Colorectal Cancer Surgery & Patient Survival

Transcript

00:00 --> 00:21Announcer Funding for Yale Cancer Answers is provided by Smilow Cancer Hospital. Welcome to Yale Cancer Answers with the director of the Yale Cancer Center, Doctor Eric Winer. Yale Cancer Answers features conversations with oncologists and specialists who are on the forefront of the battle to fight cancer. Here's Doctor Winer.
00:21 --> 01:04Eric Winer We're here tonight, with a special guest to talk about colon cancer. Rates of colon cancer, particularly among young adults, have increased fairly dramatically in recent years. Colon cancer is now the leading cause of cancer deaths among men and women under the age of 50. We're going to talk about what's driving this sharp increase, not that we have necessarily in a exact or final answer, and how people can minimize risk and maximize early detection.
01:04 --> 01:30Eric Winer Our guest tonight is, Doctor Anne Mongiu, an assistant professor of surgery here at Yale who specializes in in colon cancer. I'll say right at the beginning that she's also a cancer survivor. And we're going to touch on that, in the second half of this interview. So Anne, welcome. Thank you so much for for being with us.
01:30 --> 01:33Anne Mongiu Hi, Eric. Great to see you.
01:33 --> 01:58Eric Winer So colon cancer in in young men and women has been increasing over the past actually two decades. Although it's really received a lot of attention, I think, in the past five years, partially because there have been a number of quite famous individuals who have developed early onset colon cancer. Tell us a little bit about what's what's been going on.
01:58 --> 02:25Anne Mongiu That's a great question. I think the changes have been going on actually since the 90s. So we started screening at 50 then. And what we started finding is it worked. Rates of colon cancer were going down because screening really works. But then we saw a surprising trend that showed that people under the age of 50, especially in that 45 to 49 year old group, had a rising rate of both very suspicious precancerous lesions and early onset cancer, and they weren't getting screened.
02:25 --> 02:31Anne Mongiu And this ultimately led to the goalpost being moved a few years back to 45, which is the new screening age.
02:31 --> 02:57Eric Winer Can you, explain to people why rates of colon cancer actually go down when you screen? It's it's different from breast cancer. You do mammograms and you can't reduce rates. If anything, you increase rates by, you know, through finding some cancers that might never be a problem in someone's life. Colon cancer is a little different because it's both screening and prevention in one procedure.
02:57 --> 03:18Anne Mongiu That is correct. And that's what I tell all of my patients, because when a gastroenterologist or colorectal surgeon does a screening colonoscopy, if we see a polyp and that's just a little bump, but it can turn into a cancer if left to its own devices over a 3 to 8 year period. And so it's removed. So it actually prevents cancer by getting a colonoscopy.
03:18 --> 03:24Anne Mongiu And that's one of the few screening modalities that exists that actually has that benefit. So it's really fantastic.
03:24 --> 03:46Eric Winer The age has now gone down. The recommended age to start screening has gone down to 45. That was 45 picked, because we know that rates of colon cancer have risen in young adults. And it's not just in 45 to 50 year olds. It's among even people younger than that.
03:46 --> 04:10Anne Mongiu That's a great question. This is a goal post I think will keep moving depending on where the rates of early onset colon cancer go, and I would not be surprised if it moves earlier. Most national screening decisions are sort of based on the risk of harm of the exam itself, how many lives it saved based on complications far more complex than I can tell you.
04:10 --> 04:36Anne Mongiu And how that works out is something which is an effective screening mechanism which can save lives. And so the data with, that led to the 2021 moving the screening date earlier to 45 suggested that that group between 45 and 49 now had the largest benefit from having that screening start there. But there wasn't yet enough of a benefit between 40 and 45 at that time.
04:36 --> 04:48Eric Winer You know, in terms of early onset colon cancer, what's the age when you really begin to see this? I mean, you see it in with any in any appreciable number in 30 year olds, for example.
04:49 --> 04:50Anne Mongiu 20 year olds.
04:50 --> 04:51Eric Winer 20 year olds.
