Robotic Surgery for Colon and Rectal Cancers

Transcript

00:00 --> 00:02Support for Yale Cancer Answers
00:02 --> 00:05comes from AstraZeneca, working side
00:05 --> 00:08by side with leading scientists to
00:08 --> 00:11better understand how complex data
00:11 --> 00:15can be converted into
00:15 --> 00:16innovative treatments. More information at astrazeneca-us.com.
00:16 --> 00:18Welcome to Yale Cancer Answers with
00:18 --> 00:20your host, Doctor Anees Chagpar.
00:20 --> 00:22Yale Cancer Answers features the
00:22 --> 00:24latest information on cancer care
00:24 --> 00:26by welcoming oncologists and
00:26 --> 00:28specialists who are on the
00:28 --> 00:29forefront of the battle to fight
00:29 --> 00:31cancer. This week it's a
00:31 --> 00:33conversation about the use of
00:33 --> 00:34robotic surgery for colon and
00:34 --> 00:36rectal cancers with Doctor George
00:36 --> 00:38Yavorek. Doctor Yavorek is a
00:38 --> 00:40clinical instructor of surgery
00:40 --> 00:41specializing in gastro bariatrics
00:41 --> 00:43at the Yale School of Medicine
00:43 --> 00:45where Doctor Chagpar is a
00:45 --> 00:47professor of surgical oncology.
00:48 --> 00:50George, maybe we can
00:50 --> 00:53start off by talking
00:53 --> 00:55about screening for colon cancer.
00:55 --> 00:56I understand that guidelines
00:56 --> 00:58have recently changed in
00:58 --> 01:00that regard.
01:00 --> 01:02Yes, we've seen over the last 10 years
01:02 --> 01:04that the incidence of colon
01:04 --> 01:06cancer in younger individuals has
01:06 --> 01:08increased by about 2% per year
01:08 --> 01:11over the last five years or so,
01:11 --> 01:12so the recommendations have
01:12 --> 01:14changed to start screening
01:14 --> 01:16at age 45 rather than age 50.
01:16 --> 01:19Tell us a little bit more about
01:19 --> 01:21what that screening entails because
01:21 --> 01:24there seems to be a potpourri of
01:24 --> 01:27different screening options for people,
01:27 --> 01:29and they may be wondering about what
01:29 --> 01:32screening technique is best for them.
01:32 --> 01:35There are several options and most people
01:35 --> 01:37would agree that colonoscopy is the
01:37 --> 01:39best screening tool because it can
01:39 --> 01:41also be therapeutic at the time.
01:41 --> 01:46If you do find a polyp or a larger lesion, it
01:46 --> 01:49can be removed or biopsied at the same time.
01:49 --> 01:51Other options would include
01:51 --> 01:53fecal occult blood testing.
01:53 --> 01:55Which is not as specific.
01:55 --> 01:58There is now DNA testing, Cologuard,
01:58 --> 02:01which is rather specific for advanced
02:01 --> 02:03lesions, tumors or large polyps,
02:03 --> 02:07but when you get to smaller polyps,
02:07 --> 02:11the sensitivity is not very good, it is
02:11 --> 02:13good for people who don't want
02:13 --> 02:15to go through a colonoscopy,
02:15 --> 02:17or perhaps because of medical reasons
02:17 --> 02:18can't do that.
02:18 --> 02:20Other options might include
02:20 --> 02:22what they call ECT collography,
02:22 --> 02:24which is essentially a virtual colonoscopy.
02:24 --> 02:25The sensitivity is roughly
02:25 --> 02:27equivalent to a colonoscopy.
02:27 --> 02:27However,
02:27 --> 02:29if something is found then you
02:29 --> 02:31have to go through a colonoscopy
02:31 --> 02:33to have it removed or biopsied.
02:35 --> 02:38And so it sounds like there's
02:38 --> 02:40so many factors that are involved
02:40 --> 02:43for people to try to parse out.
02:43 --> 02:45What's the best technique for them?
02:45 --> 02:46That's probably a discussion that
02:46 --> 02:48they have with their family doctor.
02:49 --> 02:52or gastroenterologist
02:52 --> 02:53or colorectal surgeon.
02:53 --> 02:56Someone who does screening and
02:56 --> 02:58can tailor the screening
02:58 --> 03:01program to the individual.
03:02 --> 03:04And so now that the screening
03:04 --> 03:07guidelines have changed and they've
03:07 --> 03:09recommended starting screening at 45,
03:09 --> 03:12is that for average risk people or is
03:12 --> 03:16that for people who may have other
03:16 --> 03:16predisposing factors?
03:16 --> 03:19No, that's for average risk.
