Neuroendocrine Tumors

Transcript

00:00 --> 00:02Support for Yale Cancer Answers
00:02 --> 00:05comes from AstraZeneca, dedicated
00:05 --> 00:09to advancing options and providing
00:09 --> 00:13hope for people living with
00:13 --> 00:14cancer. More information at astrazeneca-us.com.
00:14 --> 00:16Welcome to Yale Cancer Answers with
00:16 --> 00:18your host, Doctor Anees Chagpar.
00:18 --> 00:20Yale Cancer Answers features the
00:20 --> 00:23latest information on cancer care by
00:23 --> 00:24welcoming oncologists and specialists
00:24 --> 00:27who are on the forefront of the
00:27 --> 00:29battle to fight cancer. This week
00:29 --> 00:30it's a conversation about
00:30 --> 00:32neuroendocrine tumors in colon
00:32 --> 00:33cancer with Doctor Pamela Kunz.
00:33 --> 00:36Doctor Kunz is director of GI Medical
00:36 --> 00:38Oncology at the Yale School of
00:38 --> 00:40Medicine where Doctor Chagpar is
00:40 --> 00:42a professor of surgical oncology.
00:43 --> 00:46Pam, maybe we can start off
00:46 --> 00:47by setting the context?
00:47 --> 00:49What exactly are neuroendocrine
00:49 --> 00:52tumors and what do they have
00:52 --> 00:54to do with colon cancer?
00:55 --> 00:56Great question.
00:56 --> 00:57So neuroendocrine tumors are
00:57 --> 00:59just another type of cancer.
00:59 --> 01:01They can originate actually in
01:01 --> 01:04almost any part of the body,
01:04 --> 01:06most commonly in the GI tract
01:06 --> 01:09and in the lungs and what makes them
01:09 --> 01:11different from colon cancer is what the
01:11 --> 01:14cells look like under the microscope.
01:14 --> 01:16So it's actually a completely different
01:16 --> 01:19type of cancer than colon adenocarcinoma,
01:19 --> 01:21which is the most common
01:21 --> 01:22type of colon cancer.
01:23 --> 01:25So these neuroendocrine tumors
01:25 --> 01:27they can arise in the colon,
01:27 --> 01:30which would make them a colon cancer.
01:30 --> 01:33But they look different under the microscope.
01:33 --> 01:35So they're not exactly the same
01:35 --> 01:37garden variety colon cancer
01:37 --> 01:39that we usually think about?
01:39 --> 01:42That's correct, and so we would call
01:42 --> 01:45those a neuroendocrine tumor of the
01:45 --> 01:47colon and what's unique about these
01:47 --> 01:50is that we try our best to
01:50 --> 01:52identify where these cancers start,
01:52 --> 01:54because that has implications
01:54 --> 01:56on how we treat that cancer.
01:56 --> 01:59So they may start in the colon,
01:59 --> 02:02which is in fact actually quite rare.
02:02 --> 02:03Most commonly, they'll originate
02:03 --> 02:06in the small intestines in the
02:06 --> 02:08pancreas and in the lungs,
02:08 --> 02:10and they can spread to lymph nodes
02:10 --> 02:12or to the liver.
02:12 --> 02:14And so when someone says
02:14 --> 02:16they have a colon cancer,
02:17 --> 02:19we often just assume that
02:19 --> 02:20that's colon adenocarcinoma.
02:20 --> 02:23The garden variety, as you said.
02:23 --> 02:25But what's very important is that we
02:25 --> 02:28rely on our pathologists to tell us
02:28 --> 02:31exactly what histologic type, that means,
02:31 --> 02:34what the cancer cells look like
02:34 --> 02:36under the microscope to determine
02:36 --> 02:39whether it's an adenocarcinoma or a
02:39 --> 02:40neuroendocrine tumor.
02:40 --> 02:42Let's talk a little bit more
02:42 --> 02:44about how that process actually
02:44 --> 02:46happens and what the big deal is.
02:46 --> 02:47I mean, for many people they
02:47 --> 02:49may think a cancer is a cancer,
02:49 --> 02:51and I don't want
02:51 --> 02:53neuroendocrine cancers.
02:53 --> 02:55I don't want this cancers,
02:55 --> 02:57and I don't want that cancer,
02:57 --> 02:58I just don't want cancer.
02:58 --> 03:01I'm beginning to sound like Doctor Seuss.
03:01 --> 03:06But how do we differentiate between an
03:06 --> 03:09adenocarcinoma and a neuroendocrine tumor?
03:09 --> 03:12And why is that important?
03:14 --> 03:17So when a patient first develops
03:17 --> 03:20symptoms that may bring them to,
03:20 --> 03:22for example, their primary care
03:22 --> 03:23doctor or a gastroenterologist,
03:23 --> 03:27some of the symptoms may in fact
03:27 --> 03:29overlap between having any sort of
03:29 --> 03:32cancer of the colon or the GI tract.
