Complications
Neutropenia, thrombocytopenia, and anaemia may develop with the chemotherapeutic agents used in the treatment of colorectal cancer. Management is temporary drug cessation and supportive treatment until there is recovery of bone marrow function.
Increase in serum liver enzymes is common during treatment. Rarely, there is evidence of a hepatic veno-occlusive disease that presents with evidence of portal hypertension or persistent abnormalities in liver biochemistry.
Occurs commonly with chemotherapeutic agents. Management is symptomatic, with loperamide, antiemetics, and analgesia.
Adverse effect of chemotherapy.
The most common adverse effects of PD-1 or PD-L1 inhibitor therapies are: anaemia (45.4%), fatigue (34.3%), dysphagia (30%), neutropenia (19.6%), lymphopenia (10.2%), hypertension (9.3%), and elevated lipase (7.2%).[345]
Other potential adverse effects include colitis, myocarditis, pericarditis, and skin toxicities. Guidelines for monitoring of patients and management of complications are available.[390]
Acneiform rash is very common and occurs particularly on the face and upper torso. It often improves with continued treatment and is reversible. It is associated with an improved chance of response to treatment and is independent of K-RAS status.[386]
Loose stool, urgency, and faecal incontinence are common after radiotherapy for rectal cancer.
Patients undergoing colorectal surgery are at a high-risk of developing perioperative VTE.[387][388][389] Many VTEs are diagnosed after discharge, making post-discharge extended prophylaxis important.[387]
VTE risk levels may be assessed in individuals undergoing colorectal surgery to allow for an informed discussion regarding the risks and benefits of VTE prophylaxis.[387] A clinical decision support system integrated into existing electronic health systems can help improve compliance with inpatient VTE prophylaxis recommendations.[387]
Mechanical strategies, such as graduated compression stockings, can be used in patients in whom chemical prophylaxis is contraindicated.[387] Patients at moderate to high-risk for VTE and not at high-risk for bleeding complications can benefit from inpatient pharmacological thromboprophylaxis.[387] Extended-duration pharmacological thromboprophylaxis may be considered in patients undergoing colorectal cancer surgery who are at high-risk of VTE.[387]
Bladder dysfunction occurs as a result of damage to the pelvic nerves during surgery for rectal cancer or as a result of neoadjuvant therapy.[382] Symptoms can include urinary urgency, incontinence, and retention. Urinary catheterisation may occasionally be required to relieve urinary retention.
Erectile dysfunction occurs as a result of damage to the pelvic nerves during surgery for rectal cancer or as a result of neoadjuvant therapy.[382]
Low anterior resection syndrome includes symptoms such as faecal incontinence or urgency, and emptying difficulties. Anal sphincter muscle or nerve damage during rectoanal resection or anastomosis construction, and intersphincteric resection for low-lying tumours or hand-sewing anastomosis, are the absolute risk factors for low anterior resection syndrome. Pre-operative radiotherapy, post-operative complications, such as anastomosis leakage, or longer duration of stoma, are also risk factors.[383]
Pulmonary fibrosis occurs in <1% of patients and presents with dry cough, dyspnoea, basal crepitations, and pulmonary infiltrates on chest x-ray or CT chest.
Neurotoxicity, a common adverse effect of oxaliplatin, usually presents as a peripheral neuropathy. There are two forms: acute and chronic. The acute form develops in >90% of patients and may begin during or shortly after the first few infusions.[384] Symptoms consist of paraesthesias and dysaesthesias of the hands, feet, and perioral region and may be exacerbated by cold. It is self-limiting.
The chronic form is a cumulative axonal sensory neuropathy and may be dose limiting. The neuropathy is reversible in some patients after stopping treatment. No intervention has definitely been shown to prevent neurotoxicity. One prospective study of patients with stage 3 colon cancer who were enrolled in the CALGB/SWOG 80702 trial showed that lower physical activity, higher body mass index, diabetes, and longer treatment duration were associated with increased severity of oxaliplatin-induced peripheral neuropathy.[385] However, no significant association of celecoxib use and vitamin B6 intake with oxaliplatin-induced peripheral neuropathy was observed.[385]
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