03:19 --> 03:22People with a higher risk
03:22 --> 03:23actually would start sooner.
03:23 --> 03:26Typical recommendation for someone with
03:26 --> 03:29a first degree relative who has had
03:29 --> 03:33colon cancer is to start at least 10 years
03:33 --> 03:36younger than when that cancer was diagnosed.
03:36 --> 03:39So if the person has a parent who
03:39 --> 03:42had colon cancer at about age 50,
03:42 --> 03:44they should start at age 40.
03:44 --> 03:46Other high risk situations might
03:46 --> 03:48be someone with Crohn's disease
03:48 --> 03:50or inflammatory bowel disease,
03:50 --> 03:53or someone with a history of
03:53 --> 03:54Polyposis syndrome that would
03:54 --> 03:57increase their risk of developing
03:57 --> 03:59polyps and possibly cancer.
03:59 --> 04:02So when should those people be screened?
04:02 --> 04:04I mean, presumably people with
04:04 --> 04:06Crohn's disease or other forms of
04:06 --> 04:08IBD or Polyposis syndrome likely
04:08 --> 04:10would have already had a colonoscopy,
04:10 --> 04:13but when would be the bare minimum
04:13 --> 04:15time that they should actually start
04:15 --> 04:18getting regular screening for cancer?
04:19 --> 04:21Well, typically when they first are seen
04:21 --> 04:23and diagnosed with the problem
04:23 --> 04:25whatever their condition might be,
04:25 --> 04:27they're likely going to have an
04:27 --> 04:29initial colonoscopy to evaluate the
04:29 --> 04:31situation and then future surveillance
04:31 --> 04:33colonoscopies would be based on that.
04:33 --> 04:35So typically if someone were
04:35 --> 04:37diagnosed with Crohn's and is in their 20s,
04:37 --> 04:40it's likely they would have a colonoscopy
04:40 --> 04:43at that time and then basically go
04:43 --> 04:45from there on an individual basis,
04:45 --> 04:48but typically every five to 10 years.
04:48 --> 04:49If there were no
04:49 --> 04:52significant clinical symptoms at
04:52 --> 04:55the time of colonoscopy.
04:55 --> 04:57You mentioend that colonoscopy can be both diagnostic and
04:57 --> 05:00therapeutic, talk a little bit more about
05:00 --> 05:03the therapeutic options when you are doing
05:03 --> 05:06a colonoscopy and you you find a lesion.
05:06 --> 05:09First of all, what kind of
05:09 --> 05:11lesions do we find in the colon?
05:11 --> 05:14And secondly, how can colonoscopy
05:14 --> 05:16be therapeutic in that regard?
05:17 --> 05:19So the whole purpose of screening
05:19 --> 05:22colonoscopy is to evaluate the person
05:22 --> 05:25to see if they have developed any
05:25 --> 05:27polyps which we know are precursors
05:27 --> 05:29to most of the colon cancers,
05:29 --> 05:32and most of those polyps can be removed
05:32 --> 05:35at the time of colonoscopy and therefore
05:35 --> 05:38never go on to progress to a cancer.
05:38 --> 05:41We have seen that the incidence of
05:41 --> 05:44colon cancer has dropped over the last
05:44 --> 05:47few decades and we attributed that to
05:47 --> 05:48screening colonoscopies and
05:48 --> 05:50polypectomy's that have removed those
05:50 --> 05:52potential future cases of cancer.
05:52 --> 05:55So there are several types of
05:55 --> 05:57polyps and they vary in size.
05:57 --> 06:00Most of them can be removed
06:00 --> 06:02endoscopically, some when they
06:02 --> 06:05get larger when they are about 2
06:05 --> 06:08centimeters or an inch get more
06:08 --> 06:11difficult to be removed and should be
06:11 --> 06:15removed by someone who has
06:15 --> 06:16advanced endoscopic skills,
06:16 --> 06:21these have the potential to have
06:21 --> 06:23malignant transformation what
06:23 --> 06:26we called dysplasia or possible
06:26 --> 06:30early invasion and might need more
06:30 --> 06:32advanced techniques to remove.
06:32 --> 06:34And presumably some of these lesions
06:34 --> 06:38may be flat and colonoscopy,
06:38 --> 06:41even if you can't remove a polyp,
06:41 --> 06:42can certainly biopsy potential
06:42 --> 06:45cancers?
06:45 --> 06:48Yes, if it is too large to remove safely,
06:48 --> 06:51then it is generally
06:51 --> 06:55biopsied and marked with ink as a
06:55 --> 06:57tattoo and referred for surgery.
