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Melanie Cole (Host): Welcome to UF Health Med Ed Cast with UF Health Shands Hospital. I'm Melanie Cole, and I invite you to join us as we discuss colorectal cancer with Dr. Kathryn Hitchcock. She's an Assistant Professor in the Department of Radiation Oncology at the University of Florida College of Medicine, and she practices at UF Health Shands Hospital. Dr Hitchcock, it's a pleasure to have you join us again. As we're getting into colon cancer and rectal cancer, and your role in these, how have advances in radiologic imaging really significantly augmented your diagnostic and therapeutic capabilities for colon and rectal cancer? Speak about any that have really changed the landscape for you.

Kathryn Hitchcock, MD, PhD (Guest): Hi, Melanie. Thank you so much for having me back again. And it's a great question to start off with because there have been some really amazing changes in imaging that have really transformed the way that we treat these diseases. The two ones that probably have created the greatest change are number one, that it's standard now for every rectal cancer patient to have a MRI of the pelvis that lets us completely understand what organs and what tissues are involved with the primary tumor prior to doing any sort of treatment. And of course, that's a huge advantage, both for radiotherapy, which I do and for the surgery that my colleagues perform, because knowing where the borders of the tumor are, is absolutely essential in being able to cure this curable cancer. And then the other type of imaging that has really transformed how we handle this, these diseases, both colon and rectal cancer, is the combination of PET imaging with MRI of the liver, because it's very difficult to see inside the liver parenchyma with a PET scan in order to understand where metastases are.

You know, not that long ago, if you had metastatic colorectal cancer, that was considered to be the end, we would try to slow things down, maybe with some chemotherapy, but nobody considered you curable. Just within my medical career, which hasn't been terribly long, that has completely changed. And now there are a tremendous number of colorectal cancer patients with oligometastatic disease, meaning, there's just a few metastases either at the time that their primary tumor is discovered or somewhere down the road, we go after those aggressively and we really cure an impressive number of people.

And even in those who we don't cure, we're able to kick the can down the road quite a bit. So, you have asked an astute question and focusing on imaging because without finding those metastases, we aren't able to do that very important trick.

Host: Well, thank you for that. So, next steps, if a rectal cancer is suspected, we're going to concentrate a little bit on that and current treatments, in your area of expertise, Dr. Hitchcock, speak about what you do. If that's suspected, you just gave us a little bit of a background on it. Just expand a little bit more.

Dr. Hitchcock: Okay. So, if somebody suspects that their patient has particularly a rectal cancer, although kind of the first steps are shared in common with a rectal cancer and colon cancer. Really the important things to do up front are of course, a good physical exam and history to try to look at symptoms. But really at that point, there is no substitute for doing a colonoscopy and for getting it done stat because the sooner we diagnose the disease and get moving on it, the better. Of course there are other options out there these days for screening. People can do you know, sampling where they send in a stool sample or do a test for occult blood in the stool, and those are okay for screening, but at the point where you have a suspicion that there might be a colon or rectal cancer present, those really aren't appropriate anymore. You need to get that patient in for colonoscopy, right away. And the things that need to happen during that colonoscopy, of course, they're visualizing the entire rectum and colon and doing biopsies of any areas that are concerning. Our practice as well is if there is an area of concern that we tattoo the wall of the rectum or colon in the place where that concerning lesion is. So that other care providers down the road will have some certainty about where that biopsy came from. Otherwise, they're kind of guessing based on your description. And although our imaging is really good these days, it's still very difficult to achieve concordance between what you see on imaging and what you see when you're doing a colonoscopy.

So that tattooing helps take out some of that uncertainty in location. And then of course, some blood work. A lot of times these patients will present with you know, complaints of rectal bleeding. That's often the thing that brings them to the doctor. So, checking on their blood counts, making sure they're not terribly anemic. It is actually not too uncommon to have a patient present with loss of consciousness because they've had bleeding for a long time. They're embarrassed. They don't know. They assume it's due to hemorrhoids or something like that. They don't come to the doctor. And the first time they see a physician about the problem is because they've passed out and nobody knows why.

So, checking those two things and doing it quickly, is really critical if one of these diseases is suspected. Once that is done, then if those things tend to point toward there being a colon or rectal cancer present, the next very important step is to get high quality imaging and if possible, it's really important not to just send the patients to any old imaging center.

It's really important that it be a place that sees cancer patients pretty regularly because not all MRIs are the same. Not all PET scans are equal. And high quality imaging can save the patient's life. So, in packaging them up and getting them to cancer doctors in a situation that lets them start on treatment as soon as possible. That set of things is just critical.

Host: So interesting. And you've made some great points. Now, are there any recent or ongoing changes in rectal cancer treatment that you'd like to highlight for other physicians? Anything in your field that you'd really like to mention that you see happening or is happening at UF Health Shands Hospital?

Dr. Hitchcock: Yes, a couple of exciting things. And one of them is already in full swing and I think it's a trend that's going across the country now. So, I think people will see this in a lot of places. And that is the use of short course radiotherapy in rectal cancer. In Europe, they've been doing this for years, that the traditional American way to treat rectal cancer was to do radiation maybe before, maybe after surgery.

