Penatalaksanaan medis Ca colon stadium III

Ca colon stadium III memiliki modalitas kuratif yaitu operasi, yang juga merupakan satu-satunya modal kuratif. Kemoterapi adjuvant juga merupakan tatalaksana standar bagi pasien dengan ca colon stadium III.

Lesi yang terletak di caecum dan kolon sebeleh kanan

Standard colectomies for adenocarcinoma of the colon.

For lesions in the cecum and right colon, a right hemicolectomy is indicated. During a right hemicolectomy, the ileocolic, right colic, and right branch of the middle colic vessels are divided and removed. Care must be taken to identify the right ureter, the ovarian or testicular vessels, and the duodenum. If the omentum is attached to the tumor, it should be removed en bloc with the specimen.

For lesions in the proximal or middle transverse colon, an extended right hemicolectomy can be performed. In this procedure, the ileocolic, right colic, and middle colic vessels are divided and the specimen is removed with its mesentery.

For lesions in the splenic flexure and left colon, a left hemicolectomy is indicated. The left branch of the middle colic vessels, the inferior mesenteric vein, and the left colic vessels along with their mesenteries are included with the specimen.

For sigmoid colon lesions, a sigmoid colectomy is appropriate. The inferior mesenteric artery is divided at its origin, and dissection proceeds toward the pelvis until adequate margins are obtained. Care must be taken during dissection to identify the left ureter and the left ovarian or testicular vessels.

Total abdominal colectomy with ileorectal anastomosis may be required for patients with any of the following:

Hereditary nonpolyposis colon cancer syndrome (HNPCC) Attenuated familial adenomatous polyposis (FAP)

Metachronous cancers in separate colon segments

Total abdominal colectomy may also be indicated for some patients with acute malignant colon obstructions in whom the status of the proximal bowel is unknown.

Laparoscopic surgery

The advent of laparoscopy has revolutionized the surgical approach to colonic resections for cancers. Large prospective randomized trials have found no significant differences between open and laparoscopic colectomy with regard to intraoperative or postoperative complications, perioperative mortality rates, readmission or reoperation rates, or rate of surgical wound recurrence. Oncologic outcomes (cause-specific survival, disease recurrence, number of lymph nodes harvested) are likewise comparable.[57, 58, 59, 60, 61, 62]

For example, the Clinical Outcomes of Surgical Therapy Study Group trial found no significant differences between laparoscopic-assisted colectomy (LAC) or open colectomy in terms of 5-year disease-free survival rate (69% versus 68% in the LAC and open colectomy groups, respectively) or overall survival (76% versus 75%).[58] In a study by Lacy et al with median followup of 95 months, LAC was more effective than open colectomy, although the tendency toward higher cancer-related and overall survival did not reach statistical significance.[61]

Metastatic colorectal cancer

Chemotherapy rather than surgery has been the standard management for patients with metastatic colorectal cancer. The proper use of elective colon/rectal resections in nonobstructed patients with stage IV disease is a source of continuing debate.

Medical oncologists properly note the major drawbacks to palliative resection, such as loss of performance status and risks of surgical complications that potentially lead to delay in chemotherapy. However, surgeons understand that elective operations have lower morbidity than emergent operations on patients who are receiving chemotherapy.

There is a trend toward nonsurgical management of patients with asymptomatic, surgically incurable colorectal cancer, with studies showing that fewer than 10% of these patients subsequently require surgery for obstruction or perforation.[63, 64] A review by Venderbosch et al found that resection of the primary tumor appears to improve survival in patients with stage IV colorectal cancer, but these researchers concluded that prospective studies are warranted, given the potential bias of those results.[65]

Curative-intent resections of liver metastases have significantly improved long-term survival, with acceptable postoperative morbidity, including in older patients.[66] A study by Brouquet et al found that resection of colorectal liver metastases after a second-line chemotherapy regimen was safe and provided a modest hope for definitive cure, making this approach viable in patients with advanced colorectal liver metastases.[67]

Hepatic arterial infusion (HAI) of chemotherapeutic agents such as floxuridine (FUDR) is a consideration following partial hepatectomy. A study by House et al found that adjuvant HAI-FUDR combined with modern systemic chemotherapy resulted in improved survival compared with adjuvant chemotherapy alone.[68]

During the past decade, colonic stents have introduced an effective method of palliation for obstruction in patients with unresectable liver metastasis. However, a study by van Hooft et al found that colonic stenting has no decisive clinical advantages compared with emergency surgery. Although it may be used as an alternative treatment in undefined sets of patients, concerns about tumor spread caused by perforations remains.[69]

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Ablation

Although resection is the only potentially curative treatment for patients with colon metastases, other therapeutic options for those who are not surgical candidates, include thermal ablation techniques. Cryotherapy uses probes to freeze tumors and surrounding hepatic parenchyma. It requires laparotomy and can potentially have significant morbidity, including liver cracking, thrombocytopenia, and disseminated intravascular coagulation (DIC).

Radiofrequency ablation (RFA) uses probes that heat liver tumors and the surrounding margin of tissue to create coagulation necrosis. RFA can be performed percutaneously, laparoscopically, or through an open approach. Although RFA has minimal morbidity, local recurrence is a significant problem and is correlated with tumor size.

Adjuvant Chemotherapy

The standard therapy for patients with stage III and some patients with stage II colon cancer for the last two decades consisted of 5-fluorouracil in combination with adjuncts such as levamisole and leucovorin.[2, 3, 4] This approach has been tested in

several large randomized trials and has been shown to reduce individual 5-year risk of cancer recurrence and death by about 30%.

In an observational study of 1291 patients with stage III colon cancer, adjuvant chemotherapy reduced the risk of distant recurrence after surgery by about half. Elderly patients benefited to a similar degree as younger patients.[70, 71]

Overall, 56% of the study participants received adjuvant chemotherapy, 31% developed distant metastases, and 37% were 75 years of age or older. In the total population, the use of adjuvant chemotherapy was associated with a significantly reduced risk of distant recurrence. In separate analyses of patients ≤75 years of age and those ≥75 years of age, the effect of adjuvant chemotherapy on recurrence risk was similar in both age groups, with hazard ratios of 0.50 and 0.57, respectively.[70, 71]

Two large randomized trials (MOSAIC and NASBP-C06) investigated the addition of oxaliplatin to fluorouracil (FOLFOX4 and FLOX, respectively) and demonstrated a significant improvement in 3-year disease-free survival for patients with stage III colon cancer. The addition of irinotecan to fluorouracil in the same patient population provided no benefit based on the results from two large randomized trials (CALGB 89803 and PETACC 3).

Another randomized study, XACT, demonstrated noninferiority of capecitabine (Xeloda) compared with fluorouracil/leucovorin as adjuvant therapy for patients with stage III colon cancer. A large trial comparing capecitabine plus oxaliplatin (XELOX) versus FOLFOX has completed accrual, but survival data have not yet been reported.

