Cancer Answers: Surgical Options for Colorectal Cancer, March 14, 2010

Dr. Charles Cha, Surgical Options for Colorectal
Cancer
 March 14, 2010Welcome to Yale Cancer Center Answers with Drs. Ed Chu and
Francine Foss, I am Bruce Barber.  Dr. Chu is Deputy Director
and Chief of Medical Oncology at Yale Cancer Center and Dr. Foss is
a Professor of Medical Oncology and Dermatology specializing in the
treatment of lymphomas.  If you would like to join the
conversation you can contact the doctors directly.  The
address is canceranswers@yale.edu
andthe phone number is 1888-234-4YCC.  This evening
Ed welcomes Dr. Charles Cha.  Dr. Cha is Assistant Professor
of Surgery specializing in gastrointestinal cancers at Yale School
of Medicine.  Here is Ed Chu.Chu
 Why is colorectal cancer still such an important health problem
here in the United States?Cha
 Just to give a little bit of a definition, colorectal cancer is a
cancer of the inside lining of the colon and it's very prevalent in
the United States; about 150,000 cancers are diagnosed per year and
some people estimate it to be as high as 190,000 for the upcoming
year.  Fortunately, when caught early, it is curable about 80%
of the time when it is diagnosed in the United States, which is a
quite a bit higher than it used to be prior to intensive screening
like that that is suggested by most physicians nowadays.  It's
a disease that in this month in particular we will be talking a lot
about. Increasing awareness of the disease, in particular screening
so we can catch these tumors earlier, is going to be very important
so that we can cure as many as these patients as possible and
hopefully increase the number of patients that are eligible for
curative surgery or therapies.Chu
 What age group is typically affected by this disease?Cha
 The peak incidence is around 60-65, but there could be a wide
variability in terms of when patients present, ten years before or
after that, but typically, as with most cancers, it is a disease of
the older population, and there is an equivalent incidence in both
males and females as well.Chu
 The latter point is an important one to emphasize to our listeners
because my sense is that for some reason women have this feeling
that they are not at the same level of risk for developing colon
cancer as their male counterparts.Cha
 Absolutely, I think it's important to emphasize that this is the
third most common cancer for both males and for females, and it's
something that women have no protective element for being female
and should be screened just as rigorously as any male.Chu
 What are some of the risk factors that are associated with the
development of colon cancer?Cha
 There are some that are a little better established, and some that
are a little bit less established, but certainly a strong family
history, if there was a patient who has a relative, particularly a
first degree relative diagnosed earlier than age 50 or so, that's
going to increase their chance of getting colon cancer quite a
bit.  Furthermore, having a history of polyps is going to
dramatically increase your3:14 into mp3 file 
http://www.yalecancercenter.org/podcast/mar1410-cancer-answers-cha.mp3
 risk for cancer and patients with inflammatory bowel disease,
particularly ulcerative colitis, those patients have to be screened
very regularly in order to try to catch colon cancer in that
population, which is quite common.  Less strong risk factors
are things like smoking, fat intake, and sedentary life style, but
those all have been associated with colon cancer.Chu
 As you mentioned, we typically think of family history as being
the major risk factor, but as you know the familial kinds of colon
cancer really only account for 10 or 15 percent of all the colon
cancers we see in the clinic, and it is the sporadic form of colon
cancer.  In sporadic colon cancer, what are the key risk
factors that one has to worry about?Cha
 When you're talking about risk factors I would say, in particular,
age being greater than 50 is going to be the number one risk factor
in terms of whether they are going to be at high risk or lower
risk, but certainly we see patients who are less than 50 and older
than 50.  Diet has also been associated, particularly a high
fiber diet, with lower incidence, and a high red meat diet is
associated with high risk of cancer. Certainly countries or
civilizations that have a lower intake of fatty foods and red meat
have a lower incidence of colorectal cancer as well.Chu
 What about African-Americans or other minority groups, because
there is some talk that perhaps African-Americans may be at
increased risk for developing colon cancer at an earlier age than
say Caucasians?Cha
 The data is not completely clear on that, but certainly it's
pretty well established that when it's discovered in the
African-American population it is discovered at a later stage, and
it tends to be caught later and the ability to provide curative
therapy for those patients are less. There are some data that
potentially suggest that there might be more aggressive strains,
