Smilow Shares: Colorectal Cancer
March 17, 2022Information
March 16, 2022
Presentations by: Drs. Michael Cecchini, Xavier Llor, Jaykumar Thumar, Vikram Reddy, Kevin Billingsley, and Kimberly Johung. Co-Sponsored by: Colon Cancer Foundation
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- 00:00Welcome everyone,
- 00:01my name is Michael Cicchini. I'm Co.
- 00:04Director of our colorectal cancer program.
- 00:06Here I'm assistant professor in
- 00:07medicine and medical oncologist.
- 00:11Going to be chairing the moderating
- 00:14this session this evening for smilow.
- 00:17Shares about colorectal cancer.
- 00:19For colorectal Cancer Awareness Month.
- 00:21We'll start tonight with some
- 00:23introductions for the various faculty
- 00:25that are going to be presenting tonight.
- 00:28And then we'll jump into their
- 00:30presentations from disease experts
- 00:32in the field of colorectal cancer.
- 00:34Please pose any questions for the
- 00:36faculty in the chat box and I will
- 00:39be going through those questions
- 00:42and posing them to the faculty,
- 00:45both as the talks can.
- 00:47As each talk concludes and again
- 00:50at the at the end of the session.
- 00:53So, so why are we having?
- 00:58They start tonight,
- 00:59so the care of patients lived with Laurel.
- 01:01Cancers become increasingly complex
- 01:03as we develop new therapies,
- 01:05radiation techniques,
- 01:06surgical techniques,
- 01:07new radiology scanning modalities,
- 01:09screening guidelines are changing
- 01:10rapidly and the Yale cancers and
- 01:12National Comprehensive Cancer Network
- 01:14designated Cancer Center and it offers
- 01:16state of the art multidisciplinary care
- 01:18to all patients with colorectal cancer.
- 01:21And our goal tonight is to provide
- 01:23information and perspectives from
- 01:25multiple smilow Cancer Hospital team
- 01:26members that provide colorectal
- 01:28cancer treatment so that attendees
- 01:29can appreciate the role of these
- 01:31various screening,
- 01:32treatment modalities, etc.
- 01:34For patients living with colorectal cancer.
- 01:36So I'm going to introduce each speaker
- 01:38now and I'll introduce them again as
- 01:41as they speak just before they speak.
- 01:43But first,
- 01:44Doctor Vikram Reddy,
- 01:45he's an associate professor of surgery.
- 01:48He'll be speaking tonight about
- 01:49the role of the colorectal surgeon
- 01:51in colorectal cancer management.
- 01:52Doctor Kimberly Jo Hung is an associate
- 01:54professor of therapeutic radiology
- 01:55who will talk about the role of radiation,
- 01:58hunk of the radiation oncologist
- 02:00in colorectal cancer,
- 02:01Doctor Shabbir lore.
- 02:02He's a professor of medicine from our
- 02:04justice disease team who will speak
- 02:05about the role of the gastroenterologist
- 02:07and colorectal cancer management.
- 02:09Doctor Jaykumar thummar.
- 02:10He's an adjunct professor of
- 02:12medicine who practices in Hartford
- 02:14at the Saint Francis Hospital,
- 02:15and he'll be speaking with the
- 02:17role the medical oncologist in
- 02:19the colorectal cancer management,
- 02:20and we also have doctor Kevin Billingsley.
- 02:22He's our.
- 02:23Professor of Surgery and Chief Medical
- 02:24Officer of Smilow Cancer Hospital,
- 02:26and he'll be speaking about the
- 02:27role the surgical oncologists in
- 02:29the management of colorectal cancer.
- 02:30And before we move on to our speakers,
- 02:33I wanted to take a faculty speakers.
- 02:35I wanted to take a moment to introduce
- 02:37a special guest that we have tonight as well.
- 02:39Cindy Barassi,
- 02:39who is president of the Colon Cancer
- 02:42Foundation.
- 02:42She spent 25 years developing and
- 02:45managing international consulting
- 02:46projects for nonprofit government
- 02:48and for profit organizations and
- 02:50the Colon Cancer Foundation is a
- 02:52national movement of thousands of
- 02:54volunteers who are dedicated to a
- 02:56world without colorectal cancer.
- 02:57I'll let you say a few words, Cindy.
- 03:02Thank you very much, I appreciate
- 03:03it and I want to welcome
- 03:05everyone tonight and.
- 03:07Also say happy Colon Cancer Awareness month.
- 03:1145 is the new 50 if you
- 03:13haven't already heard.
- 03:14If you don't mind,
- 03:15I'm going to start just a
- 03:16couple of slides I think.
- 03:17Do I have the
- 03:18ability to do it? Yeah, OK.
- 03:23OK.
- 03:27So is this little bit of
- 03:29lag time? Here we go?
- 03:36OK, so uhm.
- 03:41As Doctor Cheeney mentioned,
- 03:42I'm the President of the Colon
- 03:44Cancer Foundation, and I also
- 03:47sit on the steering committee for the
- 03:49New York City Wide Colon Cancer Control
- 03:51coalition. That is a long
- 03:54way of saying C5 and we work as a part of
- 03:57the New York City Department of Health.
- 03:59And I also serve on the colorectal
- 04:02cancer action team as part of the
- 04:04New York State Cancer Consortium.
- 04:06And then I also serve finally on
- 04:09a number of other task groups. But I
- 04:11love I love. I love this when the
- 04:13family health history and early
- 04:15age onset colorectal cancer task
- 04:17group as part of the national
- 04:19colorectal Cancer table.
- 04:23So the foundation is actually
- 04:26been around for 19 years and our mission
- 04:30is 3 pronged prevention advocacy
- 04:34and research and by prevention we
- 04:38mean working with the community at
- 04:41large. So people who've never
- 04:42been diagnosed with colorectal
- 04:44cancer as well as patients
- 04:46and clinicians.
- 04:47And we look to do that through
- 04:50education and awareness.
- 04:51And it could be something as
- 04:53simple as taking.
- 04:54It's called our rolling colon,
- 04:56which is a large inflatable colon
- 04:58into communities in and around
- 05:00New York City and even across
- 05:02the country and teaching people
- 05:04about what a healthy colon looks
- 05:06like all the way to what stage
- 05:074 rectal cancer looks like.
- 05:09And then even if you go to our website,
- 05:12we've spent a lot of time this
- 05:14year beefing up educational
- 05:16resources for patients who've been
- 05:18diognosed and clinicians who may
- 05:20not be aware of the rapidly rising
- 05:22rates of colon cancer affecting
- 05:24younger and younger Americans.
