Advances in Colon and Rectal Surgery

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers
00:02 --> 00:05is provided by Smilow Cancer
00:05 --> 00:07Hospital and AstraZeneca.
00:07 --> 00:09Welcome to Yale Cancer
00:09 --> 00:10Answers with your host
00:10 --> 00:13Doctor Anees Chagpar.
00:13 --> 00:14Yale Cancer Answers features the latest
00:14 --> 00:16information on cancer care by
00:16 --> 00:17welcoming oncologists and specialists
00:17 --> 00:20who are on the forefront of the
00:20 --> 00:22battle to fight cancer.
00:22 --> 00:24This week, it's a conversation about colorectal cancer
00:24 --> 00:26with Doctor Ira Leeds.
00:26 --> 00:27Dr. Leeds is an assistant professor of
00:27 --> 00:30surgery at the Yale School of Medicine,
00:30 --> 00:32where Doctor Chapgar is a
00:32 --> 00:33professor of surgical oncology.
00:34 --> 00:36Ira, maybe we can start
00:36 --> 00:37off by laying the groundwork.
00:37 --> 00:39Tell us a little bit
00:39 --> 00:40about colorectal cancer.
00:40 --> 00:42How common is it?
00:42 --> 00:43How lethal is it?
00:43 --> 00:45How many people get it?
00:45 --> 00:47I'd be happy to.
00:47 --> 00:49Colorectal cancer is one of the most
00:49 --> 00:51common cancers worldwide.
00:51 --> 00:53It's the third most common cancer and
00:57 --> 00:58concerningly,
00:58 --> 01:00it's also the second most lethal cancer
01:00 --> 01:02by number of total cancer deaths.
01:02 --> 01:04The good news
01:04 --> 01:06on the colon cancer side of
01:06 --> 01:08things is that early detection
01:08 --> 01:11has survival rates of over 90% whereas
01:11 --> 01:15late detection has rates of 15%,
01:15 --> 01:17so it really gives us
01:17 --> 01:19an important urgency in the
01:19 --> 01:20cancer care community to identify
01:21 --> 01:23individuals with
01:23 --> 01:25precancerous lesions early because the
01:25 --> 01:27survival difference is significant.
01:27 --> 01:29To put it in kind of very real terms,
01:33 --> 01:351 in 20 individuals in their lifetimes
01:35 --> 01:37will have colorectal cancer,
01:37 --> 01:40and so it's something where all of
01:40 --> 01:42us probably know someone or will
01:42 --> 01:44know someone or been affected.
01:51 --> 01:55And speaking of early detection,
01:55 --> 01:57tell us a little bit more
01:57 --> 01:59about the screening guidelines.
01:59 --> 02:01I understand that those have
02:01 --> 02:03changed recently so that younger
02:03 --> 02:06people now are being recommended
02:06 --> 02:07to get colorectal screening.
02:07 --> 02:09Is that right?
02:09 --> 02:10That's absolutely correct.
02:10 --> 02:12The screening guidelines continue
02:12 --> 02:15to evolve and have for many years.
02:15 --> 02:17The age of 50 was the magical
02:17 --> 02:19number where everyone should be
02:19 --> 02:21lining up to get colonoscopies or
02:21 --> 02:24alternatives to colonoscopies for
02:24 --> 02:26their colorectal cancer screening.
02:26 --> 02:28Many, if not almost all
02:28 --> 02:31societies that provide guidelines
02:31 --> 02:34on this topic have moved to 45 as
02:34 --> 02:36the new age when people should start
02:36 --> 02:38screening for colorectal cancer,
02:38 --> 02:39that's for average risk individuals.
02:39 --> 02:41So there's a number of individuals,
02:41 --> 02:43both with more rare diseases that
02:43 --> 02:45predispose themselves to colorectal cancer,
02:45 --> 02:48but also a particularly high risk
02:48 --> 02:50sociodemographic groups, for example,
02:50 --> 02:52African Americans who have earlier
02:52 --> 02:54screening guidelines as well.
02:54 --> 02:55Interestingly,
02:55 --> 02:56one of the other
02:56 --> 02:58parts of the guidelines that's
02:58 --> 03:00always a discussion point
03:00 --> 03:02when guidelines come up is
03:02 --> 03:03how do you screen?
03:03 --> 03:04Colonoscopy has been the
03:04 --> 03:06gold standard for decades.
03:06 --> 03:08Colonoscopies require you to typically
03:08 --> 03:10get a little bit of sedation,
03:10 --> 03:12and it's a procedure where you have
03:12 --> 03:14to take a bowel prep the night before,
03:14 --> 03:16so it's certainly a bit of a burden
03:16 --> 03:18on the average person to do so.
03:18 --> 03:21There are alternatives to colonoscopies.
03:21 --> 03:23There are a number of reasons
03:23 --> 03:24why a colonoscopy is arguably
03:24 --> 03:26better for people that
03:26 --> 03:27are able to adhere to the schedule,
03:27 --> 03:29but the guidelines do really try
03:29 --> 03:31to balance the burden of screening
03:31 --> 03:33along with the benefits of screening.