03:32 --> 03:34They may have abdominal pain or
03:34 --> 03:37changes in their bowel habits,
03:37 --> 03:39and then they may undergo a biopsy.
03:39 --> 03:42That biopsy could be through a colonoscopy,
03:42 --> 03:45or, if the cancer has spread
03:45 --> 03:47somewhere else it may be
03:47 --> 03:49a biopsy of that spot,
03:49 --> 03:52like a biopsy of the liver and
03:52 --> 03:54once that biopsy is taken,
03:54 --> 03:56that tissue, the tumor tissue
03:56 --> 03:59goes to a pathologist as a
03:59 --> 04:02doctor that specializes in looking at
04:02 --> 04:05cells under the microscope to help us
04:05 --> 04:08determine exactly what type of cancer it is,
04:08 --> 04:12they will look at what the cells look like.
04:12 --> 04:14They will also do very special
04:14 --> 04:17stains to help us identify
04:17 --> 04:19certain characteristics of those cells,
04:19 --> 04:21and it matters because every
04:21 --> 04:23cancer is treated differently.
04:23 --> 04:25We now have large clinical trials that
04:25 --> 04:29tell us one cancer may do better with a
04:29 --> 04:31different chemotherapy versus another,
04:31 --> 04:34and so it's very critical in fact
04:34 --> 04:37to determine what type of cancer
04:37 --> 04:39that is in order for us to tailor
04:39 --> 04:42that treatment to the patient.
04:43 --> 04:46And also you know,
04:46 --> 04:49I think going back to what you had
04:49 --> 04:52said earlier, the cell of origin
04:52 --> 04:54for these cancers is different.
04:54 --> 04:57So for adenocarcinomas as you mentioned,
04:57 --> 05:00those are cancers that arise in the
05:00 --> 05:03colon in the glands of the colon,
05:03 --> 05:05whereas these neuroendocrine tumors
05:05 --> 05:07they may arise somewhere else.
05:07 --> 05:09Now do normal endocrine tumors that
05:09 --> 05:12you mentioned that can arise most
05:12 --> 05:14commonly in the small intestine,
05:14 --> 05:17or the pancreas or the lung.
05:17 --> 05:19Do those metastasize to the colon,
05:19 --> 05:22or when you find a neuroendocrine
05:22 --> 05:23tumor of the colon,
05:23 --> 05:26is it generally a neuroendocrine tumor,
05:26 --> 05:28albiet rare that started in the colon?
05:28 --> 05:31Usually we label these
05:31 --> 05:33based on where they start,
05:33 --> 05:36so if we're calling it a colon,
05:36 --> 05:38neuroendocrine tumor or a small
05:38 --> 05:39intestine neuroendocrine tumor,
05:39 --> 05:41that's because we believe they started
05:41 --> 05:44in those places and they start,
05:44 --> 05:46you're absolutely right from cells
05:46 --> 05:48that are different from these glandular
05:48 --> 05:50cells that an adenocarcinoma
05:50 --> 05:51originate from neuroendocrine
05:51 --> 05:53cells are unique.
05:53 --> 05:55They happened to be scattered
05:55 --> 05:56throughout the body.
05:56 --> 05:57They share features of
05:57 --> 05:59some typical cancer cells,
05:59 --> 06:01but one thing that makes them
06:01 --> 06:04unique is that some of them
06:04 --> 06:06can actually secrete hormones.
06:06 --> 06:08That's how they get their name endocrine.
06:08 --> 06:11And so these cancers that
06:11 --> 06:13originate in the small intestine,
06:13 --> 06:14for example,
06:14 --> 06:16sometimes can secrete a hormone
06:16 --> 06:18called serotonin that can cause
06:18 --> 06:20things like diarrhea and flushing.
06:20 --> 06:23And some of the pancreatic neuroendocrine
06:23 --> 06:26cancers can secrete other types of hormones,
06:26 --> 06:27for example,
06:27 --> 06:27insulin,
06:27 --> 06:31that can make your blood sugar quite low.
06:31 --> 06:33So it's a combination of
06:33 --> 06:36things that helps us eventually
06:36 --> 06:37lead to that diagnosis,
06:37 --> 06:38and
06:38 --> 06:41then tailor that treatment and so
06:41 --> 06:44if a patient were to present and they
06:44 --> 06:48go and they have a colonoscopy and they
06:48 --> 06:51have a biopsy and the biopsy shows
06:51 --> 06:54a neuroendocrine origin is it likely
06:54 --> 06:56that started in neuroendocrine
06:56 --> 06:58cells of the colon itself?