- 05:26So I encourage you to visit Colon
- 05:29cancerfoundation.org second prong is
- 05:32advocacy and we do that by through
- 05:34our annual event is the early age
- 05:37onset colorectal Cancer Summit
- 05:39focused on again rapidly rising
- 05:40rates in the younger population.
- 05:43We bring faculty from all over the
- 05:46world as well as patient caregivers,
- 05:48clinicians,
- 05:49researchers,
- 05:50epidemiologists from all over the world to
- 05:52focus on what's going on with this disease,
- 05:54why it's happening,
- 05:55and then we also advocate for.
- 05:58Quality of life.
- 05:59Fertility preserving treatment no
- 06:00matter where a patient is being seen
- 06:03across the country, so equal
- 06:05opportunity access to care no
- 06:07matter where you're being served.
- 06:10And then finally research, and we've
- 06:12done that historically by supporting
- 06:14young investigators to travel
- 06:15to conferences across the world,
- 06:17promoting their translational research
- 06:19and advances that they're making.
- 06:21In colorectal cancer.
- 06:28So for 2022 we have some pretty
- 06:31big hairy audacious goals or
- 06:33behaves. We like to call them.
- 06:35We're working rapidly to ferociously,
- 06:38to try to raise enough money
- 06:40to provide 10,000 screening
- 06:42opportunities for individuals
- 06:44and underserved and underinsured
- 06:46communities around the country. And
- 06:49our goal is to reach 20. The 21
- 06:51million Americans between
- 06:52the age of 45 and 49
- 06:55that are now eligible for screening
- 06:57if they're. Average risk with our
- 06:59message that screening saves lives.
- 07:0245 is the new 50.
- 07:03If you're 45, now is the time to talk
- 07:05to your doctor about getting screened.
- 07:07And the way we're doing that is
- 07:09through our website letsgetscreen.org.
- 07:12So I encourage you again,
- 07:14those two websites,
- 07:16colon cancerfoundation.org.
- 07:17But more specifically,
- 07:18let's get screened.org.
- 07:19Has social media resources
- 07:21educational resources,
- 07:23so I encourage you to take a visit
- 07:24and you know learn more about the
- 07:26opportunities to get involved,
- 07:27but also just to share,
- 07:29you know through your social
- 07:30media channel to encourage
- 07:30people to get screened.
- 07:33And finally, just thank you for having me.
- 07:34I really appreciate being a part of this.
- 07:36I look forward to hearing what
- 07:37everyone has to say tonight.
- 07:42Excellent, thank you,
- 07:43excellent, thank you.
- 07:45So now we'll start with our
- 07:47faculty speakers and 1st we have
- 07:49Shabbir lore again Professor of
- 07:50Medicine from digestive disease.
- 07:52One of the gastroenterologists is Milo.
- 07:55Go ahead, show here.
- 07:59Thank you very much Mike. I'm glad to hear.
- 08:02Thank you for the invitation and
- 08:05hopefully we'll we'll get some all to
- 08:07learn a little bit from everyone else.
- 08:10I'm. I do have no conflicts
- 08:12of interest to disclose,
- 08:13so just to set up the stage,
- 08:15colon cancer is still a very common cancer.
- 08:17Third, leading cancer in both males
- 08:20and females in in our country,
- 08:22and also third most common cause
- 08:24of cancer related mortality.
- 08:26So it's still a big problem.
- 08:28What are the things that I really AM?
- 08:32It's interesting is how big of a
- 08:34difference there is in temporary incidence
- 08:36of this cancer around the world.
- 08:38With more than five times
- 08:41difference from some areas,
- 08:43particularly Sub Saharan Africa and Asia,
- 08:47with the lowest rate and the more
- 08:50industrialized world with the highest rates
- 08:52of in the incidence of colorectal cancer,
- 08:55which really points to her towards
- 08:58these behavioral nutritional
- 08:59lifestyle factors that probably.
- 09:02Be a very important role,
- 09:04and in fact we've learned over the
- 09:05last few years that some of them
- 09:07are clearly associated with them.
- 09:08For instance,
- 09:09obesity is clearly associated with it.
- 09:11Smoking is a big one in terms of
- 09:14increasing colorectal cancer incidence,
- 09:16and in some cases there are some
- 09:18preventive factors such as physical
- 09:20activity or intake of dairy products.
- 09:23So those have been associated with actually
- 09:26decreased risk of colorectal cancer.
- 09:29Therefore,
- 09:29there are clear factors that we can
- 09:31do something about it and modifying.
- 09:33Some of the some of these aspects can have
- 09:36an impact in colorectal cancer incidence.
- 09:40On the other hand,
- 09:41we've known for a long time
- 09:42that family history matters,
- 09:44and just having one first degree
- 09:47relative with colorectal cancer
- 09:48more than multiplies by two of the.
- 09:51The incidence of colorectal
- 09:52cancer and the more relatives,
- 09:54the more likely it is that we'll
- 09:56develop a colorectal cancer too.
- 09:58And then,
- 09:58that's even outside of the well
- 10:00defined syndromes that are the
- 10:02genetic defects that are inherited.
- 10:04But interestingly enough,
- 10:05even having an advanced polyp
- 10:07having a first degree relative with
- 10:09advanced Poly Boot is a high risk.
- 10:12Also for colorectal cancer,
- 10:14and that's really important
- 10:16to keeping in in mind so.
- 10:18Add it's truly an inter player lifestyle,
- 10:20environmental dietary factors and
- 10:22genetic defects that in some cases
- 10:25do have a disproportionate effect,
- 10:27because even though they are will
- 10:30affect a smaller number of individuals,
- 10:33the cancer risk is really important
- 10:35in the US in those cases,
- 10:38and this is the good news slide and
- 10:40hopefully we'll have a few more.
- 10:41But this is the nice trend that we've
- 10:45been seeing since the 1980s in the US.
- 10:48With this very steady decrease in
- 10:51the incidence and mortality for
- 10:53males and females of colorectal
- 10:55cancer that started even before
- 10:57we started doing a screening,
- 10:59so something was already happening.
- 11:01But certainly screening we believe
- 11:02has had a lot to do with that,
- 11:05as this slide showing here,
- 11:07which is incidence rate in that that
- 11:09red line that goes down as the number
- 11:12of colonoscopies in our country
- 11:14has been going up.
- 11:15So really, a clear association.
- 11:18And there's.
- 11:19Data showing that actually yeah,
- 11:21correct cancer screening tests decrease
- 11:24incidents and and cancer related mortality.