03:34 --> 03:35Let's talk a little bit
03:35 --> 03:38about a few things that you
03:38 --> 03:39touched on.
03:39 --> 03:42So the first point is that screening is now
03:42 --> 03:46being recommended at 45 rather than 50.
03:46 --> 03:48Is that because the demographics
03:48 --> 03:50of colon cancer are trending
03:50 --> 03:53towards younger populations?
03:56 --> 03:59And who gets colon cancer in terms
03:59 --> 04:00of the age demographic?
04:02 --> 04:05So the trends in colorectal cancer are,
04:05 --> 04:08at the very least, interesting, and
04:08 --> 04:10potentially concerning in many ways.
04:10 --> 04:14New onset of colon
04:14 --> 04:18cancer is actually declining nationwide.
04:18 --> 04:20The overall rate of colorectal cancer
04:20 --> 04:22in the United States is declining and
04:22 --> 04:24and also favorably the mortality rate
04:24 --> 04:26from colorectal cancer is declining,
04:26 --> 04:29and we attribute those overall
04:29 --> 04:32trends to fairly good adherence to
04:32 --> 04:34colonoscopy and colonoscopy
04:34 --> 04:36alternative screening schedules
04:36 --> 04:38in older individuals that are
04:38 --> 04:39getting good colonoscopies and
04:39 --> 04:41the adherence to that currently is
04:41 --> 04:43about 60 to 70% of people that are
04:43 --> 04:45supposed to be getting them on time.
04:45 --> 04:47The risk of colorectal cancer
04:47 --> 04:49occurring in those patients seems
04:49 --> 04:51to be declining and we attribute
04:51 --> 04:53that to better screening.
04:53 --> 04:56The concerning part is that in young people,
04:56 --> 04:58which is defined as
04:58 --> 05:0020 to 49 years old,
05:00 --> 05:02the rate of colorectal cancer is
05:02 --> 05:04increasing and that is concerning
05:04 --> 05:06not just because that's a patient
05:06 --> 05:07population that historically has not
05:07 --> 05:10been screened and one of the major reasons
05:10 --> 05:12why the guidelines were changed to 45.
05:12 --> 05:15But we also don't know why the rate of
05:15 --> 05:17colorectal cancer incidence is occurring
05:17 --> 05:21more frequently in that younger population.
05:21 --> 05:22So for those of us that
05:22 --> 05:23think about this every day,
05:23 --> 05:25it's relatively easy to agree that
05:25 --> 05:27the screening guidelines
05:27 --> 05:30should be lowered to younger ages
05:30 --> 05:32and 45 is where it is now and
05:32 --> 05:36in a completely unofficial
05:36 --> 05:38role I would not be surprised if
05:38 --> 05:40those guidelines potentially got
05:40 --> 05:42even earlier in future years,
05:42 --> 05:44but we don't know at all why there
05:44 --> 05:46is a higher rate of
05:46 --> 05:48cancer in that population.
05:50 --> 05:52The other thing that you mentioned was
05:52 --> 05:54that these guidelines are for average
05:54 --> 05:56risk people and that there are a number
05:56 --> 05:58of things that increase a person's
05:58 --> 06:00risk of developing colorectal cancer.
06:00 --> 06:02So you mentioned certain demographic
06:02 --> 06:04groups such as African Americans.
06:04 --> 06:07I was wondering if you could talk a little
06:07 --> 06:10bit more about some of the conditions,
06:10 --> 06:12genetic conditions,
06:12 --> 06:15other predisposing factors that
06:15 --> 06:17increase a persons risk and whether
06:17 --> 06:20those people should be screened
06:20 --> 06:23earlier than the 45 year old guideline?
06:24 --> 06:26When we think about a risk factor,
06:26 --> 06:28as I always try to break them down
06:28 --> 06:30into what I call non modifiable
06:30 --> 06:31versus modifiable risk factors.
06:31 --> 06:33So non modifiable risk factors or
06:33 --> 06:35the risk factors that an individual
06:35 --> 06:37has an increased risk based on
06:37 --> 06:39compared to the average population.
06:39 --> 06:41But at the same time there isn't a lot
06:41 --> 06:43that could be done about that other
06:43 --> 06:44than changing a screening schedule
06:44 --> 06:46to suit that increased risk which is
06:46 --> 06:48modifiable or things that we really
06:48 --> 06:50spend a lot of time talking to patients
06:50 --> 06:52about because those are risk factors
06:52 --> 06:54that if certain behaviors are changed,
06:54 --> 06:57may actually reduce their risk.
06:57 --> 06:59Increasing age is probably the
06:59 --> 07:01one that's most frequently cited
07:01 --> 07:02as a nominal risk factor.
07:03 --> 07:05We cannot get younger overtime and we
07:05 --> 07:07need to recognize that as we get older,
07:07 --> 07:08we do have an increased
07:08 --> 07:09risk of colorectal cancer,
07:09 --> 07:12which is why screening continues after
07:12 --> 07:14that first episode of colonoscopy at
07:14 --> 07:17the original age of 50 and now 45.
07:17 --> 07:19Family history and personal history
07:19 --> 07:21are both incredibly important.
