Amanda Wilde (Host): The AHN Colon and Rectal Center of Excellence offers cutting edge care for the diagnosis and treatment of colon, rectal, and related cancers. Dr. James McCormick is System Chief of Colon and Rectal Surgery at Allegheny Health Network, and we're discussing how the center highlights prevention and treatment through collaborative, patient-centered care.

Welcome to AHN MedTalks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Amanda Wilde. And welcome to you, Dr. McCormick.

Dr. James McCormick: Well, thank you. Thank you for having me on.

Host: Thank you for being here. Let's begin just briefly with an overview of your role at AHN. How did your expertise and experience bring you to the role of System Chief Colon and Rectal Surgery?

Dr. James McCormick: Well, I have a lot of training in General Surgery. And after General Surgery, if someone has a specific interest, then you can go and do additional training. And I did my training in Colorectal Surgery. And at that time, I had a specific interest in colorectal cancer. So after completing my training, I started at AHN several years ago now, we'll just say several years for the sake of argument, I started working at AHN. And I started to develop a big practice with colon and rectal cancers. And I was able to meet some other people in other specialties in Radiation-Oncology and Medical-Oncology that were also similarly interested, and we were able to get together and make what we call a tumor board. So, the three or four of us started a decade ago now, meeting in a small conference room in one of our hospitals, and talking about patients, and going over all of their information. And what we discovered was that when we did that, rather than just having less organized conversations, we really were able to create for those individual patients a very specific, tailored, and good plan for their cancer care. And we found that we actually all kind of modified our plans a little bit to actually end up with a better result than if we had come up with the plans individually. So, that's really how I got into this role of being what we call the Chair of the Colorectal Cancer Program for the Cancer Center of Excellence at Allegheny Health Network.

Host: At AHN's Colon and Rectal Center of Excellence, you have a national accreditation. What does that mean for patients?

Dr. James McCormick: So, the program that you're referring to is called the National Accreditation Program for Rectal Cancer. And that is a program that is run by the Commission on Cancer, which is a collaboration between the American Cancer Society and the American College of Surgeons. And so, what that program does is it allows places that treat rectal cancer specifically, it allows them to apply for the accreditation and the accreditation sets standards for how are you treating your rectal cancer patients. And so, it ensures for patients that these minimum standards are being met.

Now, rectal cancer is a specific disease process that is very complicated to treat. It requires chemotherapy, radiation therapy, and surgery, and so coordination of that can be very difficult. It also requires that the tumor be properly staged and the treatment planning be developed well before the treatment is initiated. And so, those are the standards that the NAPRC, the Commission on Cancer, requires of programs such as ours. And it ensures that your doctors are actually talking to each other in this tumor board that we've referenced before. And it ensures that the proper pre-treatment planning is in place and ultimately the organization of collaboration between the Medical-Oncology, who gives the chemotherapy; the Radiation-Oncologist, who gives the radiation therapy; and the surgeon, who's going to ultimately do the surgery, that is all organized in a way that best suits the patient.

Host: Well, as you touched on, getting a collaborative team working together smoothly is always a challenge. Can you talk a little bit about the nurse navigation team and their role in streamlining the process for patients?

walked this process, and having done it

Amanda Wilde (Host): for

Dr. James McCormick: Absolutely. They're really the center of the spoke in terms of that organization. That is for sure. So as soon as a person is diagnosed with colon or rectal cancer at one of our Allegheny Health Network facilities, or is introduced by a referral into the Allegheny Health Network, and they have a diagnosis of colon and rectal cancer, they're assigned a nurse navigator. A nurse navigator will pick up that case immediately. So before the patient's even seeing anybody that's going to treat their cancer, just a diagnosis, the nurse navigator is going to be in charge of making sure that that patient gets the proper appointment with the proper doctors in a timely fashion. And also, if there are tests that are required, scans or MRIs or blood work, they are going to facilitate making sure that those are done in a convenient way for the patient and in a timely manner.

Then, the nurse navigator will take all of that information and assist us to get all of that information in front of the tumor board, and then feedback to the patient what the tumor board has come up with in terms of the best treatment option. It's not a replacement for a physician having that conversation. It's an additional person walking the patient through each little step of this very complicated process. And having done it for hundreds or thousands of patients already before, they generally know the questions the patients are going to ask, the hurdles that the patients are going to have in front of them, and they can prepare the patient for them and get them over them, and really make a big difference for the patients. My experience with the nurse navigators is that I will have taken care of a patient for several years alongside, obviously, a nurse navigator, and the patient will be coming in for their surveillance visit and they're very happy to see me, but the nurse navigator gets a hug. That's how important they are to the patient.