06:58 --> 07:01Or does this prompt then a little search
07:01 --> 07:04to see whether that neuroendocrine
07:04 --> 07:07tumor that was found in the colon
07:07 --> 07:10actually came from somewhere else,
07:10 --> 07:13or how common would that be
07:13 --> 07:16for it to migrate to the colon?
07:16 --> 07:19Many of our listeners may know that garden
07:19 --> 07:22variety colon cancer goes other places.
07:22 --> 07:25It goes to the liver and
07:25 --> 07:27so on and so forth.
07:27 --> 07:29But do these neuroendocrine
07:29 --> 07:30tumors that may start,
07:30 --> 07:33for example, in the small bowel,
07:33 --> 07:35end up in the colon?
07:35 --> 07:37That would be very unusual.
07:37 --> 07:39They would more commonly spread
07:39 --> 07:42to lymph nodes and to the liver,
07:42 --> 07:44but to your original question,
07:44 --> 07:46we do something called a staging
07:46 --> 07:49work up really at the time anyone is
07:49 --> 07:51diagnosed with any sort of cancer
07:52 --> 07:54that helps us determine the extent
07:54 --> 07:56of the cancer where perhaps has
07:56 --> 07:58the cancer spread anywhere else.
07:58 --> 08:02We do that by using a CTE or a CAT
08:02 --> 08:05scan that helps us look at the chest,
08:05 --> 08:07the abdomen and the pelvis.
08:07 --> 08:10For other areas of cancer we will
08:10 --> 08:13also sometimes do blood work that
08:13 --> 08:15includes looking at blood tests,
08:15 --> 08:17cell counts, liver tests,
08:17 --> 08:20kidney tests to also see if there is
08:20 --> 08:23any other effect on other organs,
08:23 --> 08:24and so
08:24 --> 08:26you'll do this regardless of
08:26 --> 08:27whether they presented with a
08:27 --> 08:30neuroendocrine tumor or whether they
08:30 --> 08:32presented with an adenocarcinoma?
08:32 --> 08:34That's correct, yes
08:34 --> 08:38and
08:38 --> 08:42kind of getting back to where we started
08:42 --> 08:45in terms of patient presentation,
08:45 --> 08:48you had mentioned that neuroendocrine tumors,
08:48 --> 08:52because they tend to secrete these hormones,
08:52 --> 08:56they can present with symptoms of diarrhea
08:56 --> 08:59and flushing and so on and so forth.
08:59 --> 09:03Whereas many colon cancers actually
09:03 --> 09:05may be completely asymptomatic
09:05 --> 09:07often because we have screening,
09:07 --> 09:10For our listeners,
09:10 --> 09:12there was an update to the
09:12 --> 09:14screening guidelines for colon
09:14 --> 09:16cancer that was recently put out.
09:16 --> 09:19Do you want to tell us
09:19 --> 09:21a little bit more about that?
09:21 --> 09:22Yes, definitely,
09:22 --> 09:25and I think that's also another key
09:25 --> 09:27between the garden variety,
09:27 --> 09:29colon adenocarcinoma and neuroendocrine
09:29 --> 09:33tumors is that there are precursors or
09:33 --> 09:35pre cancers to colon adenocarcinoma
09:35 --> 09:37that we can detect as polyps.
09:37 --> 09:40So small little growths within the colon,
09:40 --> 09:44we can detect and remove and prevent
09:44 --> 09:48cancer and the way we do that is through
09:48 --> 09:51colonoscopies and so last week the
09:51 --> 09:54large guidelines body called the United
09:54 --> 09:57States Preventive Services Task Force,
09:57 --> 10:00a large organization that
10:00 --> 10:02helps determine guidelines for screening,
10:02 --> 10:05came out out with a new recommendation.
10:05 --> 10:08It's in draft format right now, to
10:08 --> 10:10lower the colon cancer screening
10:10 --> 10:13age to 45 from the age of 50,
10:13 --> 10:17so this is moving it earlier by five years,
10:17 --> 10:19and that's for people that have
10:19 --> 10:22an average risk of colon cancer,
10:22 --> 10:24so no strong family history
10:24 --> 10:27or personal history or other risk
10:27 --> 10:29factors that would increase your risk.
10:29 --> 10:32This is for average risk individuals.
10:32 --> 10:33And so why
10:33 --> 10:35did they do that?
10:35 --> 10:37Why are they now thinking that
10:37 --> 10:40people need to get screened earlier?
10:40 --> 10:42Are we finding cancers at
10:42 --> 10:45earlier ages?
10:45 --> 10:47We are in fact finding cancers at earlier ages
10:47 --> 10:49really, since the 1990s,
10:49 --> 10:52we've seen an increase of 2% per
10:52 --> 10:55year of the incidence of colon
10:55 --> 10:58cancer in people under the age of 55.
