Colorectal cancer is the third most commonly diagnosed cancer in the United States with an increasing number of new diagnoses under the age of 55. Screening guidelines continue to evolve in an effort to find these cancers at an early stage. New surgical advancements are increasingly less invasive, reducing recovery times and hospital stays.
Guest: Jeffrey Milsom, MD, colon and rectal cancer surgeon at Weill Cornell Medicine and NewYork-Presbyterian Hospital
Host: John Leonard, MD, a leading hematologist and medical oncologist at Weill Cornell Medicine and NewYork-Presbyterian Hospital
Advances in Colorectal Cancer Care and New Surgical Techniques
Featured Speaker:
Learn more about Jeffrey Misom, MD, FACS
Jeffrey Milsom, MD
Jeffrey Milsom, MD, FACS, is the former Chief of Colon and Rectal Surgery and the Jerome J. Decosse, MD Professor of Surgery at NewYork-Presbyterian/Weill Cornell Medical Center.Learn more about Jeffrey Misom, MD, FACS
Transcription:
Advances in Colorectal Cancer Care and New Surgical Techniques
Dr. John Leonard (Host): Welcome to Weill Cornell Medicine CancerCast, conversations about new developments in medicine, cancer care and research. I'm your host, Dr. John Leonard. And today on the podcast, we will be talking about colorectal cancer surgical advances.
Our guest for this episode is Dr. Jeffrey Milsom, a colon and rectal surgeon at Weill Cornell Medicine and NewYork-Presbyterian Hospital. Dr. Milsom is an internationally renowned pioneer in minimally invasive surgery and state-of-the-art laparoscopic and endoscopic technologies for colorectal cancer, Crohn's disease, and other inflammatory bowel diseases. Dr. Milsom is co-director of the Center for Advanced Digestive Care and the former Chief of Colon and Rectal Surgery at NewYork-Presbyterian Hospital and Weill Cornell Medicine.
Dr. Milsom is the lead inventor of the endoluminal surgical platform. That is a technique that stabilizes the colon to allow for endoscopic procedures of greater complexity than can normally be performed. A number of my patients have procedures with Dr. Milsom and some of the things he does are out of this world as far as new technologies and really provide a great benefit for patients because of the fact that they can have less aggressive, less invasive surgery. So, I'm really looking forward to talking today with Dr. Milsom about some of the latest information, our guidelines and, in particular, some of the surgical techniques that are entering the clinic for colorectal cancer patients and patients with other colon conditions. So, Jeff, thanks so much for joining us today. It's great to have you here.
Dr. Jeffrey Milsom (Guest): Thank you, Dr. Leonard. It's a pleasure for me to join you and I look forward to exploring some of these so important topics in the world of GI or gastrointestinal problems.
Dr. John Leonard (Host): So, Dr. Milsom, how did you pick surgery as a career and how'd you in particular get involved in colon and colorectal surgery and some of the new technologies that you've been working on?
Dr. Jeffrey Milsom (Guest): Surgery, from the time I was a medical student, was appealing. Colorectal cancers and disorders of the GI tract have always been appealing for some reason. As my career wore on, what I couldn't get over is the fact that these diseases are increasingly common, not just in the United States, but worldwide. So, the need is out there to find better and better ways of treating patients.
Dr. John Leonard (Host): Maybe you could just briefly summarize for the audience a little bit of the anatomy. What are some of the differences in cancers and the specific issues that you face when you're dealing with a cancer, say, in the colon versus the rectum? I know there's some local issues that are important to the management.
Dr. Jeffrey Milsom (Guest): The colon and the rectum are the most downstream parts of our intestinal tract. And although they're not a digestive organ, meaning all of your digestion of your food and your fluids really occurs in the small intestine and in the stomach. The colon and the rectal areas are the most common area where you can get a cancer. The rectal area is the last eight or ten inches of the large intestine, whereas the colon is the more upstream area. These are parts of our body that are, in a sense, concentrating and making it so that we don't have to excrete our waste except a few times a day usually. You can live without them. They are vital organs though in making it so we can run around all over the planet without having to be in the bathroom all the time.
Dr. John Leonard (Host): So, when we think about these cancers, what are the risk factors that are associated with who needs to worry more about either colon or rectal cancer? And in particular, what's the role of diet in all of this?