04:51 --> 05:01Anne Mongiu Yeah, we're seeing it in in our practice here at Yale, in 20 year olds and 30 year olds on a fairly regular basis, just in my clinic this past week.
05:01 --> 05:32Eric Winer If, in fact, we're not doing screening in those very young individuals, what's the message we can give them in terms of, paying attention to symptoms? Because I think one of the challenges with colon cancer in young adults is that they don't believe that they could have a significant health problem. Symptoms that are attributed to other things are really in some people because of the cancer.
05:32 --> 05:36Eric Winer You know, people just tend to put off going to see the doctor.
05:36 --> 05:56Anne Mongiu People put off going to see the doctor. Many young people are not insured or underinsured, and they do blow off simple symptoms. Or they go see an urgent care or primary care who often says, oh, it's probably just hemorrhoids. So what's one of the most common symptoms? Half of early onset colon cancer presents with rectal bleeding or bright red blood.
05:56 --> 06:27Anne Mongiu When you have a bowel movement, and often the delay in treatment can be months to years because they get worked up and treated for hemorrhoids. No 1st May ever do a rectal exam or even suggest a colonoscopy, and that can lead to a much later actual diagnosis. So I think it's on both ends. I think we talk about it in the news, and then I think we educate our colleagues in primary care and internal medicine to take these symptoms carefully, have a shorter follow up, 2 or 3 weeks, have a low threshold to refer to colonoscopy.
06:27 --> 06:57Eric Winer So, you know, a young person, has a bowel movement, sees a tiny bit of blood. That's that first time is that, you know, that could be hemorrhoids, of course. And in more than likely will be in most people or some other irritation after that, you know, first time, should somebody go running to the doctor or when would you recommend that someone seek medical advice?
06:57 --> 07:00Eric Winer I mean, certainly if this persists over a period of time.
07:00 --> 07:21Anne Mongiu Right. And that's usually the biggest thing that we tell patients a one time event might just be some local irritation, even a food bug or a GI bug that's going around. But when you see blood, when you have a cancer, that means that cancer is probably closer to the left side of the body, the exit in the rectum, and it's the tumor that's actually bleeding.
07:21 --> 07:40Anne Mongiu So that bleeding won't stop. So a one time blood that stops and goes away, I think you can safely say, okay, that must have just been a one off. But say it starts bleeding a little and then a week later it's a little bit more. And now you're seeing blood with every bowel movement. That's that's a time, you know, over a 2 to 4 week period that's not stopping without breaks.
07:40 --> 07:42Anne Mongiu And I would certainly call your doctor.
07:42 --> 07:54Eric Winer Yeah. No. And I think the problem is that there are people who ignore that for months and months. And what happens is that younger people tend to have more advanced stage at the time of diagnosis. Because of that.
07:55 --> 07:55Anne Mongiu They do.
07:56 --> 08:15Eric Winer You know, it's a serious problem and it's one that we we really have to address. What's your sense in terms of the etiology of cancers in these younger people? What's what has changed in the past 25 years that has led to this increase?
08:15 --> 08:41Anne Mongiu Is the million dollar question, biggest offenders that we hear about and that there's reasonable population level data on is going to be diet. So highly processed foods, red meat, sugary beverages and all of these combining together to create obesity and obesity driving many cancers, of which colorectal is one of them. Sedentary lifestyles people are glued to their phones is another one.
08:41 --> 09:03Anne Mongiu So there's a lot of environmental and preventable factors that are leading, we think, that are leading to this. And this is almost qualified by seeing that many of the early onset cancers are left sided, which, based on a lot of prior research and regular onset colon cancer, tends to be environmental cancer rather than genetic.
09:03 --> 09:06Eric Winer And why is that about the left side of the colon?
09:06 --> 09:39Anne Mongiu We're not quite sure to be, to be absolutely honest. There's longer dwell time of the form stool, which means it can sit in the colon longer on the left side, whereas when it enters the colon on the right side, it tends to be liquid and moves through there faster. And so left sided cancers are more often thought to come from a more traditional pathway of a polyp that turns into a cancer over time, whereas many right sided cancers start from very flat lesions and can grow much more quickly and silently and tend to be associated with genetic conditions.