And it was always something like five weeks of radiotherapy, along with sensitizing chemotherapy. Over time in our practice, at least, we've tried to go entirely to preoperative radiotherapy because it's very difficult to get patients through a full course of chemo, radiation following surgery. And then over the last few years, we've been paying close attention to this European data that says, in fact, that five days of radiotherapy does just as good a job in helping the surgeon create clean borders of resection for rectal cancer and what people were worried about the long-term side effects from treating with higher doses over only five days didn't come to fruition. It turns out patients do just as well after those five intense days as they did after having the radiation spread out over five weeks.

So, in a practice like UF Health Shands Hospital where a proportion of our patients have a long drive in order to get to the hospital for their care. And a lot of folks are working and taking five weeks off of work is really difficult in this context where they really need to keep their health insurance and they need to pay off their medical bills.

Being able to only have them come for five days in a row instead of five days per week for five weeks in a row, is a huge advantage for the patients. They get through radiation very successfully and we keep them moving down the line with chemotherapy and surgery to get a cancer cure. So, here at UF Health Shands Hospital, that's the most exciting and important thing we've done recently.

The number two thing I wanted to highlight is there continues to be a lot of discussion about whether we might be able to treat some rectal cancers without performing surgery. That is something that has been explored probably most throughly down in Brazil. And there's a pretty good literature there. I would say people in north America and Europe in more recent years are starting to look at it a little bit more seriously. It's certainly not standard of care right now. It's something I wouldn't ever do without enrolling a patient in a clinical trial at the moment. But boy, there are a lot of patients where it'd be really nice not to have to take them to a big surgery for this disease.

And a lot of patients would really like that too, especially those for whom it would be necessary to have a colostomy for the rest of their lives if they were to go through surgery.

Host: You've given us some great information and thank you for telling us about the benefit of short course versus long course radiation treatment. That was great. So, now speak a little bit about metastatic colorectal cancer and the current shift in thinking regarding management.

Dr. Hitchcock: Okay. So, I would say that the shift has occurred primarily, probably over the last 10 years. We knew before that, that it was possible to go after metastases when there were just a few of them, when the patient had oligometastatic disease. But I would say people are starting to really get behind this as an idea of something that we should do formally, something that should become part of our standards of practice.

There are many ways that you can treat metastases from colorectal cancer, depending on what tissue they're in. Most often, those are going to appear in the liver. And not infrequently in the lungs. Sometimes they will show up in lymph nodes or other tissues of the body, but those are the two most common places.

So, the combination of the imaging that we talked about and advanced techniques, including stereotactic body radiotherapy, which has an extremely high cure rate, one that approaches is that of surgical resection, if you really look carefully at the literature, as well as some procedures that can be performed by surgeons or by interventional radiology with ablation with either microwave or radio-frequency in order to treat these metastases. Those combination of options, make it so that most patients, even if they're not great surgical candidates can still have their oligometastases treated safely. And it's possible that we will entirely cure their cancer, if we are able to also treat their primary tumor successfully. So, it's a really exciting era where we've gone from a situation where everybody who had metastatic colorectal cancer died of colorectal cancer to a situation where this young person, cause unfortunately, sometimes young folks get colon or rectal cancers, this young person in our office who has metastatic disease at the time that the cancer is discovered, doesn't necessarily have a death sentence. We have things that we can do to try to sustain their life and maybe save their life altogether.

Host: Such an exciting time to be in your field, Dr. Hitchcock, and as we get ready to wrap up. Given everything that you've said and the complexity with these increasingly advanced treatment algorithms that are always adding these new options to your armamentarium of available therapies, speak about the importance of a multidisciplinary approach for these patients. And tell us about your team at UF Health Shands Hospital.

Dr. Hitchcock: Oh a great topic. And one I'll try not to talk too long about, but I sure do like to. Multidisciplinary care for any cancer is important. For these particular cancers, it is really critically important because all three modes of treatment, radiotherapy, surgery and chemotherapy are necessary to the care of these patients. And it's incredibly important that those efforts be coordinated, that information be shared efficiently, and that the team will be on the same sheet of music in deciding how the patient is going to be best managed. Having colleagues who will sit in a multidisciplinary conference and come to a consensus about how to treat each patient is really important.

We certainly do enjoy that privilege here at UF Health Shands Hospital. Everybody on Thursday morning sets their time aside for almost two hours. And we talk about every single colorectal cancer patient who comes to our facility. And in, in fine detail, we work out how we're going to treat them, what the sequence is going to be, who's going to take care of each part and what that results in, is really smooth care. It happens efficiently, the right steps happen at the right time. And it is really a pleasure with our team here. Excellent surgeons. Excellent medical oncologists. And I would like to think that my department is pretty excellent as well.

As well as all of the allied health professionals, physical therapy and all of those folks who are really important to the care of these cancer patients really working together. So, I would encourage anybody who has a patient with colorectal cancer to get them, if not to our facility, then to one like it, where that care is really done on a team basis.

Host: What a great message for referral to UF Health Shands Hospital. Dr. Hitchcock, you're an excellent guest. Thank you so much for joining us today and really sharing your expertise in this exciting time in your field. To refer your patient, or to listen to more podcasts from our experts, please visit ufhealth.org/medmatters.

And that concludes today's episode of UF Health Med Ed Cast with UF Health Shands Hospital. Please always remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.