10:58 --> 11:01Some other organizations,
11:01 --> 11:03the American College of Gastroenterology
11:03 --> 11:05decreased their screening recommendation
11:05 --> 11:08age to 45 years for black men.
11:08 --> 11:11This was in the mid 2000s and in 2018
11:11 --> 11:14the American Cancer Society reduced that
11:14 --> 11:18colon cancer screening age to 45 for
11:18 --> 11:22all people and that was just two years ago,
11:22 --> 11:25and I think that over the last few years
11:25 --> 11:28we've seen just stronger evidence to
11:28 --> 11:31support lowering this screening age,
11:31 --> 11:33and therefore the United States
11:33 --> 11:35Preventive Services Task Force came
11:35 --> 11:38out with this recommendation last
11:38 --> 11:39week and
11:39 --> 11:42the screening guidelines for colon
11:42 --> 11:46cancer may be a little bit confusing for
11:46 --> 11:50some of our listeners because it really
11:50 --> 11:53depends on the type of test.
11:53 --> 11:56Sometimes they say get a colonoscopy
11:56 --> 12:00every 10 years, but then there are other
12:00 --> 12:03tests like flexible sigmoidoscopy.
12:03 --> 12:05There are contact tests.
12:05 --> 12:08There are now tests like
12:08 --> 12:10Cologuard so stool DNA tests.
12:10 --> 12:14There are fecal occult blood tests, can you
12:14 --> 12:17help our listeners to understand
12:17 --> 12:21these different tests and what they
12:21 --> 12:24should be doing in terms of screening?
12:24 --> 12:27Because when they read the
12:27 --> 12:30guidelines it may get a little confusing.
12:31 --> 12:33So your team
12:33 --> 12:36of doctors will help guide you to
12:36 --> 12:37select the test that's
12:37 --> 12:39best for you and
12:39 --> 12:41full disclosure,
12:41 --> 12:43my husband is a gastroenterologist and
12:43 --> 12:46we talk about this a lot at home,
12:46 --> 12:49and I'll
12:49 --> 12:52quote something that he says which is any
12:52 --> 12:55screening is better than no screening.
12:55 --> 12:58And so I think your first stop
12:58 --> 13:01is talking to your primary care doctor.
13:01 --> 13:03So these are the doctors that will
13:03 --> 13:06often refer you to get colon cancer
13:06 --> 13:08screening that is right for you.
13:08 --> 13:11Your next stop usually is with a gastroenterologist
13:11 --> 13:13and they will talk with
13:13 --> 13:16you about this range of screening and
13:16 --> 13:18you did a very nice job listing
13:18 --> 13:21those options and these are tests
13:21 --> 13:23that look for hidden blood in stools.
13:23 --> 13:25Those are called occult blood tests.
13:25 --> 13:28There is the DNA based test so
13:28 --> 13:30we know that colon cancers can
13:30 --> 13:33actually shed DNA into the stool.
13:33 --> 13:35And we can look for that.
13:35 --> 13:38A sigmoidoscopy will look just in the
13:38 --> 13:41bottom portion of your large intestine,
13:41 --> 13:42called the sigmoid colon,
13:42 --> 13:45so it will only detect that and it is
13:45 --> 13:47an actual camera that's inserted
13:47 --> 13:49into the sigmoid colon.
13:49 --> 13:52A full colonoscopy will have a camera
13:52 --> 13:55inserted into the entirety of your colon,
13:55 --> 13:58and so there's a huge range of options.
13:58 --> 14:01And I agree it can be confusing,
14:01 --> 14:03but I think that the
14:03 --> 14:05best thing is to really talk with
14:05 --> 14:07your primary care doctor and gastroenterologist
14:07 --> 14:09about these options.
14:09 --> 14:11Some tests may be better for
14:11 --> 14:12different patients,
14:12 --> 14:15but let me talk a little bit about
14:15 --> 14:17some of the advantages of why
14:17 --> 14:19colonoscopy and perhaps even
14:19 --> 14:21sigmoidoscopy outweigh some of
14:21 --> 14:23the others right after we take
14:25 --> 14:28a short break for a medical minute.
14:28 --> 14:30Please stay tuned to learn more
14:30 --> 14:32information about colon cancer
14:32 --> 14:34with my guest, Doctor Pamela Kunz.
14:34 --> 14:37Support for Yale Cancer Answers
14:37 --> 14:40comes from AstraZeneca, dedicated
14:40 --> 14:43to providing innovative treatment
14:43 --> 14:47options for people living with
14:47 --> 14:48cancer. Learn more at astrazeneca-us.com.
14:48 --> 14:51This is a medical minute about genetic
14:51 --> 14:53testing which can be useful for
14:53 --> 14:56people with certain types of cancer
14:56 --> 14:58that seem to run in their families.