Dr. Jeffrey Milsom (Guest): The most important risk factors are a positive family history. If someone in your family has had a history of a colon and rectal cancer or polyp, then you definitely want to go and get checked. And we can talk about at what age, but the other risk factors are some diseases that cause inflammation in the intestine, like Crohn's disease and ulcerative colitis are definitely risk factors for getting a colon or rectal cancer.
As far as diet is concerned, we know that a diet that's high in fats, especially animal fats, probably contributes to an increased risk of colon and rectal cancer. We know that a diet that's low in complex carbohydrates or low in fiber can also contribute to it. There's some evidence that things like excessive alcohol intake also probably contribute. So, diet is a strong contributory factor in increasing risk for colon cancer.
Dr. John Leonard (Host): Is this just felt to be an exposure to toxic chemicals or less favorable chemicals in the diet? I know fiber has some role as well, I presume that's related to kind of transit time of stool through the GI tract. Are those the main influences?
Dr. Jeffrey Milsom (Guest): It's probably a combination of like you're saying chemical exposure, but it's also what's called the microbiome or the way the bacteria and viruses populate the colon interact with the lining of intestines. So, there are direct chemical factors, but there are also, you want to call them biological factors related to the microbiome that certainly also play a role.
Dr. John Leonard (Host): So, when we think about screening for these disorders, and I know there's a lot of different context depending on your family history, as well as other medical conditions you have, et cetera, tell us a little bit about the data and guidelines on the ways one can be screened, as well as the typical timing, recognizing that there's a lot of nuance in all of that. And as I understand it, things continue to evolve.
Dr. Jeffrey Milsom (Guest): The biggest change that's occurred as far as guidelines on screening or for colorectal cancer has been lowering of the age at which you could say a completely asymptomatic person should undergo testing. Up until a few years ago, it was around age 50 if you had no other risk factors that you should get in for your first colonoscopy. But in the last several years, we realized that there's an increasing number of people, even in their 40s or younger, that are developing colorectal cancers without apparent risk factors. So, current recommendations by most of the learned medical societies now say that age 45 with no other risk factors, you should get in for your first colonoscopy. And then, there's a little controversy about how often you should get one after that. It's probably somewhere in the range of five to 10 years without other risk factors. But if you find something like a polyp, your doctor may want you to have repeat follow-up tests even sooner than that.
The other people who need to get in potentially earlier are people whose family members may have had colon cancer or colon polyps at a young age, and that could be debated, but usually, if say, your father had a colon cancer at age 45, maybe you need to get one when you’re in your 30s. The types of tests that people get for screening purposes besides colonoscopy are certain tests where genetic markers or blood is detected in the stool. Things like Cologuard that's advertised heavily on television now is a good example of that, which is a test where you can actually take some of your fecal material and you mail it into a lab and with a fairly high, I wouldn't say it replaces colonoscopy, but a fairly high reliability, you can detect abnormalities that may indicate you should get a colonoscopy.
Dr. John Leonard (Host): I think many people would prefer a less invasive test in this regard. But is it really the idea that this is kind of saving somebody a colonoscopy in some situations? Or is it just if you're saying, "Well, I'm not going to do that," this is something that's perhaps better than not getting screened at all?
Dr. Jeffrey Milsom (Guest): I think the gold standard currently in the medical profession is to get a colonoscopy if you can. If you refuse to do that, if you say, "I can't" or there's some other reason, then I would say that you should at least get a fecal test. Ideally, colonoscopy is what you want to get though.
Dr. John Leonard (Host): You mentioned that colon cancer and rectal cancer are on the rise and also about earlier onset, and the need for some people even in their 30s to get screening, does that go back to diet changes, microbiome changes, other factors? We all occasionally hear on the news somebody very young in their 30s getting colon cancer or some celebrity perhaps that is surprising. What do we think is behind that?
Dr. Jeffrey Milsom (Guest): The safest and probably wisest thing to say is we don't know. It's possible that the factors you just mentioned, diet, some element of increased awareness. At one point, this was felt to be a Western disease. But we now know that in certain Asian countries, colon cancer has a much higher incidence than in many Western countries. And so, we think it's probably a combination of factors, diet and heredity being the two most important reasons.