Although information on results of adjuvant therapy in stage II and III colon cancer is limited, analysis of a data set assembled by the Adjuvant Colon Cancer Endpoints group showed that adjuvant chemotherapy provides a significant disease-free survival benefit because it reduces the recurrence rate. The benefit was particularly evident within the first 2 years of adjuvant therapy but some benefit extended to years 3-4.[72]

Adjuvant therapy in stage II colon cancer

The role of adjuvant chemotherapy for stage II colon cancer is controversial. Surgery alone is usually curative for stage II colon cancer, but approximately 20-30% of these patients develop tumor recurrence and ultimately die of metastatic disease. The American Society of Clinical Oncology does not recommend the routine use of adjuvant chemotherapy for patients with stage II colon cancer, and instead recommends encouraging these patients to participate in clinical trials.[73]

A large European trial (QUASAR) demonstrated small but significant benefit (3.6%) in terms of absolute 5-year survival rate for those patients who received fluorouracil/leucovorin versus those in the control group.[49] In contrast, a study by O’Connor et al found that in Medicare patients with stage II colon cancer, with or without poor prognostic features, overall survival was not substantially improved by adjuvant chemotherapy.[74]

Ongoing adjuvant trials are investigating additional risk stratification of stage II colon cancer based on clinicopathological and molecular markers. For example, the ECOG 5202 trial is comparing two forms of adjuvant therapy (oxaliplatin, leucovorin, and fluorouracil with or without bevacizumab) in high-risk patients, with low-risk patients undergoing observation only.

In this trial, high-risk patients are defined as those with microsatellite stability (MSS) or low-frequency microsatellite instability (MSI-L) and loss of heterozygosity at 18q. Low-risk patients are those with MSS or MSI-L and retention of 18q, or high-frequency MSI with or without loss of heterozygosity at 18q.

Chemotherapy for Metastatic Disease

Combination regimens provide improved efficacy and prolonged progression-free survival (PFS) in patients with metastatic colon cancer. The advent of new classes of active drugs and biologics for colorectal cancer has pushed the expected survival for patients with metastatic disease from 12 months two decades ago to about 22 months currently.

In a phase III multicenter trial in patients with advanced colorectal carcinoma refractory to fluorouracil, overall survival did not significantly differ between patients treated with fluorouracil, leucovorin, and oxaliplatin (FOLFOX4) (n=246) compared with irinotecan (n=245); however, FOLFOX 4 improved response rate (RR) and time to progression (TTP) compared with irinotecan (P=0.0009 for each RR and TTP). FOLFOX4 was associated with more neutropenia and paresthesias.[75]

Although many patients with colorectal cancer are elderly, exclusion of these patients from randomized controlled trials has impeded the creation of evidence-based guidelines for this population. A study by Seymour et al demonstrated that elderly and frail patients with untreated metastatic colorectal cancer can participate in a randomized controlled trial. Study patients, who were considered unfit for full-dose chemotherapy, underwent a comprehensive health assessment and were started on chemotherapy at 80% of standard doses.[76]

Biologic Agents

Biologic agents used in the treatment of colon cancer include monoclonal antibodies against vascular endothelial growth factor (VEGF) and epidermal growth factor receptor (EGFR), as well as a kinase inhibitor and a decoy receptor for VEGF. Such agents include the following:

Bevacizumab (Avastin) Cetuximab (Erbitux) Panitumumab (Vectibix) Regorafenib (Stivarga) Ziv-aflibercept (Zaltrap)

Bevacizumab

Bevacizumab is a humanized monoclonal antibody to VEGF. It was the first anti-angiogenesis drug to be approved in clinical practice and its first indication was for metastatic colorectal cancer. Approval was based on a pivotal trial that demonstrated improved progression-free survival (PFS) and overall survival (OS) when bevacizumab was added to chemotherapy with irinotecan, 5-fluorouracil, and leucovorin (IFL).

Bevacizumab, in combination with fluorouracil-based chemotherapy, is indicated for first- and second-line treatment of metastatic colorectal carcinoma. Bevacizumab is also approved for second-line treatment in patients who have progressed on a first-line bevacizumab-containing regimen.

Approval for continuation treatment was based on a study that showed maintenance of VEGF inhibition with bevacizumab plus standard second-line chemotherapy. The risk of death was reduced by 19% for those who received bevacizumab in combination with standard chemotherapy in both the first- and second-line compared with those who received chemotherapy alone (hazard ratio [HR]=0.81, P=0.0057). PFS improved by 32% (HR=0.68, P < 0.0001).[77]

A pooled analysis of cohorts of older patients (aged 65 years or older) from two randomized clinical trials concluded that adding bevacizumab to fluorouracil-based chemotherapy for first-line treatment of metastatic colorectal cancer improved OS and PFS in older patients as it does in younger patients, without increased risks of treatment in the older age group. Median OS improved from 14.3 months to 19.3 months with the addition of bevacizumab, while median PFS improved from 6.2 months to 9.2 months.[78]

Results from the randomized CAIRO3 trial appear to show that, compared with observation, maintenance therapy with capecitabine (Xeloda) and bevacizumab

significantly delayed disease progression in 558 previously untreated patients with stable (or better) metastatic colorectal cancer after six cycles of induction therapy with capecitabine, oxaliplatin, and bevacizumab (CAPOX-B).[79, 80] Patients in both groups were treated with CAPOX-B at first progression until second progression.

At a median follow-up of 48 months, CAPOX-B was restarted in 48% of those in the maintenance treatment group and 61% of patients in the observation group.[79,

80] Median second progression after randomization occurred at 11.7 months in the maintenance group and 8.5 months in the observation group, and median first progression after randomization occurred at 8.5 months in the maintenance group compared with 4.1 months in the observation group.[80]

In a study by Tebbutt et al, bevacizumab was found to be associated with a modestly increased risk of arterial thromboembolism (ATE). However, safety was not significantly worse in older patients or those with a history of ATE or other vascular risk factors.[81]

Despite its role in the therapy of metastatic colon cancer, bevacizumab did not significantly prolong disease-free survival in patients with stage II and III colon cancer, when added to adjuvant chemotherapy (mFOLFOX6) in a randomized trial (NASBP C-08).[82]

Cetuximab

Cetuximab is a chimeric monoclonal antibody against EGFR that is approved for treatment of KRAS mutation–negative (wild-type), EGFR-expressing, metastatic colorectal cancer. Cetuximab may be used as monotherapy or in combination with irinotecan (Camptosar) in patients with metastatic colorectal cancer refractory to fluoropyrimidine and oxaliplatin therapy.[83] Additionally, cetuximab is approved as combination therapy with FOLFIRI (irinotecan, 5-fluorouracil, leucovorin).[84, 85]

KRAS mutations, which are present in about 40% of colon adenocarcinomas, affect sensitivity to anti-EGFR treatment.[48] The addition of anti-EGFR antibody treatment to standard chemotherapy regimens for patients with advanced colorectal cancer improves progression-free survival for those with wild-type KRAS status, but not those with mutant KRAS.[86]

The CRYSTAL trial, a large international trial exploring the benefit of adding cetuximab to first-line chemotherapy with FOLFIRI, documented that only patients with wild-type KRAS derived clinical benefit from cetuximab. In patients with mutant KRAS, adding cetuximab to chemotherapy provided no clinical benefit and resulted only in unnecessary toxicity.

Based on these results, testing for KRAS mutation was added to the cetuximab indication by the European Medicines Agency (EMA). The US Food and Drug Administration (FDA) approved the use of cetuximab in combination with FOLFIRI for first-line treatment of patients with wild-type KRAS metastatic colorectal cancer, as determined by FDA-approved tests, in July 2012.

Panitumumab

Panitumumab is a fully human monoclonal antibody against EGFR. This agent was originally approved as monotherapy for patients with EGFR-expressing metastatic colorectal cancer in whom combination chemotherapy with regimens containing fluoropyrimidine, oxaliplatin, and irinotecan had failed or was not tolerated.