06:57 --> 07:00We think that these polyps should be
07:00 --> 07:02completely removed again because of
07:02 --> 07:05their potential to progress to cancer.
07:05 --> 07:08These lesions being flat are
07:08 --> 07:10much more difficult to remove,
07:10 --> 07:13and if they do develop invasion,
07:13 --> 07:14malignant invasion,
07:14 --> 07:18they are much more likely to spread
07:18 --> 07:23faster than a more polypoid lesion.
07:23 --> 07:25So let's suppose
07:25 --> 07:27you've done a colonoscopy.
07:27 --> 07:30You've either found a polyp that
07:30 --> 07:31you couldn't remove completely,
07:31 --> 07:35or you found a lesion that you've
07:35 --> 07:38biopsied, in either of those cases,
07:38 --> 07:39if cancer was found,
07:39 --> 07:41that would mean that the
07:41 --> 07:44patient moves next to surgery.
07:44 --> 07:45Is that right?
07:46 --> 07:50Typically yes. Again, depending on
07:50 --> 07:53the skill and what you're feeling of
07:53 --> 07:57the whole lesion is
07:57 --> 07:59there are very advanced techniques
07:59 --> 08:00where endoscopies will take the
08:01 --> 08:03first layer off inside called
08:03 --> 08:04endoscopic mucosal resection,
08:04 --> 08:07which is adequate for very early
08:07 --> 08:09stage cancers, but in general,
08:09 --> 08:12most of those would be referred to a
08:12 --> 08:15surgeon for removal of the whole area and
08:15 --> 08:17evaluation of the regional lymph nodes.
08:17 --> 08:20Now, before you do that,
08:20 --> 08:22are there any kinds of advanced
08:22 --> 08:24imaging tests that are required
08:24 --> 08:26or blood tests to help you get an
08:26 --> 08:28idea of the extent of disease?
08:29 --> 08:32Well, certainly if you have a diagnosis
08:32 --> 08:34of invasive cancer rather than something
08:34 --> 08:37that's questionable or early stage,
08:37 --> 08:38you're going to image them with
08:38 --> 08:41a CAT scan to evaluate the liver
08:41 --> 08:43for possible metastatic disease.
08:43 --> 08:46It's been fairly commonplace to also
08:46 --> 08:49do a CAT scan of the chest to looking
08:49 --> 08:52for possible spread to the lungs,
08:52 --> 08:55although that's much more common in
08:55 --> 08:58rectal cancer than colon cancer.
08:58 --> 09:01Blood tests the CEA or carcinogenic
09:01 --> 09:03embryonic antigen is not produced
09:03 --> 09:05by all tumors,
09:05 --> 09:07but generally if you have a diagnosis
09:07 --> 09:11of cancer you will check that if it's
09:11 --> 09:14elevated it can be used as a marker
09:14 --> 09:16later to follow the patient to see
09:16 --> 09:18if there is recurrence,
09:18 --> 09:20and so presumably if you've
09:20 --> 09:23caught this cancer early because
09:23 --> 09:25you started screening per the
09:25 --> 09:27guidelines and now you you go and
09:27 --> 09:29you have all of these tests and
09:29 --> 09:31it doesn't look like there's
09:31 --> 09:32cancer anywhere else,
09:32 --> 09:34the next step is to remove that
09:34 --> 09:36part of the colon that's got
09:36 --> 09:39the cancer in it and evaluate,
09:39 --> 09:41as you say, the regional lymph nodes.
09:41 --> 09:43Now I understand that surgical
09:43 --> 09:45techniques have improved over the last
09:45 --> 09:47several decades and this can now
09:47 --> 09:50be done in a minimally invasive way.
09:50 --> 09:52Can you talk a little bit about that?
09:53 --> 09:56Absolutely, so minimally invasive surgery
09:56 --> 09:57the revolution started
09:57 --> 10:00probably in the late 80s.
10:00 --> 10:02Around 1990 we all started
10:02 --> 10:04doing gallbladders that way and
10:04 --> 10:06it reduced the incision size.
10:06 --> 10:10Made recovery a lot faster, less pain and
10:10 --> 10:13the patients were much more satisfied and that
10:13 --> 10:16translated to colon surgery in the
10:16 --> 10:19early 90s and there were several
10:19 --> 10:24trials to determine whether or not that
10:24 --> 10:27minimally invasive surgery was equal to
10:27 --> 10:30conventional open surgery and a
10:30 --> 10:33trial in 2004 and follow up of
10:33 --> 10:36those patients over a long period
10:36 --> 10:39of time proved that the cancer
10:39 --> 10:42surgery was the same whether it was
10:42 --> 10:45done minimally invasive or open,
10:45 --> 10:48so the oncologic results were the
10:48 --> 10:50same minimally invasive surgery,
10:50 --> 10:53whether it be laparoscopic or robotic.