09:39 --> 09:58Eric Winer Yeah, no. It's hard to escape the possibility of of diet and the changes in diet. And I guess, you know, one of the worries is that it may not be the diet that somebody is eating when they're 35. It might be the diet that they ate when they were 15 or 18 or 22.
09:58 --> 10:25Anne Mongiu Yeah. There are some, really terrifying data on sugar containing drinks, drinks consumed in the teenage years between 13 and 18 were associated with a 32% increased risk of cancers. Later in life. And so that exposure so sugary beverages in particular, and there's a form of E coli bacteria that is being seen in more early onset cancers that we think is due to exposure earlier in life.
10:25 --> 10:27Anne Mongiu So yes.
10:27 --> 10:32Eric Winer Well, you mentioned E coli, which then brings us to the topic more broadly of the microbiome.
10:32 --> 10:33Anne Mongiu Yes.
10:33 --> 10:51Eric Winer You know, there's been a lot of talk about the microbiome. You know, it always reminds me of our parents and grandparents saying like, you know, you got to be careful about what you eat and about all of these aspects of the diet. It turns out that the microbiome really may play some role.
10:51 --> 11:14Anne Mongiu It does. And part of it may be a chicken and an egg. So as we eat more inflammatory diets that have more processed foods, we influence this sort of universe of bacteria that live within us because what we're feeding it supports certain bugs over other bugs, and we find that more inflammatory diets can then support more inflammatory types of bacteria that can lead.
11:14 --> 11:21Eric Winer Which then may lead to the cancer. Inflammation in general is, you know, thought not to be a good thing.
11:21 --> 11:22Anne Mongiu Correct.
11:22 --> 11:48Eric Winer However, it is that you get there. Well, so there's colon Skippy as a screening tool. There's also the mayo in test that's called cologuard. You know, is that something that if you're a 45 year old and you're, recommended to have screening, is there other individuals who should do cologuard as opposed to a colonoscopy?
11:49 --> 12:15Anne Mongiu First of all, the test, the screening test that gets done is the best test over one that doesn't get done. So I always start there. We are. Our goal is to screen 80% of patients. We're only screening about 60%. So anything that can close that gap is good. Cologuard is a test where they analyze the stool and have some markers in it that can help detect both polyps and cancer and see blood.
12:15 --> 12:25Anne Mongiu So I believe the sensitivity is around 92 to 93%. But there is a lot of false positives. And so if there's a positive.
12:25 --> 12:28Eric Winer 93% means that if you have a cancer.
12:28 --> 12:30Anne Mongiu It should be able to pick it up to.
12:30 --> 12:31Eric Winer Get over 90% of the time.
12:31 --> 12:34Anne Mongiu That is correct. So it's a good test.
12:34 --> 12:36Eric Winer And tell us about the false positives.
12:37 --> 12:57Anne Mongiu So if you have a false positive, that just means that you'll still need a colonoscopy. If you have a positive cologuard test you need to have a colonoscopy. And actually the timing, of that colonoscopy should be fairly prompt, like within, you know, weeks to months as opposed to over a half a year or three quarters of a year.
12:57 --> 13:11Anne Mongiu Delaying over ten months can actually be associated with an increase of almost a 50% of of a colorectal cancer diagnosis. So you really if it's this positive with these screening tests, it does mean that you should ask act fairly promptly.
13:11 --> 13:30Eric Winer If somebody has a cologuard test, you know, they send it off their stool and it comes back and it's positive. What's the chance that they have colon cancer? And I realize that that's going to vary in different populations. But overall, you know what what what are we thinking about.
13:30 --> 13:48Anne Mongiu Of the positive cologuard, about 73% will have something found on a colonoscopy that that's not a cancer, that can be an advanced polyp or a large polyp or a cancer. I don't know that we have the data on the exact positive aspect for cancers in particular.