07:22 --> 07:25Almost all the screening guidelines have
07:25 --> 07:27a carve out for patients who have
07:27 --> 07:29early onset colon cancer in a family
07:29 --> 07:31member and most of the guidelines
07:31 --> 07:33say that an individual should start
07:33 --> 07:36their own personal screening 10 years
07:36 --> 07:39before the age of onset
07:39 --> 07:42in a first degree relative.
07:42 --> 07:44The thinking there being that
07:44 --> 07:47there is this idea that is widely
07:47 --> 07:50accepted that most colorectal cancer
07:50 --> 07:52comes from polyps that form in the colon,
07:52 --> 07:55which is from the natural turnover
07:55 --> 07:58of the surface of the colon,
07:58 --> 08:00and so those polyps,
08:00 --> 08:01then overtime have more and
08:01 --> 08:03more turnover of cells,
08:03 --> 08:05and those cells get increasingly
08:05 --> 08:07cancer like and as that occurs
08:07 --> 08:09in anywhere between a five
08:09 --> 08:11and 10 year progression cycle,
08:11 --> 08:13you can have what was a non cancerous
08:13 --> 08:15polyp turn into a cancer.
08:15 --> 08:17So that's where this thought that if
08:17 --> 08:19you start 10 years before a primary
08:19 --> 08:20relative who had colon cancer,
08:20 --> 08:23you should be able to identify that
08:23 --> 08:25at the precancerous stage and address
08:25 --> 08:27it by removal with colonoscopy.
08:27 --> 08:30There is also a personal history if
08:30 --> 08:32certain patients have been exposed
08:32 --> 08:33to various environmental factors or
08:38 --> 08:40cancer causing agents,
08:40 --> 08:42that would be another reason to
08:42 --> 08:44screen them earlier and then there
08:44 --> 08:46are relatively rare diseases,
08:46 --> 08:47particularly inherited syndromes
08:47 --> 08:49like Lynch syndrome or
08:49 --> 08:51Familial adenomatous polyposis.
08:51 --> 08:54These are conditions where
08:56 --> 08:58numerous family members
08:58 --> 09:00who have already had colon
09:00 --> 09:02cancer or related cancers,
09:02 --> 09:05and because of that increased risk,
09:05 --> 09:07there are very well early
09:07 --> 09:09screening guidelines for those
09:09 --> 09:10particular patient groups.
09:10 --> 09:12Those diseases and inherited
09:12 --> 09:14symptoms are relatively rare,
09:14 --> 09:16and typically patients are getting
09:16 --> 09:18passed on from family members saying,
09:19 --> 09:21I started screening earlier than average
09:21 --> 09:22because of this and you should too.
09:29 --> 09:32Tell us about the modifiable risk factors.
09:32 --> 09:34So modifiable risk factors are incredibly
09:34 --> 09:37important because this is where our
09:37 --> 09:39patients own agency has something they can
09:39 --> 09:41do to reduce their risk moving forward.
09:41 --> 09:43There are things that we oftentimes
09:43 --> 09:44don't like to hear about when
09:44 --> 09:45we are patients ourselves,
09:45 --> 09:47because it does typically
09:47 --> 09:48involve behavior change.
09:48 --> 09:51But you know, I really tried to have
09:51 --> 09:53patients wrap their heads around that.
09:53 --> 09:55You can essentially
09:55 --> 09:58eliminate your increased risk if you
09:58 --> 10:00do these changes in behavior early
10:00 --> 10:02enough on in the exposure cycle and
10:02 --> 10:05the modifiable risk factors that
10:05 --> 10:07we think about most are alcohol use,
10:07 --> 10:09tobacco smoking,
10:09 --> 10:12being overweight or obese.
10:12 --> 10:15And then the more controversial area
10:15 --> 10:18are the dietary changes that one
10:18 --> 10:21can do in addition to simple weight
10:21 --> 10:22loss that's related to obesity.
10:22 --> 10:23So, for example,
10:23 --> 10:25this evidence is still evolving.
10:25 --> 10:26We don't know for sure,
10:26 --> 10:29but things like high fiber diets,
10:29 --> 10:31reducing complex artificial sugars,
10:31 --> 10:33and so forth may have an improvement
10:33 --> 10:36on one's risk factors for colon cancer.
10:39 --> 10:40The other one that
10:40 --> 10:42I would controversially put in
10:42 --> 10:43the modifiable risk factor
10:43 --> 10:45group is race.
10:45 --> 10:47Obviously a patient can't change their race,
10:47 --> 10:49but I think at the society level
10:49 --> 10:51we have to ask if whether or not
10:51 --> 10:52the fact that African Americans
10:52 --> 10:54in particular have an incredibly
10:54 --> 10:56higher rate of colorectal cancer
10:56 --> 10:57than the average population,
10:57 --> 10:59is that because of something
10:59 --> 11:00genetic and the data suggests that
11:00 --> 11:01that's probably not the case.
