Neuroendocrine Tumors

November 23, 2020

Information

November 22, 2020

Yale Cancer Center

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00:00Support for Yale Cancer Answers
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00:05to advancing options and providing
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00:13cancer. More information at astrazeneca-us.com.
00:14Welcome to Yale Cancer Answers with
00:17your host, Doctor Anees Chagpar.
00:19Yale Cancer Answers features the
00:21latest information on cancer care by
00:23welcoming oncologists and specialists
00:25who are on the forefront of the
00:27battle to fight cancer. This week
00:29it's a conversation about
00:31neuroendocrine tumors in colon
00:32cancer with Doctor Pamela Kunz.
00:34Doctor Kunz is director of GI Medical
00:36Oncology at the Yale School of
00:38Medicine where Doctor Chagpar is
00:40a professor of surgical oncology.
00:44Pam, maybe we can start off
00:46by setting the context?
00:48What exactly are neuroendocrine
00:50tumors and what do they have
00:52to do with colon cancer?
00:55Great question.
00:56So neuroendocrine tumors are
00:58just another type of cancer.
01:00They can originate actually in
01:02almost any part of the body,
01:04most commonly in the GI tract
01:06and in the lungs and what makes them
01:09different from colon cancer is what the
01:12cells look like under the microscope.
01:15So it's actually a completely different
01:17type of cancer than colon adenocarcinoma,
01:19which is the most common
01:21type of colon cancer.
01:24So these neuroendocrine tumors
01:25they can arise in the colon,
01:28which would make them a colon cancer.
01:30But they look different under the microscope.
01:33So they're not exactly the same
01:35garden variety colon cancer
01:37that we usually think about?
01:40That's correct, and so we would call
01:43those a neuroendocrine tumor of the
01:45colon and what's unique about these
01:48is that we try our best to
01:51identify where these cancers start,
01:52because that has implications
01:54on how we treat that cancer.
01:56So they may start in the colon,
01:59which is in fact actually quite rare.
02:02Most commonly, they'll originate
02:04in the small intestines in the
02:06pancreas and in the lungs,
02:08and they can spread to lymph nodes
02:11or to the liver.
02:13And so when someone says
02:15they have a colon cancer,
02:17we often just assume that
02:19that's colon adenocarcinoma.
02:20The garden variety, as you said.
02:23But what's very important is that we
02:26rely on our pathologists to tell us
02:29exactly what histologic type, that means,
02:32what the cancer cells look like
02:34under the microscope to determine
02:36whether it's an adenocarcinoma or a
02:39neuroendocrine tumor.
02:40Let's talk a little bit more
02:43about how that process actually
02:44happens and what the big deal is.
02:46I mean, for many people they
02:48may think a cancer is a cancer,
02:50and I don't want
02:52neuroendocrine cancers.
02:54I don't want this cancers,
02:55and I don't want that cancer,
02:57I just don't want cancer.
02:59I'm beginning to sound like Doctor Seuss.
03:02But how do we differentiate between an
03:07adenocarcinoma and a neuroendocrine tumor?
03:09And why is that important?
03:14So when a patient first develops
03:18symptoms that may bring them to,
03:20for example, their primary care
03:22doctor or a gastroenterologist,
03:24some of the symptoms may in fact
03:27overlap between having any sort of
03:30cancer of the colon or the GI tract.
03:33They may have abdominal pain or
03:35changes in their bowel habits,
03:37and then they may undergo a biopsy.
03:40That biopsy could be through a colonoscopy,
03:43or, if the cancer has spread
03:45somewhere else it may be
03:48a biopsy of that spot,
03:50like a biopsy of the liver and
03:52once that biopsy is taken,
03:55that tissue, the tumor tissue
03:57goes to a pathologist as a
04:00doctor that specializes in looking at
04:02cells under the microscope to help us
04:05determine exactly what type of cancer it is,
04:09they will look at what the cells look like.
04:12They will also do very special
04:15stains to help us identify
04:17certain characteristics of those cells,
04:20and it matters because every
04:22cancer is treated differently.
04:23We now have large clinical trials that
04:26tell us one cancer may do better with a
04:29different chemotherapy versus another,
04:32and so it's very critical in fact
04:35to determine what type of cancer
04:37that is in order for us to tailor
04:40that treatment to the patient.
