Colorectal Cancer
Despite advances made in the diagnosis and treatment of colorectal cancer, the disease continues to maintain its hold as the second leading cause of cancer-related deaths in the United States, and the third most common cancer in both men and women. Unfortunately, the statistics are even worse in Hampton Roads. Bruce Waldholtz, MD, a gastroenterologist with Gastroenterology & Liver Specialists of Tidewater, cites a 2015 study published by epidemiologist Rebecca Siegel, MPH in Cancer Epidemiology, Biomarkers & Prevention, reporting that the Eastern Virginia/Northeast North Carolina region is one of three hot spots in the United States for colorectal cancer, with a nine percent higher mortality rate than the rest of the country.
And yet it remains a fact that half of all U.S. colon cancer deaths a year could be prevented if everyone 50 and older were screened. And even when not prevented, colon cancer in its early stages is highly curable, with a five-year survival rate of 90 percent. However, only 39 percent of colon cancers are detected at this stage.
The main reason, of course, is that people aren’t getting screened. “Colon cancer screening right now is at about 50 to 55 percent,” says Marybeth Hughes, MD, Chief of the Division of Surgical Oncology at EVMS. “It’s woefully inadequate.”
So inadequate, in fact, that the National Colorectal Cancer Roundtable has launched the “80% by 2018” initiative.
80% by 2018 – An Ambitious But Achievable Goal
Hundreds of organizations and care providers across the country have committed to substantially reducing colorectal cancer as a major public health problem for those 50 and older (45 for African Americans).These organizations are working toward the shared goal of 80 percent of adults aged 50 and older being regularly screened for colorectal cancer by 2018. The initiative is led by the American Cancer Society (ACS), the Centers for Disease Control and Prevention (CDC) with the NCCR. The 80% by 2018 website states that “If we can achieve 80% by 2018, 277,000 cases and 203,000 colorectal cancer deaths would be prevented by 2030.”
All of the physicians interviewed for this article believe it’s an achievable goal, and all are involved in the initiative. “Bon Secours received a grant from NIH, which we used to hire personnel to visit primary care physicians’ offices and go through patient charts to identify those who need colonoscopy,” says Joseph Frenkel, MD, a colorectal surgeon with Bon Secours Maryview Medical Center, “and then trying to navigate them to a gastroenterologist or colorectal specialist for that screening.” Similarly, reports Sentara Cancer Network colorectal surgeon William Rudolph, MD, “Sentara Medical Group physicians are leveraging the power of the electronic medical record to proactively trigger screening reminders.”
“We do a lot of outreach on 80% by 18, monthly lectures, speaking with church and civic groups and the like,” says Brian Billings, MD, a colorectal surgeon with Riverside Health System. “We’ll screen any appropriate patient who comes through our doors.”
The initiative is aimed not just at the general public, Dr. Hughes says, “but also at primary care physicians. When patients come in for regular checkups – cholesterol, blood pressure, etc. – or indeed, for any office visit, these physicians should be asking about colonoscopy, and urging their eligible patients to schedule them.”
The gold standard for screening, of course, is colonoscopy, which unfortunately many patients simply refuse for a variety of reasons, not the least of which is the prep. It’s the number one complaint patients have. “We’re better with preps than we used to be,” says Dr. Billings. “We’re using Miralax, a low volume prep that’s easily tolerated.” And it may soon get more palatable, Dr. Waldholtz explains: a Boston-based company, ColonaryConcepts, is developing bowel-cleaning food bars and drinks that taste more like fruit smoothies and chocolate. “These have shown good results thus far,” Dr. Waldholtz says. “They’re not commercially available yet, but ColonaryConcepts is scheduled to begin phase 3 trials in early 2017, so we might see them enter the market by 2018.”
Noncolonoscopy Screenings
Fifteen years ago, virtual colonography was introduced, looking for a less invasive way to diagnose patients, and select out those who actually needed the full colonoscopy for follow up. While effective at finding polyps a centimeter or greater, it can’t determine which are simply polyps and which are cancer. Another problem with colonography is that it was developed “in an era when we weren’t really looking at flat polyps,” Dr. Billings says. “These are subtle, and easily missed by the CT. But for patients whose anatomy won’t allow colonoscopy, or who can’t tolerate it, there is an application for virtual colonography.”
The newest iterations of screening tests include the Fecal Immunochemical Test (FIT) and stool DNA tests. These are attractive to patients because they can be done at home, and while better than no screening at all, both of these can miss many polyps and some cancers. The FIT test can produce false positive test results. In both cases, if the results are abnormal, colonoscopy screening is indicated. Dr. Frenkel explains, “The biggest problem with these tests is they’re just not as accurate or therapeutic as colonoscopy. They’re good at ruling out cancer, and for someone who can’t have a colonoscopy, that’s promising. So there’s a place for them with very elderly or highly comorbid patients, but beyond that, I don’t use them.”
“These screening tests are better than the stool tests we’ve had in the past,” says Ray Ramirez, MD, a colon and rectal surgeon with Chesapeake Surgical Specialists. “But they are not indicated for people with a history of polyps or a first degree relative with a history of colon cancer.”