11:01 --> 11:04The data suggests that the risk of
11:04 --> 11:06increased colon cancer in certain
11:06 --> 11:09races is likely due to socioeconomic
11:09 --> 11:11factors and access issues to care,
11:11 --> 11:13so I think as a society and
11:13 --> 11:16also as a group of physicians,
11:16 --> 11:17Health care providers,
11:17 --> 11:19we need to think seriously how we're
11:19 --> 11:21making sure that race is acknowledged
11:21 --> 11:23in our care of patients because
11:23 --> 11:25there are increased risks that we
11:25 --> 11:27likely could modify with improved
11:27 --> 11:29access to care and addressing both
11:29 --> 11:31social terms of health as well
11:31 --> 11:32as biomedical risk factors.
11:34 --> 11:36A couple of pointed questions.
11:36 --> 11:39I guess the first is in terms of gender.
11:39 --> 11:40Is there a difference
11:40 --> 11:41in colorectal incidence?
11:43 --> 11:45The relationship to gender and
11:45 --> 11:48colorectal cancer has more to do with
11:48 --> 11:50where the cancers occur in the colon,
11:50 --> 11:52and this is a complex issue that we can
11:52 --> 11:54probably come back to if we have time.
11:54 --> 11:56But colorectal cancer occurs
11:56 --> 11:58in three general places.
11:58 --> 12:00The right side of the colon,
12:00 --> 12:01the left side of the colon,
12:01 --> 12:03and the rectum.
12:03 --> 12:04These are very different areas
12:04 --> 12:06in terms of how they are handled
12:06 --> 12:08from a suregons standpoint,
12:08 --> 12:10which is why it's really relevant and
12:10 --> 12:14to go to your direct question,
12:14 --> 12:16the gender differences between the
12:16 --> 12:19various anatomic sites varies as well.
12:19 --> 12:20We don't really understand why and
12:20 --> 12:22it's an area of open investigation,
12:22 --> 12:25but it does seem to color
12:25 --> 12:27where these cancers occur,
12:27 --> 12:29and therefore genders seem to have
12:29 --> 12:30differences in treatment strategies
12:30 --> 12:33because of where the sites of disease.
12:34 --> 12:37So women have more colon cancers
12:37 --> 12:39on one side of the colon than men?
12:39 --> 12:41Correct, the right side.
12:41 --> 12:43Interesting, and my second question,
12:43 --> 12:46what about inflammatory bowel disease?
12:46 --> 12:48Does that increase your
12:48 --> 12:50risk of colorectal cancer?
12:50 --> 12:53And if so, are we seeing more
12:53 --> 12:55inflammatory bowel disease in
12:55 --> 12:57younger people which might give
12:57 --> 13:00us a clue as to one potential
13:00 --> 13:03etiologic factor for younger onset?
13:04 --> 13:06So, inflammatory bowel disease
13:06 --> 13:08absolutely increases your risk.
13:09 --> 13:12The screening guidelines for both
13:12 --> 13:15patients with Crohn's disease and
13:15 --> 13:17colitis specifically target those
13:18 --> 13:20groups for early onset colonoscopies,
13:20 --> 13:22partially to evaluate their
13:22 --> 13:23inflammatory bowel disease,
13:23 --> 13:27but also to evaluate for the early
13:27 --> 13:29development of colorectal cancer.
13:29 --> 13:31We talk a lot in that
13:31 --> 13:32population about dysplasia.
13:32 --> 13:34Dysplasia is what cells
13:34 --> 13:36look like under a microscope when they're
13:36 --> 13:39headed towards potentially being a cancer,
13:39 --> 13:42and so those patients get routine regular
13:42 --> 13:45biopsies to evaluate for dysplasia as
13:45 --> 13:48a sign that that would be the case,
13:48 --> 13:50and in that patient population the
13:50 --> 13:51recommendations in terms of what
13:51 --> 13:53you do with that are changing,
13:53 --> 13:55but the historical recommendations
13:55 --> 13:57have been to move towards early
13:57 --> 13:59surgical intervention to remove
13:59 --> 14:01diseased portions of the colon because
14:01 --> 14:04of their increased cancer risk.
14:04 --> 14:06You bring up an interesting point
14:06 --> 14:08about inflammatory bowel disease
14:08 --> 14:10incidence and early onset of colon cancers,
14:10 --> 14:13and I think I would capture that
14:13 --> 14:13more broadly,
14:13 --> 14:16what one of the leading theories
14:16 --> 14:18around why we have increased colorectal
14:18 --> 14:21cancer in younger populations is
14:21 --> 14:22the inflammatory burden that the
14:22 --> 14:24colon is seeing younger in life.
14:24 --> 14:26And there's a lot of reasons
14:26 --> 14:27why that may be the case.
14:27 --> 14:28The question has been raised,
14:28 --> 14:31is it a matter of psychosocial
14:31 --> 14:32stress and modern society?
14:32 --> 14:34Is it a matter of
14:34 --> 14:36the artificial sugar
14:36 --> 14:38ingredients that are in food.
14:38 --> 14:41Do they have
14:41 --> 14:43an established higher
14:43 --> 14:45inflammatory load that's seen by the
14:45 --> 14:46body and is that somehow creating
14:47 --> 14:48more inflammation in the colon?
14:48 --> 14:50More inflammation begets this
14:50 --> 14:51dysplasia that we talked about
14:51 --> 14:53and does that lead to cancer?