14:58 --> 15:01Patients that are considered at risk
15:01 --> 15:03receive genetic counseling and testing so
15:03 --> 15:06informed medical decisions can be based
15:06 --> 15:08on their own personal risk assessment.
15:08 --> 15:10Resources for genetic counseling and
15:10 --> 15:12testing are available at federally
15:12 --> 15:14designated comprehensive cancer centers.
15:14 --> 15:16Interdisciplinary teams include geneticists,
15:16 --> 15:17genetic counselors, physicians,
15:17 --> 15:18and nurses
15:18 --> 15:20who work together to provide
15:20 --> 15:22risk assessment and steps to
15:22 --> 15:24prevent the development of cancer.
15:24 --> 15:26More information is available
15:26 --> 15:27at yalecancercenter.org.
15:27 --> 15:31You're listening to Connecticut Public Radio.
15:31 --> 15:31Welcome
15:31 --> 15:33back to Yale Cancer Answers.
15:33 --> 15:35This is doctor in Anees Chagpar
15:35 --> 15:38and I'm joined tonight by
15:38 --> 15:40my guest doctor Pamela Kunz.
15:40 --> 15:42We're talking about colon cancer,
15:42 --> 15:43and neuroendocrine tumors,
15:43 --> 15:46and right before the break we were
15:46 --> 15:48talking about some recent updates
15:48 --> 15:50to the colon cancer guidelines that
15:50 --> 15:52recommend that everybody at
15:52 --> 15:55average risk start getting their colon
15:55 --> 15:58cancer screening done at the age of 45.
15:58 --> 16:00Now, for anybody who's read those
16:00 --> 16:02colon cancer screening guidelines,
16:02 --> 16:04it's a little bit confusing.
16:04 --> 16:06There's all kinds of tests
16:06 --> 16:08that are out there, and Pamela,
16:08 --> 16:10you were telling us right before
16:10 --> 16:12the break that this is a decision
16:12 --> 16:14that you really need to make
16:14 --> 16:16with your health care team.
16:16 --> 16:17Your primary care doctor,
16:17 --> 16:18your gastroenterologist.
16:18 --> 16:20But you are going to make a pitch
16:20 --> 16:23for a particular form of screening.
16:23 --> 16:26So tell us a little bit more about that.
16:27 --> 16:30That's right, so there are a number
16:30 --> 16:33of options, but I was going to talk a
16:33 --> 16:35little bit more about colonoscopies.
16:35 --> 16:37I think that colonoscopies really
16:37 --> 16:40meet a number of different needs
16:40 --> 16:42in terms of the screening goals,
16:42 --> 16:45so number one, to take
16:45 --> 16:49a step back to describe them,
16:49 --> 16:52your gastroenterologist will use a
16:52 --> 16:54small camera on the end of a tube
16:54 --> 16:57and that allows them to detect
16:57 --> 16:59small polyps, which are these
16:59 --> 17:01precancerous spots and remove them,
17:01 --> 17:04and I think that is critical
17:04 --> 17:07in terms of cancer prevention.
17:07 --> 17:10Some of these other tools might identify
17:10 --> 17:13that perhaps you have a precancerous lesion,
17:13 --> 17:16or perhaps you have a cancer,
17:16 --> 17:19but don't also enable the ability
17:19 --> 17:22to actually remove that polyp,
17:22 --> 17:24so that's why I think colonoscopies
17:24 --> 17:27really are probably the best
17:27 --> 17:29tool and considered the gold standard.
17:30 --> 17:34So just to be honest, r
17:34 --> 17:36I think a lot of people when
17:36 --> 17:38they think about colonoscopy,
17:38 --> 17:42the things that kind of make people less than
17:42 --> 17:45enamored with the technique, is number 1,
17:45 --> 17:48the prep because your colon needs
17:48 --> 17:50to be really clean for somebody to
17:50 --> 17:53put a camera in there and actually
17:53 --> 17:56be able to see anything and #2,
17:56 --> 17:59the whole thought of having
17:59 --> 18:02to put up your bottom end is not particularly
18:02 --> 18:05appealing to people when they can think of
18:05 --> 18:07instead just sending in a stool sample,
18:07 --> 18:09which although not appealing,
18:09 --> 18:12sounds a little bit nicer than
18:12 --> 18:15putting a tube up your bottom end so
18:15 --> 18:19if you were to do the other, say,
18:19 --> 18:23a fecal occult blood test or a
18:23 --> 18:27stool DNA test that now
18:27 --> 18:31is being marketed to patients,
18:31 --> 18:32if that's negative,
18:32 --> 18:34how confident are you in the results?
18:34 --> 18:35If it's positive,
18:35 --> 18:38you'll likely end up needing a colonoscopy.