10:58 --> 11:01It hurts a lot less.
11:01 --> 11:03The recovery is faster,
11:03 --> 11:07the patients are more satisfied with it.
11:07 --> 11:11Bowel function tends to return faster,
11:11 --> 11:14and as several studies over the years
11:14 --> 11:18have shown it is oncologically
11:18 --> 11:21the same as open surgery.
11:21 --> 11:24One of the benefits though,
11:24 --> 11:26is for people with more advanced surgery,
11:26 --> 11:27more advanced cancer
11:27 --> 11:30is that since they recover faster,
11:30 --> 11:31they feel better.
11:31 --> 11:34They're much more likely to go on and
11:34 --> 11:36have chemotherapy if they need it
11:37 --> 11:39after recovering from big open surgery,
11:39 --> 11:41sometimes the people have had trouble
11:41 --> 11:44and they just never get healthy enough to
11:44 --> 11:46receive chemotherapy.
11:46 --> 11:47So it sounds
11:47 --> 11:49like we've moved into
11:49 --> 11:51an era of of minimally invasive
11:51 --> 11:53surgery for colon cancer,
11:53 --> 11:56much like we have for Gallbladder surgery.
11:56 --> 11:58But you mentioned two terms.
11:58 --> 12:00One is laparoscopic and
12:00 --> 12:01one is robotic assisted.
12:01 --> 12:04Can you help our audience kind of
12:04 --> 12:06understand the difference between the two.
12:08 --> 12:09Sure, laparoscopy is something
12:09 --> 12:12that's been around for a long time,
12:12 --> 12:14and as I mentioned,
12:14 --> 12:16the translation to more broad
12:16 --> 12:18applications began in the early 90s
12:18 --> 12:20and then into colorectal surgery.
12:20 --> 12:22But basically what that is, is
12:22 --> 12:25surgery inside the abdomen,
12:25 --> 12:27done through several small incisions
12:27 --> 12:30where you have instruments inserted.
12:30 --> 12:32It's very good when you don't have to make
12:32 --> 12:34a bigger incision to take a specimen out.
12:34 --> 12:35In colon surgery,
12:35 --> 12:37you have to make an incision that's
12:37 --> 12:39probably 2 to 3 inches in size to
12:39 --> 12:41get the piece of colon out with the
12:41 --> 12:43lymph nodes in the tumor so that
12:43 --> 12:47does have some pain associated with it
12:47 --> 12:49when you do laparoscopic hernia's and
12:49 --> 12:53you only have 3 or 4 little incisions,
12:53 --> 12:55there's much less pain.
12:55 --> 12:57Robotic assisted is attaching the
12:57 --> 13:00robotic system to those instruments an
13:00 --> 13:03that allows you much more dexterity,
13:03 --> 13:05especially in smaller confined
13:05 --> 13:07location like the pelvis when
13:07 --> 13:09you're operating for rectal cancer,
13:09 --> 13:12your visualization both laparoscopic
13:12 --> 13:14and robotic assisted is
13:14 --> 13:16a lot of times,
13:16 --> 13:18much better than open because
13:18 --> 13:20you have magnification.
13:20 --> 13:23You have a light source that's
13:23 --> 13:26right down there in his deep dark hole
13:26 --> 13:29and you have your really dexterous
13:29 --> 13:31instruments in a small space.
13:33 --> 13:35And so certainly both laparoscopic and
13:35 --> 13:38robotic seemed to be an advance over
13:38 --> 13:40open surgery and allow you to get into
13:40 --> 13:42small spaces with good visualization
13:42 --> 13:45that you might not have had before and
13:45 --> 13:47allow patients to get home sooner.
13:47 --> 13:49We're going to talk more about
13:49 --> 13:51robotic surgery and compare that
13:51 --> 13:53to laparoscopic surgery and talk
13:53 --> 13:56about what happens after the colon
13:56 --> 13:57cancer surgery right after we take
13:57 --> 14:00a short break for a medical minute.
14:00 --> 14:02Please stay tuned to learn more about
14:02 --> 14:05robotic surgery for colon and rectal
14:05 --> 14:07cancers with my guest Doctor George
14:07 --> 14:08Yavorek.
14:08 --> 14:12Support for Yale Cancer answers comes from
14:12 --> 14:15Astrazeneca, providing important treatment options
14:15 --> 14:18for various types and stages of cancer.
14:18 --> 14:22More information at astrazeneca-u.com.
14:22 --> 14:25This is a medical minute about lung cancer.