04:44And also you know,
04:46I think going back to what you had
04:50said earlier, the cell of origin
04:52for these cancers is different.
04:54So for adenocarcinomas as you mentioned,
04:57those are cancers that arise in the
05:00colon in the glands of the colon,
05:03whereas these neuroendocrine tumors
05:05they may arise somewhere else.
05:07Now do normal endocrine tumors that
05:10you mentioned that can arise most
05:12commonly in the small intestine,
05:14or the pancreas or the lung.
05:17Do those metastasize to the colon,
05:20or when you find a neuroendocrine
05:22tumor of the colon,
05:24is it generally a neuroendocrine tumor,
05:26albiet rare that started in the colon?
05:29Usually we label these
05:31based on where they start,
05:33so if we're calling it a colon,
05:36neuroendocrine tumor or a small
05:38intestine neuroendocrine tumor,
05:40that's because we believe they started
05:42in those places and they start,
05:44you're absolutely right from cells
05:46that are different from these glandular
05:49cells that an adenocarcinoma
05:51originate from neuroendocrine
05:52cells are unique.
05:53They happened to be scattered
05:55throughout the body.
05:56They share features of
05:58some typical cancer cells,
06:00but one thing that makes them
06:02unique is that some of them
06:04can actually secrete hormones.
06:06That's how they get their name endocrine.
06:09And so these cancers that
06:11originate in the small intestine,
06:13for example,
06:14sometimes can secrete a hormone
06:16called serotonin that can cause
06:19things like diarrhea and flushing.
06:21And some of the pancreatic neuroendocrine
06:23cancers can secrete other types of hormones,
06:26for example,
06:27insulin,
06:28that can make your blood sugar quite low.
06:31So it's a combination of
06:34things that helps us eventually
06:36lead to that diagnosis,
06:38and
06:38then tailor that treatment and so
06:41if a patient were to present and they
06:45go and they have a colonoscopy and they
06:48have a biopsy and the biopsy shows
06:52a neuroendocrine origin is it likely
06:54that started in neuroendocrine
06:56cells of the colon itself?
06:59Or does this prompt then a little search
07:02to see whether that neuroendocrine
07:04tumor that was found in the colon
07:08actually came from somewhere else,
07:10or how common would that be
07:13for it to migrate to the colon?
07:16Many of our listeners may know that garden
07:20variety colon cancer goes other places.
07:23It goes to the liver and
07:26so on and so forth.
07:28But do these neuroendocrine
07:29tumors that may start,
07:31for example, in the small bowel,
07:33end up in the colon?
07:36That would be very unusual.
07:38They would more commonly spread
07:40to lymph nodes and to the liver,
07:43but to your original question,
07:44we do something called a staging
07:47work up really at the time anyone is
07:50diagnosed with any sort of cancer
07:52that helps us determine the extent
07:54of the cancer where perhaps has
07:57the cancer spread anywhere else.
07:59We do that by using a CTE or a CAT
08:02scan that helps us look at the chest,
08:06the abdomen and the pelvis.
08:08For other areas of cancer we will
08:11also sometimes do blood work that
08:13includes looking at blood tests,
08:16cell counts, liver tests,
08:17kidney tests to also see if there is
08:21any other effect on other organs,
08:23and so
08:24you'll do this regardless of
08:26whether they presented with a
08:28neuroendocrine tumor or whether they
08:30presented with an adenocarcinoma?
08:32That's correct, yes
08:35and
08:39kind of getting back to where we started
08:42in terms of patient presentation,
08:45you had mentioned that neuroendocrine tumors,
08:49because they tend to secrete these hormones,
08:52they can present with symptoms of diarrhea
08:56and flushing and so on and so forth.
09:00Whereas many colon cancers actually
09:03may be completely asymptomatic
09:06often because we have screening,
09:08For our listeners,
09:10there was an update to the
09:13screening guidelines for colon
09:14cancer that was recently put out.
09:17Do you want to tell us
09:19a little bit more about that?
09:22Yes, definitely,
09:23and I think that's also another key
09:26between the garden variety,
09:28colon adenocarcinoma and neuroendocrine
09:30tumors is that there are precursors or
09:33pre cancers to colon adenocarcinoma
09:35that we can detect as polyps.