14:53 --> 14:55These theories are out there,
14:56 --> 14:58they're often discussed and they
14:58 --> 15:00have good biology that supports them.
15:00 --> 15:02We just haven't made the missing
15:02 --> 15:04link connection to the clinical evidence.
15:08 --> 15:10Well, we're going to pick up the
15:10 --> 15:11conversation right after we take a
15:11 --> 15:13short break for a medical minute.
15:13 --> 15:15Please stay tuned to learn more
15:15 --> 15:17about the surgical care of colorectal
15:17 --> 15:19cancer with my guest doctor
15:19 --> 15:21Ira Leeds.
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15:38 --> 15:40The American Cancer Society
15:40 --> 15:42estimates that more than 65,000
15:42 --> 15:44Americans will be diagnosed with
15:44 --> 15:46head and neck cancer this year,
15:46 --> 15:49making up about 4% of all cancers
15:49 --> 15:51diagnosed when detected early.
15:51 --> 15:53However, head and neck cancers are
15:53 --> 15:55easily treated and highly curable.
15:55 --> 15:57Clinical trials are currently
15:57 --> 15:59underway at federally designated
15:59 --> 16:01Comprehensive cancer centers such
16:01 --> 16:03as Yale Cancer Center and at Smilow
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16:08 --> 16:11Yale Cancer Center was recently awarded
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16:20 --> 16:23address critical barriers to treatment
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16:37 --> 16:39Welcome back to Yale Cancer answers.
16:39 --> 16:42This is doctor Anis Jaguar and I'm
16:42 --> 16:44joined tonight by my guest Doctor Ira
16:44 --> 16:46leads we're learning about the surgical
16:46 --> 16:49care of patients with colorectal cancer.
16:49 --> 16:51And before the break IRA we spent
16:51 --> 16:54a lot of time talking about kind
16:54 --> 16:57of what causes colon cancer,
16:57 --> 16:59or at least what are some of the
16:59 --> 17:01risk factors and what are the
17:01 --> 17:03factors that lead to colon cancer,
17:03 --> 17:05particularly occurring at
17:05 --> 17:08a younger age so that.
17:08 --> 17:10Guidelines have now changed
17:10 --> 17:12to get colonoscopies earlier.
17:12 --> 17:14One thing I want to talk about just
17:14 --> 17:17before we get into the management
17:17 --> 17:19of colorectal cancer is the type
17:19 --> 17:20of screening you mentioned.
17:20 --> 17:24This briefly before the break in terms
17:24 --> 17:27of colonoscopy versus alternatives.
17:27 --> 17:29It can you flesh that out a little
17:29 --> 17:32bit for us so clearly nobody is,
17:32 --> 17:34you know, chomping at the bit saying oh,
17:34 --> 17:37sign me up I'd love to get a prep and
17:37 --> 17:40have a tube put up my rear bottom end
17:40 --> 17:42so that you can look at my colon,
17:42 --> 17:44but we know that colonoscopy is a
17:44 --> 17:47great test to find colorectal cancer
17:47 --> 17:50early and allows one to actually
17:50 --> 17:53remove potentially precancerous polyps.
17:53 --> 17:56But if you're not terribly enthused
17:56 --> 17:58about having a colonoscopy,
17:58 --> 18:01how good are the alternatives and
18:01 --> 18:02D recommend them?
18:03 --> 18:04That's a loaded question
18:04 --> 18:05when it's all said and done,
18:05 --> 18:07but we'll try to break it up
18:07 --> 18:09here into bite sized pieces.
18:09 --> 18:12So I think to go to colonoscopy first, the.
18:12 --> 18:15The two biggest values to colonoscopy
18:15 --> 18:19for me are the following.
18:19 --> 18:20The first is that colonoscopy has
18:20 --> 18:23been shown to be able identify
18:23 --> 18:24lesions typically earlier than a
18:24 --> 18:27lot of the alternatives out there,
18:27 --> 18:29and the reason being is that
18:29 --> 18:32colonoscopy can dentify both truly
18:32 --> 18:34benign what so non cancerous lesions
18:34 --> 18:37it can identify precancerous lesions,
18:37 --> 18:39and it can identify cancer and
18:39 --> 18:41why that's valuable is that.
18:41 --> 18:43It by getting your regular screening,
18:43 --> 18:43colonoscopy.
18:43 --> 18:46It kind of gives a time lapse image
18:46 --> 18:49of what's happening in your colon,
18:49 --> 18:50which I think is valuable.
18:50 --> 18:52If something were to ever develop,
18:52 --> 18:54kind of what somebody saw before.
18:54 --> 18:56The second reason why colonoscopy is
18:56 --> 18:58so valuable is that you're in there.
18:58 --> 19:00You can already do what you need to do,
19:00 --> 19:03oftentimes for these precancerous lesions,
19:03 --> 19:06with almost every other screening test,
19:06 --> 19:07it's going to basically stratify
19:07 --> 19:09a patient to a low risk,
19:09 --> 19:10meaning there was nothing detected
19:10 --> 19:12on the tests or high risk group,
19:12 --> 19:15which means that the test was abnormal,
19:15 --> 19:17and therefore the patient needs
19:17 --> 19:17a colonoscopy.