14:25 --> 14:28More than 85% of lung cancer diagnosis
14:28 --> 14:31are related to smoking and quitting even
14:31 --> 14:33after decades of use can significantly
14:33 --> 14:36reduce your risk of developing lung
14:36 --> 14:38cancer for lung cancer patients.
14:38 --> 14:40Clinical trials are currently underway
14:40 --> 14:42to test innovative new treatments.
14:42 --> 14:45Advances are being made by utilizing
14:45 --> 14:47targeted therapies and immunotherapies.
14:47 --> 14:49The BATTLE-2 trial aims to learn
14:49 --> 14:52if a drug or combination of drugs
14:52 --> 14:54based on personal biomarkers can help
14:54 --> 14:57to control non small cell lung cancer.
14:57 --> 15:00More information is available
15:00 --> 15:01at yalecancercenter.org.
15:01 --> 15:05You're listening to Connecticut Public Radio.
15:05 --> 15:06Welcome
15:06 --> 15:08back to Yale Cancer Answers.
15:08 --> 15:10This is doctor Anees Chagpar
15:10 --> 15:12and I'm joined tonight by my
15:12 --> 15:15guest Doctor George Yavorek.
15:15 --> 15:17We are talking about treating patients with
15:17 --> 15:20colon cancer with robotic surgery.
15:20 --> 15:22Now right before the break we were
15:22 --> 15:25talking about this whole evolution in
15:25 --> 15:27minimally invasive surgery that really
15:27 --> 15:29helps patients with colon cancer
15:29 --> 15:32get that colon resected with minimal
15:32 --> 15:34intervention, shorter hospital stays,
15:34 --> 15:36less pain and so on.
15:36 --> 15:39But George, the question that I often
15:39 --> 15:43have is in terms of those metrics,
15:43 --> 15:45getting home faster,
15:45 --> 15:47amount of pain, blood loss,
15:47 --> 15:50how long the operation is, and cost?
15:50 --> 15:53How does robotic surgery stack up
15:53 --> 15:56to laproscopic surgery which you
15:56 --> 16:00know we all know has a number
16:00 --> 16:03of advantages over open surgery.
16:03 --> 16:07So the big thing I think would be
16:07 --> 16:09patient satisfaction and patient
16:09 --> 16:11satisfaction between both laparoscopic
16:11 --> 16:13and robotic surgery is pretty equal
16:13 --> 16:15because to them it's minimally invasive
16:15 --> 16:17in terms of oncologic outcomes.
16:17 --> 16:19Again, the same thing they've looked
16:19 --> 16:22at that compared to open and obviously
16:22 --> 16:25the standard is open surgery,
16:25 --> 16:28but the oncologic outcomes are the same in
16:28 --> 16:32terms of all the parameters that we look at.
16:32 --> 16:34Some of the other things you
16:34 --> 16:36mentioned though were the big
16:36 --> 16:39knock on robotic surgery is cost.
16:39 --> 16:41And the expense of the equipment.
16:41 --> 16:43What happens with that?
16:43 --> 16:46Is it can be actually cost effective
16:46 --> 16:48because the patients tend to
16:48 --> 16:51stay in the hospital less time.
16:51 --> 16:53If you have them on what we call
16:53 --> 16:56an ERAS, enhanced recovery
16:56 --> 16:58after surgery protocol,
16:58 --> 17:01which typically a lot of specialties
17:01 --> 17:03are using for urology, gynecology,
17:03 --> 17:06colorectal surgery and that goes from the
17:06 --> 17:08pre op preparation through the surgery,
17:08 --> 17:11anesthesia and into the postoperative period.
17:11 --> 17:13These patients are spending
17:13 --> 17:15less time in the hospital.
17:15 --> 17:17They are back to normal faster.
17:17 --> 17:20They are feeling better and
17:20 --> 17:21there are actually less
17:21 --> 17:23complications and problems which
17:23 --> 17:25cut down on hospital costs.
17:25 --> 17:29So those are things that can negate the
17:29 --> 17:31extra expense of the robotic surgery
17:31 --> 17:34and actually make it cost effective.
17:35 --> 17:39So let me push back a little.
17:39 --> 17:41Understandably, ERAS protocols
17:41 --> 17:43would improve all of those metrics,
17:43 --> 17:45whether the surgery was open,
17:45 --> 17:48patients who are on any rest protocol,
17:48 --> 17:51who have open surgery would do better
17:51 --> 17:54than people who are not.
18:00 --> 18:02So I can understand how that
18:02 --> 18:05protocol can reduce the length of stay for
18:05 --> 18:08patients who are having robotic surgery.