there might be more aggressive disease in African-American
populations.  But some of that disparity may just be access to
adequate medical care, or access to adequate screening, which is
one of the reasons why we again have to emphasize screening as the
most important aspect of Colon Cancer Awareness Month in order to
get patient's in to see a physician when they have an earlier stage
tumor so that the tumor can be caught and cured.Chu
 Now you mentioned a moment ago, a polyp.  Do most colon
cancers come from polyps, how does colon cancer actually arise?Cha
 As I mentioned earlier, it's a tumor of the lining of the colon
and there are several layers, there is sort of a mucosal layer that
these tumors come from, and in general, these tumors start out in a
very set progression. They start out as small little polyps or
lumps that start in the most inner layer of the colon and it
usually takes about 10 to 20 years for that small little polyp to
slowly grow and slowly mutate into an actual cancer, which is why
we have about a 10 year range in order to catch6:41 into mp3 file 
http://www.yalecancercenter.org/podcast/mar1410-cancer-answers-cha.mp3these early to try to remove them. Also it's one of the reasons
why if you get a colonoscopy at age 50, which is what the current
recommendation is, and if it's clean, you have another 10 years
before you need to have another one.  So if you think of it in
those terms, it's a relatively slow growing cancer and there is a
lot of opportunity to catch it early.Chu
 Do all polyps eventually turn into cancer or do only a small
fraction of the polyps actually become cancer?Cha
 A very small fraction actually become cancer, and there is sort of
sub-classifications within how we describe these polyps
histologically and physiologically, so to speak, in terms of their
shape, and in terms of how high risk they are for turning into
cancer. Certainly those that are more benign appearing can
sometimes be watched, and those that might look more malignant, or
on a biopsy appear more malignant or premalignant, we would be more
aggressive about trying to take it out either through the scope or
surgically.Chu
 What are some of the common symptoms that are associated with
colon cancer?Cha
 For early stage tumors there are essentially no symptoms, and
that's one of the reasons why screening is so important. 
Certainly as these tumors start to grow larger they are going to
obstruct the lumen and cause problems with abdominal pain,
bloating, and a lot of times, for even earlier stage tumors, they
can be associated with some blood which is why fecal occult blood
testing is also recommended starting at about age 40 and performed
yearly.  Sometimes patients can experience small caliber
stools, particularly if they have a large circumferential tumor
that's distal, but a lot of times it's very vague symptoms where
they are caught because patients have anemia, fatigue, or weight
loss, so it's very variable.Chu
 We have a lot of close family friends and relatives who say to us,
you know we are age 50 or greater but we have absolutely no
symptoms so there really is no need for me to undergo
screening.  What do you say to those individuals?Cha
 Well, I am a cancer surgeon, that's really all I deal with and
there is a certain amount of denial and a feeling amongst the
general population that it's not me, it's someone else, but if you
look at the numbers, your lifetime risk, for an average patient, is
about 6%. That means about 1 in less than 20 people will develop
cancer sometime during their lifetime and that's why screening is
so effective because we can hopefully catch these patients
early.  These are the same people who then later on, when they
see you or I in clinic say, "why me" when they are found and as you
mentioned, most of the time its sporadic, there is no rhyme or
reason to it, anybody and everybody is a potential9:38 into mp3 file 
http://www.yalecancercenter.org/podcast/mar1410-cancer-answers-cha.mp3 colon cancer patient and we need to screen and try to catch
these earlier so we can take care of them.Chu
 Let's talk a little bit about screening.  What are some of
the common screening methods that are currently being used to try
to identify colon cancer at an early stage?Cha
 I know you discussed this quite extensively last week during your
radio talk, but there are a whole set of different tests that are
used, the least invasive being fecal occult stool testing where
patients are given cards and essentially the stool is placed on the
card and sent back by mail and that can be checked for occult
blood.  Moving forward, you have screening colonoscopies,
which essentially are what I consider the gold standard, and with
that you can actually observe the entire colon from the right side
all the way down to the rectum. There are some technical issues in
terms of how slowly the scope is withdrawn from the patient as well
as how experienced the gastroenterologist or person who is
performing the procedure is in term of how effective that
colonoscopy is, but from my opinion that's the gold standard.