18:38 --> 18:39Is that right?
18:39 --> 18:40That's right,
18:40 --> 18:42so if those tests are positive,
18:42 --> 18:45you will still need to do the prep.
18:45 --> 18:47I think that's one of the
18:47 --> 18:49aspects of a colonoscopy that
18:49 --> 18:51most people are worried about.
18:51 --> 18:53That's when you have to drink a
18:53 --> 18:55special fluid that helps clean
18:55 --> 18:58out your colon in order for the
18:58 --> 19:00gastroenterologist to really see a shiny,
19:00 --> 19:03clean colon and detect the polyps so
19:03 --> 19:05the prep is scary.
19:05 --> 19:08And in terms of these other options,
19:08 --> 19:09if it's negative,
19:09 --> 19:13so if a fecal occult blood test is negative,
19:13 --> 19:16or the stool DNA test is negative,
19:16 --> 19:18it's reassuring, but it's not 100%.
19:20 --> 19:23And colonoscopy really allows the
19:23 --> 19:25gastroenterologist to look inside your
19:25 --> 19:28colon and see if there are any polyps,
19:28 --> 19:29and to remove them.
19:29 --> 19:32Now before the break we were also
19:32 --> 19:34talking about neuroendocrine tumors
19:34 --> 19:37and you had mentioned that
19:37 --> 19:40these are from a different cell of origin.
19:40 --> 19:42They often secrete hormones,
19:44 --> 19:46and rarely they can actually
19:46 --> 19:49reside inside the colon as well.
19:49 --> 19:51Now does a colonoscopy
19:51 --> 19:52find these as well,
19:52 --> 19:55or are these kind of hidden and
19:55 --> 19:57the only way that you can really
19:57 --> 20:00find them is when you present with
20:00 --> 20:01symptoms?
20:01 --> 20:04A colonoscopy will help us detect any
20:04 --> 20:08abnormalities in the colon actually, and it
20:08 --> 20:11will help detect other types of cancers.
20:11 --> 20:14It will help detect other types of conditions
20:14 --> 20:17such as inflammatory bowel disease,
20:17 --> 20:20but what's unique about neuroendocrine
20:20 --> 20:24tumors is that they don't have a
20:24 --> 20:26precursor or a precancerous spot
20:26 --> 20:28that develops before the cancer.
20:28 --> 20:31So very likely if a neuroendocrine
20:31 --> 20:33tumor is present
20:33 --> 20:36in the colon, it's already a cancer,
20:36 --> 20:38whereas for colonoscopy the
20:38 --> 20:42intent is to try to catch cancers
20:42 --> 20:45earlier before they are even cancers.
20:45 --> 20:47So detect the polyps.
20:48 --> 20:50And the guidelines for colonoscopy,
20:50 --> 20:52if I remember correctly,
20:52 --> 20:55are for a colonoscopy every 10 years.
20:55 --> 20:57Some people may look at
20:57 --> 20:59that and say 10 years.
20:59 --> 21:01What happens if I develop one
21:01 --> 21:03of these precancerous polyps
21:03 --> 21:04in the interim,
21:04 --> 21:07is 10 years really the guideline,
21:07 --> 21:09and what do you say to
21:09 --> 21:11people who have those
21:11 --> 21:14concerns?
21:14 --> 21:1510 years is the guideline that's assuming
21:15 --> 21:18that you again have average risk,
21:18 --> 21:19and assuming that
21:19 --> 21:21first, colonoscopy is completely normal.
21:21 --> 21:23If that colonoscopy shows polyps,
21:23 --> 21:27very likely you're asked to come back sooner,
21:27 --> 21:29often within three years to see
21:29 --> 21:31if there are any more polyps.
21:31 --> 21:34But if your colonoscopy is totally clean,
21:34 --> 21:38you are often asked to return in 10 years,
21:38 --> 21:40and that's because what we've learned
21:40 --> 21:43about the biology of polyps is it
21:43 --> 21:46often can take 10 years for
21:46 --> 21:48a polyp to turn into a cancer.
21:48 --> 21:49Now that's
21:49 --> 21:52I would say on average or typical
21:52 --> 21:56there are exceptions to that rule, and
21:56 --> 21:59so the good news for all of our listeners,
21:59 --> 22:03of course, is that if you do undergo
22:03 --> 22:05a colonoscopy as Doctor Kunz is
22:05 --> 22:08recommending starting at the age of 45,
22:08 --> 22:10if it's completely clean,
22:10 --> 22:13you don't have to drink that
22:13 --> 22:15prep for another 10 years,
22:15 --> 22:19which is always a nice thing to know as well.
22:19 --> 22:20Doctor Kunz,
22:20 --> 22:23you had mentioned that
22:23 --> 22:25for these polyps you can kind of
22:25 --> 22:28take them out at the time of the
22:28 --> 22:29colonoscopy and potentially prevent
22:29 --> 22:31yourself from getting a cancer.
