and be benign or malignant
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Colorectal cancer usually begins as a polyp
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Non-cancerous growth
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Most form a mound in wall of colon
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About 10% require a special dye to be seen during a colonoscopy
If metastasizes, cancer cells can develop new tumors
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Symptoms
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Change in bowel habits: diarrhea, constipation
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Pain without a bowel movement
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Feeling like the bowel does not empty completely
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Rectal bleeding
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Dark/bloody stools
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Cramping/abdominal pain
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Weakness/fatigue
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Unintended wt loss
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Tests to diagnose
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Many develop symptoms after it has already developed
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If symptoms occur, a doctor will do a physical exam and review
medical hx
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Blood tests: CBC, liver enzymes, or tumor markers (CEA)
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Sometimes colorectal CA will bleed into large intestine or rectum
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Can cause anemia
Tests and procedures to detect:
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colonoscopy, biopsy, molecular testing of the tumor, CT scan, MRI,
ultrasound, chest x-ray, and PET scan.
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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
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Treatment- Rectal
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Rectal:
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Polypectomy
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Transanal resection instrument is inserted thru the anus & cuts thru all
the layers of the rectum to remove any cancerous tissues
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Low anterior resections part of the rectum containing the tumor is
removed and then the colon attached to remaining rectum.
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Proctectomy entire rectum is removed and then the colon is attached
to the anus (colo-anal anastomosis)
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Abdominoperineal resection (APR) removal of anus, sphincter muscle,
and tissues.
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Pelvic exenteration rectum will be removed, along with the bladder,
prostate in men, or uterus in women, if the cancer has spread
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Radiation therapy
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Radiation therapy
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Can be used with colon CA that has spread to the lining of the abdomen
or other organs
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For rectal CA, can be used before or after sx
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Chemoradiation radiation given with chemo
Side Effects:
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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
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Chemotherapy
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Systemic uses drugs that are injected into a vein or given by mouth;
travel to difference parts of the body
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Regional drugs are injected directly into an artery leading to a part of
the body containing a tumor; less side effects
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Drugs:
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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
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Stages
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Stage 0: cancer cells found only in inner lining of colon/rectum
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Stage I: grown through the mucosa and invaded mucosa layer
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Stage 2A: grown into outermost layers of colon/rectum
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Stage 2B: grown into the layers of the muscle to the visceral
peritoneum
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Stage 2C: spread through the wall of the colon/rectum and grown
into or attached to nearby tissues or organs
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Stages Continued
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Stage 3A: grown through the inner lining/the muscle layers of the
intestine; 1-3 lymph nodes
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Stage 3B: grown thru bowel wall or into surrounding organs; 1-3
lymph nodes
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Stage 3C: 3-4 lymph nodes
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Stage 4A: spread to one part of the body (such as liver/lungs)
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Stage 4B: spread to more than one organ/set of lymph nodes
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J.W.’s sx/procedures
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2/19 GI consult. US showed mass in abdominal area.
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2/20 EGD/colonoscopy with small bowel biopsy; rectal
polypectomy
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Post-op diagnosis: diverticulosis, mass in colon, rectal polyp
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Mid to proximal transverse colon mass most likely cancer
2/21 Right hemicolectomy
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Post-op diagnosis: proximal transverse colon CA
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Await pathology results
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Oncology consult
2/24Pathology results showed stage 3B colon CA
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Medications
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Cefotan- antibiotic
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Protonix- antigerd
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Heparin- anticoagulant
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Zofranantiemetic/antinauseant
Decadron- corticosteroid, antiinflammatory,
immunosuppressant
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Lantus
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Humalog- diabetic
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Toradol- pain
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Sennagen- laxative/stimulant
Venofer- antianemic to treat
iron deficiency
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Important Labs
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HgA1c: 9.0%- 2/21
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Glucose: 358 mg/dl- 2/21
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Serum albumin: 2.3 gm/dl- 2/21
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H/H: 5.6 gm/dl/22.3%- 2/21
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CRP: 9.37 mg/dl
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Dietary treatment
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J.W. was NPO on 2/19
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Advanced to full liquids on 2/22
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Regular diet on 2/24
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Glucerna shake TID
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
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Dietary treatment continued
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The Diabetic high diet was recommended d/t his newly dx DM and for his
increased needs
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J.W. was also constipated since 2/20, which delayed his discharge
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He lost 5 lbs during his stay of 1 week. NPO x 3 days.