These newer screening tests are included in the recently published Recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer, which again confirm the primacy of the colonoscopy, Dr. Hughes says. The new guidelines have expanded, she says: “If you have a first degree family member, you should have your first screening when you are 10 years younger than that relative was diagnosed. For instance, if your sister got colon cancer at 45, your colonoscopies should start when you are 35.”
“It’s true that a DNA or FIT test is better than nothing,” Dr. Rudolph says, but cautions, “These tests are adequate at picking up cancers – we’re talking about 70 to 90 percent sensitivity – but advanced adenomas, precancerous polyps, aren’t picked up by the standard DNA test. And getting the polyps out before they turn into cancers has made a huge impact.”
David Z. Chang, MD, a medical oncologist with Virginia Oncology Associates, confirms. “With screening colonoscopy, when polyps are found, we can actually prevent cancer by taking out the polyp. Even if it is cancer, it’s very curable in its early stages. For example, in Stage I, 95 percent of patients can be cured by surgery alone. Unfortunately, without screening colonoscopy, by the time people present with symptoms and come to see surgical oncologists, they likely already have cancer, likely beyond Stage I.”
Genetic Tests
“There are colon cancers that act differently,” Dr. Hughes says. “Some are well differentiated, some poorly. And there are other markers, like BRAF, KRAS mutations that can help us guide the biologic behavior of these tumors.”
Knowing that wouldn’t dictate the type of surgery performed, she adds. A lot of that information is gleaned after the specimen is removed. “We’re also looking at micro-satellite instability, in the subset of patients who have problems with their repair genes. In these patients, when a cell divides, it makes a mistake, and the four repair genes that we look at are compromised, so these patients are at higher risk for another cancer. They don’t respond as well to chemotherapy.”
“The discovery of micro-satellite instability in colorectal tumors has increased our awareness of the diversity of colorectal cancers,” Dr. Chang adds, “and their implications for specialized management of patients, for example, using the modern immunotherapy.”
There are other genetic abnormalities that can occur as well, Dr. Rudolph notes, including Lynch Syndrome and familial polyposis. “We have standard genetic tests, looking for these conditions,” he says. “In fact, for three years, nearly 100 percent of cancer specimens obtained from Sentara’s colonoscopy or surgery patients have undergone testing,” giving patients’ family members the opportunity to be tested and seek treatment. For example, if a family member tests positive for Lynch Syndrome, one of the options is either to screen the colon on a yearly basis, or to have a partial colectomy. And some women, if they are beyond childbearing years, may choose to undergo prophylactic oophorectomy or hysterectomy.
“We’re starting to see some of the fruits of our genetic work,” Dr. Billings says, “and really starting to understand the genetic mutations that are driving these tumors. So the future is going to see us more and more tailoring therapy to individuals.” Tumors are different, he explains, some slow growing and easy to treat, while others are very aggressive and fast. “We can’t really tell the difference between them, other than that some patients do well and some poorly. Now we’re starting to be able to take these tumors apart genetically, and look for markers that can tell us if the patient has an aggressive tumor.”
Colorectal Surgeries
The procedure the surgeon chooses depends on where the tumor is, each patient’s unique presentation and anatomy, whether there have been multiple prior surgeries, and other conditions, including obesity.
For Stage I, II and even III, surgery is always an essential part of treatment, Dr. Chang says. And staging determines the prognosis. “In Stage IV, when cancer has spread to other organs like the liver or lungs, it has traditionally not been curable. But today, chemotherapy has become so effective that we are sometimes able to shrink cancer in the liver to allow surgery to remove it. Looking at the data from M. D. Anderson and other institutes, between 40 and 60 percent of these patients can become long-term survivors after liver metastasis resection, basically cured and living relatively comfortable lives.”
Among the most significant advances in the field of colorectal cancer are the new surgical techniques that are being employed today, and especially those being contemplated. “It’s acceptable to do an open colon with an old-fashioned incision,” Dr. Hughes says, “although more surgeons are doing laparoscopic colectomies, which make it easier on the patient to recover. More and more minimally invasive procedures will be done in the future.” Nationally, only about a third of colon cancer surgery is now being done minimally invasive, adds Dr. Ramirez, who teaches the technique to residents and surgeons several times a year. “That, to me, is one area where we can improve, because of the many benefits to the patient.”
Today, some surgeons believe robotic surgery affords better visualization in the pelvis, especially in men with their smaller pelvises, because the magnification on the camera is better than laparoscopic, especially for low rectal surgery.