- 11:27And unfortunately though,
- 11:29even though again we have this
- 11:32very nice decrease in the older
- 11:35individual older than 50 individuals,
- 11:37this is the worrisome trend that we've
- 11:40been seeing since the early 1990s.
- 11:42This steady increase in the incidence
- 11:45among the 20 to 49 year olds which
- 11:48we've seen in other cancers.
- 11:50But in colon,
- 11:51cancer really is has been quite
- 11:54significant and and as we look at the.
- 12:00At this increase,
- 12:01what stands out here is that this
- 12:04carries through along all individuals
- 12:06have been born since the 1960s,
- 12:09and that was reflected here.
- 12:11These are individuals born
- 12:13from the 1960s to the 1990s,
- 12:15and in all those cases where we
- 12:18see this trend going up in the
- 12:20early onset colorectal cancer,
- 12:23which is very different from this
- 12:24trend in the older individuals,
- 12:26individuals that were born before
- 12:281960s in the US, where we see.
- 12:30He's a significant decrease
- 12:31in that incidents,
- 12:33to the point that among
- 12:34adults younger than 55,
- 12:36there's been a 51% increase in the
- 12:39incidence of correct cancer from
- 12:4194 to 2014 and an 11% increase in
- 12:44mortality from 2005 to 2015 there.
- 12:47So that's something that we
- 12:48really need to tackle and,
- 12:50and it's interesting to see
- 12:54this in this graph here.
- 12:57This is individuals age 45
- 12:59and these are the years.
- 13:00From 1975 to 2015 and the
- 13:03upper one is age 50,
- 13:06and as you can see here,
- 13:08the and that's incidence among the this
- 13:11age group and what we can see here is
- 13:14that individuals that in 2015 were 45,
- 13:17had the same incidence that
- 13:20individuals who were age 50 in 1993.
- 13:22So I've seen this set and that
- 13:24we won't stop repeating it.
- 13:2645 is the new 50 in many different ways,
- 13:29and that really tells you why.
- 13:30At 45,
- 13:31is the new 50 because we are
- 13:34seeing these numbers are looking
- 13:36similar to what the incidence was.
- 13:4030 years ago.
- 13:41So because of all that,
- 13:44the American Cancer Society was the
- 13:461st that really started becoming
- 13:48very concerned about these trends
- 13:50in in early onset and they basically
- 13:54commissioned some modeling studies
- 13:56to really try to understand if
- 13:59screening earlier with with.
- 14:04Resulted in a significant decrease in
- 14:07correct or cancer and and mortality
- 14:10related to that and the model is really
- 14:13convincingly demonstrated that due to
- 14:14the rising incidence of colorectal
- 14:16cancer in this younger individuals,
- 14:18screening out average risk persons
- 14:20between the age of 45 and 6075 would
- 14:24reduce mortality from colorectal cancer
- 14:26with a with an acceptable risk that seem
- 14:29to be clear from the modeling studies
- 14:31and the benefit in burden balance.
- 14:33Strongly favors changing the
- 14:35starting age from 50 to 45,
- 14:37so that was 2018 when they published
- 14:40this report and it was in May
- 14:452020, 2020, one when the United States.
- 14:50SDF the task force that actually really went.
- 14:54They come up with recommendations is
- 14:57pretty much binding the insurance
- 14:59company company coverage and
- 15:01Medicare coverage for these services.
- 15:04They also endorsed last year to start a
- 15:08colorectal cancer screening for average risk.
- 15:10Individuals down to 45 instead of 50,
- 15:14so that's where the society medical
- 15:17societies have also endorsed that change.
- 15:21And that's where we live right now.
- 15:22And that's why Cindy's talking to us about
- 15:25this big challenge of really bringing
- 15:28all this newly eligible population
- 15:30from 45 to 50 to get screened and
- 15:33also making a push for the 50 to 54,
- 15:36which is the group of individuals
- 15:38who's also very under screen,
- 15:40even though for many years we've been
- 15:42recommending screening starting at 50.
- 15:44Probably because there is this lag
- 15:45time in our message from when we
- 15:47start talking to our patients about
- 15:49screening until they actually have the.
- 15:51Course screening test.
- 15:52So very important that we actually also
- 15:54increase screening rates in the 50 to
- 15:5754 because they are still a bit low.
- 15:59So altogether the recommendations from
- 16:02the USPSTF have been screening average
- 16:05risk is symptomatic adults ages 50
- 16:08to 75 is of substantial benefit but
- 16:10also through these modeling studies
- 16:13the benefits can be extended to
- 16:15the starting age of 45.
- 16:17The benefits of early detection intervention
- 16:19intervention for collector cancer screening.
- 16:21Seem to decline after age 75
- 16:23and from 76 to 85.
- 16:26Really should be an individualized decision
- 16:29and taking really everything into account,
- 16:32particularly overall health status of
- 16:34everyone at the benefit after age 85.
- 16:37Just because the morbidity or the
- 16:40potential problems with screening started
- 16:43to be disproportionately high does not
- 16:46seem to warrant in this case is when
- 16:49we're each 85 and older to really.
- 16:52Health screening, So what are the options?
- 16:54We really have two sets of options.
- 16:56One that we call direct visualization
- 16:58options and then the the stool based tests.
- 17:01And pretty soon you'll be hearing other
- 17:03ones which are mostly blood based,
- 17:05but we are not there yet for this
- 17:08direct visualization,
- 17:09the more common one,
- 17:10the one that we've been more used
- 17:12is colonoscopy,
- 17:13but also the shorter testing with
- 17:15Alaska P or sigmoid osca P along
- 17:17with the blood with a stool test and
- 17:19seek colon ography every five years.
- 17:21Those are options that are.
- 17:23Fat endorsed and then when we look
- 17:25at stool based tests then we have the
- 17:28physical blood test that's really
- 17:30not being used much more right now
- 17:32because feed test which is an
- 17:35immunohistochemical test base has
- 17:37been more has been more broadly used.
- 17:40It actually performs better and also
- 17:43the fickle multi target DNA test which
- 17:46is a mixed test that includes fit
- 17:49tests and and some DNA markers that
- 17:51are associated with laughing laugh.
- 17:53Cells that are malignant premalignant
- 17:55in that colon.
- 17:57So those are our options and and this
- 17:59is the one we've been used the most,
- 18:02and that's a colonoscopy where
- 18:04basically patients are sedated and
- 18:06then E two piece passed through
- 18:09the ****** and the entire colon,
- 18:11and the advantage of the test is
- 18:13not only you visualize the colon,
- 18:15but you can also remove those polyps,
- 18:17which as we know for the majority
- 18:19of cases removing polyps is how
- 18:22we do prevent colorectal cancer.
