Transcription:
Follow-Up Care for Colorectal Cancer

Melanie:    Welcome to Back to Health, your source for the latest in health, wellness, and medical care. Keeping you informed, so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole and I invite you to listen to this lively podcast as we discuss post-surgical care for colorectal cancer. Joining me in this panel is Dr. Srihari Mahadev, he's an Assistant Professor of Medicine within the Division of Gastroenterology at Weill Cornell Medicine, he specializes in advanced endoscopy; and Dr. Allyson Ocean, she's a medical oncologist and attending physician in Gastrointestinal Oncology at New York Presbyterian Weill Cornell Medical Center; and Dr. Kelly Garrett, she's an Associate Professor of Surgery at Weill Cornell Medicine and a colorectal surgeon at New York Presbyterian Weill Cornell Medical Center.

Doctors, it is really a pleasure to have you here today. Dr. Mahadev, I'd like to start with you. Can you tell us some of the exciting emerging technology to maximize detection of precancerous polyps? What's exciting in your field of advanced endoscopy? How are you finding these cancers early?

Dr Srihari Mahadev: Hi, thank you, Melanie, for the invitation. It is a really exciting time to be in this space, because the technology has gotten a lot more advanced and so we're able to really use microscopic evaluation when we're looking at the colon during colonoscopy. And there's even some incorporation of artificial intelligence. So we've gotten really good at detecting polyps even before they become a cancer, so that is to say they're precancerous. And when we detect a precancerous polyp, our goal is to take it out and really prevent it from ever having a chance to become a cancer.

Melanie: Thank you for that. And it certainly is an exciting time to be in your field. And really colonoscopy is such a gold standard. It amazes me how you are able to find those precancerous polyps. It's actually a prevention of cancer. So Dr. Garrett, how do you approach a patient that screening has found a cancerous polyp? What happens after that? What surveillance is necessary? Tell us a little bit about that process.

Dr Kelly Garrett: Well, once the polyp turns into a cancer, then the gold standard would be surgery. And after a patient is diagnosed with having colon cancer, we usually get some imaging to stage the cancer, and then we would proceed with surgery at that time.

Melanie: Well, then Dr. Mahadev, tell us about some of the minimally invasive approaches to very early colon and rectal cancer, and hopefully they've been found early. And then Dr. Garrett, you join in as well. So Dr. Mahadev, why don't you start with this one?

Dr Srihari Mahadev: So when we find a polyp in colonoscopy, we use special capabilities of our new endoscopes to try to determine then and there, whether it's a precancerous polyp or a cancerous polyp. And if it's a precancerous polyp, we can almost always take it out using a combination of techniques at the time of the colonoscopy. Sometimes a polyp when it's found is too large or too complicated to take out right then and there. And in that situation, the endoscopist might refer that polyp on to an advanced endoscopist or one of their colleagues who specializes in removal of complex polyps.

If the polyp is deemed to be at high risk of containing a cancer, then we actually need to make a decision about whether it is something that could be removed endoscopically, that is to say without having to create incisions. So a minority of colon cancers are detected early enough to remove from the inside, but we are getting better and better at it.

So for colon cancers that are really super early and that haven't spread much through the wall of the colon, we can actually scrape them out from the inside using sort of endoscopic and microscopic surgery. And so that's sort of something that's come together in the last five years and is being practiced in selective centers. For those cancers that are a little more advanced, we obviously we need to consult our surgical colleagues and that's where Dr. Garrett really, her expertise, comes in.

Dr Kelly Garrett: Right. And so I'd just like to add to that, one thing that's important in treating colon cancer is staging like I said before, and part of staging for colon cancer is looking and examining the lymph nodes that are around that area. So that's one of the reasons besides removing the colon cancer, why surgery is important. Because along with the actual tumor, we take out all of the lymph nodes that are associated with that portion of the colon and then the pathologist will take a look at all that under the microscope and then let us know what stage the cancer is.

As far as minimally invasive techniques, most colon cancers, I would say we can attempt to remove minimally invasively, meaning either laparoscopically or robotically, which means with small incisions. And this is important for patients to know because laparoscopic surgery and robotic surgery, although it's more cosmetically pleasing than a large open incision, also has benefits. There's faster recovery, quicker return of bowel function and shorter length of stay in the hospital and patients tend to get back to regular life quicker after minimally invasive surgery.