18:08 --> 18:10But given that robotic surgery
18:10 --> 18:11and laparoscopic surgery are
18:11 --> 18:13both minimally invasive,
18:13 --> 18:16and robotic surgery is much more expensive
18:16 --> 18:18if you have patients who have laparoscopic
18:18 --> 18:21surgery who are on an ERAS protocol
18:21 --> 18:24and patients who have robotic surgery
18:24 --> 18:28who are on an ERAS protocol,
18:31 --> 18:33are there really any differences
18:33 --> 18:36in terms of length of stay,
18:36 --> 18:38length of hospital time,
18:38 --> 18:39length of surgical procedure,
18:39 --> 18:43blood loss that are different between the
18:43 --> 18:45laparoscopic group and the robotic group?
18:45 --> 18:49That would tend to favor one over the other.
18:51 --> 18:54So if you look at it across the board just
18:54 --> 18:57comparing laparoscopic for robotic surgery,
18:57 --> 18:59typically the outcomes are
18:59 --> 19:01going to be very similar.
19:01 --> 19:03They're going to be about the same.
19:03 --> 19:06Robotic surgery would be more
19:06 --> 19:08expensive because of the equipment
19:08 --> 19:10part of the problem becomes the
19:10 --> 19:13skill level of the surgeon.
19:13 --> 19:15Where robotic surgery makes it
19:15 --> 19:18easier for most surgeons to do
19:18 --> 19:21more complex operations.
19:21 --> 19:23The inexperienced laparoscopic surgeon
19:23 --> 19:27could probably do about the same things
19:27 --> 19:30that a robotic surgeon does, and
19:30 --> 19:33most people are well versed in both,
19:33 --> 19:37but I think you're correct in that
19:37 --> 19:39across both procedures
19:39 --> 19:43it's going to be less expensive for
19:43 --> 19:45laparoscopic surgeon and the results
19:45 --> 19:48are pretty much going to be the same.
19:48 --> 19:51Part of the idea behind the robotic
19:51 --> 19:53surgery is that it takes more
19:53 --> 19:55open cases and makes them minimally
19:55 --> 19:57invasive across the country.
19:57 --> 20:00At least 50% of the colectomies
20:00 --> 20:02are still done
20:02 --> 20:03through a traditional incision,
20:03 --> 20:05only about 50% are done
20:05 --> 20:07minimally invasively and of those the vast
20:07 --> 20:10majority are still done laparoscopically.
20:10 --> 20:12It's somewhere between 5 and 10%,
20:12 --> 20:15are done robotically the other 40% are
20:15 --> 20:17done laparoscopic and the other 50%
20:17 --> 20:21are still done through an open incision.
20:21 --> 20:23So the penetration is
20:23 --> 20:25increasing for robotic surgery,
20:25 --> 20:30but back to the question, I think that
20:30 --> 20:32all things given certainly
20:32 --> 20:34laproscopic surgery is more
20:34 --> 20:36cost effective than robotic surgery.
20:37 --> 20:39So I guess what I'm getting from
20:39 --> 20:42you is that robotic surgery may be
20:42 --> 20:45a good option for some cases where
20:45 --> 20:48you really don't think that you would
20:48 --> 20:51be able to do this laparoscopic
20:51 --> 20:54but given the dexterity that you can get
20:54 --> 20:56particularly low down in the pelvis,
20:56 --> 20:58which would otherwise mandate an open
20:58 --> 21:01surgery, robotic surgery might have an
21:01 --> 21:03advantage in that realm over
21:03 --> 21:05laparoscopic is that right?
21:05 --> 21:07Yes, I agree with that.
21:07 --> 21:09And in complex surgery so
21:09 --> 21:11not only for colon cancer,
21:11 --> 21:14but if it's a complex cancer that may
21:14 --> 21:16be attached to the bladder of the
21:16 --> 21:18uterus and even non cancer surgery
21:18 --> 21:21like complex diverticular disease,
21:21 --> 21:23I think the robot is an advantage
21:23 --> 21:25over laparoscopic surgery and the
21:25 --> 21:27one thing is that conversion rate
21:27 --> 21:30is lower for robotic surgery.
21:30 --> 21:33So if you look at it in that
21:33 --> 21:35light robotic surgery has an
21:35 --> 21:37advantage over laparoscopic surgery
21:37 --> 21:39because the conversion from
21:39 --> 21:41minimally invasive to open surgery,
21:41 --> 21:44which adds more to cost and
21:44 --> 21:46actually increases hospital stay
21:46 --> 21:48for someone who's gone through
21:48 --> 21:51an open incision to begin with,
21:51 --> 21:53the robot does decrease the chance
21:53 --> 21:56of conversion and therefore is an
21:56 --> 21:58advantage in those situations,
21:58 --> 21:59so you
21:59 --> 22:02know with people who have expertise in
22:02 --> 22:05both laparoscopic and robotic surgery,
22:05 --> 22:07how do you decide which procedure
22:07 --> 22:08to offer your patients?
