Colorectal cancer has its mortality rate of around 655,000 a year throughout the world (World Health Organization, 2006); this is seen to be the third leading cancer cause death in western world and in united states colorectal cancer is fourth common in all cancer types causing disease (National Cancer Institute. 2009), around 35,000 morbidity rate causing common solid organ malignancy in United Kingdom (Hall Nigel, 2007). Colorectal cancer is commonly called as bowel cancer or colon cancer.
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This essay mainly focuses on the pathophysiology of colorectal cancer, its psychological and sociological responses. Here the pathophysiological part gives a clear idea of the clinical signs and symptoms, pathology and medical management of the disease, the main psychological part deals with the body image of the patient who lives with stoma. The result of final medical and surgical management of colorectal cancer is an opening in the abdominal surface, done as a life saving measure. So the opening may be a colostomy or ileostomy where a bag is given to collect the body waste from the intestine usually stools. Then the sociological aspect of the patient’s body image and living with stoma is been understood.
Colorectal cancer can be defined as the cancerous stage of colon and rectum. These cancerous cells are seen as malignant tumours in the inner wall of the large intestine (Medicinenet.com, 1998).
Clinical features and Diagnoses:
The clinical features of the disease can be, rectal bleeding, diarrhoea, right side abdominal lump and sometimes in rectum, weight loss, abdominal pain, patient being anaemic due to bleeding, bowel obstruction, sickness due to constipation and bloating (Cancer Research UK, 2010). The most common are the gastrointestinal symptoms; these are seen in the pathological absence and even there’s similarity at the time of malignancy and benign tumour.
Recent research study at Portsmouth has found that this symptom is first recommendation for confirming colorectal cancer and is considered to be the consistent pointers of malignant colorectal (Hall Nigel, 2007). When the tumour size increases bowel lumen is likely narrowed causing obstructive symptoms. At this time the patient experiences loosening of the stool instead of constipation, the other problems arising from determined bowel habit changes should be examined carefully with proper investigation. Whereas the distal tumours shows bowel habit alterations leading to the solid state of stool consistency, this distal tumour symptom is more possible than proximal tumours. Since the proximal tumours shows its symptomatic outcomes only after complete obstruction. Tenesmus or an incomplete evacuation feeling is the cancerous mass effect in the rectum (Hall Nigel, 2007).
The most disturbing symptom is rectal bleeding (Hall Nigel, 2007). This bleeding looks bright blooded same like haemorrhoids if the tumour is in the low rectum and bleeding in case of left sided tumours it’s in dark redden colour and stools with blood is seen. There are some uncommon symptoms like pain, weight loss and anorexia unless or not extensive metastatic disease or else the disease reaching its malignancy to bone and/or nerves. If the patient is obstructed with abscess formation the immediate requirement is surgical emergence (Hall Nigel, 2007). Patients by these symptoms indicate that the colorectal pathology must go through abdominal examination, rectal examination and a rigid sigmoidoscopy at proper diagnostic centres. General examination might expose the signs of anaemia. Most of the colorectal cancers due to its mass is palpable and helps the examiner to give something the once-over. Colorectal cancer investigation has its most important findings from sigmoidoscopy (Hall Nigel, 2007).
The most basic stages of colorectal tumour genesis start with the normal mucosa, with a widespread condition of cell replication, then with the clustered appearance of enlarged crypts. These abnormalities of aberrant crypts or the enlarged crypts are very proliferative, biochemical and bio-molecular (Ponz de Leon, M. & Di Gregorio, C. 2001). The most part of colorectal malignancies are been developed from adenomatous polyps. These are said to be the well-defined epithelial dysplasia masses with the uncontrolled crypt cell division. When the neoplastic cells are passing through the muscularis mucosae and submucosal infiltrate it is been considered as malignant adenoma (Ponz de Leon, M. & Di Gregorio, C. 2001).
The more used confusing definitions like “carcinoma in situ” or “intramucosal carcinoma” should be abandoned (Ponz de Leon, M. & Di Gregorio, C. 2001). Even though numerous lines of suggestion specify that carcinomas typically initiate from pre-existing adenomas, this doesn’t indicate that all tumours go through malignant variations, and doesn’t eliminate “de novo” carcinogenesis. Above and beyond of adenomas, there are several other polypoid lesions, they are hyperplastic polyps which shows the elongated crypts frequently by cystic dilatation, serrated adenomas seen as serrated glandular pattern, flat adenomas are usually flat lesions and makes the investigation process difficult when using routine lower endoscopy so it can even be a malignancy, hamartomatous polyps is in the pattern of smooth muscle branching supports lamina propria and glands and next one is inflammatory polyps (Ponz de Leon, M. & Di Gregorio, C. 2001).