- 18:23Add to develop.
- 18:26The city Colonography is a is like a tap
- 18:29of a CAT scan that's really focusing
- 18:31on the colon and this seems to be
- 18:34extremely good for Polydor starting
- 18:35to be of a certain certain size.
- 18:40Obviously a positive finding will will
- 18:42take us to a colonoscopy because that's
- 18:44how we can actually remove those polyps,
- 18:47but a negative finding would take us
- 18:50to a repeating five years is that
- 18:52that's the test of choice and these
- 18:54very graphic one of the stool based.
- 18:57Yes, we just really based on examining
- 19:00a sample of stool from the positions,
- 19:03and here we have this menu of
- 19:06tests that we're using right now.
- 19:08Colonoscopy, again,
- 19:09being like the final Test.
- 19:11If any of the other ones are positive,
- 19:14so we could actually call the other
- 19:16ones like pre screening tests,
- 19:17but they can be very effective,
- 19:19particularly for average risk individuals,
- 19:22because it's negative,
- 19:23there would be no need for colonoscopy
- 19:25yet if they are positive then
- 19:27we will go with colonoscopy.
- 19:28Obviously, as we mentioned before,
- 19:30the advantage of colonoscopies
- 19:32is that as you are there,
- 19:34you can remove those polyps,
- 19:36but obviously the the the the the
- 19:38drawbacks about a colonoscopy.
- 19:40It's a big production,
- 19:41it's a day off, its sedation.
- 19:44It's having to come with someone else to
- 19:49have the procedure done is the preparation.
- 19:52So a lot of considerations that some
- 19:54patients are not so eager to do and
- 19:56that's why the decision really should.
- 19:58Be based on on on really having that
- 20:02conversation with providers and trying to
- 20:04figure out what suits best for everyone.
- 20:07City Hall in Agra fee.
- 20:09The advantage really is
- 20:10there's no need for sedation.
- 20:12They are still preparing the colon and
- 20:15and the pollen colon gets inflated,
- 20:19but it again does not require that
- 20:21sedation and on the other hand the stool
- 20:24based tests that fit test and the Cologuard.
- 20:27The multitarget stool DNA tests.
- 20:29The advantage is that you
- 20:30don't need to take a day off,
- 20:32but it's it's a test that you can do
- 20:35it at home and the it's not invasive,
- 20:38so you don't expect any side
- 20:39effects from me from from them.
- 20:41And as we said before,
- 20:43those tests,
- 20:44if they are positive they take us
- 20:47to colonoscopy,
- 20:48but if negative we can continue
- 20:50being tested that way,
- 20:52particularly if it's average
- 20:53average trick at risk individuals
- 20:55when there is a family history
- 20:57or other factors we tend to.
- 20:59Feebler colonoscopy,
- 21:00but certainly for average risk.
- 21:03These are all legitimate options
- 21:05that we know they work.
- 21:07And and again I think you've heard it before,
- 21:10but the best test for
- 21:11screening is the one that
- 21:12gets done for sure.
- 21:13So colorectal cancer screening
- 21:15saves lives that's been shown.
- 21:17That's clearly been demonstrated.
- 21:20No, no need to stay more about it,
- 21:23and it looks like modeling
- 21:25is showing us that starting
- 21:27at 45 would also help us too.
- 21:29We'll see more on.
- 21:30Time, but at least modeling truly
- 21:32suggests very strongly that that's
- 21:33gonna see if life still there are
- 21:36different options for screening,
- 21:37and the best screening again is the test
- 21:40that the one that gets done 45 years,
- 21:42the new 50 has seen this set and
- 21:44one stop repeating that it's very
- 21:46important that's a big message
- 21:47that over the last couple of years
- 21:49we've been trying to get out.
- 21:52And pay attention also
- 21:53the family history of cancer.
- 21:55We always have to talk about that
- 21:57and and ask our family members for
- 22:01any history of colorectal cancer or
- 22:03even advanced polyps because that
- 22:04means that we are at a higher risk
- 22:06and actually recommendations are to
- 22:08start screening 40 and not a 45 or
- 22:1010 years earlier than the earliest
- 22:12colorectal cancer in the family.
- 22:14And of course there are more cancers
- 22:17or there's anything that suspicious
- 22:18for a syndrome than what we need is to
- 22:21have an evaluation in cancer genetics.
- 22:23To make sure we don't have one of those
- 22:25syndromes, particularly lynching,
- 22:26that causes a very high risk
- 22:28of colorectal cancer,
- 22:30and I think that's all I wanted
- 22:31to share with you.
- 22:35Thank you Shabir.
- 22:36So we'll do one question now.
- 22:37And just to remind everybody in the audience,
- 22:39you can feel free to message me
- 22:41directly questions or just put them
- 22:43in there or just put them in the chat
- 22:45and that should be fine. So shall we?
- 22:47Are there people you recommend as stool
- 22:49based test for instead of a colonoscopy?
- 22:52Sure. So in general
- 22:54we try to recommend it for
- 22:56average risk individuals,
- 22:57meaning no family history and
- 22:59obviously not that to anyone who's
- 23:02had adenomatous rated polyps that
- 23:03would not be a person who will want
- 23:06to do stool testing because those
- 23:09individuals have already shown us that
- 23:11they have a higher risk of developing
- 23:13lesions and therefore those would be
- 23:15not would not be the prime candidates.
- 23:17But then at average risk
- 23:19individuals who again may have.
- 23:22Uh, issues about taking a day off,
- 23:26or actually let me consider
- 23:27that the risk of colonoscopy,
- 23:29something that scares them
- 23:30or or something like that.
- 23:32There may or individuals who have
- 23:34a hard time finding someone who
- 23:35will go with them and and spend
- 23:37the day with them really to take
- 23:39them back home and all that.
- 23:40What we just want to make sure is that
- 23:43we do know we have that conversation,
- 23:45so actually we can.
- 23:47We, together with the patients,
- 23:48can choose the right test again,
- 23:50the the drama and I think one
- 23:52of the biggest issues we had.
- 23:53For many years is as physicians.
- 23:56We've been prescribing colonoscopies like
- 23:58this without having those discussions,
- 24:00and then all of a sudden our patients
- 24:01won't show up for the colonoscopy
- 24:03because we did not go through all
- 24:05the issues that and what it means to
- 24:07really going through a colonoscopy.