19:17 --> 19:19So a lot of these,
19:19 --> 19:22even the best non colonoscopy
19:22 --> 19:25screening modalities are still routing.
19:25 --> 19:25Folks,
19:25 --> 19:27two colonoscopy when they have
19:27 --> 19:28an abnormal test.
19:28 --> 19:30So there is a little bit of this
19:30 --> 19:31question of you know if there's
19:31 --> 19:32so much that can be gleaned from
19:32 --> 19:34a colonoscopy to begin with,
19:34 --> 19:35should we putting everyone through
19:35 --> 19:36the colonoscopy round and then,
19:36 --> 19:38as I mentioned before,
19:38 --> 19:39the the biggest argument against that,
19:39 --> 19:41is that colonoscopy for some
19:41 --> 19:43folks is has an undue burden,
19:43 --> 19:45both in terms of pleasantness but also
19:45 --> 19:48in terms of work loss and so forth.
19:48 --> 19:49So if you can do,
19:49 --> 19:50for example a stool test that
19:50 --> 19:53you can do in your home at 1
19:53 --> 19:55evening when you've got the time.
19:55 --> 19:57To do it and send it off for analysis,
19:57 --> 19:59and that if it's negative then you're done.
19:59 --> 20:00You have no further burden on
20:00 --> 20:02your day to day life to get your
20:02 --> 20:04results you need to go back to
20:04 --> 20:05being an average risk individual
20:05 --> 20:07with no further colonoscopy needs.
20:07 --> 20:12So I think we're the both the the.
20:12 --> 20:14The clearance for these tests.
20:14 --> 20:15In other words,
20:15 --> 20:17what they're allowed to proclaim to be,
20:17 --> 20:18and also where they really do,
20:18 --> 20:20have a sweet spot as the average
20:20 --> 20:22risk individual who's never had
20:22 --> 20:24any abnormal findings on a prior
20:24 --> 20:25colonoscopy and does not have
20:25 --> 20:27the high risk family features
20:27 --> 20:29that we talked about before those
20:29 --> 20:31individuals if interested in
20:31 --> 20:35pursuing a non invasive test like
20:35 --> 20:37a colonoscopy have been shown to
20:37 --> 20:40have equal benefit from one of the
20:40 --> 20:42more advanced tests out there.
20:42 --> 20:44It's basically a test that you
20:44 --> 20:46give a stool sample and it uses a
20:46 --> 20:48variety of assays or laboratory
20:48 --> 20:51tests on that sample to look for both
20:51 --> 20:54cancerous DNA in the stool as well as
20:54 --> 20:55a signature of what a bleeding
20:55 --> 20:57lesion in your colon might be like,
20:57 --> 20:59which is one of the micro bleed
20:59 --> 21:02is one of the hallmarks for pre
21:02 --> 21:04cancer or early cancer in the colon,
21:04 --> 21:07so that's what it's detecting and it's been
21:07 --> 21:09shown to have a very good detection rate.
21:09 --> 21:11And so if that's normal,
21:11 --> 21:13then we can confidently say that
21:13 --> 21:15patient does not need a colonoscopy if
21:15 --> 21:17they have no other high risk features,
21:17 --> 21:19there are a number of different options
21:19 --> 21:20that are listed in the guidelines,
21:20 --> 21:22but those two are probably the
21:22 --> 21:24most common recommended today.
21:24 --> 21:27The biggest drawback to the stool test that
21:27 --> 21:29I mentioned is that it is quite expensive.
21:29 --> 21:31Depending on insurance
21:31 --> 21:33reimbursements and so forth,
21:33 --> 21:35so it's not the biggest.
21:35 --> 21:37The biggest benefit to it is
21:37 --> 21:39the is the burden of going to
21:39 --> 21:40get a colonoscopy more so than.
21:40 --> 21:42Anything else in regards to
21:42 --> 21:43resource use for it?
21:44 --> 21:47Cool, so let's suppose you
21:47 --> 21:49went for your colonoscopy,
21:49 --> 21:51and a lesion was found.
21:51 --> 21:54A polyp was found and biopsied and
21:54 --> 21:56it turns out that it is a cancer.
21:56 --> 21:58Can you help us to understand a
21:58 --> 22:00little bit more about how you know
22:00 --> 22:03whether this is kind of a good
22:03 --> 22:04cancer where your colonoscopy
22:04 --> 22:06has has gotten it and you don't
22:06 --> 22:08need anything further versus a
22:08 --> 22:10not so good cancer where there
22:10 --> 22:12might actually be a need for you
22:12 --> 22:14to see a colorectal surgeon and?
22:14 --> 22:16Have more therapy done
22:16 --> 22:18so there's a couple key things that
22:18 --> 22:20you need to know when you as a
22:20 --> 22:22surgeon when you're getting given a
22:22 --> 22:24biopsy report from a colonoscopy.
22:24 --> 22:26The things that we think about
22:26 --> 22:29the most are for a true cancer is
22:29 --> 22:31something called TNM staging or
22:31 --> 22:34tumor nodes and metastasis staging.