In May 2014, the FDA approved panitumumab for first-line treatment of patients with wild-type KRAS (exon 2) metastatic colorectal carcinoma in combination with fluorouracil, leucovorin, and oxaliplatin (FOLFOX4).[87] Approval was based on results from the PRIME trial.[88]

The PRIME trial, a phase III study, showed that patients with wild-type KRAS tumors achieved statistically significant improvement in PFS with panitumumab and FOLFOX4 versus FOLFOX4 alone (9.6 versus 8.0 months, P=0.02) and a nonsignificant improvement in OS versus FOLFOX4 alone (23.9 versus 19.7 months, P =0.07). In contrast, patients with mutant KRAS had significantly reduced PFS with panitumumab-FOLFOX4.[88]

Thus, panitumumab becomes an option, or an alternative to cetuximab, for patients who have tumors with wild-type KRAS.[89, 90] However, Hecht et al reported that adding panitumumab to bevacizumab and chemotherapy (oxaliplatin- and irinotecan-based) as first-line treatment of metastatic colorectal cancer resulted in increased toxicity and decreased PFS.[91]

In a randomized study of first-line treatment of metastatic colorectal cancer, Bokemeyer et al concluded that the overall response rate for cetuximab plus FOLFOX-4 was higher than with FOLFOX-4 alone. However, a statistically significant increase was seen only in patients with KRAS wild-type tumors, for whom the addition of cetuximab increased chance of response and lowered the risk of disease progression.[92]

Douillard and colleagues reported that in addition to KRAS mutations in exon 2, additional RAS mutations (KRAS exon 3 or 4; NRAS exon 2, 3, or 4; or BRAF exon 15) are associated with inferior PFS and OS with panitumumab-FOLFOX4 treatment.[93] Other mutations that involve some of the kinases downstream from KRAS (such

as BRAF and PI3K) are being investigated and may result in even more selective methods to identify patients that may benefit from EGFR inhibition.

Regorafenib

Regorafenib, a kinase inhibitor, was approved in September 2012. It is indicated for patients with metastatic colorectal cancer who have been previously treated with fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy; anti-VEGF therapy (eg, bevacizumab, ziv-aflibercept); and, if KRAS wild type, anti-EGFR therapy (eg, cetuximab, panitumumab).[94]

Approval was based on a multicenter trial (n=760) that randomized patients at a 2:1 ratio to receive regorafenib in addition to best supportive care or placebo plus best supportive care. Statistically significant benefit in OS and PFS was observed for regorafenib over placebo in patients with metastatic colon cancer in whom all approved standard therapies had failed.[95]

Ziv-aflibercept

Ziv-aflibercept is a fusion protein that acts as a decoy receptor for VEGF-A, VEGF-B, and placental growth factor (PlGF). This agent was approved for use in combination with FOLFIRI for the treatment of patients with metastatic colorectal cancer that is resistant to or has progressed after an oxaliplatin-containing fluoropyrimidine-based regimen.[96]

A phase III trial by Van Cutsem and colleagues in patients with metastatic colorectal cancer previously treated with an oxaliplatin-based regimen found that the addition of ziv-aflibercept fluorouracil, leucovorin, and irinotecan (FOLFIRI) improves survival. Median survival time was 13.5 months with ziv-aflibercept plus FOLFIRI versus 12.06 months with FOLFIRI alone (P = O.0032); PFS was 6.90 versus 4.67 months, respectively (P < 0.0001).[97]

Radiation Therapy

Although radiation therapy remains a standard modality for patients with rectal cancer, it has only a limited role in colon cancer. Radiation therapy is not used in the adjuvant setting, and in metastatic settings it is used only for palliative therapy in selected metastatic sites such as bone or brain metastases.

Newer, more selective ways of administering radiation therapy, such as stereotactic radiotherapy (CyberKnife) and tomotherapy, are currently being investigated. In the

future, these techniques may extend the indications for radiotherapy in the management of colon cancer.

A prospective, multicenter, randomized phase III study by Hendlisz et al showed that the addition of radioembolization with yttrium-90 significantly improved time to liver progression and median time to tumor progression in patients with unresectable, chemotherapy-refractory, liver-limited metastatic colorectal cancer. The study compared treatment with fluorouracil alone with fluorouracil plus yttrium-90 resin, which was injected into the hepatic artery.[98]

Deterrence/Prevention

Colorectal cancer prevention strategies fall into three categories:

Screening (see Workup) Lifestyle measures Pharmacologic prevention

Lifestyle measures

Abundant epidemiologic literature suggests an association of risk for developing colorectal cancer with dietary habits, environmental exposures, and level of physical activity. For example, a prospective cohort study in the general population of two Danish cities concluded that if all participants had followed recommendations for five lifestyle factors (physical activity, waist circumference, smoking, alcohol intake, and diet), 23% of colorectal cancer cases might have been prevented.[99]

There is also evidence that diet and physical activity affect the risk for recurrence of colon cancer. A prospective observational study involving patients with stage III colon cancer from the CALGB 89803 adjuvant chemotherapy trial demonstrated adverse effect with regards to risk for recurrence and increased mortality for patients following a "Western" diet (high intake of red meat, refined grains, fat, and sweets) versus a "prudent" diet (high intake of fruits and vegetables, poultry, and fish).[10]

In another observational study from the same cohort of patients, patients were prospectively monitored and physical activity was recorded. The study concluded that physical activity reduces the risk of recurrence and mortality in patients with resected stage III colon cancer.[100]

Morikawa et al reported that in patients with colorectal cancer that tested negative for cadherin-associated protein β 1 (CTNNB1 or β-catenin), high physical activity (≥18 metabolic equivalent task [MET] hours/week) after diagnosis was associated with

significantly better cancer-specific survival. No association between physical activity and survival was seen in CTNNB1–positive cases.[101]

In a study by Campbell et al, recreational physical activity before and after colorectal cancer diagnosis was associated with lower mortality. These researchers determined that 6 hours or more of sitting per day was associated with an increase in mortality compared with sitting 3 hours or less per day. The findings suggest that increasing physical activity helps reduce mortality in patients with colorectal cancer.[26]

Pharmacologic prevention

Pharmacologic prevention is based on the understanding of colorectal carcinogenesis and the availability of pharmacologic agents that are effective yet minimally toxic. The efficacy of these agents is usually first tested in high-risk populations.

Celecoxib (Celebrex), a selective cyclooxygenase-2 inhibitor, was first tested in patients with familial adenomatous polyposis (FAP). Celecoxib was effective in decreasing the number and size of polyps on serial colonoscopies, which was the primary surrogate endpoint for this trial.[102] The drug was approved for FAP patients, although it remains to be seen whether this intervention translates to reduced cancer incidence and prolonged survival.

Enthusiasm for cyclooxygenase-2 inhibitors as chemopreventive agents has dampened because of a high incidence of cardiovascular toxicity in trial patients, which led to the removal of rofecoxib from the market. Other nonsteroidal anti-inflammatory drugs (NSAIDs), such as sulindac and nonselective cyclooxygenase inhibitors, have been tested in lower-risk populations.

