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UAB MedCast is an ongoing medical education podcast. The UAB Division of Continuing Education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA Category 1 credit. To collect credit, please visit uabmedicine.org/medcast and complete the episode's post-test.

VO: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole: Welcome to UAB MedCast. I'm Melanie Cole, and I hope you'll join us today as we update the benefits of a multidisciplinary care for colorectal cancer patients. In this thought leader conversation physician round table today, we have Dr. Drew Gunnells, he's an assistant professor and a gastrointestinal surgeon; Dr. Rojymon Jacob, he's a radiation oncologist and professor; and Dr. Moh'd Khushman, he's an Associate Professor of Hematology and Oncology. They're all at UAB Medicine.

Gentlemen, thank you so much for joining us today. And Dr. Gunnells, I'd like to start with you. What had been the thought previously regarding colorectal cancers. We've done a previous podcast on this topic and now we're updating it. What's different now? Do you have any exciting updates to share with us today?

Dr. Drew Gunnells: Well, thanks. And I'm certainly excited to be here and appreciate you having us on. Yeah, so there are several things new in the world of colorectal cancer. One of the main things is the screening algorithm has changed. And we have updated the age to 45 as opposed to 50 for getting screening colonoscopy for average risk individuals. The reason that occurred was the American Cancer Society looked at the increasing incidence of colon and rectal cancer in those under the age of 50. And given that increased rate, we decided that 45 would be the new screening age so that we could catch these colon and rectal cancers sooner and hopefully able to treat these patients more efficiently and catch these cancers early.

Colon cancer screening has certainly changed since the last podcast, which is a new update. And then, the overall treatment of colorectal cancer at UAB has continued to evolve. We started our multidisciplinary GI Cancer Clinic in 2019, and that has now become more robust. We see on average four to eight patients every week where they're seen by the radiation oncologist, medical oncologist and the surgery team all in the same clinic. So it provides a great efficient care for the patient and also allows us to discuss these patients in a multidisciplinary fashion so that they can get the most up-to-date and best cancer care.

Other treatments that have come online at UAB in the last two years, we are starting a HIPEC, which is intraperitoneal chemotherapy for peritoneal metastatic colorectal cancer. We've also started placing hepatic artery infusion pumps to help treat metastatic colorectal cancer to the liver. And then we are doing more and more upfront neoadjuvant chemo and radiation for rectal cancer with the hope that there are some patients that will have complete clinical and pathological responses, and some may not even need surgery which will spare them the morbidity of those operations.

Melanie Cole: Those are such exciting advancements, Dr. Gunnells. Thank you so much for sharing that. And Dr. Jacob, we would be remiss if we did not speak about the impact COVID has had on your clinic and these updates. Can you share a status update on where things are, how protocols and recommendations have changed as a result of the pandemic, how your clinic has really evolved care and the role that technology has played in management of these patients?

Dr. Rojymon Jacob: Yes, Melanie. Unfortunately, COVID impacted us like it did everybody else. So, we had to quickly adapt in such a way that it caused least risk to our patients or all in urgent need for care and also, at the same time, protecting our staff without disrupting any of the services. So in addition to the universal measures like masking and maintaining safe distance, we adopted testing for all our patients who needed surgery or radiation treatments pretty quickly. So that meant that we had the least amount of disruption to our services.

From the radiation perspective, couple of things that I would like to quote, what is the use of hypofractionated radiation. Hypofractionated means fewer fractions, fewer treatments of radiation whenever that is feasible, especially for patients who used to be treated with 25 to 30 treatments. We calculated how it is safe and effective to do the treatment over 10 to 13 treatments.

In addition for people who were being treated aggressively for a cure with surgery and chemotherapy, we started doing more and more of the five-treatment regimen where upfront radiation for five fractions is used and it is found to be equivalent to a long protracted 25 or 30 treatments. So by quickly making these changes, we will be able to adapt to the COVID situation.

The other very important thing is we started using the telehealth program more effectively and more efficiently since COVID. And we already had the system in place, but COVID really pushed us to using this more often. Now we have a lot of followup patients who are using telehealth program and we have a very robust telehealth program at UAB. I'm pretty sure this is the same experience that doctors Khushman and Gunnells would have, and I welcome them to add their experiences too.

Melanie Cole: Dr. Jacob, just for a second, you don't see telehealth going anywhere now? As the pandemic, you know, as we get it more under control, you don't see telehealth going away, right? It's been a nice adjuvant to all of this technology.