13:48 --> 14:16Eric Winer But better on a colonoscopy, you would be likely to to find something so correct. No, that seems that seems quite useful. Well, we're going to have to take a brief break. It's been a pleasure so far and we'll talk more when we come back again. I've been speaking to Doctor Anne Mongiu, professor of surgery at Yale School of Medicine and Yale Cancer Center and an expert in colon cancer, early onset colon cancer.
14:16 --> 14:18Eric Winer We'll be right back.
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15:34 --> 16:04Eric Winer Welcome back to the second half of Yale Cancer Answers. We're speaking with Anne Mongiu, an assistant professor of surgery at Yale School of Medicine who specializes in colon cancer. We're going to spend this half of this show on something a little more personal, and we're going to talk, about Anne’s diagnosis of cancer. Now, 16 years ago, I actually met Anne
16:04 --> 16:27Eric Winer at that time, because we were both living in Boston, and it happened that I was able to provide some advice. So for me, getting to talk with you on this show is really, is really a pleasure. And, and, brings back memories. So tell us about your diagnosis of breast cancer.
16:27 --> 16:49Anne Mongiu So I was in my second year of residency at the Brigham in Boston, and I was a urology resident at the time, and I had had a fiber adenoma, or I had been told it was one ultrasound did when I was in medical school. And so I never really thought about it. And I actually injured my shoulder pretty badly and needed to have shoulder surgery.
16:49 --> 17:09Anne Mongiu And so out of nowhere, I thought of my favorite breast surgeon for my intern year and said, hey, I'm having shoulder surgery next month. I've had this fiber adenoma. It's on the opposite side. It's been there for years, but I figure I'm having a seizure. Would you just take it out? She said, sure, get a mammogram. I'll do it.
17:09 --> 17:30Anne Mongiu At the same time, I get the mammogram and the radiologist is like, we're going to go do an ultrasound guided biopsy now, which was the first sort of warning sign that something bad might happened. And a day later I got like the phone call, that call that everyone dreads where the doctor calls you and says, I'm so sorry, and you already know.
17:30 --> 17:40Anne Mongiu Or I knew I was a physician in training, or I was a physician then in surgeon and training and I'm so sorry. And that's when I got my diagnosis on it.
17:40 --> 17:43Eric Winer And you were in your 20s.
17:43 --> 17:47Anne Mongiu I was in my early 30s. I was 32 years old.
17:47 --> 17:50Eric Winer Did you initially have surgery or initially have other treatment?
17:50 --> 18:00Anne Mongiu I had upfront chemotherapy before, Act and age. So all the things that you can get because I also had a Her2 positive tumor.
18:00 --> 18:25Eric Winer So this was a Her2 positive cancer at that time, you know, and things have evolved. And we actually sometimes give less in the way of chemotherapy and more in the way of targeted therapy. But at that time, you got what I would call a pretty big slide of chemotherapy. It lasted for about six months. You lost your hair, your blood cancer were low.
18:25 --> 18:32Eric Winer It was not an easy time. Did you continue to work as a surgery resident during the chemotherapy?
18:32 --> 18:49Anne Mongiu I did not. I ultimately ended up taking a medical leave because it was somewhat overwhelming. And the reality is, I don't think I could have kept up with our schedule, as exhausted as I felt. And then later after surgery and surgery and radiation, there would have been no way.
18:49 --> 19:03Eric Winer My recollection is that your diagnosis also led you to question how you were going to spend your your time and what you wanted to do in life in terms of your career.
19:03 --> 19:27Anne Mongiu It did. And it it led to, my, my social referral due to talk about it to make that decision. I was really concerned and, you know, surgery I would say is an inflammatory field that I'm a part of. It's a tough lifestyle. I love what I do, but I was really concerned that I wouldn't find my way back to myself.
19:27 --> 19:42Anne Mongiu And it actually, it took a very long time for me to make a decision to actually come back to academic medicine. I did leave my field of urology and was adopted by the general surgery program at the Brigham. Because they had so many residents per year, they were able to give me a more flexible schedule.