Aspirin use has been shown to be effective in both primary prevention of colorectal cancer (at doses of 300 mg or more daily for about 5 years[103] ) and secondary prevention (at doses ranging from 81 to 325 mg daily[104] ) of colorectal adenomas. The decrease in colon cancer risk with aspirin use may vary among population subgroups. However, body mass index, physical activity, and plasma C-peptide levels were shown to not have a significant impact on aspirin’s effect on colon cancer risk.[105]

Examination of questionnaire data collected from the Nurses’ Health Study and the Health Professionals Follow-up Study showed regular aspirin use was associated with lower risk of BRAF –wild-type colorectal cancer (multivariable hazard ratio [HR], 0.73) but not with BRAF -mutated cancer risk (multivariable HR, 1.03). Status of tumor PTGS2 expression or PIK3CA or KRAS mutation had no effect on this association.[106]

A 2013 study showed that low-dose aspirin taken every other day lowers the risk for colorectal cancer in middle-aged women. Nearly 40,000 women aged 45 and older were randomized to low-dose aspirin (100 mg) or placebo every other day for roughly 10 years; 84% were followed for an additional 7 years after treatment ended. At followup, colorectal cancer risk was lower in the aspirin group, mostly owing to a reduction in proximal colon cancer; this reduction in risk emerged after 10 years.[107]

Some trials focused on combined inhibition of polyamine production and cyclooxygenase inhibition. A report from a large randomized trial of a combination of sulindac and dimethylformamine (DMFO), an inhibitor of ornithine decarboxylase (ODC), described a dramatic effect of this combination in reducing polyp recurrence in patients with prior history of colon polyps. Confirmatory trials are ongoing.[108]

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Consultations

Colorectal cancer, especially early stage disease, can be cured surgically. Following diagnosis and staging, obtaining surgical consultation for the possibility of resection may be appropriate. After surgery, the stage of the tumor may be advanced depending on the operative findings (eg, lymph node involvement, palpable liver masses, peritoneal spread).

In the care of patients with colorectal cancer and isolated liver metastases, consider surgical consultation for possible resection. In some cases, resection of previously unresectable liver metastases may become feasible after cytoreduction with neoadjuvant chemotherapy. Therefore, ongoing involvement of the surgical oncologist is very important in patient care, even if the tumor is not considered resectable at the time of diagnosis. In patients with advanced disease, palliative surgery may be helpful in cases of bleeding or obstruction.

Gastroenterology (GI) consultation is critical for screening of high-risk individuals (ie, patients with a family history of colorectal cancer or polyposis syndromes) and those individuals who are found to be inappropriately iron deficient or to have occult blood on screening fecal examination. A colonoscopy or sigmoidoscopy is necessary to visualize the colon endoscopically, to obtain biopsies, or to resect polyps.

GI consultation may also be necessary in the management of advanced disease. The advent of colorectal stents allows a nonsurgical management of impending obstruction in patients who present with unresectable, metastatic disease.

GI consultation is necessary in the follow-up of patients after surgical resection and adjuvant chemotherapy. Patients must be screened for recurrent disease in the colon by colonoscopic examination at 1 year after surgery and then every 3 years.

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Long-Term Monitoring

Pooled analysis from several large adjuvant trials showed that 85% of colon cancer recurrences occur within 3 years after resection of primary tumor, with 95% occurring within 5 years. Therefore, patients with resected colon cancer (stage II and III) should undergo regular surveillance for at least 5 years following resection.[109] See Table 2 below.

Table 2. Surveillance recommendations for stage II and III colon cancer  (Open Table in a new window)

ParameterOrganization

ESMO [JSMO](2013)[110] ASCO (2013)[109] NCCN (2013)[111]

History and physical exam

Every 3-6 mo for 3 y, then every 6 -12 mo at 4 and 5 y

Every 3-6 mo for 3 y, then every 6 mo to 5 y

Every 3-6 mo for 2 y, then every 6 mo to 5 y

CEA Every 3-6 mo for 3 y, then every 6 -12 mo at 4 and 5 y

Every 3 mo for 3 y* Every 3-6 mo for 2 y, then every 6 mo to 5 y

Chest CT* Every 6-12 mo for first 3 y Every 1 y for 3 y Every 1 y for 5 yColonoscopy** At y 1 after surgery, and

every 3-5 y thereafterAt 1 y, then every 5 y, dictated by the findings on the previous colonoscopy

At 1 y, 3 y, and 5 y if negative

Abdominal CT* Every 6-12 mo for first 3 y Every 1 y for 3 y Every 1 y for 5 y; scans to include pelvis

ESMO = European Society of Medical Oncology; JSMO = Japanese Society of Medical Oncology; ASCO = American Society of Clinical Oncology; NCCN = National Comprehensive Cancer Network; CEA = carcinoembryonic antigen; CT = computed tomography

* For patients at high risk for recurrence (eg, lymphatic or venous invasion, or poorly differentiated tumors).

**Colonoscopy should be performed 3-6 mo postoperatively if preoperative colonoscopy was not done, due to an obstructing lesion; otherwise, colonoscopy in 1 y; if abnormal, repeat in 1 year; if no advanced adenoma (ie, villous polyp, polyp > 1 cm, or high-grade dysplasia), repeat in 3 y, then every 5 y.

Followup should be guided by the patient’s presumed risk of recurrence and functional status. Testing at the more frequent end of the range should be considered for patients at high risk. Patients with severe comorbid conditions that make them ineligible for surgery or systemic therapy should not undergo surveillance testing.[109]

Cancer Care Ontario published guidelines for the follow-up care of survivors of stages II and III colorectal cancer, and these were endorsed by the American Society of Clinical Oncology. The recommendations include the following[112, 109] :

Surveillance is especially important in the initial 2-4 years following treatment, when most recurrences occur

Patients should be followed for 5 years, and regular reviews of medical history, physical examination, and carcinoembryonic antigen testing should be performed every 3-6 months

Annual computed tomography (CT) scanning of the abdomen and chest should be performed for 3 years

Pelvic CT scanning should be performed in patients with rectal cancer annually for 3-5 years

In patients who have not received pelvic radiation, a rectosigmoidoscopy should be performed every 6 months for 2-5 years

A surveillance colonoscopy should be performed approximately 1 year after initial surgery

Patients should be counseled to maintain a healthy body weight, be physically active, and follow a healthy diet

Komplikasi pada pasien dengan kanker kolon yaitu:1.    Pertumbuhan tumor dapat menyebabkan obstruksi usus parsial atau lengkap.2.    Metastase ke organ sekitar, melalui hematogen, limfogen dan penyebaran langsung.3.    Pertumbuhan dan ulserasi dapat juga menyerang pembuluh darah sekitar kolon yang menyebabkan hemorragi.4.    Perforasi usus dapat terjadi dan mengakibatkan pembentukan abses.5.    Peritonitis dan atau sepsis dapat menimbulkan syok.6.    Pembentukan absesF.    PencegahanPencegahan Kanker Kolon.1.    Konsumsi makanan berserat. Untuk memperlancar buang air besar dan menurunkan derajat keasaman, kosentrasi asam lemak, asam empedu, dan besi dalam usus besar.2.    Asam lemak omega-3, yang terdapat dalam ikan tertentu.3.    Kosentrasi kalium, vitamin A, C, D, dan E dan betakarotin.4.    Susu yang mengandung lactobacillus acidophilus.5.    Berolahraga dan banyak bergerak sehingga semakin mudah dan teratur untuk buang air besar.6.    Hidup rileks dan kurangi stress.G.    Penatalaksanaan