Dr. Rojymon Jacob: Absolutely. Our patients love it. Remember a lot of our patients have to travel very long distances to get here. So, whenever possible, we are making use of the telehealth program, which is convenient for the patient. Of course, it is convenient for the physicians too. Most importantly, it does not impact on the quality of services.

Not all patients are always eligible for telehealth follow-up. For example, where a clinical examination is required, then the patient certainly will have to show up in clinic or there is a more complex procedure or radiological test, which is available only at UAB has to be performed, of course they'll have to come to UAB. But by and large, a very good proportion of our patients are using telehealth and they are happy to continue to use it.

Melanie Cole: Well, thank you for that. And Dr. Khushman, how have advances in imaging augmented your diagnostic and therapeutic capabilities these days? Speak about anything that's changed the landscape for you, technologies, diagnostic tools, anything worth talking about that you would like to mention to other providers?

Dr. Moh'd Khushman: Yes. Thank you for asking this question. I would like to start by saying that accurate staging for colorectal cancer is absolutely essential to deliver the right treatment for our patients. In most recent years, the National Comprehensive Cancer Network guidelines actually helped us by providing more guidance of how to stage cancers, especially rectal cancer.

So historically speaking, local staging for rectal cancer has been accomplished by endoscopic ultrasound, which was okay for quite some time. But recent data suggested that the endoscopic ultrasound is not very accurate. It has limitations and it is operator-dependent, meaning that the person who does it can have an impact on the accuracy of the interpretation of the data. And that's why the National Comprehensive Cancer Network guidelines actually recommended for local staging to be done ideally by a pelvis MRI. And that's what we do here at UAB. And that's an essential component for staging our patients with rectal cancer that we look at and review before we actually decide about treatment. So that's for local staging.

When it comes to other staging and systemic staging, PET CT scan was clearly referred to as insufficient to replace contrast-enhanced diagnostic CT scans and it should not be routinely done. However, if you have equivocal findings that need to further quantify, then a PET scan can be done. But what I'm trying to say here is the staging of patients with colorectal cancer is absolutely essential. And I believe we do a better job now staging our patients compared to the staging workup that was done a few years ago.

When it comes to new technologies and diagnostic, I would like to say a couple of things. It is now important for any GI oncologist or medical oncologist to really start looking into utilizing CT DNA. CT DNA stands for circulating tumor DNA, which is a new technology that can help. It's still being studied to to be further understood, but it can help to assess disease response and sometimes detect early disease recurrence. So this is a new technology that has become and it looks very promising that, in my opinion, would be essential part of how we take care of patients with GI malignancies in the future.

Melanie Cole: Thank you, Dr. Khushman. So Dr. Gunnells, and then I'd like the response to come from Dr. Jacob, because these two questions go together. So given the complexity, as you guys are describing the increasingly complex treatment algorithms that are adding new options all the time for colorectal cancer patients, tell us about the importance of a multidisciplinary team, this approach that you're all doing together, you all come from different backgrounds. And as we're seeing this improved coordination of care, many viewpoints are being said. So is there sometimes a differing of decisions? I'd like Dr. Gunnells to start with the importance of this multidisciplinary approach, and then Dr. Jacob to come in with how you are all formulating these opinions.

Dr. Drew Gunnells: Yeah, great question. I think moving forward, the multidisciplinary approach to cancer care in general is going to be standard of care, and it provides us such a great avenue to collaborate and discuss patients and make sure that they are getting the absolute best and most up-to-date treatment algorithm that they possibly can.

And I think one of the unique things that we're doing here at UAB is our multidisciplinary clinic. A lot of people have multidisciplinary conferences, but we actually see the patients, all the providers from the multidisciplinary teams see the patient at the same time. And this has been a huge benefit for the patient.

Dr. Jacob mentioned earlier, our patients travel from distances a lot of times. And so for them just to have one clinic appointment as opposed to three separate clinical appointments with three different providers provides them a great chance to have efficient care and also to get one clear message. So a lot of times all the specialists will be in the room talking to the patient at the same time. So they get a clear, consistent message that this is the treatment plan moving forward.

So I think, you know, multidisciplinary care has been around for a while. It has mainly been done from a conference standpoint. Our clinic, where we take care of all of our rectal cancer and a lot of our colon cancer, has been a great addition and really provided excellent patient care.

Dr. Rojymon Jacob: Melanie, I just wish to add to Dr. Gunnell's discussion of the multidisciplinary model. Just to point that each one of us are experts in our own field. We, all of us, stick to national guidelines. And we keep up with the latest research publications. However, when it comes to an individual patient, we can have slight differences in our approaches to care. And that's where the discussions and formulating the multidisciplinary consensus becomes important.