Melanie: Dr. Ocean, I'd like you to jump in here with adjuvant therapies. So we've been talking about surgery and we're talking about post-surgical colorectal care. However, people that have had colon cancer found and maybe they're going through surgery, can you tell us a little bit what adjuvant therapy is, whether they're doing chemo or whether they're doing radiation? And does that happen before or after surgery? Tell us where you come into this picture.

Dr Allyson Ocean: Sure. I am a medical oncologist, so I treat patients after they have a diagnosis of cancer. And in this case for colon cancers that are removed by surgery, we need to stage them as Dr. Garrett referred to. And that involves removing the tumor, looking at the lymph nodes under the microscope and figuring out whether or not lymph nodes are involved with cancer. And if they are involved with cancer, that's considered to be a stage III. And stage III cancers, we know that we can make people live longer and significantly improve their overall survival if we give them adjuvant chemotherapy and adjuvant means prevention.

And why are we giving them chemotherapy if the tumor is completely removed and there's nothing left anymore? Well, we know that a portion of these people who have lymph node involvement with their original diagnosis, that they recur. And so the chemotherapy that they get after surgery is to basically target and kill any microscopic cancer cells that could be in the bloodstream that we can't see, that no one can see, not the surgeon, not the pathologist, no one. And so it's a preventive course of chemotherapy that we give to patients.

Now, some patients with rectal cancer, which is lower down in the intestine. From the large intestine, the colon, the rectum is lower down in the pelvis. Those patients are the ones that we usually treat with a combination of chemotherapy, radiation, and surgery. But the pure colon cancers that are removed, they get treated with adjuvant chemotherapy if they have lymph node involvement.

Melanie: And before we get into post-surgical care, Dr. Ocean, can you just expand a little bit for us what's exciting in medical oncology for colorectal cancers? Are you using immunotherapy? What else is going on that's really cool and exciting?

Dr Allyson Ocean: It is an exciting time actually, because we do have the breakthrough of immunotherapy to treat certain colorectal cancers. And when I say certain, these are the type of colorectal cancers that are considered to be hereditary type of colon cancers associated with a syndrome called Lynch syndrome.

And, with Lynch syndrome, that means hereditary colon cancer, those patients have cancers that run in the family and those specific types of colon cancers or colorectal cancers, they have a signature, a genetic signature inside them. That means that they will not respond most likely to chemotherapy, but they will respond very well to immunotherapy.

And everyone is asking me now who gets introduced to treatment for cancer because when anyone gets diagnosed with a cancer, it's a whole new language, a whole new dialogue that they have to learn. Immunotherapy is not chemotherapy. Immunotherapy works by enabling our own immune system to rev up to fight the cancer. So it works completely differently than chemotherapy and only a small percentage of patients can be treated with immunotherapy instead of chemotherapy.

Another exciting thing that I think is really going take hold and it's just coming out now, but is going to take hold in the future and be probably much more standard is something called ctDNA, which stands for circulating tumor DNA testing. And this is what is also called a liquid biopsy. Basically, anyone who's diagnosed with cancer, colorectal cancer in particular, we draw their blood and we see if there is tumor DNA in the bloodstream.

And if there is tumor DNA in the bloodstream, whether it's before, during or after treatment, having the presence of tumor DNA in the bloodstream means that the person is at high risk of recurrence. And so that may help us survey the patient more closely when we're looking for recurrences or it may help us extend the treatment if we need to extend the treatment for the patient. So this is just coming into play now, and there's a lot of clinical trials trying to incorporate this new technology, if you will, of this liquid biopsy looking for circulating tumor DNA. And I think that's a really exciting thing because we can predict as early as sometimes 16 months that they may recur with a colon cancer.

Melanie: Isn't that amazing? And as I said, it's an exciting time to be in your field. So, Dr. Garrett, you're speaking to people that have loved ones that have been diagnosed with colon cancer, and they've maybe been told they need a colostomy or an ileostomy. What is life like for them? Can a person live without their colon?