- 24:08So I think what this really calls
- 24:10for is having those conversations.
- 24:12Finding the right tests for for
- 24:14every patient, so again,
- 24:15the test that that that is the
- 24:17one that's going to get done is
- 24:19the is what really matters is not
- 24:22just prescribing colonoscopies.
- 24:23Again, but with a high risk individuals,
- 24:25we would be we would look at
- 24:28things differently,
- 24:28but in general for this big chunk of
- 24:31population that are average risk,
- 24:32certainly those are very legitimate tests
- 24:35that they've been shown to prevent mortality.
- 24:38That's been done and,
- 24:39and so we don't have any issues about that.
- 24:42And again,
- 24:42it's just making sure that everyone
- 24:44who's eligible gets tested.
- 24:49Excellent. There are more questions,
- 24:50but I'll save them for for the
- 24:51end so that we make sure we
- 24:53get through everybody talk.
- 24:54So next is Doctor Victor ready again.
- 24:57He's associate professor of surgery
- 24:59and he'll speak about the role
- 25:01of the colorectal surgeon and
- 25:02colorectal cancer management.
- 25:14Thank you Mike,
- 25:16you know thank you Doctor Laura for
- 25:18talking about screening for those
- 25:20unfortunate patients who you know,
- 25:23even despite screening,
- 25:24they kind of cancer.
- 25:26The surgeon gets involved in those.
- 25:28You know, as far as we know,
- 25:30the distribution of colorectal cancer varies
- 25:34depending on the location of the cancer.
- 25:36You know about 30% of these cancers
- 25:38tend to be on the right side,
- 25:39so we actually tend to have more on the left
- 25:42side and about 20% density the right now.
- 25:45The outcomes for these cancers are
- 25:48different because there it starts
- 25:50even in Embryology like the the
- 25:52cancers which are on the on the on the
- 25:54right side tend to be derived from
- 25:56the midgut and they have different
- 25:59genetics compared to the ones that.
- 26:01Derive on the left side.
- 26:03Now I know it talks about overall prognosis.
- 26:05Please ignore that,
- 26:06because chemotherapy has gotten better,
- 26:08so this becomes kind of
- 26:10neutral at this point.
- 26:12Now once someone gets
- 26:13diagnosed with colon cancer,
- 26:15you know surgery depends on
- 26:17the anatomy that we deal with.
- 26:19So people always ask me.
- 26:20One common question is if I
- 26:22have a small colon cancer,
- 26:23how come they're picking out a foot
- 26:25of the colon and it has to actually do
- 26:27with the blood supply to the colon.
- 26:28So if the cancer is here when I take
- 26:30out the blood supply to the colon,
- 26:32unfortunately I gotta take out
- 26:33this big piece of colon.
- 26:35Now,
- 26:35this is an idealistic view
- 26:37of the colon anatomy.
- 26:38Now in real life, inside the body,
- 26:40it sort of looks like this.
- 26:41These are the blood vessels
- 26:42that someone has a cancer.
- 26:44Here, you know,
- 26:44because we're taking out the
- 26:46lymph nodes and the blood vessel.
- 26:47Here I will be ending up taking
- 26:49out a bigger piece of colon,
- 26:51usually about a foot on average.
- 26:54Now that surgeries before.
- 26:56You know I have evolved overtime
- 26:58initially even when I was in training
- 27:00patients used to have this big
- 27:02incision right around the belly
- 27:03button where we used to put the
- 27:05hands and then do the surgery at
- 27:07Yale for the past 12 to 15 years,
- 27:09we've been pushing the envelope
- 27:11a little bit and we've been doing
- 27:12it with little holes.
- 27:13And then usually we have to give
- 27:15an incision where we extract the
- 27:17specimen out because we can't.
- 27:19You know,
- 27:19we can't choke the specimen and pull
- 27:20it out through one of the small holes.
- 27:24So for laparoscopic surgery,
- 27:25what we used to do was that we
- 27:28would insulate the belly with air,
- 27:30usually carbon dioxide,
- 27:31and then we use these little
- 27:33instruments to go and dissect that
- 27:35the blood vessels dissect out the
- 27:36colon and do the surgery that way.
- 27:38But over the past two three years mainly
- 27:42so that we can make minimally invasive
- 27:44surgery more accessible to everyone.
- 27:46We have started using the
- 27:48rollback people always ask me.
- 27:50Is there difference between the
- 27:51robot and the laparoscopic approach?
- 27:52People who are good at laparoscopic.
- 27:54Are able to do the robotic surgery
- 27:56but the robotic surgery makes
- 27:57it a little bit easier to to do.
- 28:00The minimally invasive surgery.
- 28:01The second thing is it's much
- 28:03easier on the surgeon because
- 28:05they're sitting down here.
- 28:06You can see the surgeon
- 28:07sitting at the console.
- 28:08Here's the robot you know
- 28:10with the instruments here,
- 28:12and the surgeon manipulates the
- 28:14instruments and they do the surgery.
- 28:15The visualization is phenomenal,
- 28:17but you can actually see very clearly.
- 28:19You can see every little baby blood vessel
- 28:22along with the major blood vessels,
- 28:24so the surgeries.
- 28:25Want to be more precise?
- 28:27And it's much more easier
- 28:28to do the surgeries.
- 28:32First, let me talk about colon cancer
- 28:33because colon cancer is different than
- 28:35rectal cancer and even I'm colon cancer,
- 28:37we differentiate between right sided
- 28:39colon cancers and left side of colon
- 28:41cancer when it comes to circuit.
- 28:43Now when any patient gets
- 28:44diagnosed with colon cancer,
- 28:46the first thing we make sure is that the
- 28:48colonoscopy has tattooed the lesion so that
- 28:50we know exactly where the chancellor is.
- 28:52We usually do this blood work.
- 28:53We also do a CAT scan to make sure
- 28:55that we don't see lesions like
- 28:57this and deliver and this is an
- 28:59indication of metastatic disease.
- 29:00If a patient doesn't have
- 29:01any metastatic disease.
- 29:02Then we can sleep for surgery.
- 29:05And the goal of surgery is to 1st we
- 29:07make sure that there's no tumor within
- 29:10the belly anywhere outside of the colon.
- 29:12We make sure we remove the segment
- 29:14of the colon with good margins,
- 29:16and then we make sure that we do
- 29:17a wide lymphadenectomy which is
- 29:18taking out all the lymph nodes that
- 29:20drain that segmented bowel so that
- 29:22we don't leave any possible cancer.