So having all these specialists work together, mutually discussing and interacting results in patients being the largest beneficiaries of this model. So at the multidisciplinary clinic, we aim to be efficient and to provide expedited expertise.

Melanie Cole: Well, it certainly is the wave of how this goes. And you're right, Dr. Jacob, that this benefits the patients so very much when they have such expertise and all of you working together. Dr. Khushman, tell us about any research that other providers may not know about that you're doing at UAB, what you'd like them to know and how you see this translating to patient care.

Dr. Moh'd Khushman: Yeah, that is a great question. I would like to start answering this question by saying molecular profiling in GI cancers, obviously that includes colorectal cancer, was to be ASCO's Advance of the Year of 2021. So I really would encourage any provider, when they see a patient with colorectal cancer, to conduct molecular profiling.

This has become part of taking care of patients. Previously, it used to be part of conducting research and clinical trials. But now, it has become part of the standard of care. So knowing the genetic makeup of patients can actually help every medical oncologist to pick the right treatment and know how to sequence subsequent treatment.

Beyond this, I would also say that putting patients on clinical trials should be a priority. And we have noticed this firsthand when we have changed our practice of taking care of patients with rectal cancer. Historically speaking, we used to do chemoradiation first followed by surgery, and then potentially more chemotherapy. With this TNT, total neoadjuvant therapy approach, which a product of putting patients in clinical trials, the way of taking care of patients with rectal cancer have changed. So now, we try to give pretty much chemotherapy and chemoradiation before doing surgical resection. And thus far, this has shown to provide more responses and sometimes eliminating the cancer, and that can sometimes lead to organ preservation where patients can be just watched and not have an actual surgical resection.

So this is just kind of how molecular profiling and the importance of putting patients on clinical trial should be done in patients with gastric cancer. At UAB, we have a portfolio of clinical trials that this may not be the right venue to go through them, but we have multiple clinical trials that are currently being opened and will be open in the future where those trials will provide opportunities for patients beyond the standard of care where they can benefit from an additional treatment.

Melanie Cole: Such an informative episode this is. And Dr. Gunnells, I'd like to give you the last word as we talk about this multidisciplinary approach. We are updating the previous podcast with such exciting technology. Tell us how this care model will improve the way patients are receiving their care. What would you like to let other providers know about all the exciting changes and updates and things that you're doing at UAB Medicine?

Dr. Drew Gunnells: Yeah, I think it's just a really exciting time to take care of patients right now at UAB from a cancer standpoint, and really from a colorectal specific standpoint. We've got a lot of new treatments that we're going to be able to provide patients that sometimes we were referring out such as our patients with disseminated or metastatic disease that need intraperitoneal chemotherapy, patients that previously were deemed not surgical candidates because they had metastatic disease. We now have, in conjunction with surgical oncology, great treatment options with intra-arterial hepatic infusion pumps so that we're able to render these patients sometimes without any disease after surgical and medical treatment.

And, you know, we're really hoping to be a center of excellence for the region. And right now, there's a nationwide push to create centers of excellence for rectal cancer. And there's only a handful of centers that are online right now. And we're in the process of becoming a nationally accredited center for rectal cancer and we're in the process of applying for that. And so we hope that we can be a center of excellence, not only for the city of Birmingham and the state of Alabama, but really the Southeast.

So there's a lot of exciting things coming down the pipe at UAB and we are always happy to see anyone. And we've been very happy with how our multidisciplinary clinic has evolved and how we've been able to efficiently take care of patients and see them in a timely manner.

Melanie Cole: It is such an exciting time to be in your field. Dr. Jacob and Dr. Kushman, do you have any final thoughts? Anything that you'd like to add to this conversation as we conclude?

Dr. Moh'd Khushman: I would like to add that the efforts that UAB now is making to become or to establish this NAPRC program at UAB, I think this would really provide state of the art team and comprehensive approach to patients with rectal cancer. So for any patient with rectal cancer that is being diagnosed, I would encourage them that at least have a second opinion at one time at a tertiary cancer center like UAB to really make sure that the treatment that they are getting is the right treatment, so they can get the best outcome.

Melanie Cole: Great show. Thank you so much doctors for joining us today, sharing your incredible expertise as we update the benefits of multidisciplinary care for colorectal cancer patients.

A physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or by visiting our website at uabmedicine.org/physician.

That concludes this episode of UAB MedCast. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.