22:34 --> 22:35The tea or the tumor is what
22:35 --> 22:37is happening at the microscopic
22:37 --> 22:39level in terms of local invasion.
22:39 --> 22:41Where is the thing that was biopsied?
22:41 --> 22:42Where is it going?
22:42 --> 22:45Is it in just the very first flute fuels
22:45 --> 22:48level layers of cells of the colon?
22:48 --> 22:50Is it invading through the colon?
22:50 --> 22:52Is invading into other structures in
22:52 --> 22:55as nodes or there are nodes lymph
22:55 --> 22:57nodes that are basically the first
22:57 --> 22:59sign that a colon cancer has been
22:59 --> 23:02getting to spread beyond the original
23:02 --> 23:04tumor and then finally, is Amar metastases?
23:04 --> 23:06That means they're spread of the
23:06 --> 23:08cancer beyond the colon,
23:08 --> 23:09intestine into other organs.
23:09 --> 23:10The body,
23:10 --> 23:12most commonly the liver or the lungs.
23:12 --> 23:15So four colon cancer that's been diagnosis.
23:15 --> 23:15Colon cancer.
23:15 --> 23:18On colonoscopy it is important to
23:18 --> 23:21get a complete scan of the body of
23:21 --> 23:23particularly of the chest and the
23:23 --> 23:25abdomen to make sure that you don't
23:25 --> 23:27have any far ranging metastases
23:27 --> 23:30or or tumor spread.
23:30 --> 23:31The second issue that is
23:31 --> 23:33where does it look locally?
23:33 --> 23:35And that's where sometimes
23:35 --> 23:37the biopsy alone can do that.
23:37 --> 23:39If the biopsy comes back as cancer
23:39 --> 23:41and the entire polyp was not
23:41 --> 23:43removed with that biopsy,
23:43 --> 23:44then that's kind of the first step
23:44 --> 23:46that someone needs to go back and see
23:46 --> 23:48if that can be removed into Scopic Lee.
23:48 --> 23:50Sometimes it's very obvious from the
23:50 --> 23:52original colonoscopic exam that it's
23:52 --> 23:54not going to be removed locally,
23:54 --> 23:55but if it's on a stock,
23:55 --> 23:57if it's kind of dangling into the colon,
23:57 --> 23:59sometimes those are at a very
23:59 --> 24:01good candidates for local removal
24:01 --> 24:02with Columbus scope.
24:02 --> 24:05If that's done and on the micro,
24:05 --> 24:07the microscopic evaluation of that specimen,
24:07 --> 24:09you can say clearly that here's
24:09 --> 24:12the cut edge of where we took this
24:12 --> 24:14tumor off this polyp off and there
24:14 --> 24:16is no cancer at that.
24:16 --> 24:18And then we looked at the individual
24:18 --> 24:19cancer cells in the bulk of the
24:19 --> 24:22polyp and we can see that they have
24:22 --> 24:24certain features that are favorable
24:24 --> 24:27then that may be all that patient needs.
24:27 --> 24:28On the flip side,
24:28 --> 24:29if there is tumor invasion,
24:29 --> 24:30if there's high concerning features
24:30 --> 24:32of the polyp in terms of what it
24:32 --> 24:33looks like under the microscope,
24:33 --> 24:36then that's something we're a segment of.
24:36 --> 24:38The colon needs to be removed,
24:38 --> 24:40and that would require a typically,
24:40 --> 24:42and in 2021 it would typically
24:42 --> 24:44require mentally invasive surgery
24:44 --> 24:46to remove a segment of the colon and
24:46 --> 24:48the nodal bundle that's attached to it.
24:48 --> 24:50To get that end staging for very
24:50 --> 24:51early tumors,
24:51 --> 24:53the risk of an end spread meaning
24:53 --> 24:55a nodal spread is so low that for
24:55 --> 24:57those very early tumors that we
24:57 --> 24:59just took off. Instead, we're done.
24:59 --> 25:00Those don't need that nodal bundle,
25:00 --> 25:02which is where that justification comes from.
25:03 --> 25:04So Speaking of burden,
25:04 --> 25:07if you had a very small cancer
25:07 --> 25:10such that it was just in a polyp,
25:10 --> 25:12do those patients still need the
25:12 --> 25:14scans of their chest in their abdomen
25:14 --> 25:16to look for distant metastases?
25:16 --> 25:18One would think that if
25:18 --> 25:19the nodal burden is low,
25:19 --> 25:20then the distant metastases
25:20 --> 25:23burden should also be very low.
25:23 --> 25:25I think it's certainly consideration
25:25 --> 25:27this is one of those particularly
25:27 --> 25:28controversial points and staging
25:28 --> 25:32guidelines that has is up for discussion,
25:32 --> 25:33and I think shared decision
25:33 --> 25:34making does come into it.
25:34 --> 25:36This is something that either that a
25:36 --> 25:37colorectal surgeon should probably involve
25:37 --> 25:40with to talk to the patient about one on one,
25:40 --> 25:43because there are very small risks up
25:43 --> 25:47spread and that needs to be discussed.