22:31 --> 22:34But if you've got a neuroendocrine tumor,
22:34 --> 22:36that's often a cancer that's already there.
22:36 --> 22:39And sometimes you can find colon cancers
22:39 --> 22:42that are already in the form of a
22:42 --> 22:44colon cancer before finding it just as
22:44 --> 22:46a polyp. Is that right?
22:46 --> 22:49Yes, and so the biopsy that's done at the time
22:49 --> 22:53of the colonoscopy can help us to tell
22:53 --> 22:55what kind of cancer this is,
22:55 --> 22:56is this an adenocarcinoma?
22:56 --> 22:58Is it just a pre cancer?
22:58 --> 23:00Is this a neuroendocrine cancer?
23:00 --> 23:02So if it's a pre cancer and
23:02 --> 23:04the polyps removed is that it?
23:04 --> 23:06Do you have to take anymore
23:06 --> 23:08medications or is removing the
23:08 --> 23:10polyp and getting your follow up
23:10 --> 23:13colonoscopy all you need to do?
23:13 --> 23:15If all that is detected is a
23:15 --> 23:17polyp and they're able to
23:17 --> 23:20completely remove it
23:20 --> 23:22then the recommendation is just
23:22 --> 23:23following up your gastroenterologist
23:23 --> 23:25says in terms of recommended intervals.
23:25 --> 23:28So if they find multiple polyps,
23:28 --> 23:31or even just one, it will certainly be,
23:31 --> 23:34please come back and see us before 10 years
23:34 --> 23:37but there is no treatment needed.
23:37 --> 23:39There's no chemotherapy needed,
23:39 --> 23:40and nothing else is needed.
23:43 --> 23:47Let's move on to
23:47 --> 23:49the other two scenarios.
23:49 --> 23:53Let's suppose this is an actual
23:53 --> 23:55garden variety adenocarcinoma.
23:55 --> 23:56What happens then?
23:58 --> 24:01So if we determine that based on the
24:01 --> 24:03biopsy that it's a colon adenocarcinoma,
24:03 --> 24:05then patients are usually
24:05 --> 24:08referred to see an oncology team.
24:08 --> 24:09That team consists of
24:09 --> 24:11usually a medical oncologist,
24:11 --> 24:13like myself, and often a surgeon,
24:13 --> 24:16and we will embark on this staging work up
24:16 --> 24:20that I'd mentioned a little bit earlier.
24:20 --> 24:23So that includes blood work and that
24:23 --> 24:26will usually also include a CT scan of
24:26 --> 24:29the chest and the abdomen and the pelvis.
24:29 --> 24:31To determine extent of disease,
24:31 --> 24:32meaning, where
24:32 --> 24:33has the cancer gone?
24:33 --> 24:36Is it localized just in the colon?
24:36 --> 24:38Has it spread to nearby lymph nodes
24:38 --> 24:40or has it spread further,
24:40 --> 24:43perhaps to the liver or to the lungs?
24:44 --> 24:47And so, let's say it
24:47 --> 24:48hasn't spread anywhere then what?
24:48 --> 24:51Then we will often have
24:51 --> 24:53a multidisciplinary team meeting.
24:53 --> 24:56We do this for many of our cancers.
24:56 --> 24:58It's called a tumor board.
24:58 --> 25:01In fact, we have our GI cancer
25:01 --> 25:03tumor board this afternoon,
25:03 --> 25:06and the tumor board is a place where
25:06 --> 25:08there are multiple specialists,
25:08 --> 25:09medical oncologists,
25:09 --> 25:10surgeons, pathologists, radiologists,
25:10 --> 25:13a whole group of doctors that
25:13 --> 25:15will help determine the next
25:15 --> 25:17best plan for someone who has a
25:17 --> 25:19localized colon cancer that often
25:19 --> 25:21the next step is often a surgery
25:21 --> 25:24to remove a portion of the colon
25:24 --> 25:26that contains the cancer plus
25:26 --> 25:28some additional colon to make
25:28 --> 25:30sure that we've removed enough and
25:30 --> 25:33also some lymph nodes to help us
25:33 --> 25:35determine if the cancer
25:35 --> 25:37has spread to those lymph nodes.
25:38 --> 25:40And then is chemotherapy or
25:40 --> 25:42radiation in their future as well?
25:42 --> 25:44That depends on
25:44 --> 25:46the stage of the tumor.
25:46 --> 25:49So now that the patient
25:49 --> 25:51has had their surgery,
25:51 --> 25:53we are able to accurately determine
25:53 --> 25:56what stage they have in this stage is
25:56 --> 25:59determined based on three key features,
25:59 --> 26:01and that's called the TNM staging.