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He consumed 100% of most meals and drank every Glucerna that was sent to
him
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Glucerna coupons provided
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Academy of Nutrition and Dietetics handouts: Carbohydrate Counting for People
with Diabetes, Fat Content of Foods List, and Fiber Content of Foods List
provided.
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Nutritional guidelines
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Low-fat, high-fiber diet to prevent
future polyps
 Limit fiber post sx until bowels
return to normal
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Tobacco and alcohol are
discouraged
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Drinking 6-8 glasses water/day &
exercise 30 min, 5 days/wk
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Fish oil can help inflammation
Rich in vegetables (cruciferous),
fruits, whole grains
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Consume less red meat
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 intake of poultry, fish, beans, and
tofu
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Multi-vitamin- especially folic acid,
vitamins B6 and D3
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Omit trans fatty acids
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 unsaturated fats- salmon,
flaxseed, canola and olive oils
Dairy products encouraged for
calcium and vitamin D
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Nutrition diagnosis and Goals
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Unintended weight loss related to
malabsorption as evidenced by 75
pounds weight loss (29%) over 6
months.
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Altered nutrition-related lab values
related to newly diagnosed DM as
evidenced by HgA1c of 9.0%.
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Increased calorie and protein needs
related to newly diagnosed colon
cancer stage IIIB as evidenced by
biopsy results.
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Altered GI function related to changes
in motility as evidenced by
constipation x 5 days.
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Goal- Provide adequate kcal and
protein to meet estimated needs
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Pt will maintain po intake of 75%
or more of meals, including
supplement
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Prevent further wt loss, maintain
lean body mass
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Improvement with blood sugars
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Start solid foods by day 5-7
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Prognosis
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MD set him up with free class at Diabetes Wellness Center in April
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Free meter and glucose test strips
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Sent home with Metformin
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Port to be placed for chemo in a few weeks
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J.W. is very intelligent and driven
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Will be staying with family friends in Mason
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His stage of colon cancer hasn’t spread to other organs yet
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Doctors have a lot of faith in him
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References
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"Colorectal Cancer." Welcome to the Johns Hopkins Colon Cancer Center.
N.p., 2001-2014. Web. 21 Apr. 2014.
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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.
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Pronsky ZM, Crowe JP. Food Medication Interactions. 17th edition.
Birchrunville, PA: Food-Medication Interactions; 2012
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"Colon Cancer Treatment." Treatment for Colon Cancer. N.p., 2014. Web.
21 Apr. 2014.
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"Colorectal Cancer." University of Maryland Medical Center. N.p., 2014.
Web. 21 Apr. 2014.
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References
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"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
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"Colon Cancer Nutrition." EMedTV: Health Information Brought To Life. Clinaero,
Inc, 2006-2014. Web. 21 Apr. 2014.
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"Colorectal Cancer." American Cancer Society, 2013. Web. 21 Apr. 2014.
<http://www.cancer.org/acs/groups/cid/documents/webcontent/003096pdf.pdf>.
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Escott-Stump, Sylvia. "Colorectal Cancer." Nutrition and Diagnosis- Related Care.
7th ed. Philadelphia: Lippincott Williams and Wilkins, 2012. 759-62. Print.
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"SuperTracker." ChooseMyPlate.gov. United States Department of Agriculture,
2014. Web. 21 Apr. 2014.