Now in the western society colorectal carcinomas is seen to be the most frequent condition. When seeing the macroscopic appearance it’s the lesions as polypoid vegetating mass and even sometimes as a flat infiltrating lesion. About 96% of tumours remain as adenocarcinomas and in quite few cases shows mucinous component. There are even some very rare malignant cases in large bowel like signet ring cell carcinoma, squamous carcinoma, undifferentiated neoplasms and medullary type adenocarcinoma which is seen to be solid carcinoma having very less cellular pleomorphism or slight glandular differentiation. The three grades of colorectal carcinoma are well differentiated lesions, moderately differentiated lesions and poorly differentiated lesions. These grading usually helps in evaluating the disease prognosis from the patient even considered being as little evidence (Ponz de Leon, M. & Di Gregorio, C. 2001).
By the end of this pathophysiological section of colorectal cancer it is clear that the disease covers widespread premalignant and malignant lesions, in which most of the lesions are being removed at the time of endoscopy. By interfering at the numerous stages of a carcinogenesis it is possible to prevent the neoplasmic stage of colorectal. The stages after carcinogenesis begins are uncontrolled epithelial cell replication, the adenomas are formed in various sizes and finally progresses into malignancy (Ponz de Leon, M. & Di Gregorio, C. 2001).
During the last decade we have seen dramatic variations in managing colorectal cancer. The most noticeable changes in case of colorectal cancer are like, very precise pre-operative assessment, extensive use multimodality treatments and this includes neo-adjuvant therapy, there’s even changes in procedures through minimal invasive and a very good prognosis in rectal cancer surgery (Cunningham C and Lindsey I, 2007). So this section of medical management speaks about the various management of colorectal cancer.
The sufficient management of cancer rising inside the polyps is colonoscopic polypectomy. Now there are lots of advancements in kind of colonoscopic polypectomy treatment like endoscopic mucosal resection. This advanced colonoscopic polypectomy techniques has its goal to recover tumour clearance and decrease the occurrence of colonic meticulous pathological assessment (Cunningham C and Lindsey I, 2007). Later this help in defining the importance in the involvement of lymph node and adequacy of local excision. The former condition is conducted by Haggitt’s staging of malignant-polyps & Kikuchi’s-levels of sub-mucosal invasion in sessile lesions. Now the possibility of lymph node involvement is been easily estimated, because of the classifications it helps in preventing some great loss like avoiding the necessity of prescribed resectional surgery. This is also depending on some aspects like age of the patient, fitness and personal choice. In the remaining histo-pathological factors are favouring formal resection over the local excision which includes poor tumour differentiation, invasion of lymph and vessels and resection margin involvement (Cunningham C and Lindsey I, 2007).
Radiotherapy is usually not as much of effective as preoperative treatment (Cunningham C and Lindsey I, 2003). Also, it is accompanying injurious effects on the functioning of the neo-rectum and destruction to small-bowel confined in the pelvis as an effect of surgical-adhesions. This is used at the event when circumferential margin seen to involve in pathological specimen and if the prior treatment was not given. So this will be signifying the failure of surgical excision (Cunningham C and Lindsey I, 2003).
Since the last two decades, more advancement in the chemotherapy for treating colorectal cancer has been achieved (Lawes D and Taylor I, 2005). These advancements have made the treatment as optimal by systemic chemotherapy for the colorectal cancer over last decades. The average life of a patient has been gradually increased.
This systematic chemotherapy progressively increased the survivalist from six months (normally without treatment) to reach more than twenty months when given the combinations of 5-FU/FA, irinotecan, oxaliplatin or monoclonal antibodies. Adjuvant therapy by means of 5-FU established routines outcomes in an enhanced 5 year continued existence in stage III disease from 51 to 64%, by other modest aids for those with stage II disease (Lawes D and Taylor I, 2005).
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Body image and stoma bag
The result of final medical and surgical management of colorectal cancer is an opening in the abdominal surface, done as a life saving measure. So the opening may be a colostomy or ileostomy where a bag is given to collect the body waste from the intestine usually stools. Here comes the concept of body image, this is a concept being used in various fields which includes psychology, medicine, psychiatry, psychoanalysis, philosophy, cultural and feminist studies (Cash S & Brown T A, 1987).
More often this concept is carried by public media. Other than these fields and media the term does not have an approved definition (Cash S & Brown T A, 1987). Basically in psychology it can be said that the belief and perception of an individual body being intended along with the emotional attitude (Cash S & Brown T A, 1987).
About one quarter of stoma patients know how clinically important psychological symptoms post-operatively (White C.A & Hunt JC, 1997). Those who involved in the care of stoma patients are usually not detecting the psychological disorders. Psychological morbidity after the surgery is resulted from the unawareness of the condition which includes the past psychiatric history, dis-satisfaction with pre-operative preparation for surgery, post-operative physical symptoms and the negative thoughts and beliefs related to stoma and the condition of being a patient (White C.A & Hunt JC, 1997).