Dr. John Leonard (Host): So, when we see a patient that's diagnosed with colon cancer, let's say that they undergo a colonoscopy, a biopsy is done, and they have evidence of a colon cancer, seen. What are typically the next steps? How are patients managed and tested and sorted out as far as their prognosis and treatment at a high level?
Dr. Jeffrey Milsom (Guest): The most important thing once a diagnosis is made is to do what's called stage the tumor. So, if it's an early stage, which means it's confined to the wall of the intestine, it's possible that either a very limited surgical procedure or, let's say, removing a section of the intestine would be curative. And so, all the doctors taking care of a patient with colorectal cancer are going to initially want staging. And once you see there's an absence of any spread to anywhere except the colon wall, that patient generally will be scheduled to have some type of surgical procedure where a section of the intestine is removed either through some type of minimally invasive procedure or perhaps with limited incisions looking at the inside with a camera, which we call laparoscopic procedures. If a cancer seems to be very, very early, potentially just in the innermost layer of the colon wall, sometimes it can even be removed endoscopically, like say with a colonoscope. If the disease is more advanced, then surgery is sometimes indicated or sometimes it is not indicated. And then, some of the advances that we'll get into, that we are finding in certain rare instances that no surgery at all is needed, and the patient is treated with either chemotherapy or chemotherapy and radiation.
Dr. John Leonard (Host): So, I'd like to focus a little bit now on your area of expertise and on the surgical management of patients with colon cancer and related disorders that might be handled this way. I think that people used to think of big procedures, large incisions, needing a colostomy bag, obviously not always the easiest thing to deal with. But things have really changed a lot. And maybe you could just walk us through a little bit about how surgery has evolved for these conditions and some of the newer things that people might not be as familiar with that are now options for people, particularly when they're treated at very specialized centers that have expertise in these techniques.
Dr. Jeffrey Milsom (Guest): The first thing that comes to the mind of a patient if they have colon or rectal cancer is, number one, are they going to be okay? Can it be treated? Can they be cured? And the good news there is, today, if you have a cancer that seems to be at an early stage, then the chances are way more than 50/50, taking that whole group of patients who have a colon cancer, that you're going to be able to be cured. That means you're going to be alive in, well, five years from now at least without evidence of disease.
The treatment has evolved so that only a very, very small percentage of patients out of, let's say, a hundred patients, probably only a few percentages of those patients are going to end up with wearing a bag or a colostomy because of the evolution in new techniques. It's only needed in a minority of patients.
The newer things that have come down the pike over the last few decades, things like laparoscopic surgery, minimally invasive surgery, laparoscopic surgery plus or minus using robotic methods. These all have allowed us to treat patients’, so they don't have big incisions. They'd still get a section of their intestine removed, but they get out of the hospital, and they return to a normal function more quickly after usually about a three to five-day hospitalization.
Particularly in some rectal cancer patients, we're finding that in certain cases we can treat these patients with a combination of chemotherapy, plus or minus a limited amount of radiation therapy. And a significant number of those patients about 20 to 30%, the tumor will go away. There are now options for many rectal cancer patients to not have to have any major surgery at all.
And now, what's happening over time and what's happening with advances in three-dimensional imaging techniques where we can now have a 3D reconstruction of a patient's intestinal tract, we're learning that we are able to oftentimes go in with a combination of advanced imaging methods and endoscopes, like a colonoscope, and potentially treat the patient without the need for any kind of surgery. What we see coming is that patients with early-stage cancers may be able to avoid any kind of major surgery. And what's going to happen over the next five to ten years is we're going to find increasingly that we're able to treat patients without cutting out any section of the intestine and provide a high level of cure.
The patients we haven't talked about yet are patients with more advanced cancers. And the good news there as well is that using a combination of surgical methods, chemotherapy and/or immunotherapies, which have come on the scene over the last five to 10 years. We know that many patients, even with what's called stage IV or advanced colon cancers can be cured. The ability to treat things inside the body, again, using advanced imaging methods, what are called percutaneous or entering the body with small needle-like instruments that we can ablate or destroy certain types of tumors in colorectal cancer, even inside the liver. And the patient can live many years or even be cured. So, there are a lot of exciting new recent surgical advances that are coming down the pike in concert with advanced imaging and new and better forms of what people call chemotherapy, but also immunotherapy. And there are targeted cells that are also under development that are going to allow patients to have treatments in new and exciting ways.