09:37So small little growths within the colon,
09:41we can detect and remove and prevent
09:44cancer and the way we do that is through
09:48colonoscopies and so last week the
09:51large guidelines body called the United
09:55States Preventive Services Task Force,
09:58a large organization that
10:00helps determine guidelines for screening,
10:02came out out with a new recommendation.
10:05It's in draft format right now, to
10:08lower the colon cancer screening
10:10age to 45 from the age of 50,
10:14so this is moving it earlier by five years,
10:17and that's for people that have
10:19an average risk of colon cancer,
10:22so no strong family history
10:25or personal history or other risk
10:27factors that would increase your risk.
10:30This is for average risk individuals.
10:32And so why
10:34did they do that?
10:36Why are they now thinking that
10:38people need to get screened earlier?
10:41Are we finding cancers at
10:43earlier ages?
10:45We are in fact finding cancers at earlier ages
10:47really, since the 1990s,
10:50we've seen an increase of 2% per
10:53year of the incidence of colon
10:55cancer in people under the age of 55.
10:59Some other organizations,
11:01the American College of Gastroenterology
11:04decreased their screening recommendation
11:05age to 45 years for black men.
11:08This was in the mid 2000s and in 2018
11:12the American Cancer Society reduced that
11:15colon cancer screening age to 45 for
11:19all people and that was just two years ago,
11:22and I think that over the last few years
11:25we've seen just stronger evidence to
11:29support lowering this screening age,
11:31and therefore the United States
11:33Preventive Services Task Force came
11:36out with this recommendation last
11:38week and
11:39the screening guidelines for colon
11:43cancer may be a little bit confusing for
11:47some of our listeners because it really
11:50depends on the type of test.
11:54Sometimes they say get a colonoscopy
11:57every 10 years, but then there are other
12:01tests like flexible sigmoidoscopy.
12:04There are contact tests.
12:06There are now tests like
12:09Cologuard so stool DNA tests.
12:11There are fecal occult blood tests, can you
12:14help our listeners to understand
12:18these different tests and what they
12:21should be doing in terms of screening?
12:24Because when they read the
12:27guidelines it may get a little confusing.
12:31So your team
12:34of doctors will help guide you to
12:36select the test that's
12:38best for you and
12:40full disclosure,
12:41my husband is a gastroenterologist and
12:43we talk about this a lot at home,
12:47and I'll
12:50quote something that he says which is any
12:53screening is better than no screening.
12:55And so I think your first stop
12:58is talking to your primary care doctor.
13:01So these are the doctors that will
13:04often refer you to get colon cancer
13:06screening that is right for you.
13:08Your next stop usually is with a gastroenterologist
13:11and they will talk with
13:14you about this range of screening and
13:16you did a very nice job listing
13:19those options and these are tests
13:21that look for hidden blood in stools.
13:24Those are called occult blood tests.
13:26There is the DNA based test so
13:28we know that colon cancers can
13:30actually shed DNA into the stool.
13:33And we can look for that.
13:35A sigmoidoscopy will look just in the
13:38bottom portion of your large intestine,
13:41called the sigmoid colon,
13:43so it will only detect that and it is
13:45an actual camera that's inserted
13:48into the sigmoid colon.
13:49A full colonoscopy will have a camera
13:52inserted into the entirety of your colon,
13:55and so there's a huge range of options.
13:58And I agree it can be confusing,
14:01but I think that the
14:03best thing is to really talk with
14:05your primary care doctor and gastroenterologist
14:08about these options.
14:09Some tests may be better for
14:11different patients,
14:12but let me talk a little bit about
14:16some of the advantages of why
14:18colonoscopy and perhaps even
14:19sigmoidoscopy outweigh some of
14:21the others right after we take
14:26a short break for a medical minute.
14:28Please stay tuned to learn more
14:31information about colon cancer
14:32with my guest, Doctor Pamela Kunz.
14:34Support for Yale Cancer Answers
14:38comes from AstraZeneca, dedicated
14:40to providing innovative treatment
14:43options for people living with
14:47cancer. Learn more at astrazeneca-us.com.