1.    Penatalaksanaan medisPasien dengan gejala obstruksi usus diobati dengan cairan IV dan pengisapan nasogastrik. Apabila terjadi perdarahan yang cukup bermakna terapi komponen darah dapat diberikan.Pengobatan medis untuk kanker kolorektal paling sering dalam bentuk pendukung atau terapi ajufan. Terapi ajufan biasanya diberikan selain pengobatan bedah. Pilihan mencakup kemoterapi, terapi radiasi dan atau imunoterapi.Kemoterapi yang diberikan ialah 5-flurourasil (5-FU). Belakangan ini sering dikombinasi dengan leukovorin yang dapat meningkatkan efektifitas terapi. Bahkan ada yang memberikan 3 macam kombinasi yaitu: 5-FU, levamisol, dan leuvocorin. Dari hasil penelitian, setelah dilakukan pembedahan sebaiknya dilakukan radiasi dan kemoterapi2.    Penatalaksanaan bedahPembedahan adalah tindakan primer untuk kebanyakan kanker kolon dan rektal, pembedahan dapat bersifat kuratif atau paliatif. Kanker yang terbatas pada satu sisi dapat diangkat dengan kolonoskop. Kolostomi laparoskopik dengan polipektomi merupakan suatu prosedur yang baru dikembangkan untuk meminimalkan luasnya pembedahan pada beberapa kasus. Laparoskop digunakan sebagai pedoman dalam membuat keputusan dikolon, massa tumor kemudian di eksisi. Reseksi usus diindikasikan untuk kebanyakan lesi kelas A dan semua kelas B serta lesi C.

Pembedahan kadang dianjurkan untuk mengatasi kanker kolon kelas D. Tujuan pembedahan dalam situasi ini adalah paliatif. Apabila tumor sudah menyebar dan mencakup struktur vital sekitar, operasi tidak dapat dilakukan.Tipe pembedahan tergantung dari lokasi dan ukuran tumor.3.    Penatalaksanaan Keperawatan a)    Dukungan adaptasi dan kemandirian.b)    Meningkatkan kenyamanan. c)    Mempertahankan fungsi fisiologis optimal.d)    Mencegah komplikasi. e)    Memberikan informasi tentang proses/ kondisi penyakit, prognosis, dan    kebutuhan pengobatan. 4.    Penatalaksanaan Diet a)    Cukup mengkonsumsi serat, seperti sayur-sayuran dan buah-buahan. Serat dapat melancarkan pencemaan dan buang air besar sehingga berfungsi menghilangkan kotoran dan zat yang tidak berguna di usus, karena kotoran yang terlalu lama mengendap di usus akan menjadi racun yang memicu sel kanker. b)    Kacang-kacangan (lima porsi setiap hari) c)    Menghindari makanan yang mengandung lemak jenuh dan kolesterol tinggi terutama yang terdapat pada daging hewan. d)    Menghindari makanan yang diawetkan dan pewarna sintetik, karena hal tersebut dapat memicu sel karsinogen / sel kanker. e)    Menghindari minuman beralkohol dan rokok yang

berlebihan. f)    Melaksanakan aktivitas fisik atau olahraga secara teraturH.     Pemeriksaan penunjanga)    Endoskopi. Pemeriksaan endoskopi perlu dikerjakan, baik sigmoidoskopi maupun  kolonoskopi. Gambaran yang khas karsinoma atau ulkus akan dapat dilihat dengan jelas pada endoskopi, dan untuk menegakkan diagnosis perlu dilakukan biopsi.b)    Radiologi. Pemeriksaan radiologi yang dapat dikerjakan antara lain adalah : foto dada dan foto kolon (barium enema).Pemeriksaan dengan enema barium mungkin dapat memperjelas keadaan tumor dan mengidentifikasikan letaknya. Tes ini mungkin menggambarkan adanya kebuntuan pada isi perut, dimana terjadi pengurangan ukuran tumor pada lumen. Luka yang kecil kemungkinan tidak teridentifikasi dengan tes ini. Enema barium secara umum dilakukan setelah sigmoidoscopy dan colonoscopy.Computer Tomografi (CT) membantu memperjelas adanya massa dan luas dari penyakit. Chest X-ray dan liver scan mungkin dapat menemukan tempat yang jauh yang sudah metastasis.Pemeriksaan foto dada berguna selain untuk melihat ada tidaknya metastasis kanker pada paru juga bisa digunakan untuk persiapan tindakan pembedahan. Pada foto kolon dapat dapat terlihat suatu filling defect pada suatu tempat atau suatu striktura.

c)    Ultrasonografi (USG). Pemeriksaan ini berguna untuk mendeteksi ada tidaknya metastasis kanker kelenjar getah bening di abdomen dan di hati.d)    Histopatologi/ Selain melakukan endoskopi sebaiknya dilakukan biopsi di beberapa tempat untuk pemeriksaan histopatologis guna menegakkan diagnosis. Gambaran histopatologi karsinoma kolorektal ialah adenokarsinoma, dan perlu ditentukan differensiasi sel.e)    Laboratorium. Tidak ada petanda yang khas untuk karsinoma kolorektal, walaupun demikian setiap pasien yang mengalami perdarahan perlu diperiksa Hb. Tumor marker (petanda tumor) yang biasa dipakai adalah CEA. Kadar CEA lebih dari 5 mg/ ml biasanya ditemukan karsinoma kolorektal yang sudah lanjut. Berdasarkan penelitian, CEA tidak bisa digunakan untuk mendeteksi secara dini karsinoma kolorektal, sebab ditemukan titer lebih dari 5 mg/ml hanya pada sepertiga kasus stadium III. Pasien dengan buang air besar lendir berdarah, perlu diperiksa tinjanya secara bakteriologis terhadap shigella dan juga amoeba.f)    Scan (misalnya, MR1. CZ: gallium) dan ultrasound: Dilakukan untuk tujuan diagnostik, identifikasi metastatik, dan evaluasi respons pada pengobatan.g)    Biopsi (aspirasi, eksisi, jarum): Dilakukan untuk diagnostik banding dan menggambarkan pengobatan dan dapat dilakukan melalui sum-sum tulang, kulit, organ dan sebagainya.h)    Jumlah darah lengkap dengan diferensial dan

trombosit: Dapat menunjukkan anemia, perubahan pada sel darah merah dan sel darah putih: trombosit meningkat atau berkurang.i)    Sinar X dada: Menyelidiki penyakit paru metastatik atau primer.

Keterbukaan mengenai tindakan bedah yang akan dilakukan, pilihan anestesi, dan perubahan atau kejadian pasca operatif yang diharapkan akan menghilangkan banyak tak berdasar terhadap anestesi. Bagi sebagian pasien, adalah suatu peristiwa hidup yang bermakna.Kemampuan perawat dan dokter untuk memandang pasien dan keluarga sebagai manusia yang layak

didengarkan dan dimintai pendapat, ikut menentukan hasil pembedahan. Egbert et al. (1963,dikutip gruendamann, 2006). Memperliahatkan bahwa kecemasan pasien yang dikunjungi dan dimintai pendapat sebelum dioperasi akan berkurang saat tiba di kamar operasi dibandingkan mereka yang hanya sekedar diberi pramedikasi dengan fenobarbital. Kelompok yang mendapat premedikasi melaporkan rasa mengantuk, tetapi tetap cemas. 