Dr. John Leonard (Host): So, I know one of your areas of research and clinical care relates to these novel and new ways of doing surgery in a less invasive way. Can you be a little more specific, recognizing that these may not be for everybody?
Dr. Jeffrey Milsom (Guest): I'd be glad to. We've formed a center here. It's called the Center for Intelligent Image-Guided Interventions, which is specifically focused on developing some of these new methods, and I'm one of the physician directors of this. But basically, we now believe that using new tools, which you would consider things like tiny instruments that can be inserted either through an endoscope or through the skin combined with advanced three-dimensional imaging methods, we can now take a CAT scan that is then reconstructed to give a three-dimensional picture of the intestines. And by using that, we can superimpose those images onto a patient's body now in a procedure room, which has advanced imaging tools along with new types of surgical instruments. We can go inside the body of a patient through tiny little openings or through their mouth or through their bottom. And we can attack these tumors and actually remove or destroy them such that the patient's not gonna need to have a section of the intestine removed. And the difference is the patient wakes up and actually goes home that day or the next day versus a long hospital stay healing up from many incisions.
So, this is a transformative journey that we're on to show that even with colorectal cancer, which you would consider standard treatment today to be cutting out a section, we're beginning to show now that that may not be necessary. And so, a way to think about this is that it's safer, less invasive, and actually less expensive. Something that everybody, the government, insurance carriers and patients as well as doctors, nurses, and other people working in the hospital want to hear. We think our research is exciting because it's providing alternatives to more invasive treatments, and it's going to be less expensive.
Dr. John Leonard (Host): What about older people? It seems like what you described could be beneficial for somebody in their 80s and 90s who may not want to go through such a big procedure, I presume this makes it easier for people to do that.
Dr. Jeffrey Milsom (Guest): You bet. And it's increasingly going to become an alternative. Even though there are many people in their 80s and 90s who are very fit, who have had very few, if any, health issues other than maybe a new diagnosis of some problem in their intestine, it's much safer and much more palatable to them to have something that may require only an outpatient visit rather than a three to five-day hospitalization with general anesthesia and a recovery with wounds and incisions to heal from. So, the paradigm that we're working on is one where patients can have procedures done where they have minimal or no incisions and transform what's normally an inpatient stay of many days into an overnight or just a day visit. And that's on our horizon.
Dr. John Leonard (Host): Technically speaking, what are some of the other things on the horizon that you think will be different in care of this group of patients in the next three to five years? Will the incisions get even smaller? Will the number of these types of procedures go up? What do you think?
Dr. Jeffrey Milsom (Guest): There's no question that we're at a point in the history of medical care where all parameters point to a paradigm shift. Those parameters are things like I mentioned early on that disease incidence is going up. The number of patients that we're going to need to treat are getting older and older. The cost of healthcare continues to go up. And anytime you see a graph of trends over time going up, up, up, one after the other, you know there's going to be a paradigm shift. And that paradigm shift is occurring because of the intersection of new technologies, plus people who are working on innovative treatments that are going to be less and less expensive.
And so, changing the field, making it so what in the 20th century was something where you invade inside the body is very much going to change even in the near future, in the next three to five years. This is very much within our grasp. We're already beginning to see it in some of the early-stage colorectal diseases that we treat. And it will become increasingly applicable so that a patient doesn't have to have a big surgery, doesn't have to have an incision or, if they have incisions, they're tiny little needle puncture-type incisions.
Dr. John Leonard (Host): So, before we wrap up, I just want to ask you what advice you have for a patient who may have just been diagnosed with colon cancer, their doctor says they may need surgery. What advice do you have for patients to kind of avail themselves of all the knowledge they need and access to these sorts of procedures? What would you tell someone?
Dr. Jeffrey Milsom (Guest): I would tell them bounce off all of the facts that you've been given by your doctor with your family. Seek out expert care. Ask a lot of questions and understand that there are many exciting new therapies that offer a chance for a less invasive, less extensive and safer way to treat their disease and that there are exciting new options that are not just on the horizon that are in play right now, that going to a place that has great expertise in treating colorectal problems is extremely important in seeking those things out.