14:48This is a medical minute about genetic
14:51testing which can be useful for
14:54people with certain types of cancer
14:56that seem to run in their families.
14:59Patients that are considered at risk
15:01receive genetic counseling and testing so
15:04informed medical decisions can be based
15:06on their own personal risk assessment.
15:09Resources for genetic counseling and
15:10testing are available at federally
15:12designated comprehensive cancer centers.
15:14Interdisciplinary teams include geneticists,
15:16genetic counselors, physicians,
15:17and nurses
15:18who work together to provide
15:21risk assessment and steps to
15:23prevent the development of cancer.
15:25More information is available
15:27at yalecancercenter.org.
15:28You're listening to Connecticut Public Radio.
15:31Welcome
15:32back to Yale Cancer Answers.
15:34This is doctor in Anees Chagpar
15:36and I'm joined tonight by
15:38my guest doctor Pamela Kunz.
15:40We're talking about colon cancer,
15:42and neuroendocrine tumors,
15:44and right before the break we were
15:46talking about some recent updates
15:48to the colon cancer guidelines that
15:51recommend that everybody at
15:53average risk start getting their colon
15:55cancer screening done at the age of 45.
15:58Now, for anybody who's read those
16:01colon cancer screening guidelines,
16:03it's a little bit confusing.
16:04There's all kinds of tests
16:06that are out there, and Pamela,
16:08you were telling us right before
16:10the break that this is a decision
16:13that you really need to make
16:15with your health care team.
16:16Your primary care doctor,
16:18your gastroenterologist.
16:18But you are going to make a pitch
16:21for a particular form of screening.
16:23So tell us a little bit more about that.
16:27That's right, so there are a number
16:30of options, but I was going to talk a
16:33little bit more about colonoscopies.
16:36I think that colonoscopies really
16:38meet a number of different needs
16:40in terms of the screening goals,
16:43so number one, to take
16:46a step back to describe them,
16:49your gastroenterologist will use a
16:52small camera on the end of a tube
16:55and that allows them to detect
16:57small polyps, which are these
16:59precancerous spots and remove them,
17:02and I think that is critical
17:04in terms of cancer prevention.
17:07Some of these other tools might identify
17:10that perhaps you have a precancerous lesion,
17:14or perhaps you have a cancer,
17:17but don't also enable the ability
17:19to actually remove that polyp,
17:22so that's why I think colonoscopies
17:25really are probably the best
17:27tool and considered the gold standard.
17:30So just to be honest, r
17:34I think a lot of people when
17:37they think about colonoscopy,
17:39the things that kind of make people less than
17:42enamored with the technique, is number 1,
17:46the prep because your colon needs
17:48to be really clean for somebody to
17:51put a camera in there and actually
17:54be able to see anything and #2,
17:57the whole thought of having
17:59to put up your bottom end is not particularly
18:03appealing to people when they can think of
18:05instead just sending in a stool sample,
18:08which although not appealing,
18:10sounds a little bit nicer than
18:13putting a tube up your bottom end so
18:16if you were to do the other, say,
18:20a fecal occult blood test or a
18:23stool DNA test that now
18:27is being marketed to patients,
18:31if that's negative,
18:32how confident are you in the results?
18:35If it's positive,
18:36you'll likely end up needing a colonoscopy.
18:38Is that right?
18:39That's right,
18:40so if those tests are positive,
18:42you will still need to do the prep.
18:45I think that's one of the
18:47aspects of a colonoscopy that
18:49most people are worried about.
18:51That's when you have to drink a
18:53special fluid that helps clean
18:55out your colon in order for the
18:58gastroenterologist to really see a shiny,
19:00clean colon and detect the polyps so
19:03the prep is scary.
19:06And in terms of these other options,
19:08if it's negative,
19:10so if a fecal occult blood test is negative,
19:13or the stool DNA test is negative,
19:16it's reassuring, but it's not 100%.
19:20And colonoscopy really allows the
19:23gastroenterologist to look inside your
19:25colon and see if there are any polyps,
19:28and to remove them.
19:30Now before the break we were also
19:32talking about neuroendocrine tumors
19:34and you had mentioned that
19:38these are from a different cell of origin.
19:41They often secrete hormones,
19:44and rarely they can actually
19:47reside inside the colon as well.