Dr Kelly Garrett: So, of course, yes. People can live without their colon. The colon is responsible for absorbing water and electrolytes. And so people can live perfectly normal lives without their colon. And when people are diagnosed with colon cancer, it doesn't always mean that they need to have a bag or a colostomy or ileostomy. In fact, I would say most people don't need to have a colostomy. Sometimes patients need to have a temporary ileostomy. But again, patients can live perfectly normal lives without their colon or with a bag.

In general, when patients have to have a portion of their colon removed, immediately after surgery, their bowels will probably be a little irregular and they may have one or two extra bowel movements a day. But I would say in general, most patients go back to the way that they were prior to surgery. Sometimes people have to have their whole colon removed. And in that case, they may have, you know, three to four bowel movements a day.

And then of course, when patients have to have a colostomy or ileostomy, we do try to educate them prior to surgery on what life is going to be like with an ileostomy or a colostomy. But in general, people can do anything that they did before with an ileostomy or a colostomy.

Melanie: Dr. Mahadev, how often do patients need followup after colon cancer surgery? So when do they need another colonoscopy after surgery? How often does this happen? And what's your part in that?

Dr Srihari Mahadev: It's an important part of the management of people with colon cancer, is that if you've had one colon cancer, that you are at risk of both having colon cancer in another part of the colon as well as developing a second cancer or recurring at the site of the removal. So all patients who are diagnosed with colon cancer should have a full colonoscopy ideally before surgery to make sure that there is nothing further up in the colon that could be removed at the same session.

Sometimes when colon cancer presents, that actually causes a blockage and we're not able to examine the entire colon before the operation. And in that situation, you should have a colonoscopy within six months of the initial operation. After that, we do recommend a colonoscopy at one year. And if that's clear at three years and then after that, basically every five years, just because if you've had a cancer, you are at a higher risk than the average person. The average person can have a colonoscopy every 10 years, as long as they don't have polyps. But we recommend at least every five years for colon cancer survivors.

Dr Kelly Garrett: I just wanted to add on top of that, in general, people are at highest risk the first two years after surgery to have a recurrence. So we tend to watch patients very closely during that time. So they do need a colonoscopy a year after surgery, but there's also certain other tests that we do during that time. We do imaging, so we get CAT scans and we also send off blood tests just to make sure that we know when something is abnormal.

Melanie: Then Dr. Ocean, one of the things I find most fascinating is how you're all working together and you represent different specialties here in this podcast. Can you tell us about your combined efforts, the benefits to the patients and to all of you and why this multidisciplinary approach is so important for these patients?

Dr Allyson Ocean: You have to think of having your dream team when you go through a cancer. And I think of all of these specialists as members of the dream team, because you want your surgeon, your, gastroenterologists, your oncologist, your radiation oncologist, your geneticist, your nutritionist, your social worker, all of these are part of the multidisciplinary team.

And what's wonderful about the care that we give here at Weill Cornell Medicine is that we meet as a team very regularly to discuss the cases and to get input from all the team members about what's the best way to proceed in any given situation. So we meet once a week to review the pathology, that's the first time we meet. And then we meet to discuss treatment planning. Along the way we represent cases, if there's a question, someone has a complication or if or someone isn't tolerating something well, and how can we change it, we meet again to talk about that stuff.

So we're always engaging the team together for the best care of the patient. And it really requires multi-specialties that give their input for the patients to get the best care, because I'm not a specialist in gastroenterology. I'm certainly not a specialist in surgery. I don't do any surgery. I don't do any scoping either. So, you know, I need all of my colleagues to assist in the care of the patient as they're going through cancer therapy. And that's why it's very, very important that you have a multi-disciplinary team. And, frankly, patients should be asking for that, I think, like make sure that they have all these team members lined up to get the best care.

Dr Kelly Garrett: I agree. I think the multidisciplinary approach really improves coordination of care. And it really gives us the opportunity to assess each patient for many viewpoints. And sometimes, it can also lead to a change in the originally proposed procedure. And it really guarantees the patient an optimal procedure for the best outcome.

Melanie: Well, I certainly agree. And it is really great for patients to have this kind of multidisciplinary team supporting them. I'd like to give you each a chance for a final thought. So Dr. Ocean, as survivorship continues to grow because of all this exciting technology and advancements, where do you see this coordination of care and speak about survivorship? What do you see happening in the future in medical oncology for colorectal cancers?