Dr. John Leonard (Host): Well, I want to thank you very much for sharing this information. I think it's very helpful to patients and, certainly, important to keep in mind for patients that are dealing with these increasingly common issues. So, thank you for joining us and I'd like to invite our audience to download, subscribe, rate, and review CancerCast on Apple Podcast, Google Podcasts, Spotify or online at weillcornell.org. We also encourage you to write to us at cancercast@med.cornell.edu with questions, comments, and topics you'd like to see us cover more in-depth in the future.
That's it for CancerCast, conversations about new developments in medicine, cancer care, and research. I'm Dr. John Leonard. Thanks for tuning in.
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Advances in Colorectal Cancer Care and New Surgical Techniques
Dr. John Leonard (Host): Welcome to Weill Cornell Medicine CancerCast, conversations about new developments in medicine, cancer care and research. I'm your host, Dr. John Leonard. And today on the podcast, we will be talking about colorectal cancer surgical advances.
Our guest for this episode is Dr. Jeffrey Milsom, a colon and rectal surgeon at Weill Cornell Medicine and NewYork-Presbyterian Hospital. Dr. Milsom is an internationally renowned pioneer in minimally invasive surgery and state-of-the-art laparoscopic and endoscopic technologies for colorectal cancer, Crohn's disease, and other inflammatory bowel diseases. Dr. Milsom is co-director of the Center for Advanced Digestive Care and the former Chief of Colon and Rectal Surgery at NewYork-Presbyterian Hospital and Weill Cornell Medicine.
Dr. Milsom is the lead inventor of the endoluminal surgical platform. That is a technique that stabilizes the colon to allow for endoscopic procedures of greater complexity than can normally be performed. A number of my patients have procedures with Dr. Milsom and some of the things he does are out of this world as far as new technologies and really provide a great benefit for patients because of the fact that they can have less aggressive, less invasive surgery. So, I'm really looking forward to talking today with Dr. Milsom about some of the latest information, our guidelines and, in particular, some of the surgical techniques that are entering the clinic for colorectal cancer patients and patients with other colon conditions. So, Jeff, thanks so much for joining us today. It's great to have you here.
Dr. Jeffrey Milsom (Guest): Thank you, Dr. Leonard. It's a pleasure for me to join you and I look forward to exploring some of these so important topics in the world of GI or gastrointestinal problems.
Dr. John Leonard (Host): So, Dr. Milsom, how did you pick surgery as a career and how'd you in particular get involved in colon and colorectal surgery and some of the new technologies that you've been working on?
Dr. Jeffrey Milsom (Guest): Surgery, from the time I was a medical student, was appealing. Colorectal cancers and disorders of the GI tract have always been appealing for some reason. As my career wore on, what I couldn't get over is the fact that these diseases are increasingly common, not just in the United States, but worldwide. So, the need is out there to find better and better ways of treating patients.
Dr. John Leonard (Host): Maybe you could just briefly summarize for the audience a little bit of the anatomy. What are some of the differences in cancers and the specific issues that you face when you're dealing with a cancer, say, in the colon versus the rectum? I know there's some local issues that are important to the management.
Dr. Jeffrey Milsom (Guest): The colon and the rectum are the most downstream parts of our intestinal tract. And although they're not a digestive organ, meaning all of your digestion of your food and your fluids really occurs in the small intestine and in the stomach. The colon and the rectal areas are the most common area where you can get a cancer. The rectal area is the last eight or ten inches of the large intestine, whereas the colon is the more upstream area. These are parts of our body that are, in a sense, concentrating and making it so that we don't have to excrete our waste except a few times a day usually. You can live without them. They are vital organs though in making it so we can run around all over the planet without having to be in the bathroom all the time.
Dr. John Leonard (Host): So, when we think about these cancers, what are the risk factors that are associated with who needs to worry more about either colon or rectal cancer? And in particular, what's the role of diet in all of this?
Dr. Jeffrey Milsom (Guest): The most important risk factors are a positive family history. If someone in your family has had a history of a colon and rectal cancer or polyp, then you definitely want to go and get checked. And we can talk about at what age, but the other risk factors are some diseases that cause inflammation in the intestine, like Crohn's disease and ulcerative colitis are definitely risk factors for getting a colon or rectal cancer.