Bantu pasien meningkatkan citra tubuh memberi kesempatan pasien mengungkapkan perasaannya.     Perubahan yang terjadi pada citra tubuh dan gaya hidup sering sangat mengganggu, oleh karena itu pasien memerlukan dukungan empatis dalam mencoba menyesuaikannya. Oleh karena stoma ditempatkan pada abdomen pasien dapat berfikir bahwa setiap orang akan melihat ostomi. Perawat dapat membantu informasi aktual tentang prosedur pembedahan dan pembentukan, serta penatalaksaan ostomi. Apabila pasien menghendaki, diagram, foto dan slat dapat digunakan untuk menjelaskan dan memperjelas. Pasien juga dapat mengalami stres emosional, perawat perlu mengulang beberapa intonasi. Berikan kesempatan pada pasien untuk mengajukan pertanyaan. 

Hadirkan pasien yang pernah dilakukan kolostomi.    Berdiskusi dengan individu yang berhasil menghadapi kolostomi sering membantu menurunkan kecemasan

pasien pasca prabedah.Berikan privasi untuk pasien dan orang terdekat.    Memberi waktu untuk mengekplorasikan perasaan, menghilangkan cemas dan perilaku adaptasi. Adanya kelurga dan teman-teman yang dipilih pasien melayani aktifitas dan pengalihan (membaca) akan menurunkan perasaan terisolasi.Kolaborasi :Beriak anti cemas sesuai indikasi contohnya diazepam.

Meningkatkan relaksasi dan menurunkan kecemasan.

Risiko injuri b.d. pasca-prosedur reseksi kolonTujuan : Dalam waktu 2 X 24 jam pascaintervensi reseksi kolon, pasien tidak mengalami injuri.Kriteria evaluasi:-    TTV dalam batas normal-    Kondisi kepatenan selang dada optimal-    Tidak terjadi infeksi pada insisi.Intervensi    RasionalKaji faktor-faktor yang meningkatkan risiko injuri.    Pascabedah pasien akan terdapat drain pada tubuh pasien. Keterampilan keperawatan kritis diperlukan agar pengkajian vital dapat sistematis dilakukan.Monitor adanya komplikasi pasca bedah.    Perawat memonitor adanya komplikasi pasca bedah seperti kebocoran dari sisi anastomosis, prolaps stoma, perforasi, retraksi stoma, inpaksi feka,l dan iritasi kulit, serta komplikasi paru yang dihubungkan dengan

abdomen. Andomen dipantau terhadap tanda kembalinya peristaltil dan kaji karakteristik feses.Bantu ambulasi dini.    Paisen yang menjalani kolostomi dibantu turun dari tempat tidur pada hari pertama pascaoperatif dan didorong untuk mulai berpartisipasi dalam menghadapi kolostomi.Beri perhatian khusus pada pasien usia lanjut.    Pasien lansia dapat mengalami penurunan penglihatan sampai beberapa derajat dan kerusakan pendengaran, serta kesulitan melakukan keterampilan yang memerlukan koordinasi motorik halus. Oleh karenanya, membantu pasien memegang alat ostomi pada periode praoperatif dan simulasi perbersihan kulit periostomal, seta irigasi stoma akan membantu pasien.Jatuh akibat ketidaksengajaan sering terjadi pada lansia. Oleh karena itu, pengting untuk memastikan apakah pasien dapat berjalan tanpa bantuan kekamar mandi. Perawatan kulit adalah masalah utama untuk para lansia dengan ostoma, karena pada lansia terjadi perubahan pada kulit akibat proses penuaan. Lapisan lemak subkutan dan epitel menjadi tipis dan kulit mudah teriritasi. Untuk mencegah krusakan, perhatian khusus diberikan pada hygiene kulit dan penempatan alat yang tepat. Arteri sklerosis terjadi akibat penurunan aliran darah pada luka dan sisi stoma.Pertahankan status hemodinamik yang optimal.    Pasien akan mendapat cairan intravena sebagai pemeliharaan status hemodinamik

Monitor kondisi selang nasogatrik.    Secara umum pasien pasca esofagektomi akan terpasang selang nasogatrik. Perawat berusaha untuk tidak mengubah posisi, mengangkat, memanipulasi, atau mengirigasi selang, kecuali memang diperlukan untuk terapi.Kolaborasi untuk pemberian antibiotic pasca bedah.    Antibiotik menurunkan risiko infeksi yang akan menimbulkan reaksi inflamasi local dan dapat memeperlama proses penyembuhan pasca-funduplikasi lambung.

Risiko tinggi infeksi b.d. adanya port de entrée dari luka pembedahaanTujuan : Dalam waktu 12 x 24 jam tidak terjadi infeksi, terjadi perbaikan pada integritas jaringan lunak.Kriteria evaluasi:—    Jahitan dilepas pada hari ke-12 tanpa adanya tanda-tanda infeksi dan peradangan pada area luka pembedahan—    Leukosit dalam batas normal—    TTV dalam batas normalIntervensi    RasionalKaji jenis pembedahan, hari pembedahan, dan apakah

adanya order khusus dari tim dokter bedah dalam melakukan perawatan luka.    Mengidentifikasi kemajuan atau penyimpangan dari tujuan yang diharapkan.Buat kondisi balutan dalam keadaan bersih dan kering.    Kondisi bersih dan kering akan menghindari kontaminasi komensal dan akan menyebabkan respons inflamasi lokal, serta akan memperlama penyembuhan luka.Lakukan perawatan luka:•    Lakukan perawatan luka steril pada hari kedua pasca bedah dan diulang setiap dua hari sekali pada luka abdomen

•    Lakukan perawatan luka pada sekitar drain

•    Bersihkan luka dan drainase dengan cairan antiseptic, jenis iodine providium dengan caraswabbing dari arah dalam keluar.

•    Bersihkan bekas sisa iodine providium dengan alcohol 70% atau normal salin dengan cara swabbing

dari  arah dalam keluar.

•    Tutup luka dengan kasa steril dan tuutp dengan plester adhesive yang menyeluruh menutupi kasa.    Perawatan luka sebaiknya tidak setiap hari untuk menurunkan kontak tikndakan dengan luka yang dalam kondisi steril sehingga mencegah kontaminasi kuman ke luka bedah.

Drain pasca bedah merupakan material yang menjadi jalan masuk  kuman. Perawat melakukan perawatan luka setiap hari atau disesuaikan dengan kondisi pembalut drain, apabila kotor maka harus diganti.

Pembersihan debris (sisa fagositosis, jaringan mati) dan kuman sekitar luka dengan mengoptimalkan kelebihan dari iodine providium sebagai antiseptic dan dengan arah dari dalam keluar sehingga dapat mencegah kontaminasi kuman ke jaringan luka.

Antiseptic iodine providium mempunyai kelemahan dalam menurunkan proses epitelisasi jaringan sehingga memperlambat pertumbuhan luka, maka harus  dibersihkan dengan alcohol atau normal salin.

Penutupan secara menyeluruh dapat menghindari kontaminasi dari benda atau udara yang bersentuhan dengan luka bedah.

Angkat drainase pascabedah sesuai pesanan medis.    Pelepasan sesuai indikasi bertujuan untuk menurunkan risiko infeksi.Kolaborasi penggunaan antibiotic.    Antibiotic injeksi diberikan selama tiga hari pascabedah yang kemudian dilanjutkan antibiotic oral sampai jahitan dilepas. Peran perawat mengkaji adanya reaksi dan riwayat alergi antibiotic, serta memberikan antibiotic sesuai pesanan dokter.