19:49Now does a colonoscopy
19:51find these as well,
19:53or are these kind of hidden and
19:55the only way that you can really
19:58find them is when you present with
20:00symptoms?
20:02A colonoscopy will help us detect any
20:04abnormalities in the colon actually, and it
20:08will help detect other types of cancers.
20:12It will help detect other types of conditions
20:15such as inflammatory bowel disease,
20:18but what's unique about neuroendocrine
20:20tumors is that they don't have a
20:24precursor or a precancerous spot
20:26that develops before the cancer.
20:29So very likely if a neuroendocrine
20:32tumor is present
20:33in the colon, it's already a cancer,
20:37whereas for colonoscopy the
20:39intent is to try to catch cancers
20:42earlier before they are even cancers.
20:45So detect the polyps.
20:49And the guidelines for colonoscopy,
20:51if I remember correctly,
20:52are for a colonoscopy every 10 years.
20:55Some people may look at
20:57that and say 10 years.
20:59What happens if I develop one
21:02of these precancerous polyps
21:04in the interim,
21:05is 10 years really the guideline,
21:07and what do you say to
21:10people who have those
21:12concerns?
21:1410 years is the guideline that's assuming
21:16that you again have average risk,
21:18and assuming that
21:20first, colonoscopy is completely normal.
21:22If that colonoscopy shows polyps,
21:24very likely you're asked to come back sooner,
21:27often within three years to see
21:29if there are any more polyps.
21:32But if your colonoscopy is totally clean,
21:35you are often asked to return in 10 years,
21:38and that's because what we've learned
21:41about the biology of polyps is it
21:43often can take 10 years for
21:46a polyp to turn into a cancer.
21:49Now that's
21:50I would say on average or typical
21:53there are exceptions to that rule, and
21:56so the good news for all of our listeners,
22:00of course, is that if you do undergo
22:03a colonoscopy as Doctor Kunz is
22:06recommending starting at the age of 45,
22:09if it's completely clean,
22:11you don't have to drink that
22:13prep for another 10 years,
22:15which is always a nice thing to know as well.
22:20Doctor Kunz,
22:21you had mentioned that
22:23for these polyps you can kind of
22:25take them out at the time of the
22:28colonoscopy and potentially prevent
22:30yourself from getting a cancer.
22:32But if you've got a neuroendocrine tumor,
22:34that's often a cancer that's already there.
22:37And sometimes you can find colon cancers
22:39that are already in the form of a
22:42colon cancer before finding it just as
22:44a polyp. Is that right?
22:47Yes, and so the biopsy that's done at the time
22:50of the colonoscopy can help us to tell
22:53what kind of cancer this is,
22:55is this an adenocarcinoma?
22:57Is it just a pre cancer?
22:59Is this a neuroendocrine cancer?
23:00So if it's a pre cancer and
23:03the polyps removed is that it?
23:05Do you have to take anymore
23:06medications or is removing the
23:08polyp and getting your follow up
23:10colonoscopy all you need to do?
23:13If all that is detected is a
23:16polyp and they're able to
23:18completely remove it
23:20then the recommendation is just
23:22following up your gastroenterologist
23:24says in terms of recommended intervals.
23:26So if they find multiple polyps,
23:28or even just one, it will certainly be,
23:31please come back and see us before 10 years
23:35but there is no treatment needed.
23:38There's no chemotherapy needed,
23:39and nothing else is needed.
23:44Let's move on to
23:47the other two scenarios.
23:50Let's suppose this is an actual
23:53garden variety adenocarcinoma.
23:55What happens then?
23:58So if we determine that based on the
24:01biopsy that it's a colon adenocarcinoma,
24:04then patients are usually
24:06referred to see an oncology team.
24:08That team consists of
24:10usually a medical oncologist,
24:11like myself, and often a surgeon,
24:14and we will embark on this staging work up
24:17that I'd mentioned a little bit earlier.
24:20So that includes blood work and that
24:23will usually also include a CT scan of
24:26the chest and the abdomen and the pelvis.
24:30To determine extent of disease,
24:31meaning, where
24:32has the cancer gone?
24:34Is it localized just in the colon?
24:36Has it spread to nearby lymph nodes
24:39or has it spread further,
24:41perhaps to the liver or to the lungs?
