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52 CPD ACTIVITY FROM PAGE 51 for women.21 See Figure 4 for an indication of the foods necessary to maintain an appropriate fibre intake. Medicines In post hoc analyses of cardiovascular disease prevention trials, predominantly in males, there was evidence for a real but small reduction in incidence and mortality from colorectal cancer beginning 10 years Table 1. Prominent adverse effects of chemotherapy and monoclonal antibodies prescribing for treatment of colorectal cancer.12 Therapy Prominent adverse effects Description Treatment plan Fluoropy-rimidines Hand-foot syndrome Hand-foot syndrome is the gradual onset of bilaterally symmetric reactions over the palms and soles, including erythema, tenderness, pain, swelling, tingling, numbness, hyperpigmentation, pruritus, bullous lesions, dry rash, moist desquamation, ulceration and sensory impairment or paraesthesia. Preventative treatments have not undergone robust randomised controlled trials. Active treatment consists of dose reduction and/or increasing the dose interval. Urea 10 per cent cream and administration of regular analgesics can be advised. Irinotecan Diarrhoea (up to 51 per cent incidence) Diarrhoea can occur early within a few hours alongside other cholinergic symptoms, eg, hypersalivation. Late onset occurs 24 hours or more after the infusion. Atropine is administered before administration of irinotecan. Loperamide is prescribed as a take- home medicine to combat diarrhoea. If patients ask for advice, ensure they are taking their loperamide correctly, staying hydrated, have no other symptoms and are following the advice of the oncology multidisciplinary team. Patients may need hospital inpatient care. Oxaliplatin Peripheral neuropathy Most patients report acute symptoms of sensory change and temperature sensitivity to cold exposure in the extremities and in the throat, peaking at day three following the infusion. Chronic symptoms are dose related for cumulative doses >800mg/M2. Paraesthesia, numbness in a stocking- and-glove distribution, and mild sensory symptoms are common. Symptoms are usually reversible with dose reduction or treatment delay. If patients discuss these symptoms with you, ensure they have reported them to their treating oncology team. Symptoms generally start to improve around three months after completion of chemotherapy, although they can be a chronic problem for some patients. Treatments include: • Massage. • Moderately intense exercise has been shown to have some benefit in symptom management. • Duloxetine. Anti-EGFR MABs Acneiform rash See Figure 3. The rash usually appears within the first four weeks of therapy initiation and has been reported to occur in about 85 per cent of patients. There are pre-emptive and reactive measures employed to manage acneiform rash. These include moisturisers, sunscreens, steroid creams and tetracyclines. Box 2 Lifestyle advice for primary prevention of colorectal cancer. • Avoid smoking. • Alcohol consumption should be < 2 units per day for males and < 1 unit per day for females. • Increase intake of cereal fibre. • Lean red meat (up to 100 g/day) can be eaten as part of a mixed diet. Charring of red meat is best avoided. Processed meat intake should be limited. • Maintain weight in health BMI range. • Aim for 30-60 minutes of physical. activity/day. Figure 4. Fibre content of certain foods after starting aspirin. It’s not known if the colorectal cancer risk reduction and mortality reduction benefits can be extrapolated to populations without cardiovascular risk. The risk of aspirin in these average risk settings still needs more empirical data. However, the recommendations are for those at “average” risk to commence low dose aspirin (100-300mg) between the ages of 50 and 70 years for 2.5 years in total, if it’s not contra-indicated. People who are at high risk of colorectal cancer due to Lynch syndrome carrier status should be advised to begin aspirin from the commencement of their colonoscopy screening, usually at age 25.22 Secondary prevention The best method to prevent colorectal cancer is colonoscopy. This is normally performed six to 12 months post-surgery. Serum carcinoembryonic antigen should be completed every six months and undertaking two CT scans of the chest, abdomen and pelvis in the first three years following surgery to detect metastases should be undertaken.2 Staying healthy once diagnosed with colorectal cancer is important. A cohort study in patients with colon cancer who had a healthy body weight, were physically active, and ate a diet rich in vegetables and fruit and chose whole over refined grains had a 42 per cent lower risk of death during the five-year study period than patients who did not engage in these behaviours. Furthermore, patients who changed to a healthier lifestyle after diagnosis had a 33 per cent lower risk of death during the follow-up period than those who did not change their lifestyle.23 Summary Pharmacists can assist patients who should partake in screening, those receiving treatment for colorectal cancer, and discuss prevention strategies with at-risk patients. We’re in an ideal position to start conversations, motivate people and support individuals and their families receiving treatment. Consider getting your team involved in Bowel Cancer Awareness Month RETAIL PHARMACY • JUN 2021