19:42 --> 19:48Eric Winer Was this a big switch for you, or was like something where you were ambivalent and you were happy to make the change?
19:48 --> 19:59Anne Mongiu I had not thought about it. Urology was really my love from the moment I saw it in medical school, but I like complex pelvic surgery and that is what I do today.
19:59 --> 20:04Eric Winer How long did it take you to recover from all the treatment? Were you better or a year later?
20:04 --> 20:33Anne Mongiu I would say that the fatigue was probably gone by about 6 to 7 months after the radiation was completed. I would say the brain fog lasted for a few years. I mean, I could have probably functioned at a normal level, but if you're at a pretty high powered academic surgery training program, switching to a new field, I really did feel it for a few years, and I didn't know to give myself the grace there at that time, so it was a little hard.
20:33 --> 20:37Eric Winer And so did you take an extra year or two to finish.
20:37 --> 20:51Anne Mongiu From when I came back, they were very gracious and allowed me to basically take my last four years of training over five with sort of planned downtime in it, and that was just absolutely a game changer for me.
20:51 --> 21:09Eric Winer It's it's great that they were flexible. I actually know some of the people you worked with, and I'm I'm not surprised that they were flexible. But it's not something you find everywhere. How does that experience influence you when you see a young person with cancer?
21:09 --> 21:32Anne Mongiu For for anyone, but especially a young person with cancer, I just stop and after. If I'm the one giving them the diagnosis, I just stop and just say, reflect on this. Maybe we'll talk again in a week. Because I will say that phone call was the most surreal that I've had. And I and I'd given bad news to patients before.
21:32 --> 21:53Anne Mongiu But when you're on the receiving end and someone says you have cancer and your brain just goes, It's Friday. I'm supposed to be going to New York for the weekend. How is that? This was not in my plan, and a lot of the words that come after you hear them, but you really don't process what they mean. And it may take several attempts at it.
21:53 --> 22:02Anne Mongiu And if you're by yourself and you don't have any family to listen to all the details or to write it down, it it just it washes right through you.
22:02 --> 22:26Eric Winer I assume that, you know, in those years, you know, both when you were diagnosed and in the next few years, it's now a long time and you can be pretty confident you're you're okay. But, I'm sure in those years you're worried about having a recurrence of the cancer of the cancer, ultimately taking your life at a very young age.
22:26 --> 22:27Eric Winer How did you deal with that?
22:27 --> 22:52Anne Mongiu That was hard. I had a friend. I found an outstanding therapist, and I took it one day at a time. It's a mindset I still have today. Which is just to say that every day is a gift. And I try to remind myself of that every day that I'm so lucky. And it gave me this sense of gratitude for the moment that perhaps I didn't appreciate at the time.
22:52 --> 22:57Eric Winer Does it keep you from getting frustrated about little things or not?
22:57 --> 23:20Anne Mongiu Sometimes the little things still frustrate me, but it makes you know anything that interferes with the living of the life. And I probably take more gelato breaks and more me time. And I certainly see my dentist and I talk to her every year because I am all about taking care of myself. And so it has made me very focused on that.
23:20 --> 23:25Eric Winer That or that. That's good. And do you share this with your patients?
23:25 --> 23:46Anne Mongiu I do, I share it with my patients. I've written on it and I've talked about it before because I think it's really important. My oncologist, the first time I met her, I think I sat there and bawled for 30 minutes and I never forgot that. And she didn't even touch her computer screen. And so to this day, when I'm in the room with a patient, I don't I don't use our computer on wheels.
23:46 --> 24:07Anne Mongiu I just talk to them. I spend more time with my cancer patients. I have a short time slot that I just someone's new and they're crying. Then I'm just going to sit there because someone sat there with me, and I remember being the survivor in the follow up oncology clinic, and sometimes the wait would be an hour and a half, and I just couldn't care less because I knew she was holding someone else's hand who needed it.
24:07 --> 24:10Eric Winer Yeah. No, it, it does take time.