4.    EvaluasiHasil yang Diharapkan1.    Mempertahankan eliminasi usus adekuat.2.    Mengalami sedikit nyeri.3.    Meningkatkan toleransi aktivitas.4.    Mencapai tingkat nutrisi optimal.a.    Makan diet rendah residu, tinggi protein, dan tinggi kalori.b.    Kram abdomen berkurang.5.    Keseimbangan cairan tercapai.a.    Membatasi masukan makanan dan cairan oral bila terjadi mual.b.    Berkemih sedikitnya 1½ liter per 24 jam.6.    Mengalami penurunan ansietas.a.    Mengungkapkan masalah dan rasa takut dengan bebas.b.    Menggunakan tindakan koping untuk menghadapi stress.7.    Memerlukan informasi tentang diagnosis, prosedur

bedah, dan perawatan diri setelah pulang.a.    Mendiskusikan diagnosa, prosedur bedah, dan perawatan diri pascaoperatif.b.    Mendemonstrasikan teknik perawatan ostomi.8.    Mempertahankan insisi tetap bersih, stoma, dan luka perineal.a.    Secara bertahap meningkatkan partisipasi dalam perawatan stoma.9.    Mengungkapkan perasaan dan masalah tentang diri sendiri secara verbal.10.    Tidak mengalami komplikasi.a.    Menggunakan antibiotic oral sesuai resep.b.    Bekerjasama dalam protocol pembersihan usus.c.    Tidak demam.d.    Bisisng usus ada.e.    Lingkar abdomen dalam batas normal atau menurun.f.    Tidak ada bukti perforasi atau pendarahan.

STUDI KASUSPADA KANKER KOLON

PengkajianPENGKAJIAN KEPERAWATANNama Perawat            : Ns. CindraTanggal Pengkajian        : 05 Mei 2012Jam Pengkajian        : 08.00 WIB1.    Biodata :

Pasien Nama                 : Tn. AUmur                 : 35 thAgama             : IslamPendidikan             : SarjanaPekerjaan             : PNSStatus Pernikahan         : MenikahAlamat             : Kalirejo, Lampung TengahTanggal Masuk RS         : Sabtu, 05 Mei 2012Diagnosa Medis         : Ca. ColonPenanggung JawabNama                 : Ny. BAgama             : IslamPendidikan             : SarjanaPekerjaan             : PNSStatus Pernikahan         : MenikahAlamat             : Kalirejo, Lampung TengahHubungan dengan klien     : Istri2.    Keluhan utama :Nyeri hebat pada bagian perut3.    Riwayat Kesehatan :a.    Riwayat Penyakit Sekarang :Klien masuk ke Rumah Sakit tanggal 5 Mei 2012 akibat mengalami penyakit Ca. Colon. Klien datang ke RSUD Pringsewu diantar oleh keluarganya melalui IGD, pada tanggal 5 Mei 2012, dengan keluhan nyeri pada abdomen, kram perut, pola defekasi bermasalah, sering sembelit, feses berwarna kehitaman dan kadang disertai darah merah segar, tidak nafsu makan,

penurunan berat badan, dan cepat letih. b.    Riwayat Penyakit Dahulu :Klien mengatakan tidak mempunyai alergi terhadap makanan atau obat-obatan, hanya saja tidak terlalu suka sayuran. + 4 tahun yang lalu klien pernah terkena penyakit thypoid sampai diopname. Klien pernah mengalami kecelakaan motor namun tidak fatal. Keluarga klien mengatakan bahwa klien hampir setiap hari mengkonsumsi daging hewan, jarang makan sayur, dan klien mempunyai riwayat peminum / alkoholic.c.    Riwayat Penyakit KeluargaKeluarga klien menjelaskan anggota keluarganya tidak ada yang menderita penyakit keturunan yang umumnya menyerang, seperti DM, Asma, Hipertensi.4.    Basic Promoting physiology of Healtha.    Aktifitas dan latihanPekerjaan Tn. A yaitu seorang PNS dan waktu luangnya diisi dengan beristirahat di rumah dan berkumpul bersama keluarga. Klien jarang berolahraga. Saat sakit, klien hanya bisa berbaring di tempat tidur, aktifitas terbatas, dan klien dibantu oleh keluarganya.b.    Tidur dan istirahatSebelum sakit lama tidur klien 7-8 jam/hari, hanya dipergunakan untuk tidur malam karena klien jarang sekali tidur siang dan tidak ada gangguan dalam tidur. Saat sakit lama tidur klien hanya 5 jam dengan tidur siang selama 1 jam. Klien kadang-kadang kesulitan tidur di rumah sakit karena nyeri yang dialami klien, klien tampak lemah.

c.    Kenyamanan dan nyeriKlien merasakan nyeri pada perutnya dalam 2 bulan belakangan ini. Nyeri akan lebih terasa menyakitkan jika beraktifitas dan saat defekasi, dan akan berkurang saat klien beristirahat. Region nyeri yaitu pada abdomen bagian bawah (dessendens bawah). Skala nyeri klien 8, raut muka klien tampak menahan nyeri.d.    NutrisiSebelum sakit, frekuensi makan Tn. A tidak teratur dikarenakan kesibukan jam kerja yang mengakibatkan sering telat makan. Berat badan klien 68 kg. Berat badan dalam 2 bulan terakhir turun drastis menjadi 57 kg. Jenis makanan yang paling sering dikonsumsi klien yaitu daging hewan dan makanan cepat saji (sate & gulai). Klien tidak suka sayuran, dan tidak memiliki pantangan terhadap makanan apapun. Klien tidak pernah mengalami operasi gastrointestinal. Saat sakit, klien hanya mengkonsumsi nasi lembek, sayuran hijau, buah tapi jarang habis karena klien mual, tidak nafsu makan, & klien tidak makan yang pedas & berminyak. Diet di rumah sakit adalah diet rendah lemak hewani dan tinggi serat. Kebutuhan pemenuhan nutrisi dibantu oleh keluarganya.e.    Cairan, elektrolit, dan asam basaSebelum sakit frekuensi minum klien 7-8 gelas/hari. Saat sakit, frekuensi minum klien + 2-3 gelas/hari. Turgor kulit tidak elastis. Klien mendapat support IV Line jenis RL 20 tetes/menit.f.    Oksigenasi

Klien tidak mengalami sesak, tidak ada keluhan saat bernafas, irama teratur, klien tidak batuk, klien tidak merokok, klien tidak terpasang oksigen.g.    Eliminasi fekal/bowelFrekuensi BAB klien sebelum sakit 1x sehari di pagi hari. Feses berwani kuning, konsistensi padat, berbau khas, warna kuning kecoklatan, dan tidak ada keluhan.Saat sakit, klien kesulitan BAB, mengalami sembelit, baru 1x selama dirawat di RS, feses berwarna kehitaman, konsistensi keras, kadang disertai darah merah segar, berbau anyir.h.    Eliminasi urinFrekuensi BAK klien 2x sehari. Klien tidak mengalami perubahan pola berkemih. Klien tidak menggunakan kateter, kebutuhan pemenuhan ADL dengan bantuan keluarga.i.    Sensori, persepsi, dan kognitifKlien tidak memiliki gangguan dan riwayat penyakit yang menyangkut sensori, persepsi, dan kognitif