22:08 --> 22:11Or are you offering all of them one
22:11 --> 22:14particular route as a first choice?
22:15 --> 22:18I think it depends on a few things.
22:18 --> 22:19Depends on the complexity,
22:19 --> 22:20location of the tumor.
22:20 --> 22:22If I feel that, especially rectal
22:22 --> 22:24cancers, down in the pelvis,
22:24 --> 22:27I really like the robot down there
22:27 --> 22:29again because of the confined
22:29 --> 22:32space and the ability to get down
22:32 --> 22:34there with good visualization.
22:34 --> 22:36If the person may be someone
22:36 --> 22:39who I'd like to get in and out
22:39 --> 22:42of surgery a little bit faster,
22:42 --> 22:44an older person with a lot of health issues,
22:44 --> 22:48I may choose to do it laparoscopically,
22:48 --> 22:50because generally the times
22:50 --> 22:52for those surgeries are less, so
22:52 --> 22:53it's an individual basis.
22:53 --> 22:56I offer all my
22:56 --> 22:58patients one or the other.
22:59 --> 23:00And the other question that
23:00 --> 23:02many of our listeners may have
23:02 --> 23:04especially thinking about
23:04 --> 23:05the cost of robotic surgery
23:05 --> 23:08is, is it covered by insurance?
23:10 --> 23:12Generally speaking, there's no cost to
23:12 --> 23:15the patient that if there is a cost,
23:15 --> 23:18the hospital ends up absorbing it
23:18 --> 23:21because they can't pass that on to
23:21 --> 23:23the patient. The insurance company
23:23 --> 23:25doesn't always reimburse more
23:25 --> 23:27for a specific procedure,
23:27 --> 23:29but the hospital has figured out a
23:29 --> 23:32way to in terms of making things more
23:32 --> 23:36efficient to make these cost effective.
23:37 --> 23:40And it sounds like if
23:40 --> 23:44the patient costs are all equal and
23:44 --> 23:47oncologic outcomes are all equal,
23:47 --> 23:49then it sounds like the real cost
23:49 --> 23:52is to the health care system.
23:52 --> 23:55And that's something that health care
23:55 --> 23:58systems will need to figure out
23:58 --> 24:00now if during that staging work up
24:00 --> 24:03needed before the the surgery itself,
24:03 --> 24:06let's suppose you did find a
24:06 --> 24:09little metastasis to the liver,
24:09 --> 24:12can you take that out at the same time as
24:12 --> 24:15you do the colon surgery with the robot?
24:17 --> 24:19Yes you can. The paddle biliary
24:19 --> 24:21surgeons are doing liver resections
24:21 --> 24:23laproscopically and robotically
24:23 --> 24:27so you can do that if it's the
24:27 --> 24:29right thing to do at that time.
24:33 --> 24:34Sometimes it's removed at
24:34 --> 24:37the same time in the surgery.
24:37 --> 24:39Sometimes they get chemotherapy first
24:39 --> 24:42to see if it progresses or regresses,
24:42 --> 24:46or new lesions pop up so, but it can be done
24:46 --> 24:48minimally invasive, yes.
24:48 --> 24:51And so it sounds like you know,
24:51 --> 24:55there have been so many great advances on
24:55 --> 24:58the surgical front once patients go home.
24:58 --> 25:01You mentioned that one of the advantages
25:01 --> 25:03of minimally invasive surgeries that
25:03 --> 25:06they can actually get onto their adjutant
25:06 --> 25:08systemic therapy, their chemotherapy
25:08 --> 25:10a little bit quicker there.
25:10 --> 25:12After some older patients may
25:12 --> 25:14have difficulty in that post
25:14 --> 25:16operative period recovering and
25:16 --> 25:19so delay or potentially dismiss
25:19 --> 25:20their chemotherapy.
25:20 --> 25:22Can you talk a little bit about
25:22 --> 25:25whether all patients with colon cancer
25:25 --> 25:27require chemotherapy after surgery,
25:27 --> 25:29and whether there have been
25:29 --> 25:31any advances in that regard?
25:33 --> 25:36So not all patients require chemotherapy.
25:36 --> 25:39Cancer is staged one through 4.
25:39 --> 25:42Obviously one being very early
25:42 --> 25:44in those patients. Generally,
25:44 --> 25:47surgery alone is curative between 90-95%
25:47 --> 25:51of the time they do not require
25:51 --> 25:56chemotherapy , it does not add to their cure rate.