Host: So, they guide patients all the way through the process. And can you quantify what an improvement that has made?

Dr. James McCormick: Well, I can tell you that I couldn't possibly do the job that I do as the Chair of the Rectal Cancer Program without them being able to organize this process. So, I can tell you that when we initiated this program that before there was an accreditation program. We were trying to implement a lot of the standards that were in place, like I said, maybe a decade ago.

And so when we started with that process, we actually hired the nurse navigators, and we set up parameters that we were going to try to improve upon. And some examples would be the time to the first office visit after diagnosis. So, we are able because of the nurse navigators to make sure that the patients are getting in to see the doctors that are going to treat their cancer quicker after their diagnosis is made. And our goal is to have that visit occur within a week. And we're able to achieve that. And the nurse navigators help do that.

The other thing that the nurse navigators have been able to help us with, again, it's related to timeliness of care, is to make sure there's no gaps in the care between the chemotherapy part, the radiation part, and the surgery part. They keep the patients on that path so that the gaps in care between those things are as optimal as possible and minimal. Because obviously, any type of delay like that, if there is a delay, may in fact impact outcomes. So, an example for that would be a patient may have surgery for colon cancer. And we don't really know if with colon cancer always whether someone's going to need chemotherapy or not until after the surgery because the pathology component, the surgery component, and the pathology assessment of the specimen is required sometimes to determine that.

Our goal is to make sure that patients get to that chemotherapy within about a month. And we know that if people take longer than a month to get the chemotherapy, the chemotherapy doesn't quite work as well. And our nurse navigators are able to keep that number below a month for our patients on average. And before we had them in place, there were times when you might be out six, eight weeks because there's just hurdles and obstacles that patients simply can't navigate themselves, and the nurse navigators pick up that piece for them.

Host: Yeah, timing is a real key in treatment. And speaking of treatment, you focus on minimally invasive techniques and preservation. Can you talk a little bit about that? What are the advantages for patients? I assume the obvious advantage is reduced recovery time.

Dr. James McCormick: Those are very good points. There's several elements to that. So when we talk about minimally invasive approaches, there's two pieces. One is minimally invasive, meaning with a laparoscope and a robot, so the incisions that patients have on their bodies are very small. Almost all of our surgeries are done that way, and that really makes a big difference for patients. And I can tell you that across the country, probably about half of the patients are getting their surgeries done in that minimally invasive fashion. And the other half are still getting it the old-fashioned way. And in my opinion, that's not as good for the patient. So thankfully, at AHN, our surgeons are skilled at the minimally invasive approaches, and we employ them in most of the cases when it's technically feasible.

So, the other part to that, so there's the minimally invasive, meaning the laparoscope and the robot, is that sometimes we can remove tumors through people's rectum. So rather than making an incision on the abdomen where we have to cut open the muscles to get into the abdominal cavity and remove the tumor, we can remove tumor through the natural orifice of the rectum and avoid any type of incision that anyone would see at all. So, very small tumors and very early tumors can be treated that way. And like I said, patients will leave the hospital the same day after that and not even necessarily realize that anything was done at all. And that's a tremendous benefit to the patients. It does require skill on the part of the surgeon, and it requires an understanding that that service is available for certain patients And so, we have to do something called an ultrasound of that tumor beforehand to make sure that it's amenable to that.

So, those two elements are important for what we call TAMIS. It's called transanal minimally invasive surgery for specific tumors. You also mentioned preservation. So, there's two parts of preservation that we would like to keep in mind that are really tremendously important for patients. One is sphincter preservation, meaning that we're able to save for the patient their sphincter that holds their bowel movements. And if we're very skilled and very careful in most cases, we can do that. But that does require planning and does require skill. In the old days, people would end up with a colostomy bag. But now, with modern techniques and modern skill, we're able to help people avoid that by doing some very detailed operations to reconstruct them.