26:01 --> 26:04which stands for tumor (T), nodes (N), and metastases (M).
26:04 --> 26:07And the T stage generally refers to
26:07 --> 26:11ia combination of the size and then
26:11 --> 26:14how deep in the lining of the colon
26:14 --> 26:16that tumor has spread, the N stage
26:16 --> 26:19refers to the number of lymph nodes
26:19 --> 26:22involved and the M stage refers
26:22 --> 26:24to has the cancer metastasized
26:24 --> 26:26or spread to a distant location,
26:26 --> 26:28like the liver or the lungs,
26:28 --> 26:30and so our pathologists help
26:30 --> 26:32us with that.
26:32 --> 26:35The CT scan itself also helps us,
26:35 --> 26:37and so for someone with a colon
26:37 --> 26:40cancer it's a little bit nuanced,
26:40 --> 26:42but I would say in general,
26:42 --> 26:45if someone has a colon cancer
26:45 --> 26:48that is stage three or greater,
26:48 --> 26:51that would mean that they have
26:51 --> 26:53local lymph nodes involved
26:53 --> 26:56that usually does mean that
26:56 --> 26:58they need post surgical chemotherapy
26:58 --> 27:01and so now let's move to the
27:01 --> 27:03neuroendocrine situation.
27:03 --> 27:05How are these different?
27:05 --> 27:08How often do you find metastases
27:08 --> 27:10at the time of diagnosis?
27:10 --> 27:12Are these resected surgically?
27:12 --> 27:15Is there more often medical management?
27:15 --> 27:18How is your approach similar or
27:18 --> 27:22different to regular colon cancer?
27:22 --> 27:24Well, I think that
27:24 --> 27:26the work up for many of these GI
27:26 --> 27:29cancers are the same where we get a
27:29 --> 27:31biopsy and we do this staging work
27:31 --> 27:34up with blood tests and a CT scan.
27:34 --> 27:36And then we meet and
27:36 --> 27:38we have a tumor board discussion
27:38 --> 27:40to come up with the next plan,
27:40 --> 27:42so those are the common principles.
27:42 --> 27:43But you're right,
27:43 --> 27:45the treatment plan and tailoring
27:45 --> 27:47that treatment to the patient often
27:47 --> 27:49differs by cancer and so that is
27:49 --> 27:50true for neuroendocrine tumors.
27:50 --> 27:52Neuroendocrine tumors are
27:52 --> 27:53often much slower growing than
27:53 --> 27:55their adenocarcinoma counterparts,
27:55 --> 27:57and neuroendocrine
27:57 --> 27:59tumors have a very different
27:59 --> 28:01system of classification.
28:01 --> 28:05I won't go into all of those details now,
28:05 --> 28:08but that does help us determine
28:08 --> 28:11what the next best step is and
28:11 --> 28:15we do include things like surgery.
28:15 --> 28:18Sometimes patients will have had the
28:18 --> 28:21cancer spread at the time of diagnosis,
28:21 --> 28:23and if that's the case,
28:23 --> 28:24we have medications,
28:24 --> 28:25including some chemotherapies
28:25 --> 28:28that help us slow down the
28:28 --> 28:31growth of that cancer, and so the
28:31 --> 28:34chemotherapies though are different than
28:34 --> 28:37what you would get for a regular colon
28:37 --> 28:38cancer?
28:38 --> 28:41This is an important
28:41 --> 28:43take home for every cancer type.
28:43 --> 28:46The chemotherapy regimen
28:46 --> 28:48is often different
28:48 --> 28:50depending on that cancer type.
28:50 --> 28:52There's sometimes some overlap,
28:52 --> 28:54but for the most part,
28:54 --> 28:57the way we determine if a chemotherapy
28:57 --> 28:59regimen works for a given cancer
28:59 --> 29:01is through a clinical trial.
29:01 --> 29:04Clinical trials are ways we test new
29:04 --> 29:05medicines or new combinations of
29:05 --> 29:08medicines and prove that it works
29:08 --> 29:10in a very specific cancer type.
29:10 --> 29:11Doctor Pamela Kunz
29:11 --> 29:14is the director of GI Medical
29:14 --> 29:17Oncology at the Yale School of Medicine.
29:17 --> 29:19If you have questions,
29:19 --> 29:20the address is canceranswers@yale.edu
29:20 --> 29:22and past editions of the program
29:22 --> 29:24are available in audio and written
29:24 --> 29:26form at yalecancercenter.org.
29:26 --> 29:29We hope you'll join us next week to
29:29 --> 29:32learn more about the fight against
29:32 --> 29:34cancer here on Connecticut Public Radio.

Information

Neuroendocrine Tumors with guest Dr. Pamela Kunz November 22, 2020 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095