24:45And so, let's say it
24:47hasn't spread anywhere then what?
24:49Then we will often have
24:51a multidisciplinary team meeting.
24:53We do this for many of our cancers.
24:57It's called a tumor board.
24:59In fact, we have our GI cancer
25:01tumor board this afternoon,
25:03and the tumor board is a place where
25:06there are multiple specialists,
25:08medical oncologists,
25:09surgeons, pathologists, radiologists,
25:11a whole group of doctors that
25:13will help determine the next
25:15best plan for someone who has a
25:18localized colon cancer that often
25:20the next step is often a surgery
25:22to remove a portion of the colon
25:25that contains the cancer plus
25:26some additional colon to make
25:28sure that we've removed enough and
25:31also some lymph nodes to help us
25:33determine if the cancer
25:35has spread to those lymph nodes.
25:38And then is chemotherapy or
25:40radiation in their future as well?
25:43That depends on
25:45the stage of the tumor.
25:47So now that the patient
25:49has had their surgery,
25:51we are able to accurately determine
25:54what stage they have in this stage is
25:57determined based on three key features,
25:59and that's called the TNM staging.
26:02which stands for tumor (T), nodes (N), and metastases (M).
26:05And the T stage generally refers to
26:08ia combination of the size and then
26:11how deep in the lining of the colon
26:14that tumor has spread, the N stage
26:17refers to the number of lymph nodes
26:20involved and the M stage refers
26:22to has the cancer metastasized
26:24or spread to a distant location,
26:27like the liver or the lungs,
26:29and so our pathologists help
26:31us with that.
26:32The CT scan itself also helps us,
26:35and so for someone with a colon
26:38cancer it's a little bit nuanced,
26:40but I would say in general,
26:43if someone has a colon cancer
26:45that is stage three or greater,
26:48that would mean that they have
26:52local lymph nodes involved
26:54that usually does mean that
26:56they need post surgical chemotherapy
26:58and so now let's move to the
27:02neuroendocrine situation.
27:03How are these different?
27:05How often do you find metastases
27:08at the time of diagnosis?
27:10Are these resected surgically?
27:13Is there more often medical management?
27:16How is your approach similar or
27:19different to regular colon cancer?
27:22Well, I think that
27:24the work up for many of these GI
27:27cancers are the same where we get a
27:29biopsy and we do this staging work
27:32up with blood tests and a CT scan.
27:34And then we meet and
27:36we have a tumor board discussion
27:38to come up with the next plan,
27:41so those are the common principles.
27:43But you're right,
27:44the treatment plan and tailoring
27:46that treatment to the patient often
27:47differs by cancer and so that is
27:49true for neuroendocrine tumors.
27:51Neuroendocrine tumors are
27:52often much slower growing than
27:54their adenocarcinoma counterparts,
27:55and neuroendocrine
27:58tumors have a very different
28:00system of classification.
28:02I won't go into all of those details now,
28:05but that does help us determine
28:08what the next best step is and
28:12we do include things like surgery.
28:16Sometimes patients will have had the
28:18cancer spread at the time of diagnosis,
28:21and if that's the case,
28:23we have medications,
28:25including some chemotherapies
28:26that help us slow down the
28:28growth of that cancer, and so the
28:32chemotherapies though are different than
28:34what you would get for a regular colon
28:37cancer?
28:39This is an important
28:41take home for every cancer type.
28:44The chemotherapy regimen
28:46is often different
28:49depending on that cancer type.
28:51There's sometimes some overlap,
28:52but for the most part,
28:54the way we determine if a chemotherapy
28:57regimen works for a given cancer
29:00is through a clinical trial.
29:01Clinical trials are ways we test new
29:04medicines or new combinations of
29:06medicines and prove that it works
29:08in a very specific cancer type.
29:11Doctor Pamela Kunz
29:11is the director of GI Medical
29:14Oncology at the Yale School of Medicine.
29:18If you have questions,
29:19the address is canceranswers@yale.edu
29:21and past editions of the program
29:23are available in audio and written
29:25form at yalecancercenter.org.
29:26We hope you'll join us next week to
29:29learn more about the fight against
29:32cancer here on Connecticut Public Radio.