- 29:26So here are some example of right
- 29:27colon cancer, so pretty much anything
- 29:29that comes up here, here or here
- 29:31is considered right colon cancer.
- 29:32Pretty much anything to this side.
- 29:36In in reality, inside the body,
- 29:37it looks sort of like this.
- 29:38So imagine there's a cancer here
- 29:41the way we would approach it.
- 29:43Is that you know we can do
- 29:45this both open or laparoscopic.
- 29:46First, what we do is we divide the
- 29:48blood supply so that any of these
- 29:50cancer cells don't travel through the
- 29:51bloodstream somewhere to the heart,
- 29:53lung, liver or stuff like that.
- 29:55And then we start dividing the entire
- 29:57blood supply to the piece of colon.
- 29:58We're taking it.
- 29:59Then we divide the small intestine
- 30:02and the colon.
- 30:03And then we free it up from the side walls.
- 30:05We also free it up from the liver
- 30:06because it's on the right side.
- 30:07We free it up from the kidney and
- 30:10vital structures underneath the colon.
- 30:12And then we do the connection in
- 30:14such a way where the small intestine
- 30:17is hooked up into the colon.
- 30:19Or left sided colon cancers.
- 30:20There's only pretty much two options you
- 30:22know you can get the cancer for you up here,
- 30:24or cancer is a little bit lower.
- 30:26And for that,
- 30:27depending on where the tumor is located,
- 30:28we take out a bigger piece of colon.
- 30:31Here in this example,
- 30:31we're going to look at a cancer up here
- 30:34similar to the right side of colon cancers.
- 30:36We first identify the blood vessels.
- 30:38We divide it so that the cancer
- 30:40doesn't travel in the bloodstream.
- 30:41We divide off the bowel.
- 30:44We have the attachments now on the
- 30:46left side from the left belly wall and
- 30:48also from the spleen in the stomach.
- 30:50And then what we do is we use the
- 30:53specialized stapler which goes
- 30:54through the **** up the ******.
- 30:56And we kind of re attached to
- 30:58intestine sort of factors.
- 31:00So for most patients who have
- 31:01had rectal cancer surgery or left
- 31:03side of colon cancer surgery,
- 31:04we do this kind of connection.
- 31:07Usually patients are in the
- 31:08hospital about three to four days.
- 31:09Some take a little bit longer,
- 31:11especially if you do this
- 31:12laparoscopic Lee and there's some
- 31:14diet restrictions for about 2 weeks,
- 31:15and usually patients are able to return
- 31:18to normal activity in six weeks,
- 31:19and hopefully if they need
- 31:20chemotherapy or anything like that,
- 31:21they should be able to start it within
- 31:23a month after the surgery and afterwards.
- 31:25We do a colonoscopy in a year,
- 31:27CAT scan every year and blood
- 31:29work every three months.
- 31:30Now this is for colon cancer.
- 31:32Rectal cancer is kind of
- 31:34different for rectal cancer.
- 31:35In addition to the CAT scan,
- 31:37the blood work,
- 31:38we also get an MRI.
- 31:39And the purpose of the MRI and
- 31:41needs to do ultrasound before.
- 31:42But we have now switched over
- 31:44to MRI because it's better.
- 31:45The purpose of the MRI is to make
- 31:47sure that the cancer has not
- 31:49gone through the wall into the
- 31:51fat or into the lymph nodes if it has
- 31:53gone into the fat or the lymph nodes,
- 31:55then we'd like to do chemotherapy
- 31:57and radiation, and I will leave it
- 31:59up to the oncologist to talk about
- 32:00the different regimens we have.
- 32:01And there's been some changes even recently.
- 32:05And you know they will talk about
- 32:06the regiments, and once they're done
- 32:08with the chemotherapy and radiation,
- 32:09then we come in for surgery.
- 32:12Again, the goal of the surgery,
- 32:13just like for colon cancer,
- 32:14is to make sure it hasn't spread anywhere.
- 32:17Completely remove the piece of bowel
- 32:19which is involved with the cancer.
- 32:21Remove the lymph nodes.
- 32:23But for rectal cancer it's different
- 32:25because because it's much lower in the colon.
- 32:28No, because the cancer somewhere
- 32:30here and here's the ****.
- 32:31What we want to do is re
- 32:33establish continuity,
- 32:34meaning avoid a permanent bag when possible.
- 32:37But the goal this should not
- 32:38be the primary goal,
- 32:39because in some patients if you
- 32:41reestablish the connection and if
- 32:43they're not able to have good outcome,
- 32:45meaning they're either incompetent or
- 32:46going to the bathroom 20 times a day,
- 32:49that is actually worse.
- 32:50It's actually better to have
- 32:51a bag in this situation.
- 32:54The key for rectal surgery more than
- 32:56colon surgery is to know their anatomy.
- 32:58So this how this these are the sphincter
- 33:01muscles which control when we poop in and
- 33:03make sure that we don't have accidents.
- 33:05As long as the tumor is above this area,
- 33:09meaning somewhere up here and we have
- 33:10a 1 centimeter margin, which is margin,
- 33:13probably the size of your index finger,
- 33:15we can re attach the intense.
- 33:18Now you know, usually I start with
- 33:20the least aggressive one for some
- 33:22cancers which are very early cancer.
- 33:24What we can even do is go through the ****.
- 33:27Here we are using the Qatari kind of
- 33:29cutting out the lesion going all the way
- 33:31down to the muscles and then slowing it up.
- 33:33But these are only for select
- 33:34patients or for even for advanced
- 33:36cancers and older patients that can't
- 33:39tolerate that application.
- 33:40Then we started probably about 10-12
- 33:43years ago or more fancier equipment
- 33:45where even for higher lesions,
- 33:47as long as there are precancerous
- 33:49or early cancers,
- 33:50this is laparoscopic Lee going through the
- 33:52**** and then we use these instruments,
- 33:55and we're able to work on tumors
- 33:57even as far as 15 centimeters.
- 34:00And it sort of looks like these
- 34:02these instruments come out and
- 34:03then we kind of dig it out.
- 34:04The problem with these is that
- 34:06if the tumor goes any deeper,
- 34:07we could potentially lead
- 34:08cancer cells behind,
- 34:09so we tend to do the more aggressive
- 34:12surgeries for the more people.
- 34:15And the classic operation for rectal cancer.
- 34:18In this case, it's in the it's
- 34:19in the upper ****** the tumor.
- 34:20What we do is if you if you look at it,
- 34:22this is the ******.
- 34:23And this is the sigmoid colon.