Dr Allyson Ocean: Once a patient has gone through treatment for colorectal cancer and they're in what we call observation or surveillance mode, it's really, really important for us to make sure that the patient stays engaged with the healthcare team and comes in for regular followups, and comes in for their screenings or colonoscopy, their labs, and their imaging tests and all that.

But something else that the patient can do to help themselves is there are some lifestyle modifications that patients can do. Exercise is really, really important. It's the only non-medicinal intervention that has been shown to increase survival in colorectal cancer. So I encourage all of my patients to exercise.

I encourage them to reduce the amount of red meat intake that they eat because, there are carcinogens and red meat, and we want to reduce that. I encourage patients to make sure that their vitamin D levels get checked and get repleted if they are low. And just to stay in touch with the medical team and to take ownership of the care that they're getting and make sure, both for themselves and their family members, that they're getting screened for colorectal cancer, because we have to keep in mind that this is sometimes a hereditary disease and we have to screen the family members as well.

I would also like to mention as part of survivorship that I started a nonprofit called Michael's Mission, which is heavily involved in providing counseling to patients at Weill Cornell Medicine. We actually have a specially trained social worker that meets one-on-one with the patients while they're getting chemotherapy and afterwards to provide counseling about any subject they want to talk about that relates to their cancer journey whether they're worried about fear of recurrence or how to navigate the financial burden of treatment or how to manage certain side effects or whatever the patient wants to talk about.

And Michael's Mission is a nonprofit that funds this patient and family support program that's available to the patients who get treated here. And I think it's a really important resource for patients to get the kind of help and support that professionals can offer while they're going through cancer treatment. It really makes the experience easier to navigate and they have a better overall outcome getting that support directly to them. So they don't have to travel anywhere to get it. It's really a wonderful program that we fund.

Melanie: Dr. Garrett, for all the listeners who might have loved ones that are diagnosed with colon cancer, or if they themselves have heard those words, give them some hope for the future. Tell them what you would like them to know about what's going on in this world of colon cancer.

Dr Kelly Garrett: I just want to make sure that people know that surgery can be curative for colon cancer, especially when colon cancer is diagnosed at an early stage. I think it's also important to know surgery for colon cancer doesn't always mean that you have to have a colostomy bag. In fact, like I said before, the minority of patients need to have acolostomy or ileostomy. And in general, a lot of times it's just temporary. If you do need a stoma, you can live a perfectly normal life with a stoma, and there are support groups available, like Allyson talked about having support groups. There's many support groups that are available for patients with a colostomy bag.

And recovery from surgery, nobody wants to have surgery, but recovery from surgery is going to take some time, but most patients will return to a perfectly normal life after having surgery for colon cancer.

Melanie: And Dr. Mahadev, I'm giving you the last word here as I would like you to reiterate the importance of colonoscopy to listeners, the ease of this particular surgery and why all of your advanced endoscopic techniques are so amazing that they can find cancer before it strikes and possibly even prevent it in the first place.

Dr Srihari Mahadev: I think if there's one thought to takeaway from this it is that colon cancer is an incredibly treatable disease. It's treatable, it's curable. And people can live a normal life after a diagnosis of colon cancer. And the outcome that someone has from their colon cancer really depends on many things, but it really depends on how early we catch it. And the earlier the better. The best is if we catch the polyp before it becomes a cancer. But even if it is a colon cancer, the earlier the better.

And the most powerful tool we have in our arsenal for detection and prevention of colon cancer at the moment is colonoscopy. It's gotten really, really good. The worst part about it is the bowel preparation, and that's gotten much better this year. They just released an edible bowel preparation that's basically a tablet. So I encourage everyone who is thinking about it, is on the fence, has a relative who had it, go see a gastroenterologist, get your colonoscopy, and find out if you have a problem. We'll get it taken care of.

Melanie: That's great advice. And I'm so glad you mentioned colonoscopy prep, because that is the worst part. As someone who's had many of these things, it goes fast. It's not a big deal. And you wake up and you get a great nap. So thank you all for such an informative episode.

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