People also talk about flexible sigmoidoscopy, which really just
examines the left side of the colon and is considered by some to be
a little bit less invasive because you are not going through the
entire colon. More historically speaking, people also talk about
Barium enemas as a way to evaluate the colon, which really is not
very good for right-sided colon lesions or really small lesions
even in the left side of the colon.Chu
 As you know there has been a lot of discussion, a lot of attention
being placed on the use of virtual colonoscopy, and I am just
curious, what are your thoughts on the role of virtual colonoscopy
and screening?Cha
 We use virtual colonoscopy in select situations.  We do not
use it for screening per se, but we are using it in situations
where we can't actually perform a colonoscopy due to a tumor that
might be causing too narrow of a stricture of the colon to allow
the colonoscope to go past.  In terms of using it for
screening, I do not think it's really been well established, it's
particularly not good for small lesions, if they are smaller then 5
cm in size, if you don't have really good prep a small stool
particle can sometimes appear on virtual colonoscopy as a polyp
because the computer just sort of models that stool ball as part of
the wall of the colon, and ultimately the most important weakness
is at the time of the procedure if you do find a polyp, you are
going to have to have a colonoscopy anyway in order to get a tissue
diagnosis.  We sort of think of colonoscopy as one stop
shopping where you can go in, you can screen, and if there is
something you can biopsy it, or potentially if it is an early stage
polyp, just take it out and you will be done.Chu
 It's interesting though that many people have this inappropriate
fear and anxiety about undergoing colonoscopy, can you maybe
explain why that might be?13:07 into mp3 file 
http://www.yalecancercenter.org/podcast/mar1410-cancer-answers-cha.mp3Cha
 I think that attitude is changing over the course of the past 10
years, but colon cancer is something that people did not even want
to talk about almost to the point where they were embarrassed about
the fact that they had colon cancer, and it's something that as we
have more awareness and understanding that it is a common disease
and a potentially deadly disease, patients seem to become more open
to the idea of screening and to the idea of saving themselves or
their loved ones and moving forward with colonoscopy.  We have
seen a dramatic increase in the past decade in terms of screening
colonoscopies, but even now the most recent estimate is that only
about 50% to 55% of patients who should be getting screened are
getting screened, but that's up from the 30% or so in the past
decade.  There is a psychological element to it and I think
it's something similar to breast cancer where as we get more
awareness, and as we understand more about the disease, patients
are going to be more open and more willing to undergo a
colonoscopy. Nowadays in the year 2010 it is a very comfortable
procedure.  It is something that is done as an outpatient
procedure, it is covered by medicare and most insurance companies,
and as I mentioned earlier, it is recommended for anyone who is at
the age of 50 without any other risk factors.Chu
 Great. We are going to take a short break for a medical
minute.  Please stay tuned to learn more information about the
evaluation, screening, and treatment of colorectal cancer with my
guest Dr. Charles Cha from Yale Cancer Center.Chu
 Welcome back to Yale Cancer Center Answers.  This is Dr. Ed
Chu and I am joined here in the studio this evening by my good
friend and colleague Dr. Charles Cha from Yale Cancer Center to
discuss the screening, early detection, diagnosis, and treatment of
colorectal cancer in honor of the fact that March is Colorectal
Cancer Awareness Month.  Before the break we were talking
about the different screening methods that are currently being
used, and I guess an important point to emphasize to our listeners
is when would you recommend for screening to begin?16:16 into mp3 file 
http://www.yalecancercenter.org/podcast/mar1410-cancer-answers-cha.mp3Cha
 For the average patient with no additional risk factors, the
recommendation is for screening to occur at age 50, if you have a
normal colonoscopy after that you don't need another for 10
years.  If at the time of screening there is a small polyp
found, then the recommendation is for another colonoscopy within 3
to 5 years after that.  If you have any additional risk
factors, for instance a family member who had colon cancer say at
age 50, the recommendation is to get screening starting about 10
years prior to when that relative of yours had colon cancer. For
the rare occasions where you have a genetic history such as
familial adenomatous polyposis syndrome or Lynch
syndrome, which are some of the genetic types of
diseases that are associated with colon cancer, the screening is
much earlier. For FAP in particular you will start while you are
still less than 10 years old and those patients will have hundreds
of polyps that will have to be monitored over their entire
lifetime.  For some of these genetic diseases, which are
different from sporadic diseases, we will sometimes do prophylactic
colectomies to prevent a cancer from occurring, which in the case