- 34:25But if you look at the
- 34:26line where we take out,
- 34:27we actually take out the entire
- 34:29sigmoid colon and the main reason is
- 34:31it has to do with this flex seal.
- 34:33On this picture you can see it better.
- 34:34Here's the cancer.
- 34:35Here are the blood vessels we have to
- 34:37take out all the lymph nodes here a month.
- 34:39Because of that one.
- 34:40Once I take out this blood vessel,
- 34:42this piece of colon also comes up.
- 34:46And in the old days,
- 34:47before we really knew about
- 34:48rectal cancer surgery,
- 34:49what they used to do was if this is the
- 34:51****** here's the fact around the ******.
- 34:53If you notice, there's a lot of blood
- 34:55vessels people used to dig right by
- 34:57the ****** and take out the cancer.
- 34:59And they did this by 20 to 30% of
- 35:01the time the cancer came back.
- 35:02Now we tend to be more aggressive.
- 35:04We go right next to the bone and in
- 35:07the front almost close to the bladder,
- 35:09the vagina or the prostate.
- 35:11And we actually take out all this
- 35:12fat and all the long flights.
- 35:13And when we do this just going
- 35:15from here to here.
- 35:16The incidence of the possibility
- 35:17of the cancer coming back has
- 35:19dropped to less than 7%.
- 35:20Now you throw in chemotherapy and radiation.
- 35:22It drops a lot, though.
- 35:26So here's here's an example
- 35:27of how we do the surgery.
- 35:28Again, we first divide the blood vessel.
- 35:30Now this is for open surgery.
- 35:32We divide the bowel and then we free up.
- 35:34This is the backbone called the sacrum,
- 35:37and we free up all the fat which
- 35:39contains the lymph nodes and the
- 35:41****** away from all of that,
- 35:42we identify and preserve all these nerves.
- 35:45Now here in the front where
- 35:46dividing the ****** of the
- 35:48prostate or in this case logina.
- 35:50And then we continue going lower.
- 35:53And the open surgery used to be
- 35:54much more difficult because you're
- 35:56operating in a deep opening and
- 35:58you know patients hand waving
- 35:59the surgeon's hand used to go
- 36:01in there to kind of dig it out.
- 36:04And the surgery was a lot more bloody
- 36:06and so slowly we have transitioned
- 36:08over to laparoscopic surgery and
- 36:10we've been doing that here at Yale,
- 36:12probably for the past 12 years.
- 36:15And usually once the surgery is done,
- 36:18we divide the bowel and
- 36:19reattach the intestines.
- 36:20Now with laparoscopic surgery it's it's
- 36:22even better or this is even robotic.
- 36:24What we do is we identify the blood vessel.
- 36:26This is the major blood vessel that
- 36:28comes off the heart. We identify it.
- 36:30We divide off the blood vessel,
- 36:32free up the colon.
- 36:33So here we're dividing the blood
- 36:35vessel and free up the colon.
- 36:37Mobilize the rest of the colon.
- 36:39Free it up from every other tissue,
- 36:41like the spleen and everything,
- 36:43and then here we can clearly identify all the
- 36:46nerves so we can preserve sexual function.
- 36:48If possible, if it's involved with cancer,
- 36:50we do take them and then here we're
- 36:52freeing it away from the from the vagina.
- 36:54This situation.
- 36:56And here's an example of
- 36:57how it looks in real life.
- 36:59It's it's been up like 5 fold so
- 37:02you know we don't go this fast.
- 37:03But here we're freeing up here
- 37:05at major blood vessels here,
- 37:07here in this area there's the
- 37:09tube which states the urine
- 37:10from the kidney to the bladder.
- 37:12You saw the green light lighting up.
- 37:14It's a specialized dye we
- 37:15use to identify them.
- 37:17And then you have to get rid
- 37:18of all these lymph nodes.
- 37:20And there's a specific plane we
- 37:21need to be in to make sure we got.
- 37:22We get all the lymph nodes.
- 37:24And here we're preserving the nerves
- 37:26which are involved with sexual function
- 37:28which is right around here and you
- 37:30see this huge white dish bundle which
- 37:32goes there and we'll preserve the
- 37:34not going to show the whole video.
- 37:35We continue to keep doing that
- 37:37and keep getting lower and lower.
- 37:40And now in this in this video.
- 37:43We're dissecting it off in the front.
- 37:45This is a male,
- 37:46so here's the prostate and everything.
- 37:48And if you notice,
- 37:49this instrument is about the
- 37:50size of my index finger,
- 37:51and if I had to do it with open surgery
- 37:53where I had to have my full hand in there,
- 37:56you can't see that much.
- 37:57So when we do it minimally invasive,
- 37:59we can actually do a much better surgery.
- 38:01And here we're dissecting off the
- 38:02products to preserving all the notes.
- 38:04Getting around the tumor.
- 38:07And once we get around the tumor
- 38:09and dissected off the backbone,
- 38:10preserve all the energy we
- 38:11use a stapler to come across,
- 38:13and then we usually remove this passing
- 38:15through a protected area so no cancer
- 38:17implants itself in a better way.
- 38:19Then this one. You know there's
- 38:21a little video of how we do it.
- 38:23There's a stapler coming in.
- 38:24We're going all the way down.
- 38:25So here's the bladder.
- 38:27Underneath it is the prostate,
- 38:28and we're just divided it.
- 38:33And then once we divide it,
- 38:35we bring up, you know we have the
- 38:37specialized tape where we bring it in.
- 38:38Here's the camera holding up the
- 38:41the bladder and the prostate and we
- 38:43do this connection and then we get
- 38:46these margins and make sure that
- 38:47there's no cancer in any of these.
- 38:49That shows you how it's being done,
- 38:51so there's the state we're coming from below.
- 38:54Here we're docking from above.
- 38:56The spike is getting deployed,
- 38:58so the spike and then and this thing.
- 39:02Yeah, we call it band.
- 39:03Will they kind of deployed and once
- 39:06they're deployed we kind of close it up.
- 39:09I'm sorry.
- 39:12Gotta repeat the video a little bit.
- 39:18So there's the spike.
- 39:22And most patients who've had rectal
- 39:23cancer have had surgery like this.
- 39:25If they have avoided back.
- 39:27And then what we do is this comes
- 39:29together and it's got to be stable built
- 39:32into it and it makes this connection.
- 39:35And you can see it coming together.
- 39:37So there's the ****** and or the
- 39:39lower portion venous and ******.
- 39:41And this is the colon from higher up.
- 39:42Now we have made the connection and
- 39:44then usually we put some stitches to
- 39:45reinforce it because sometimes we don't
- 39:47trust the staplers all by itself.