5. Pemeriksaan Fisik Head To Toea.    Keadaan UmumKesadaran klien composmentis, Vital Sign TD 110/90 mmHg, Nadi 70x/menit, irama reguler kekuatan sedang, Respirasi 26x/menit, irama regular, Suhu 36,50 Cb.    Kepala : kulit kepala normal, tidak ada hematoma,

lesi atau kotor. Rambut mudah patah saat dicabut, hitam tanpa uban, dan bersih.Mata : mata klien secara umum normal, bentuk simetris, konjungtiva tampak anemis, sklera tidak ikterik, pupil dapat merespon terhadap cahaya, palpebra normal, tidak ada oedema. Lensa mata normal, jernih, visus mata kanan dan kiri normal. Tampak garis kehitaman pada kelopak mata klien bagian bawah.Hidung : Hidung klien simetris, tidak ada septum deviasi, polip, epistaksis, gangguan indera pencium, atau secret.Mulut : Mulut klien normal, dimana gigi klien  normal, tidak ada lubang, dan tidak ada gigi palsu. Bibir klien kering, tidak stomatitis, dan tidak sianosis. Gusi klien berwarna merah, lidah klien tampak kotor.Telinga : telinga klien simetris, bersih, dan tidak ada gangguan pendengaran.Leher : leher klien normal, tidak ada pembesaran thyroid, tidak ada kaku kuduk, tidak ada hematoma, tida ada lesi.Tenggorokan klien normal, tidak ada nyeri tekan, tidak hipremis, dan tidak ada pembesaran tonsil.c.    Dada : bentuk dada klien normalPulmo : Inspeksi : pengembangan dada simetris. Palpasi : Fremitus taktil kanan sama dengan kiri. Perkusi : pulmo kanan dan kiri sonor. Auskultasi : vesikuler pada pulmo kanan dan kiriCor : Inspeksi: ictus cordis tidak nampak. Palpasi : Ictus

cordis teraba pada mid clavicula sic 5, Perkusi : menunjukkan batas jantung normal.Auskultasi : Bunyi jantung I (SI) di ruang intercosta V sebelah kiri, Bunyi jantung II (SII) di ruang intercosta II sebelah kanan, Bunyi jantung III (SIII) tidak ada, murmur tidak ada.d.    Abdomen : inspeksi : bentuk agak cembung. Palpasi : adanya nyeri tekan pada    perut bawah. Auskultasi : peristaltik  permenit.e.    Genetalia : Laki-laki : normal, tidak ada perdarahan.f.     Rektum : Normal, tidak ada hemoroid, tidak ada prolaps, dan tidak ada tumor.g.    Ekstremitas : - atas : Kekuatan otot ka/ki : 6/6, ROM ka/ki : aktif/aktif- bawah : kekuatan otot ka/ki: 6/6, ROM ka/ki : aktif/aktif

Psiko sosio budaya dan spiritual :Psikologis :Perasaan klien setelah mengalami masalah ini adalah gelisah. Cara mengatasi gelisahnya klien dihibur keluarga. Dukungan yang diberikan oleh keluarga sangat baik, keluarga memberikan semangat kepada klien agar klien selalu berdo’a supaya cepat sembuh.Rencana klien setelah masalah terselesaikan adalah istirahat di rumah. Klien juga mengatakan sedikit cemas dengan penyakitnya. Klien takut akan perubahan status kesehatannya.Sosial :  

Aktivitas atau peran di masyarakat adalah sebagai anggota RT 5 Kalirejo. Kebiasaan lingkungan yang tidak disukai adalah lingkungan yang kotor. Cara mengatasinya dengan melakukan kegiatan kerja bakti.Budaya : Budaya yang diikuti klien adalah budaya jawa. Kebudayaan yang dianut tidak merugikan kesehatannya.Spiritual :Aktivitas ibadah sehari-hari sholat 5 waktu. Kegiatan keagamaan yang biasa dilakukan adalah yasinan. Keyakinan klien tentang masalah kesehatan yang sekarang sedang dialami : klien yakin akan dirinya pasti sembuh.

6. Pemeriksaan PenunjangTes Diagnostik : (05 Mei 2012)Hematologi    Hasil    Nilai Normal    InterpretasiHb    11,5    12-18 g/dL    TurunHt/PVC    42    40-52%    NormalLeukosit    7.000    4.000-10.000 /uL    NormalTrombosit    253.000    150.000-450.000 /uL    NormalMasa protrombin    13.0    11.0-17.0 detik    Normal

Radiologi :   Foto colon ( Barium Enema)  Colonoscopy7.    Terapi Medis•                Bed rest

•                IVFD RL 20 tetes/menit•                Th/oral : •                Th/inj :•           Kemoterapi•           Leukovorin•           5-FU, Levamisol, Leuvocorin •           Pembedahan / Laparaskopi

ANALISA DATA

Nama Klien     : Tn. A                No. Register         : 123Umur         : 35 tahun            Diagnosa Medis     : Ca. Colon Ruang Rawat     : Paviliun Asri 3        Alamat         : KalirejoTGL/JAM    DATA FOKUS    PROBLEM    ETIOLOGI05/05/1208.00 WIB    DS : -        Klien mengatakan perutnya sangat sakit bagian bawah-        Klien mengatakan perutnya bertambah sakit saat bergerak-        Klien mengatakan nyeri hilang timbulDO :-        Klien tampak meringis kesakitan-        Klien tampak gelisah-        Skala nyeri klien 8-        Klien tampak tidak nyaman dengan perutnya        Nyeri akut    Obstruksi tumor pada usus dengan

kemungkinan menekan organ yang lain

06/05/1213.00 WIB    DS :-       Klien mengatakan nyeri pada daerah yang di insisi-       Klien mengatakan tubuhnya masih lemahDO :-       Klien tampak lemah-       Klien tampak menahan nyeri-       Ekspresi wajah klien cemberut-       Tampak kemerahan pada daerah bekas operasi      Nyeri akut    Agen cedera fisik (insisi pembedahan)

06/05/1213.30 WIB    DS :-       Klien mengatakan gatal pada daerah yang di insisi-       Keluarga klien mengatakan badan klien hangatDO :-       Daerah pembedahan tampak masih baru dan terfiksasi-       Leukosit : 15.000 /Ul-       Suhu : 37,5 C    Risiko infeksi 

    Tindakan invasif, insisi post pembedahan

06/05/1214.00 WIB

06/05/1215.00 WIB    DS -       Klien mengatakan punggungnya terasa panas-       Klien mengatakan susah bergerak-       Klien mengatakan tidak mampu beraktifitas secara mandiri

DO :-       Klien terlihat berbaring di tempat tidur-       Klien tampak terpasang kateter-       Aktifitas klien terlihat dibantu keluarga-       Klien tampak lemah-       Tampak adanya luka insisi pada perut klien

DS :-       Klien mengatakan tidak nafsu makan-       Klien mengatakan tubuhnya lemas-       Keluarga klien mengatakan klien belum memakan apapun pasca operasi-       Klien mengatakan lidahnya terasa pahitDO :-       Klien tampak lemas -       Bibir klien tampak kering & pucat-       BB turun + 11 kg selama sakit    Intoleransi aktifitas

Ketidakseimbangan nutrisi kurang dari kebutuhan tubuh     Kelemahan fisik

Ketidakmampuan untuk mencerna makanan

Diagnosa keperawatan yang mungkin muncul (NANDA):   Pre OperasiNyeri akut b.d obstruksi tumor pada usus dengan kemungkinan menekan organ yang lain   Post Operasi1.    Nyeri akut b.d agen cedera fisik (insisi pembedahan)2.    Risiko infeksi b.d tindakan invasif, insisi post pembedahan3.    Intoleransi aktivitas b.d kelemahan fisik4.    Ketidakseimbangan nutrisi kurang dari kebutuhan tubuh b.d ketidakmampuan untuk mencerna makanan