of FAP is essentially 100%.Chu
 Again, in your view, colonoscopy sounds like the gold standard
screening method that should be done.Cha
 Absolutely, there are a number of different screening methods
available, but in my mind colonoscopy still remains the gold
standard both in terms of diagnosing and treating patients who have
early stage polyps. There's a lot of great data to show that for
early stage polyps, even if there is a small focus of cancer within
in it, through the colonoscope they can be resected and patients
essentially would need a surgical resection after that, so both
from a screening perspective and a diagnosis perspective in terms
of biopsy as well as a therapeutic perspective, colonoscopy still
remains the gold standard.Chu
 Our listeners out there that have tuned into the show in previous
years, and last week's show, have heard me already say this, but
yours truly, because I have a very strong family history of colon
cancer at an early age, I have actually already had four
colonoscopies, and I have to say it becomes easier and easier each
time I undergo the colonoscopy procedure.Cha
 That's great, the more that people talk about having had one
themselves and discussing it openly, the less of a psychological
blockade there will be in terms of patients getting screening
colonoscopies.  There certainly was a big affect when Katie
Couric had her colonoscopy shown on TV.  There is even
something that they call the Katie Couric effect where the rate of
colonoscopies increased dramatically after that particular episode
of the Today's Show, and I think that is going to continue to
increase as people become more aware and are more open to getting
screening colonoscopies.19:37 into mp3 file 
http://www.yalecancercenter.org/podcast/mar1410-cancer-answers-cha.mp3Chu
 Let's talk a little bit about once a colonoscopy is performed,
colon cancer has been diagnosed, what is the general approach to
that individual then?Cha
 There is a multidisciplinary approach and you and I work very
closely with patients, you're a medical oncologist and I am a
surgical oncologist.  For rectal cancer, radiation oncologists
are involved, the pathologist, the radiologist, and we all work
together to formulate the best plan, but in general, if we can
remove it, then that is the best treatment for any type of colon
cancer.  As I mentioned earlier, for the earliest stage colon
cancer, those that are not invading the wall at all and are just in
that most inner lining of the colon, through the colonoscope you
potentially can snare that, remove it, and that potentially can be
it and no further therapy may be needed.  As that tumor grows
larger, the tumor starts to invade the wall and a surgical approach
is often needed.  Nowadays we have very good data that shows
that a laparoscopic approach, where you use small incisions and TV
cameras, is as effective as the old open procedure; they are
equivalent to one another. I don't think there is a down side to
doing a laparoscopic approach for colon cancers.  We can talk
about that a little bit later, but there is more debate in terms of
whether the laparoscopic approach is as appropriate for rectal
cancer, but clearly for colon cancer, which is the first part of
the large bowel, a laparoscopic approach is as effective as an open
procedure. There are certain technical issues that we don't have to
go into, but getting an adequate distance away from the tumor,
making sure that we acquire an adequate amount of lymph node
drainage, are both very important aspects of doing a good cancer
operation.Chu
 In your view, can a general surgeon do these kinds of what sound
like a bit more sophisticated laparoscopic procedures, or should
someone like yourself who is really focused and has a particular
expertise in colorectal surgery be the one to perform these newer
types of procedures?Cha
 That is somewhat of a loaded question, but I think traditionally
general surgeons have always done open colon resections and
surgical oncologists as well. There are also colorectal surgeons
who are trained to do open resection.  I think any of those
people are well qualified, well trained to do open colon
resection.  In terms of laparoscopic surgery, it is
unfortunately a little bit difficult to know and it's almost case
by case situations where somebody has the expertise, has the
training, and has experience doing those types of procedures. If
you have a general surgeon who is well trained and does these types
of procedures routinely, that's more than adequate experience to do
that procedure.  Surgical oncologists such as myself who have
expertise in laparoscopic surgery and colon surgery in particular,
or colorectal surgeons who have that type of experience and
training, those are all appropriate people to perform those types
of procedures.  Unfortunately, for the general public it
becomes a little bit difficult to know for sure whether your
particular surgeon has those skill, and I would just say when you
go to meet your surgeon you need to ask any important questions,
how many have they done, or what type of training do they have? Is
this something that you are uncomfortable doing? Because I think we
are in the process right now where we are23:32 into mp3 file 
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 transitioning from a point where these types of procedures were