Robotic surgery solves one of the persistent problems with traditional laparoscopic surgery, says Dr. Rudolph, who performs robotic colorectal procedures at his home base at Sentara Virginia Beach General Hospital, and also at Bon Secours DePaul Medical Center, both of which house a daVinci Xi® system. “The generation of the Xi robot at DePaul was specifically designed – in part, at least – for colorectal surgery,” Dr. Frenkel says, “because unlike some of the other surgeries that are done robotically, colorectal surgeons sometimes need to be in more than one corner of the abdominal cavity. For example, in a patient having rectal cancer surgery, we may need to remove a portion of their sigmoid colon. It was difficult for the older robot to go into different areas because of the way it was built. With the newer Xi, we can go to different areas more easily. I love the greater visualization and the ease it allows me to dissect the rectum.” That matters, he adds, because in rectal cancer surgery, the quality of the dissection is extremely important as it relates to patient outcomes oncologically.
“Fine movements and the ability to dissect very precisely just aren’t possible with straight laparoscopy,” Dr. Rudolph explains. “It’s like using chopsticks.” But with the daVinci robot, he says, “we have fully articulated motions with our instruments, allowing us to get into areas we normally wouldn’t be able to get into, with precision we normally wouldn’t have.” Since employing the Xi, Dr. Rudolph confirms that robotic surgery has improved his patients’ recovery, significantly reduced hospital stays and lessened complications.
Dr. Frenkel, a proponent of single incision surgery, has recently begun doing surgeries robotically as well, and agrees wholeheartedly. And with the recent installation of a new daVinci Xi® system at Bon Secours Maryview Medical Center, there is now a third location where surgeons can perform the procedure.
What’s Next?
Colorectal Cancer Treatment 5-10-15 Years From Now.
Colorectal cancer is being studied across the country with a view toward prevention and cure. An ongoing local research project is an Alliance trial: N1048, looking at patients with rectal cancer who are candidates for curative intent sphincter-sparing surgery – without high risk features such as tumor encroaching upon the mesorectal fascia or distal tumors.
“The biggest hope I have in terms of treating colon cancer is immunotherapy,” says Dr. Chang. “It’s been around for many years, but becoming more popular recently as we see more effective immunotherapy agents approved for various cancers, e.g., melanoma, lung cancer, kidney cancer, bladder cancer, etc. However, other than for micro satellite instable colon cancer, immunotherapy hasn’t been as effective in most colon cancer because of the cancer’s different biology. It’s being studied extensively, and I foresee that in 10 years, immunotherapy will be used for colon cancer. We’re also seeing encouraging results for cancer control from radioembolization in patients whose colon cancer has spread to the liver.”
“There are major advances in the way we treat rectal cancer,” Dr. Rudolph says, “one is the idea that we can treat it locally, or transanally.” Dr. Rudolph emphasizes that transanal surgery is not the standard of care in the United States – yet – but explains: “Normally what we worry about with colorectal cancer is ensuring that we get an adequate sampling of lymph nodes, to ensure that the cancer staging is complete and that there is no residual cancer left. Particularly in rectal cancer, there’s a high risk of recurrence. Because of this, for many rectal cancers we give preoperative chemotherapy and radiation therapy, followed by resection through the abdomen. In some countries, they are now taking out the cancers locally through the anus, sparing patients a very big surgery and possible colostomy. Although we do not have large randomized studies at this point to be able to make this approach the standard of care in the US, in the future this may be a tremendous advantage to our patients.”
Preliminary results outside of the United States are good, but it won’t be available in the US until sufficient data is accrued to ensure equivalency between a transabdominal and a transanal resection. There are several trials going on in America, but it will take a while to accrue the data.
Perhaps the most dramatic potential change in the treatment of colorectal cancer is the advent of the transanal total mesorectal excision. “The pioneers in our field are working on ways to do the entire rectal cancer surgery from the anal area,” Dr. Frenkel says, “removing both the tumor and the surrounding lymph nodes, just as it would be done transabdominally. Many people feel that, as opposed to rectal dissection from the abdomen, which can be challenging when you’re dealing with the prostate or the vagina and uterus, that dissection might become the standard. We’re only a couple of years into this now, but it’s on the horizon.”
Postsurgical Innovation
A new post-operative protocol being introduced throughout the country is ERAS, Dr. Ramirez says. “It stands for Enhanced Recovery After Surgery, and the goal is to minimize post-operative pain without the use of narcotics. The actual prep for surgery is totally different.” It’s a very involved prep, Dr. Billings notes, that includes having the patient drink a carbohydrate rich drink the night before and the morning of the surgery. “The patient is given a spinal injection before surgery, and nonnarcotic pain medicine during and immediately after surgery.”
The NIH website defines the key principles of the ERAS protocol as “pre-operative counseling, preoperative nutrition, avoidance of perioperative fasting and carbohydrate loading up to two hours preoperatively,” and calls ERAS “an important focus of perioperative management after colorectal surgery.”
The Bottom Line
Colon and rectal cancers, while not 100 percent preventable, can be treated when detected early, and for that to happen, patients are going to have to make screening – at the age appropriate to their particular medical profile – a priority. And physicians are going to have to even more aggressively prevail upon their patients to take this life-saving step.
“Don’t fear the scope,” Dr. Hughes urges patients. “It saves lives.”
And if they won’t have a colonoscopy? As Dr. Waldholtz says, quoting the American Cancer Society, “The best test is the one that gets done.”