As far as diet is concerned, we know that a diet that's high in fats, especially animal fats, probably contributes to an increased risk of colon and rectal cancer. We know that a diet that's low in complex carbohydrates or low in fiber can also contribute to it. There's some evidence that things like excessive alcohol intake also probably contribute. So, diet is a strong contributory factor in increasing risk for colon cancer.
Dr. John Leonard (Host): Is this just felt to be an exposure to toxic chemicals or less favorable chemicals in the diet? I know fiber has some role as well, I presume that's related to kind of transit time of stool through the GI tract. Are those the main influences?
Dr. Jeffrey Milsom (Guest): It's probably a combination of like you're saying chemical exposure, but it's also what's called the microbiome or the way the bacteria and viruses populate the colon interact with the lining of intestines. So, there are direct chemical factors, but there are also, you want to call them biological factors related to the microbiome that certainly also play a role.
Dr. John Leonard (Host): So, when we think about screening for these disorders, and I know there's a lot of different context depending on your family history, as well as other medical conditions you have, et cetera, tell us a little bit about the data and guidelines on the ways one can be screened, as well as the typical timing, recognizing that there's a lot of nuance in all of that. And as I understand it, things continue to evolve.
Dr. Jeffrey Milsom (Guest): The biggest change that's occurred as far as guidelines on screening or for colorectal cancer has been lowering of the age at which you could say a completely asymptomatic person should undergo testing. Up until a few years ago, it was around age 50 if you had no other risk factors that you should get in for your first colonoscopy. But in the last several years, we realized that there's an increasing number of people, even in their 40s or younger, that are developing colorectal cancers without apparent risk factors. So, current recommendations by most of the learned medical societies now say that age 45 with no other risk factors, you should get in for your first colonoscopy. And then, there's a little controversy about how often you should get one after that. It's probably somewhere in the range of five to 10 years without other risk factors. But if you find something like a polyp, your doctor may want you to have repeat follow-up tests even sooner than that.
The other people who need to get in potentially earlier are people whose family members may have had colon cancer or colon polyps at a young age, and that could be debated, but usually, if say, your father had a colon cancer at age 45, maybe you need to get one when you’re in your 30s. The types of tests that people get for screening purposes besides colonoscopy are certain tests where genetic markers or blood is detected in the stool. Things like Cologuard that's advertised heavily on television now is a good example of that, which is a test where you can actually take some of your fecal material and you mail it into a lab and with a fairly high, I wouldn't say it replaces colonoscopy, but a fairly high reliability, you can detect abnormalities that may indicate you should get a colonoscopy.
Dr. John Leonard (Host): I think many people would prefer a less invasive test in this regard. But is it really the idea that this is kind of saving somebody a colonoscopy in some situations? Or is it just if you're saying, "Well, I'm not going to do that," this is something that's perhaps better than not getting screened at all?
Dr. Jeffrey Milsom (Guest): I think the gold standard currently in the medical profession is to get a colonoscopy if you can. If you refuse to do that, if you say, "I can't" or there's some other reason, then I would say that you should at least get a fecal test. Ideally, colonoscopy is what you want to get though.
Dr. John Leonard (Host): You mentioned that colon cancer and rectal cancer are on the rise and also about earlier onset, and the need for some people even in their 30s to get screening, does that go back to diet changes, microbiome changes, other factors? We all occasionally hear on the news somebody very young in their 30s getting colon cancer or some celebrity perhaps that is surprising. What do we think is behind that?
Dr. Jeffrey Milsom (Guest): The safest and probably wisest thing to say is we don't know. It's possible that the factors you just mentioned, diet, some element of increased awareness. At one point, this was felt to be a Western disease. But we now know that in certain Asian countries, colon cancer has a much higher incidence than in many Western countries. And so, we think it's probably a combination of factors, diet and heredity being the two most important reasons.
Dr. John Leonard (Host): So, when we see a patient that's diagnosed with colon cancer, let's say that they undergo a colonoscopy, a biopsy is done, and they have evidence of a colon cancer, seen. What are typically the next steps? How are patients managed and tested and sorted out as far as their prognosis and treatment at a high level?
