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Scott Webb: When it comes to rectal cancer, family history, genetics, and lifestyle are all factors. It's important that we all know our risks and that we are screened for rectal cancer. And joining me today to tell us about a patient who had not been screened until he was 60 years old. And who was subsequently diagnosed and treated for rectal cancer is Dr. Michael Nichols. He's a radiation oncologist with NHRMC Radiation Oncology.

This is Healthy Conversations, the podcast from New Hanover Regional Medical Center. I'm Scott Webb. Doctor, it's so great to have you on today. We're talking about rectal cancer and we're going to get to staging and workup and treatment and followup. But before we get there, I want to have you talk about the history of a present illness.

Dr. Michael Nichols: Today, we will talk about a patient who presented at the age of 60 years of age, a healthy male, no family history of colorectal cancer, occasional alcohol, no tobacco use and presented with bright red blood per rectum. And so he started to notice as he was going to the restroom that he would see some blood on the toilet paper. Because he noticed this and this was unusual, he went for a colonoscopy. And colonoscopy is generally recommended to start at the age of 50. And although he was 60, he had not yet had a colonoscopy. Recently, those guidelines have been changed and the new recommended start date is 45 as an aside.

On colonoscopy, a 5 to 6-centimeter ulcerated mass was seen on the anterior rectal wall and it was about 2.5 centimeters from the anus. And so this was biopsied and pathology revealed invasive moderately differentiated adenocarcinoma. He subsequently went on what's definitely called an endoscopic ultrasound, which gives more information in regards to the staging of these cancers. And that revealed a 5-centimeter fungating mass on the left anterior rectal wall, about 2.5 centimeters from the dentate line. And that basically is kind of an anatomic distinction. Below which, or even when you get very close to that, it kind of dictates the type of surgery the patient will be able to have and whether or not they will need an ostomy or whether they can take out the rectal cancer and put them back together again and keep all those parts intact.

So these days, really that staging has shifted more towards rectal MRI scans. So MRI stands for magnetic resonance imaging, and these are found to be more accurate in terms of their staging and giving the surgeons a good idea of whether or not they're going to be able to get a clear margin when they do the surgery. By margin, I mean make sure that all of the cancer is removed and that no cells are left behind, which is critical to obtaining control of that cancer and eventual cure of that cancer.

When he had his EUS, that was still a very common staging mechanism. It's still okay today in cases where MRI is contraindicated or otherwise not available. But our preference these days would be an MRI. In any case, on EUS, what this showed was that the tumor was extending through all layers of the wall through what's called the muscularis propria, which is a thick muscular layer around the rectum and it was into the surrounding fat. No lymph nodes were seen on CAT scan of the chest, abdomen and pelvis, and no evidence of distant metastasis were seen. And so his staging therefore made him what's called a T3 because it penetrated through the muscularis propria into the surrounding fat, N0 for node negative, M0 for no distant metastasis, making him a stage IIA.

We also checked a marker at that time called a CEA and his value at that time was 1.8. Anything less than 3 nanograms per milliliter is normal, so he had a normal CEA, which is also reassuring that in all likelihood he does not have distant metastasis in which case that number would have to be higher. So for patients with a T3N0 stage IIA rectal cancer, their five-year overall survival is predicted to be greater than 90%. So he was really in a good place with his cancer. As long as we go ahead and do what we need to do, very good chance that he would be cured.

Scott Webb: So you've done the staging and workup on that patient. Let's talk about the treatment now.

Dr. Michael Nichols: For his treatment, he received the standard of care, which remains current, but has changed somewhat in the recent month. This patient received daily radiation to the whole pelvis with concurrent chemotherapy over the course of five and a half weeks. This was then followed by a surgery called a low anterior resection, meaning they were able to preserve the lower sphincters, meaning the anus such that he did not require an ostomy.

And at the time of surgery, he was found to have residual invasive moderately differentiated adenocarcinoma extending just beyond the muscularis propria as we'd seen on this staging studies into the perirectal fat. He had zero of 13 lymph nodes positive, and we always want the surgeons to try to get at least 12 if possible he had 13. Margins were negative. And so we had a temporary diverting loop ileostomy, meaning he had a temporary ostomy/bag where it gives them a break so that they can heal down below and then later go back and have that reversed.

One difference from what we're starting to see develop today in a much more current paradigm is that we are starting to give all of their treatment upfront. And so in this patient, he underwent the chemotherapy and radiation at the same time for five and a half weeks. This was then followed by his surgery. And he was then recommended to undergo what we call adjuvant chemotherapy, so six months of chemotherapy following his surgery and the patient declined that treatment.

There's a new paradigm I'd like to talk about a little bit today that is very current and still evolving. In this case, the patient would have received all of his treatments prior to surgery. In that paradigm, the patient would receive any chemotherapy and/or radiation before surgery and then would have either a reduced schedule of chemotherapy afterward or no chemotherapy afterwards. But in this case, the patient had chemotherapy and radiation followed by surgery and he then declined chemotherapy. Following his surgery, his CEA had dropped to a 0.5, which made sense because we had removed the known cancer in the rectum. And he subsequently had a take-down of ileoestomy. So basically, he was put back together again and he was doing great.

Scott Webb: So let's talk about followup and especially the ongoing followup with both this patient and cancer patients in general.