So normally surgeons are the important healthcare professionals dealing with the patient who needs to take the responsibility to collect patient information and let them know the process before and after surgery (White C.A & Hunt JC, 1997). Various forms, questionnaires and surveys should be introduced for the screening purpose, where the other healthcare professionals and Para-medicals could take the in-charge of detecting the possibilities of psychological morbidities. This can even develop with applying effort in liaising with the mental health services. The author’s future research will be done on the prospective using valid measurements psychologically and to be focussed on the morbidity by predicting, preventing, detecting and treating the psychological upset after the surgery of stoma (White C.A & Hunt JC, 1997).
PSYCHOLOGICAL AND SOCIALOGICAL ASPECTS OF COLORECTAL CANCER
In a recent survey on the colorectal cancer patients, they have found that the patients have a good quality of life after the treatment (Medical News Today, 2011). This is because the patients has followed the medical management with some physical restrictions but the survey also shows there are sufferers from this condition post operatively. They are mostly dealing with the emotional and social living where the life of the patient is seriously affected even after many years (Medical News Today, 2011).
Even though the disease is a common one, only a few details are known about post-operative and the quality of life they lead (Medical News Today, 2011). The survey dealt with approximately 300 patients who received treatment for colorectal cancer. But after many years of investigation they diagnosed that the patients are having lots of suffering due to the disease. The reason behind suffering is not with the physical problems but the fact is very serious about the problems facing psychologically. Patients are struggling due to the psychological causes. Dr. Volker Arndt and his colleagues of the Division of Clinical Epidemiology and Aging Research of the German Cancer Research Centre (Deutsches Krebsforschungszentrum, DKFZ), the Saarland Cancer Register and the Department of Epidemiology of Ulm University did this research and found that the patients are suffering from mental strains (Medical News Today, 2011).
The patients are also having secondary diseases and these were studied from the sufferers who are relatively young age (Medical News Today, 2011). Throughout the world for one year there are about one million new cases being recorded. So this takes the colorectal cancer as the most common form of cancer among other types of tumours. For the past decade there is consistent and significant prognosis as most of the cases are been detected at the early stages. Long-term researches concerning colorectal cancer patients frequently deal with repetition of tumours and/or survival rates, whereas the long term wellbeing and eminence of life of patients once completion of therapy has been of slight systematic attention to date (Medical News Today, 2011).
Arndt et al. has diagnosed after many years that the colorectal cancer patient’s quality of life is been restricted due to the emotional and social problems they face (Medical News Today, 2011). Other than this the colorectal cancer patient’s is suffering from a list of problems like respiratory distress, sleeping dis-orders, listlessness, problems in bowel and most important is financial worries. When seeing the quality of life of these patients even after three years of treatment, the improvement was modest and mostly they were restricted by the financial problems and/or living an adjustable life with stoma (Medical News Today, 2011). The persistent depression of the patient was continued for a long period. The researchers concluded that these sufferings and problems have its impact mainly due to the age and there is lots of influence in age factor on the psychological resistance. That’s the reason behind young patients are predominantly affected by the mental illness. Therefore, the younger patients are more affected by the disease compared to the older patients. This is even more threatening and having health deficits to the younger ones than the older sufferers. But still the older patients have to come up with the physical problems (Medical News Today, 2011).
A literature review clearly states that the depression state is not only to the patients but the depression is seen in the life of spouses (Goldzweig. G et al. 2009). However the communication and distress issues and sufferings between the patient’s and spouses are still being understudied (Goldzweig. G et al. 2009). “Accommodating the primacy of gender, attention should be given to whether the demand-withdrawal pattern in female cancer patients and their spouses is similar to the demands and emotional needs of both male cancer patients and male caregivers” (Goldzweig. G et al. 2009). Price (1990) developed a method for taking care of patients with altered body image (Price B, 1990). He recommended that the nurses who are dealing with the patient’s with body image problem should use the principles of body components. He states that the body should be viewed as three components, body reality, body ideal and body presentation (Price B, 1990).
As summarizing the colorectal cancer patient’s body image and living stoma, the issues primarily dealing with loss of energy, loss of control, isolation, feeling dirty, sexual dysfunction, fertility and the female patients face pregnancy and menopause. As Price Bob recommended the social workers, health care workers and even the relations or care takers of the colorectal cancer patients should know well about the body components principles and do the rehabilitation. The basic problem of the disease deals with the medical management, if the patient in the later stage suffering from psychological issues he must be under critical care under psychologist. Most of the health professionals believe that the patient suffering from stoma is their concern but the thought should be changed and particularly stoma care nurses should be thinking wisely in helping the psychological issues faced by the colorectal cancer patients.
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