Introduction

Several clinical issues in colon cancer risk, detection, diagnosis, and treatment were discussed at the 2007 Oncology Nursing Society Congress in Las Vegas, NV.

Screening

Charlene Marinelli, RN, BSN, OCN, Nora Katurakes, RN, MSN, OCN, and Sandra Donnelly, RN, OCN of Christina Health Care Services in Newark, Delaware presented on their experience with the Christina Health Care portion of a major colorectal cancer screening project in the state of Delaware.¹ The program targeted a group of underserved adults and included a variety of strategies to address barriers to care including use of educational materials that were sensitive to the culture of the target population, assistance in enrolling in the state-funded colon cancer screening program for the uninsured, use of a network of established partners for referrals, and structured tracking of referrals and case management through a web-based system. The major outcome evaluated was improvement in the screening rate as reported to the Behavioral Risk Factor Surveillance Survey from 1999 to 2004. The rates of ever having a sigmoidoscopy or colonoscopy increased from 45% to 62% for caucasians and from 40% to 58% for African Americans. The authors concluded that oncology nurses were effective in the role of colorectal screening nurse navigators across the multiple elements of the navigator role, including public education, program development, addressing barriers to screening, direct services to clients, and coordination of care.

Genetics

The role of genetics in colorectal cancer and issues in genetic predisposition testing relevant to colorectal cancer were discussed in two different instructional sessions. Alice Veitz, RN, MSN, CRNP and Amy Tranin, ARNP, MS, AOCN presented the session on genetic testing using Hereditary Nonpolyposis Colon Cancer (HNPCC) as one of two exemplars.^2,3 This session provided valuable background information about the role of different types of genes in cancer and current recommended practice and practice standards or guidelines in cancer genetic predisposition testing. Key issues included a review of criteria for genetic predisposition testing for HNPCC, guidance on determining whether or not the test would be useful, the ethics and practicalities of consent for testing, reimbursement, possible risks such as insurance discrimination, and the interpretation of results of cancer genetic predisposition testing.

Emerging Technology

Future contributions of emerging technology in the diagnosis and treatment of colon cancer were addressed in a special session on nanotechnology and cancer and in an instructional session describing advanced technologies to diagnose and treat gastrointestinal malignancies. Mauro Ferrari, PhD, and Catherine Handy, PhD, RN, AOCN presented the basics of nanotechnology and discussed current and anticipated applications of nanotechnology to the diagnosis, treatment, and monitoring of cancer.⁴ The use of directed therapy, which involves the delivery of drug directly to cancer cells is one of the exciting ideas directly relevant to most of the solid tumor forms of cancer because the therapy is delivered only where it is needed, a paradigm that is narrower than the targeted therapies which act on a more general target.

Minimally invasive surgery, new endoscopy techniques, and refinements of interventional techniques are being applied to all phases of care for people with colorectal cancer. Liver metastases in colorectal cancer are being treated using new technology for percutaneous radiofrequency ablation, stents are being used in gastric outlet obstruction as well as small bowel obstruction, while new smaller instruments and new variants of existing techniques, like embolization, are being developed and applied in the diagnosis and treatment of colorectal cancer.⁵

Advances in Adjuvant Chemotherapy

Advances and controversies in adjuvant chemotherapy for colorectal cancer were addressed in a satellite symposium chaired by Carolyn M. Grande, MSN, CRNP, AOCNP. A number of studies reported in the past two years and recently initiated studies were discussed. Presentations in this symposium included the following:

• challenges in the use of irinotecan and oxaliplatin in patients with colorectal cancer,
• experience in clinical trials using monoclonal antibodies such as bevacizumab or cetuximab alone or in combination with cytotoxic chemotherapy,
• sequencing of therapy,
• differential responses to chemotherapy regimens between patients with Stage II and those with Stage III disease,
• the use of complex combination regimens in metastatic disease, and
• the use of chemotherapy holidays in patients with colorectal cancer.

Toxicities of the new agents and key decision points in the response to a treatment toxicity were also discussed with an emphasis on the monoclonal antibodies that are being used in colorectal cancer.⁶ The presentations in this symposium captured the high volume of research and the use of novel therapies in the treatment of colorectal cancer. New approaches to the management of metastatic colorectal cancer may cause a situation similar to that seen in breast cancer where multiple lines of therapy are applied over long time periods essentially changing the disease from a terminal illness to a chronic management challenge.

Role of Targeted Agents in Metastatic Colorectal Cancer

The role of targeted agents in metastatic colorectal cancer was discussed in a satellite symposium chaired by Jill Ashton, RN, BSN, OCN from Duke Comprehensive Cancer Center.⁷ Conventional chemotherapy and the sequencing of targeted therapies were discussed and the improved survival with multi-agent therapy was highlighted. (See Table 1) Multiple genetic events underlie the malignant transformation and progression of colorectal cancer and growth factors contribute to the progression and metastasis of colorectal cancer. Knowledge of these events provides novel targets for drug therapy and therapy is more likely to be effective if all of the events are targeted.

 Table 1: Survival and First-Line Treatment of Colorectal Cancer

Adapted from Dan Laheru, MD

Laura Zitella, RN, MS, NP, AOCN, Stanford University Medical Center, discussed several of the targeted pathways currently being investigated and utilized in the management of metastatic colorectal cancer, including anti-vascular endothelial growth factor (VEGF) monoclonal antibodies (bevacizumab) and anti-epidermal growth factor receptor (EGFR) monoclonal antibodies (cetuximab, panitumumab, and matuzumab).