24:10 --> 24:12Anne Mongiu Sometimes it does.
24:12 --> 24:20Eric Winer And it's, And it's what we have to do. And when you tell people about your experience, how do they respond?
24:20 --> 24:42Anne Mongiu I think for those who are very concerned about the chemo and the radiation, I feel comforted knowing that you can survive it, that it's you can get there sometimes there's a lot of distrust in these medications. People. I've seen people just die from the chemotherapy, maybe from older versions, and there's a lot of fear. And I think hearing that like, hey, I made it.
24:42 --> 24:53Anne Mongiu I made it through. Was it bad? Was it tough? Yes. Was it so bad I couldn't make it through? No. And you know, I'm here today. I think that really helps them and gives them some comfort.
24:53 --> 25:04Eric Winer And I'm sure that when you share your diagnosis or your history with patients, it must at times lead to some pretty interesting conversations.
25:04 --> 25:05Anne Mongiu It does.
25:05 --> 25:47Eric Winer Well, you know, as you know, we're developing a program focused on early onset cancers to try to make sure that young people and we define young is as 45 or less, get both the necessary medical attention that they need, because sometimes it's a little more complicated in younger people. And there are a few more issues to deal with, and also the psychological support and access to services like, fertility services and, and others that really become very important when you're when you're a young person facing this kind of diagnosis.
25:47 --> 26:07Anne Mongiu Yeah. Colorectal does our colorectal surgery division participates in that. And I work closely with Doctor Sri Kumar and you know, talk about our early onset patients to try and make sure that not just the patient but the family and partners, family and partners really struggle a lot. And they also need support in these situations.
26:07 --> 26:12Eric Winer When you are going through everything in your, your family, where they around.
26:12 --> 26:22Anne Mongiu So my family lived in Florida, but they came up from Florida and actually stayed with me for probably four months just to make sure I was okay and a good friend stayed with me.
26:22 --> 26:56Eric Winer You have done, incredibly well yourself and, you know, I, I often say to patients that, of course they would never want to develop cancer, but they're stuck with it once it's diagnosed. And once that happens, you know, I think that people should do their best to take something positive from the experience. It's pretty hard, but I think that many people can and people grow.
26:56 --> 27:16Eric Winer And I think, you know, you're a good example of that. And many people are it really, you know, it changes them. Do you have, some last thoughts you want to share about, either about you or about, early onset colon cancer?
27:16 --> 27:40Anne Mongiu For everyone listening, I would say if you have a symptom that concerns you, go talk to your doctor. And if it persists, advocate for yourself. I know a lot of times people don't feel like they want to advocate against doctors like, oh, it's okay, but if you have something that's going on, do it. Make sure you're always keeping an eye out on your health, because we can always treat things on the early side and catch them.
27:40 --> 28:03Eric Winer Yeah. Now I think that's a very important message. And I you know, I think the other thing and that you're such a great example of this is that, you know, we we are, you know, able to cure a large number of, of patients with cancer these days. Far more people are cured than not. And, our treatments continue to get better, but you have to get them in order to get better.
28:03 --> 28:38Eric Winer So, with that, I think we'll we'll close. And it has been a real pleasure for me to talk to you. I've. I've enjoyed it. So thank you so much for being with us. To our, listeners, again, this is Eric Winer with Yale Cancer Answers, and I've been speaking with Anne Mongiu,, a surgeon, assistant professor of surgery at Yale, a cancer survivor, and someone who is, very focused on the best care for young people with colon cancer.
28:38 --> 28:57Announcer If you have questions, the address is CancerAnswers@yale.edu. And past editions of the program are available in audio and written form at YaleCancerCenter.org. We hope you'll join us next time to learn more about the fight against cancer. Funding for Yale Cancer Answers is provided by Smilow Cancer Hospital.

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The latest trends on colorectal cancer surgery and survival with guest Anne Mongiu MD PhD, FACS, FASCRS

Yale Cancer Center

visit: www.yalecancercenter.org

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Anne Mongiu, MD, PhD, FACS, FASCRS

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