25:47 --> 25:49With the patient eventually,
25:49 --> 25:51because those guidelines are in flux,
25:51 --> 25:53and then if I can go back for one second,
25:53 --> 25:55I think you know we we talked a lot about
25:55 --> 25:57the kind of you see a polyp in the colon,
25:57 --> 25:58just to kind of clarify,
25:58 --> 26:00one of the tricky parts about the
26:00 --> 26:02anatomic specificity that we mentioned
26:02 --> 26:03earlier was that colon cancer can
26:03 --> 26:05be dealt with and more with less
26:05 --> 26:06the way that we just discussed.
26:07 --> 26:09Whereas rectal cancer is a different bird,
26:09 --> 26:11rectal cancer does make up about
26:11 --> 26:1330% of all colorectal cancer,
26:13 --> 26:15and the decision making around how
26:15 --> 26:18to address those tumors does differ.
26:18 --> 26:20OK, tell us more about that.
26:20 --> 26:21How does it differ?
26:22 --> 26:23So the interesting thing with
26:23 --> 26:24rectal cancer is biologically,
26:24 --> 26:25it's very similar to colon cancer.
26:25 --> 26:27It looks very the same under the
26:27 --> 26:28microscope and it's the same
26:28 --> 26:30kind of cell story that created
26:30 --> 26:31those cancers in the first place,
26:31 --> 26:33where rectal cancer does differ
26:33 --> 26:35is that it's anatomically fixed,
26:35 --> 26:36meaning the ****** is fixed in the pelvis,
26:36 --> 26:39whereas the colon flops around.
26:39 --> 26:42It's an incredibly powerful difference
26:42 --> 26:44that becomes more so every day
26:44 --> 26:46because we realize that we have more
26:46 --> 26:48modalities or options for therapy
26:48 --> 26:50that we can use for rectal cancer
26:50 --> 26:51because of its anatomically fixed.
26:51 --> 26:55Position what this means in 2021 is
26:55 --> 26:57that many many rectal cancers need
26:57 --> 26:59chemotherapy and radiation upfront,
26:59 --> 27:01which is entirely different.
27:01 --> 27:03Colon cancer, which if anything,
27:03 --> 27:05only gets those options for therapy
27:05 --> 27:07after the original tumor is removed.
27:07 --> 27:09Rectal cancer has been shown that it
27:09 --> 27:11seems to do better if we give those
27:11 --> 27:13modalities up front and then follow
27:13 --> 27:14with surgery after considerable
27:14 --> 27:16lead in period of often times,
27:16 --> 27:19three to six months of chemo
27:19 --> 27:19radiation therapy.
27:21 --> 27:22This brings up an interesting point.
27:22 --> 27:25Oftentimes, here on the show we we
27:25 --> 27:28talk about multidisciplinary care and
27:28 --> 27:30we talk about personalized therapy.
27:30 --> 27:33So how do you decide which
27:33 --> 27:34patients need chemotherapy?
27:34 --> 27:36Which patients need radiation?
27:36 --> 27:39Which patients do well with surgery alone?
27:39 --> 27:41It the multidisciplinary point
27:41 --> 27:43that you mentioned is critical.
27:43 --> 27:45It's getting increasingly complicated,
27:45 --> 27:47particularly with advanced disease.
27:47 --> 27:50It's very hard to make these decisions
27:50 --> 27:51without a colorectal surgeon,
27:51 --> 27:54medical oncologists and a number
27:54 --> 27:56of others supporting positions
27:56 --> 27:58from radiology pathology.
27:58 --> 27:59Interventional radiology all
27:59 --> 28:01getting together to talk about
28:01 --> 28:03what's the best course of action?
28:04 --> 28:05There are a couple sort of
28:05 --> 28:07easier points to make here.
28:07 --> 28:09I think that for colon cancer that's
28:09 --> 28:12early stage in the colon and not the
28:12 --> 28:14****** that's typically a surgery
28:14 --> 28:17first approach in most cases for things
28:17 --> 28:20that are in that for rectal cancer
28:20 --> 28:22as well as advanced colon cancer,
28:22 --> 28:25it really does require everyone in the room
28:25 --> 28:28to have that conversation about a patient.
28:28 --> 28:28Ultimately,
28:28 --> 28:30with the patient to see what's
28:30 --> 28:32the best first line approach.
28:33 --> 28:35Doctor Ira leads is an assistant professor
28:35 --> 28:38of surgery at the Yale School of Medicine.
28:38 --> 28:39If you have questions,
28:39 --> 28:40the address is cancer.
28:40 --> 28:43Answers at yale.edu and past editions of
28:43 --> 28:46the program are available in audio and
28:46 --> 28:47written form at yalecancercenter.org.
28:47 --> 28:50We hope you'll join us next week to
28:50 --> 28:52learn more about the fight against
28:52 --> 28:53cancer here on Connecticut Public
28:54 --> 28:55radio funding for Yale Cancer
28:55 --> 28:56Answers is provided by Smilow
28:56 --> 29:00Cancer Hospital and Astra Zeneca.

Information

Advances in Colon and Rectal Surgery with guest Dr. Ira Leeds December 5, 2021 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095