always done open, to a point where the data is pretty convincing
that a laparoscopic approach is as good if not better than an open
procedure, particularly in terms of length of stay in hospital,
size of the incisions, and postoperative pain.Chu
 I am just curious, is there a minimum number of say laparoscopic
operations that a surgeon should be doing each year in order to
have a patient feel like that person has the necessary
experience?Cha
 I don't think there is any established number.  People talk
about two of the biggest trials, one is the classic trial and one
is the cost trial, and they use a cut off of about 20 procedures in
those trials as having some expertise, but even within those trials
as surgeons went along and did more of these procedures their
conversion rate, meaning how often they had to go from a
laparoscopic procedure to an open procedure, decreased suggesting
that there is a learning curve even higher than 20, but I would say
around 20 would be sort of a minimum number per yearChu
 What about the role of robotic surgery?Cha
 Robotic surgery is something that obviously for prostate cancer
has been well established and even within prostate cancer there is
some controversy.  There is a recent New York Times article on
whether it's a true benefit because it sounds very compelling, but
the data for prostate is somewhat questioned for rectal cancer,
which is what it is used for nowadays.  There essentially is
no data and it is something that I would consider still
investigational and is something that I think has some potential
advantages, but that has not really been teased out in any good
data that I am aware of.  What is also controversial is the
role of laparoscopic surgery for rectal cancer, and for rectal
cancer that would be what the robotic surgery would be replacing
essentially, and I think that has also been considered more
investigational as well, particularly for low lying cancer, low
down in the pelvis, and it's something where there are currently
ongoing trials investigating it.Chu
 You are known as one of the leading experts in the surgical
approach to patients who have colorectal cancer that spreads,
specifically to the liver.  Can you tell us a bit about when
would be a situation in which you would consider operating on a
patient who has got metastatic disease, but it seems to be confined
only to the liver?Cha
 This is one of the really exciting aspects that has changed in
colorectal cancer care in the past decade or so.  There used
to be a very bleak outlook for patients who had cancer,
particularly colorectal cancer that had metastasized to the liver,
which is the most common organ for colorectal cancer to metastasize
to.  We now know from a lot of good data that if we can remove
all the cancer that has gone to liver, there is still a relatively
good chance for cure and there is a great chance for long term
survival which is a huge difference compared to a lot of other
cancers where27:18 into mp3 file 
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 once it has gone to the liver it is suggestive of more systemic
disease; whereas for colon cancer, the liver seems to serve as
almost a filter to prevent disease from going beyond the
liver.  So, we have become more and more aggressive with our
ability to resect lesions that have gone to the liver.  We are
applying laparoscopic approaches as well to the liver and we are
able to do both minor and major liver resection using laparoscopic
approaches, which is something that's really new within the last
five years. A lot of this is made possible because we have such
good chemotherapeutic agents.  As you well know, we have
agents and targeted agents as well as standard chemotherapeutic
agents that allow us to have response rates as high as 50 to 60% in
some situations, and so we are getting to the point where we are
able to resect patients who have five, six, sometimes ten liver
lesions, sometimes in a staged approach, sometimes simultaneously,
but we have a number of different techniques up our sleeves to
benefit these patients.Chu
            
 This actually is the one subset of patients with metastatic
disease that we can really cure with a combination of surgical
resection and chemotherapy.Cha
 Absolutely, and there is good long term data now showing five year
survivals for resection of liver metastasis as high as 50% to 60%,
 which if you think about it is not that different than
patients who did not have liver metastasis, which is pretty
remarkable.Chu
 Thanks Dr. Cha, it has been great as always to have you on Yale
Cancer Center Answers.  The time goes really quickly, so I
will have to have you come back and talk more about what your own
research group is doing with respect to the treatment of colorectal
cancer.Cha
 Thank you very much for having me.Chu
 Thanks for giving us a really nice overview of the importance of
screening and early detection, especially since this is Colorectal
Cancer Awareness Month.  Until next week, this is Dr. Ed Chu
from Yale Cancer Center wishing you a safe and healthy week. If you have questions or would like to share your comments,
visit yalecancercenter.org, where you can also subscribe to our
podcast and find written transcripts of past programs.  I am
Bruce Barber and you are listening to the WNPR Health Forum on the
Connecticut Public Broadcasting Network.