Dr. Jeffrey Milsom (Guest): The most important thing once a diagnosis is made is to do what's called stage the tumor. So, if it's an early stage, which means it's confined to the wall of the intestine, it's possible that either a very limited surgical procedure or, let's say, removing a section of the intestine would be curative. And so, all the doctors taking care of a patient with colorectal cancer are going to initially want staging. And once you see there's an absence of any spread to anywhere except the colon wall, that patient generally will be scheduled to have some type of surgical procedure where a section of the intestine is removed either through some type of minimally invasive procedure or perhaps with limited incisions looking at the inside with a camera, which we call laparoscopic procedures. If a cancer seems to be very, very early, potentially just in the innermost layer of the colon wall, sometimes it can even be removed endoscopically, like say with a colonoscope. If the disease is more advanced, then surgery is sometimes indicated or sometimes it is not indicated. And then, some of the advances that we'll get into, that we are finding in certain rare instances that no surgery at all is needed, and the patient is treated with either chemotherapy or chemotherapy and radiation.
Dr. John Leonard (Host): So, I'd like to focus a little bit now on your area of expertise and on the surgical management of patients with colon cancer and related disorders that might be handled this way. I think that people used to think of big procedures, large incisions, needing a colostomy bag, obviously not always the easiest thing to deal with. But things have really changed a lot. And maybe you could just walk us through a little bit about how surgery has evolved for these conditions and some of the newer things that people might not be as familiar with that are now options for people, particularly when they're treated at very specialized centers that have expertise in these techniques.
Dr. Jeffrey Milsom (Guest): The first thing that comes to the mind of a patient if they have colon or rectal cancer is, number one, are they going to be okay? Can it be treated? Can they be cured? And the good news there is, today, if you have a cancer that seems to be at an early stage, then the chances are way more than 50/50, taking that whole group of patients who have a colon cancer, that you're going to be able to be cured. That means you're going to be alive in, well, five years from now at least without evidence of disease.
The treatment has evolved so that only a very, very small percentage of patients out of, let's say, a hundred patients, probably only a few percentages of those patients are going to end up with wearing a bag or a colostomy because of the evolution in new techniques. It's only needed in a minority of patients.
The newer things that have come down the pike over the last few decades, things like laparoscopic surgery, minimally invasive surgery, laparoscopic surgery plus or minus using robotic methods. These all have allowed us to treat patients’, so they don't have big incisions. They'd still get a section of their intestine removed, but they get out of the hospital, and they return to a normal function more quickly after usually about a three to five-day hospitalization.
Particularly in some rectal cancer patients, we're finding that in certain cases we can treat these patients with a combination of chemotherapy, plus or minus a limited amount of radiation therapy. And a significant number of those patients about 20 to 30%, the tumor will go away. There are now options for many rectal cancer patients to not have to have any major surgery at all.
And now, what's happening over time and what's happening with advances in three-dimensional imaging techniques where we can now have a 3D reconstruction of a patient's intestinal tract, we're learning that we are able to oftentimes go in with a combination of advanced imaging methods and endoscopes, like a colonoscope, and potentially treat the patient without the need for any kind of surgery. What we see coming is that patients with early-stage cancers may be able to avoid any kind of major surgery. And what's going to happen over the next five to ten years is we're going to find increasingly that we're able to treat patients without cutting out any section of the intestine and provide a high level of cure.
The patients we haven't talked about yet are patients with more advanced cancers. And the good news there as well is that using a combination of surgical methods, chemotherapy and/or immunotherapies, which have come on the scene over the last five to 10 years. We know that many patients, even with what's called stage IV or advanced colon cancers can be cured. The ability to treat things inside the body, again, using advanced imaging methods, what are called percutaneous or entering the body with small needle-like instruments that we can ablate or destroy certain types of tumors in colorectal cancer, even inside the liver. And the patient can live many years or even be cured. So, there are a lot of exciting new recent surgical advances that are coming down the pike in concert with advanced imaging and new and better forms of what people call chemotherapy, but also immunotherapy. And there are targeted cells that are also under development that are going to allow patients to have treatments in new and exciting ways.
Dr. John Leonard (Host): So, I know one of your areas of research and clinical care relates to these novel and new ways of doing surgery in a less invasive way. Can you be a little more specific, recognizing that these may not be for everybody?