The other type of preservation that we talk about now is preserving the entire organ. In other words, not doing surgery at all. So, I'm a surgeon talking, I make my living doing the surgery part, but I also manage the patients through their entire journey from their development of their cancer and their diagnosis of their cancer and through their treatment. And there are patients that we're able to treat with chemotherapy and radiation treatments. And then, we see them in the office and we say, "Well, those treatments have worked so well that we're not going to have to go through a surgery for you. We're going to be able to watch this situation and perhaps put you into surveillance and maybe never need to have surgery at all." And again, that's a newer kind of technique that is not necessarily offered in all settings. So, we're very proud to be able to offer all of those those things. things.

Host: Yeah. There's so many technological breakthroughs in recent years. Do you expect those to continue?

Dr. James McCormick: Oh, I don't think there's ever going to be a change to that. And we should all be thankful for that. Every time that we see a new, breakthrough come through, we're careful to test it out and make sure that it's safe and appropriate. But the sharing of information, in this day and age, means that all of our treatment algorithms, all of our technical skill sets that we're developing, all of the technology that we can use, such as the robot, such as a specific radiation machines that may be connected to an MRI so that the radiation beam can be focused intensely on the tumor itself and protect the other organs, all of those things, when we add them into the puzzle, helps so much for us to be able to incrementally improve the quality of the care that we're giving patients, improve our ability to do those preservation procedures that we talked about. But we're always careful to make sure that they're safe before we implement that on anybody, that's for sure.

Host: And who gets referred to AHN? Can you provide guidelines for referral to the Colon and Rectal Center of Excellence?

Dr. James McCormick: People will have their diagnosis made through a colonoscopy. So, it's very important to understand that there's guidelines for what we call screening colonoscopies. So, everyone at age 45, regardless of their risk, should have a colonoscopy. There are people that should have that colonoscopy done at a younger age. So, anybody with any symptoms whatsoever should have a colonoscopy. And people with a family history of colon cancer or rectal cancer should have that colonoscopy at a younger age.

So, what happens is people go get a colonoscopy. And they have a biopsy taken and it comes back as colon cancer or rectal cancer. That is the patient that should be referred into the Center of Excellence for Care. And at that time, we see patients from all around, hundreds of miles away. They come in to get care at our center of excellence for the reasons that we discussed. There are other times when people present with their cancers who maybe it's more advanced. And so, they present with different types of symptoms and maybe in the hospital with a problem. Those patients likewise can be referred in for evaluation to see if we can come up with a treatment plan for them. That may be involving more intensive types of therapies, and I didn't mention this yet, but one of the things that we offer at AHN, through our Surgical-Oncology group is something called HIPEC. So, that is a situation where people have a very advanced tumor, and the surgery removes the tumor. And then, chemotherapy is used to bathe the abdominal cavity to help prevent a recurrence. So, there's a lot of reasons why people may be referred to us from very, very far away to receive these kinds of specialty services that are really not offered in all settings.

Host: Well, this is a state-of-the-art center, and it sounds like it will remain that way as you keep up with the changes that are happening. And also, i just want to end with asking you if you have any data on patient outcomes.

Dr. James McCormick: Well, it's interesting that you asked that. So when we look at the data, so the data that we have is through we mentioned the accreditation earlier. So, the Commission on Cancer has a database called the National Cancer Database. And being an accredited body, we put our data into that and we can receive feedback from that regarding the outcomes and our outcomes are excellent. We are what is considered by the NAPRC, the rectal cancer accreditation program, to be a high volume program. So, that's a program that does a lot of volume. And when we have a lot of volume, we have a great number of patients. It means obviously we have more experience, but it also means that the data that we're able to retrieve back has more validity because there's so many patients that we can use to analyze. So, what we found is that our sphincter preservation rate, our organ preservation rate and our medium-term and long-term outcomes are superior to what would be expected, given the demographic that we're treating. So, we're in very good shape. Some of this data is publicly reported. Most of this data, unfortunately, is more private, but we're able to look at that and see that we're actually outperforming, what would be expected for our patients. And we're very proud of that.

Host: That is exceptional. Dr. McCormick, thank you so much for joining today and sharing your expertise.

Dr. James McCormick: Well, I appreciate that. I appreciate the opportunity to get this message out there.

Host: Dr. James McCormick is System Chief Colon and Rectal Surgery at Allegheny Health Network. To learn more, visit findcare.ahn.org/james-t-mccormick. Thank you so much for listening to this edition of AHN MedTalks with the Allegheny Health Network.