25:56 --> 25:59Stage two is the big gray zone.
25:59 --> 26:01That's a very large stage,
26:01 --> 26:04and some of those patients,
26:04 --> 26:06depending on individual tumor characteristics
26:06 --> 26:08may benefit from chemotherapy.
26:08 --> 26:11They may be at a higher
26:11 --> 26:12risk to develop recurrence,
26:12 --> 26:15and that's something that has really
26:15 --> 26:18progressed over the last 10 years.
26:18 --> 26:20Our evaluation of individual tumors
26:20 --> 26:23and what those individual tumor
26:23 --> 26:26characteristics mean in terms of prognosis.
26:26 --> 26:27Stage three,
26:27 --> 26:30there are lymph nodes involved and those
26:30 --> 26:33people are all candidates for chemotherapy,
26:33 --> 26:37which has been shown to have a
26:37 --> 26:39significant improved survival.
26:39 --> 26:42And stage four is distant metastases
26:42 --> 26:43and generally chemotherapies
26:43 --> 26:45are used there too.
26:45 --> 26:48Also in more of a palliative manner,
26:48 --> 26:50and as you kind
26:50 --> 26:53of mentioned and briefly talked about,
26:53 --> 26:56in that stage two discussion have there
26:56 --> 26:59been advances in terms of chemotherapy?
26:59 --> 27:01I mean the robotic surgery,
27:01 --> 27:03getting to minimally invasive surgery
27:03 --> 27:06really seems to be advantageous in
27:06 --> 27:09terms of fine tuning surgery to an
27:09 --> 27:11individual patient and you talked
27:11 --> 27:14a little bit about how you tailor
27:14 --> 27:16the surgical management
27:16 --> 27:17according to patients,
27:17 --> 27:20has that filtered into the
27:20 --> 27:22medical oncology management as well?
27:25 --> 27:28Yes, most people will get
27:28 --> 27:30a combination of chemotherapy drugs,
27:30 --> 27:32usually two or three, and generally
27:32 --> 27:35it's tapered to their situation,
27:35 --> 27:37their age, their medical comorbidities,
27:37 --> 27:39and also the tumor itself.
27:39 --> 27:40As I mentioned,
27:40 --> 27:43they do several analysis of the tumor,
27:43 --> 27:46and there are some studies that can tell
27:46 --> 27:50you whether or not they will respond
27:50 --> 27:52to a particular chemotherapeutic agent.
27:52 --> 27:57And as with a lot of medicine that's gotten,
27:57 --> 27:59rather involved and complex over the
27:59 --> 28:01last few years and most people will
28:01 --> 28:04end up with an oncology consultation
28:04 --> 28:05and the medical oncologist
28:05 --> 28:07will tailor their therapy to that.
28:09 --> 28:12Now the third arm of the
28:12 --> 28:13stool is always radiation.
28:13 --> 28:15Do colorectal patients require
28:15 --> 28:17radiation after surgery as well?
28:18 --> 28:21So radiation is generally used for
28:21 --> 28:23rectal cancer, not colon cancer.
28:23 --> 28:25When it's out of the pelvis,
28:25 --> 28:27there's generally not a role for radiation.
28:27 --> 28:30It's when it's in the fixed
28:30 --> 28:31confines of the pelvis that
28:31 --> 28:32radiation is used.
28:32 --> 28:34It's not used all the time,
28:34 --> 28:37and we do a lot of work up
28:37 --> 28:39and staging before hand,
28:39 --> 28:42and a lot of times radiation is
28:42 --> 28:43given with chemotherapy before
28:43 --> 28:46surgery for rectal cancer to shrink
28:46 --> 28:48the tumor and allow
28:49 --> 28:50for preservation of these sphincters
28:50 --> 28:52so you don't have a permanent
28:52 --> 28:54ostomy bag.
28:54 --> 28:54Doctor
28:54 --> 28:56Georgia Yavorek is a clinical instructor
28:56 --> 28:58of surgery specializing in gastro
28:58 --> 29:01bariatrics at the Yale School of Medicine.
29:01 --> 29:03If you have questions,
29:03 --> 29:04the address is canceranswers@yale.edu
29:04 --> 29:06and past editions of the program
29:06 --> 29:08are available in audio and written
29:08 --> 29:10form at yalecancercenter.org.
29:10 --> 29:13We hope you'll join us next week to
29:13 --> 29:15learn more about the fight against
29:15 --> 29:18cancer here on Connecticut Public Radio.

Information

Robotic Surgery for Colon and Rectal Cancers with guest Dr. George Yavorek December 6, 2020 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095