Dr. Michael Nichols: I will jokingly say that the cure rate of all patients on day one following their treatment is 100%, but we know that not all cancer patients are cured. And so, as we mentioned earlier, his five-year overall survival given his stage is predicted to be a 90% or even higher. But it is important that we follow these patients. So in that 10% that may fail, we can catch that as early as possible and be able to address any failures as they occur and potentially still cure the patient even though, let's say, they fail locally in the rectum or, if we were to find that they failed elsewhere, we can aggressively treat. And that happens to be the case with this patient.

And so we will typically follow these patients with a history and physical exam every three to six months for the first two years and then every six months for a total of five years. We also check their CEA every three to six months for two years, and then every six months for a total of five years. But then we also do imaging of their chest, abdomen and pelvis using a CAT scan. And in his case for stage II, we would do this every six to 12 months for a total of five years. In addition, these patients are recommended to have a colonoscopy in one year following their surgery.

So he was seen in routine follow-up and was doing well at three months. At six months, he underwent a CT of his abdomen and pelvis, which showed some expected postoperative changes, but otherwise, nothing to mention. However, on evaluation of his CEA shortly thereafter, that was seen to have risen from a value of 0.5 to 0.7. And around that time, it was time for his next restaging CT of the chest, abdomen and pelvis.

And unfortunately that time, what was seen was a right upper lobe nodule of his lung measuring 1.3 by 1.3 centimeters, which is clearly abnormal and very suspicious for either a primary lung cancer or spread of his rectal cancer to his lungs. There was also a second lesion on the left lower lobe of the lung measuring 1.1 by 0.9 centimeters. And so that was quite concerning that the patient had developed metastatic disease.

Fortunately, for him, this was very limited metastatic disease. And we call this oligometastatic disease anytime the patient has five or fewer metastases. However, it was also important to rule out that this was not either two new primary lung cancers or metastases from some other place. We essentially needed to prove that this was metastatic colorectal cancer.

So something called a PET scan was ordered, which is more of a functional scan, such that cancer will "light up" on that scan. And when it does that, it can be due to cancer. It can also be due to other things such as infection. But when you have something that fits this clinical picture that looks like it's cancer, and then it lights up on a PET scan, that is highly suspicious. The other thing that the PET scan does is allow us to rule out that there are other places, which were not seen on the CAT scan. For example, rectal cancer may go to the liver. And when it does go to the liver, on a conventional CAT scan, it can be very difficult to see those lesions. On a PET scan, those may light up.

In his case, the PET scan only lit up in the two lung lesions. He then underwent a biopsy of which was suspicious, but not definite. And so he was referred to thoracic surgery to undergo resection of those two lung lesions, which would be nice because number one, that's definitive; number two, that would give us pathology and confirm where those nodules came from. However, the patient refused surgery at that time.

In cases where the patient refuses surgery, we have another option. There are several other options, but one of which is something called stereotactic body radiation therapy. And that is what I did for him. And so this is a highly-focused targeted radiation delivered over the course of only three or five fractions in his case of a high dose, but safe dose, in order to eradicate the surgery. In essence, we're trying to replace surgery such that we eradicate the tumor.

And so he was treated with curative intent for his two presumed metastatic colorectal cancer lesions. He received treatments to both those lesions. The right upper lobe lesion was treated five times. The left lower lobe lesion was treated three times and he tolerated that with no acute or chronic side effects. I'm happy to say that he is now a year and a half out from completion of his treatment to the lungs and currently has no evidence of disease. He is healthy, his weight is stable and he is continuing to work.

Scott Webb: Probably never really out of the woods when it comes to cancer. And as we wrap up here today, doctor, whether it's this patient or rectal cancer in general, what are your takeaways? What do you want to make sure everybody knows? I assume it's probably get your colonoscopy and so on, but let's hear it from the expert.

Dr. Michael Nichols: Yes, I think that's exactly right. And so my recommendation would be to know your family history when possible. Patients with a strong family history are certainly at higher risk to develop a colorectal cancer and they should talk to their family physician in that regard. Sometimes genetic testing is indicated. Other times, starting colonoscopies at an earlier age are indicated. For a person with average risk, I recommend following the guidelines and getting your first colonoscopy at age 45. And then following recommendations subsequent to that, depending on what's found, for example, if polyps are found, the patient may come back earlier than if absolutely nothing is found.

In regard to treatment, my recommendation is that, generally speaking, the recommendations of the medical community are whenever possible based on data. And so this patient declined adjuvant chemotherapy. There's no way to know for sure whether that would have prevented these two lung metastases. It may have not prevented those lung metastases. And in fact, there's some controversy as to the benefit of adjuvant chemotherapy for colorectal cancer. But I would say my general advice would be to follow the recommendations of your oncologist.

Another take home from today though, is that even though this patient recurred, we were still able to come back in and treat him. And although he is not yet out of the woods completely, it's very encouraging that a year and a half after being treated for his two lung metastases, he is doing well and continuing to work and going on about his life.

Scott Webb: Well, I really appreciate you sharing this story with us today. It's really fascinating and really kind of interesting to hear. Not a hypothetical, but a real case that you dealt with and good to know that he's doing well. Thank you so much for your time and you stay well.

Dr. Michael Nichols: Thank you. You too.

Scott Webb: To learn more about cancer treatment and resources, go to nhrmc.org. This is Healthy Conversations, the podcast from New Hanover Regional Medical Center. I'm Scott Webb. Stay well.