Dr. Jeffrey Milsom (Guest): I'd be glad to. We've formed a center here. It's called the Center for Intelligent Image-Guided Interventions, which is specifically focused on developing some of these new methods, and I'm one of the physician directors of this. But basically, we now believe that using new tools, which you would consider things like tiny instruments that can be inserted either through an endoscope or through the skin combined with advanced three-dimensional imaging methods, we can now take a CAT scan that is then reconstructed to give a three-dimensional picture of the intestines. And by using that, we can superimpose those images onto a patient's body now in a procedure room, which has advanced imaging tools along with new types of surgical instruments. We can go inside the body of a patient through tiny little openings or through their mouth or through their bottom. And we can attack these tumors and actually remove or destroy them such that the patient's not gonna need to have a section of the intestine removed. And the difference is the patient wakes up and actually goes home that day or the next day versus a long hospital stay healing up from many incisions.
So, this is a transformative journey that we're on to show that even with colorectal cancer, which you would consider standard treatment today to be cutting out a section, we're beginning to show now that that may not be necessary. And so, a way to think about this is that it's safer, less invasive, and actually less expensive. Something that everybody, the government, insurance carriers and patients as well as doctors, nurses, and other people working in the hospital want to hear. We think our research is exciting because it's providing alternatives to more invasive treatments, and it's going to be less expensive.
Dr. John Leonard (Host): What about older people? It seems like what you described could be beneficial for somebody in their 80s and 90s who may not want to go through such a big procedure, I presume this makes it easier for people to do that.
Dr. Jeffrey Milsom (Guest): You bet. And it's increasingly going to become an alternative. Even though there are many people in their 80s and 90s who are very fit, who have had very few, if any, health issues other than maybe a new diagnosis of some problem in their intestine, it's much safer and much more palatable to them to have something that may require only an outpatient visit rather than a three to five-day hospitalization with general anesthesia and a recovery with wounds and incisions to heal from. So, the paradigm that we're working on is one where patients can have procedures done where they have minimal or no incisions and transform what's normally an inpatient stay of many days into an overnight or just a day visit. And that's on our horizon.
Dr. John Leonard (Host): Technically speaking, what are some of the other things on the horizon that you think will be different in care of this group of patients in the next three to five years? Will the incisions get even smaller? Will the number of these types of procedures go up? What do you think?
Dr. Jeffrey Milsom (Guest): There's no question that we're at a point in the history of medical care where all parameters point to a paradigm shift. Those parameters are things like I mentioned early on that disease incidence is going up. The number of patients that we're going to need to treat are getting older and older. The cost of healthcare continues to go up. And anytime you see a graph of trends over time going up, up, up, one after the other, you know there's going to be a paradigm shift. And that paradigm shift is occurring because of the intersection of new technologies, plus people who are working on innovative treatments that are going to be less and less expensive.
And so, changing the field, making it so what in the 20th century was something where you invade inside the body is very much going to change even in the near future, in the next three to five years. This is very much within our grasp. We're already beginning to see it in some of the early-stage colorectal diseases that we treat. And it will become increasingly applicable so that a patient doesn't have to have a big surgery, doesn't have to have an incision or, if they have incisions, they're tiny little needle puncture-type incisions.
Dr. John Leonard (Host): So, before we wrap up, I just want to ask you what advice you have for a patient who may have just been diagnosed with colon cancer, their doctor says they may need surgery. What advice do you have for patients to kind of avail themselves of all the knowledge they need and access to these sorts of procedures? What would you tell someone?
Dr. Jeffrey Milsom (Guest): I would tell them bounce off all of the facts that you've been given by your doctor with your family. Seek out expert care. Ask a lot of questions and understand that there are many exciting new therapies that offer a chance for a less invasive, less extensive and safer way to treat their disease and that there are exciting new options that are not just on the horizon that are in play right now, that going to a place that has great expertise in treating colorectal problems is extremely important in seeking those things out.
Dr. John Leonard (Host): Well, I want to thank you very much for sharing this information. I think it's very helpful to patients and, certainly, important to keep in mind for patients that are dealing with these increasingly common issues. So, thank you for joining us and I'd like to invite our audience to download, subscribe, rate, and review CancerCast on Apple Podcast, Google Podcasts, Spotify or online at weillcornell.org. We also encourage you to write to us at cancercast@med.cornell.edu with questions, comments, and topics you'd like to see us cover more in-depth in the future.
That's it for CancerCast, conversations about new developments in medicine, cancer care, and research. I'm Dr. John Leonard. Thanks for tuning in.
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