Jill Ashton discussed nursing considerations regarding side effect management of targeted therapies. Some of the side effects from bevacizumab that were discussed include hypertension, wound healing complications, gastrointestinal perforations, hemorrhage, arterial thromboembolic events, proteinuria, and congestive heart failure. Regarding EGFR inhibition, cetuximab administered weekly and panitumumab administered every two weeks were discussed. Both of these EGFR inhibitors may result in dermatologic toxicities, hypomagnesemia, and diarrhea. Dermatologic toxicities including, dermatitis, rash, and paronychia, require careful monitoring. Monitoring for super infection of the rash is a critical part of the management plant. Monitoring magnesium levels for hypomagnesemia and administering oral and IV supplementation as necessary is also important for patients being treated with cetuximab or panitumumab. Interstitial lung diseas, although occurring at a very low rate, should also be monitored. Diarrhea is usually mild to moderate. The management of toxicities is key to keeping patients on therapy and improving outcomes. Nursing research could play a vital role in how we manage toxicities.

Dan Laheru, MD, from Johns Hopkins University School of Medicine, discussed the treatment options for patients with metastatic colorectal cancer as summarized in Table 2.

Table 2: Multiple Treatment Options for Metastatic Colorectal Cancer Patients

FOLFOX= 5-FU (bolus/infusion for 2 d), LV, oxaliplatin q 2wk

FOLFIRI= 5-FU (bolus/infusion for 2 d), LV, irinotecan q 2wk

IFL= bolus 5-FU, LV, irinotecan weekly

Oxaliplatin: Managing Peripheral Neuropathy

One of the nursing care challenges being encountered in colorectal cancer patients treated with oxaliplatin is peripheral neuropathy. Virginia Sun, RN, MSN and colleagues from the City of Hope in Duarte, CA studied the symptom concerns of colorectal cancer patients with oxaliplatin-induced peripheral neuropathy and the impact on quality of life.8 Nearly 62% of the subjects experienced neuropathy. Symptom concerns crossed the physical, emotional, and functional domains of quality of life and qualitative data indicated that patients were living with symptoms of neuropathy and attributed some decrements in function to neuropathy.  Data collection in this study was limited to the first sixty days following the initiation of oxaliplatin therapy in oxaliplatin naïve subjects. Additional studies are needed to characterize the pattern of change in neuropathy and the impact of neuropathy on quality of life outcomes later in treatment and following completion of treatment.  The qualitative data suggest that functional testing may be helpful in understanding patient reports of the impact of neuropathy in terms of the potential safety risks related to mobility and balance problems associated with peripheral neuropathy.    

Conclusion

The presentations on colorectal cancer reflect the diversity of the issues seen in this disease including promoting screening, cancer health disparities in underserved populations, practice in genetic susceptibility testing, and the application of new technologies to colon cancer diagnosis, treatment, and monitoring. The information on evolving treatment strategies also demonstrated that the changes in treatment have resulted in new challenges in oncology nursing practice in symptom management, rehabilitation, and survivorship issues. 

To successfully complete this CME activity, please read the additional articles from the 2007 ONS Conference Coverage before you take the post test:

Updates in the Management of Thrombocytopenia 
Kimberly Noonan, RN, NP, Division of Hematologic Oncology, Dana Farber Cancer Institute

Strategies for Preventing Infection in Cancer Patients with Neutropenia 
Lillian Nail, PhD, RN, FAAN, Rawlinson Professor & Senior Scientist, Oregon Health & Science University School of Nursing, Portland, Oregon

Myelosuppression: Oncology Nursing Society Congress 2007 
Lillian Nail, PhD, RN, FAAN, Rawlinson Professor & Senior Scientist, Oregon Health & Science University School of Nursing, Portland, Oregon

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References

1. Marinelli C, Katurakes N, Donnelly S. Oncology nurse as a colon cancer screening nurse navigator. Proceedings from the 32nd Oncology Nursing Society Congress. Las Vegas, NV. 2007, Abstract # 2009.

2. Veitz A, Tranin A. Genetic testing in the clinical setting: Where do we start? Proceedings from the 32nd Oncology Nursing Society Congress. Las Vegas, NV. 2007.

3. Devita D. The oncology nurse's role in caring for the patient with hereditary non polyposis colorectal carcinoma. Proceedings from the 32nds Oncology Nursing Society Congress. Las Vegas, NV. 2007, Abstract # 2117.

4. Ferrari M, Handy C. Big payoff for a small wager: Nanotechnology in cancer patients. Proceedings from the 32nd Oncology Nursing Society Congress. Las Vegas, NV. 2007.

5. Sansivero G, Coleman J. Advanced technologies to diagnose and treat gastrointestinal malignancies. Proceedings from the 32nd Oncology Nursing Society Congress. Las Vegas, NV. 2007.

6. Grande CM, Handy CM, Venook AP, Viale PH. Practice patterns in colorectal cancer: A panel discussion. Proceedings from the 32nd Oncology Nursing Society Congress. Las Vegas, NV. 2007.

7. Ashton J, Laheru D, Zitella L. Sequencing Therapies: The role of targeted agents in metastatic colorectal cancer (mCRC). Proceedings form the 32nd Oncology Nursing Society Congress. Las Vegas, NV. 2007.

8. Sun V, Ferrell B, Otis-Green S, Shibata S, Juarez G. Symptom concerns and quality of life in patients with oxaliplatin-induced peripheral neuropathy. Proceedings from the 32nd Oncology Nursing Society Congress. Las Vegas, NV. 2007, Abstract #2100.