- 39:51And there's different kinds of reservoirs.
- 39:52We make. The whole purpose of
- 39:54the ****** is to store stool,
- 39:55and if you're removing a part of it,
- 39:57you know the capacity is decreased.
- 39:58So what we do is we we kind of do
- 40:00this connection where you know you
- 40:02have the ****** and then usually
- 40:04you know there's another piece here.
- 40:06But because we don't have the piece we
- 40:08kind of use this to make it a reservoir.
- 40:10Some people do this.
- 40:11The problem with this is that there's two
- 40:14areas where there could potentially be leaks.
- 40:16This would do it only in select
- 40:18patients who are very young.
- 40:20It's called the phonic J pouch.
- 40:22After about a year,
- 40:23all three of them are equivalent,
- 40:24so you know either one.
- 40:25You know.
- 40:26Any of these are good,
- 40:27and usually for low connections,
- 40:29especially for rectal cancer,
- 40:30we do give a temporary bag and
- 40:32a bag sort of looks like this.
- 40:34And usually they you know after
- 40:36you eat poop comes out this way.
- 40:39And if you actually go in down here,
- 40:41you can eventually make their way down
- 40:42to the ****** but it's usually closed
- 40:44off and then later on we do a surgery.
- 40:47Now for some patients where the
- 40:49rectal cancer tends to be much lower,
- 40:50like closer to the sphincter muscles,
- 40:52we do some unique procedures where
- 40:54we can avoid a permanent bag,
- 40:55but I'll go with the more traditional
- 40:57one where we take it out and patients
- 40:59end up with a permanent bag because
- 41:00we usually would take out the ****
- 41:02and then so patients have a firm.
- 41:05And what we do now,
- 41:06most of the surgery is similar
- 41:07to what I just showed you.
- 41:09But in addition what we do is we make
- 41:11this circular incision right around the ****.
- 41:13We kind of dig down into that area.
- 41:15We take out the muscles and then we free
- 41:18up all the way down to the backbone.
- 41:20So here's the the coccyx we go all
- 41:22the way down to the coccyx take
- 41:23off all this fat and in the front
- 41:25we take out all the tissue up to
- 41:27the prostate in this case and the
- 41:29movement sometimes even the back
- 41:30wall of the vagina would take
- 41:32it out and then we slow it out.
- 41:35Usually patients are in the hospital four
- 41:36to five days for the RE operative cases.
- 41:38Patients are in the hospital
- 41:40even for seven to 10 days.
- 41:41Most patients do have restrictions on
- 41:43diet for about 2 weeks and they're kind
- 41:45of back to normal in about 6 weeks.
- 41:47For patients who have a bag this fast
- 41:49and the teaching is very important.
- 41:51And we make sure that you know
- 41:52patients get passed into teaching
- 41:53both in the hospital and had to start.
- 41:57Now, for some cancers unfortunately,
- 41:59which extend into other organs,
- 42:01like in this one,
- 42:02it's extending into the into the prostate.
- 42:04We do this major surgery
- 42:05where we pick out the Blair,
- 42:07the prostate and the ****** or in this
- 42:09case it's extending up into the universe.
- 42:11So we take out the universe and sometimes
- 42:13if it's extending into the bladder bladder,
- 42:15this one I'm going to leave it for
- 42:18another more intensive talk and people
- 42:21always ask me what is the future.
- 42:23We used to do these for big
- 42:25incisions measuring, you know.
- 42:27Probably you know you know
- 42:30at least a foot in size.
- 42:32So now with these little holes,
- 42:33this device is not FDA approved,
- 42:36but it is a robot which we
- 42:38can make small incisions,
- 42:39but one small incision and we have
- 42:41these instruments that come out,
- 42:43which bent,
- 42:43and we can do these surgeries
- 42:45through one incision.
- 42:46So potentially we can do it.
- 42:47So we have done this with animals
- 42:49where you know we're able to go
- 42:51through the **** itself and do the
- 42:53entire surgery through the ****.
- 42:54I think we're a long way away
- 42:56from doing these and humans,
- 42:57but I think that's that's the future.
- 43:01Have any questions?
- 43:05Thank you Doctor Ready.
- 43:07So when one question from the audience,
- 43:09do you routinely recommend aspirin
- 43:11or other measures after surgery?
- 43:15So I do recommend aspirin to some patients.
- 43:19I I make sure that you know they have no
- 43:21other contraindications for the aspirin,
- 43:23but not the not the everyone.
- 43:25Is this for blood thinners
- 43:27after surgery or is this
- 43:28I think more in in under the
- 43:30theme of reducing recurrence?
- 43:34No, the aspirin by itself doesn't do
- 43:36anything for reducing the recurrence.
- 43:37But it does decrease politics.
- 43:41Excellent so I will say the
- 43:44other questions for for the
- 43:46end and we'll keep moving along.
- 43:47Next is Doctor Kimberly Jo Hong,
- 43:49associate professor of therapeutic radiology.
- 43:51She'll be talking about the role of the
- 43:53radiation oncologist and colorectal cancer.
- 44:03OK, still still muted.
- 44:15I am muted. I'm not muted anymore.
- 44:19Alright. And then screen share.
- 44:40Alright, can I run soon?
- 44:41My slides were good.
- 44:46Very good.
- 44:51Mike, we're good.
- 44:52We're good. Yep, we can see him perfectly.
- 44:55Can't hear you though.
- 44:59We can hear you.
- 45:05OK, so uhm. Kim Jong I'm a
- 45:10radiation oncologist and talking
- 45:12to you about up for a few minutes.
- 45:15The role of radiation which we
- 45:17typically use for colorectal cancer
- 45:20in the management of rectal cancer
- 45:22and not so much colon cancer.
- 45:25So that's where I'll be focusing
- 45:29my discussion.
- 45:48Are people hearing me? I feel
- 45:50like I don't have feedback here.
- 45:55We can hear you
- 45:57OK good alright?
- 45:58So how does radiation treat cancer
- 46:00I'm this is I tried to make this
- 46:03talk very patient oriented so how
- 46:06does radiation treat cancer?
- 46:08It's a local treatment option.
- 46:10We're directing radiation
- 46:12to pinpoint your tumor.
- 46:14The radiation damages the DNA in
- 46:16your cancer cells so they can.
- 46:19We're trying to make them not be able
- 46:21to be able to grow anymore with the.
- 46:24Damage from the radiation to provide
- 46:29local control of your tumor.
- 46:40Radiation is delivered by something
- 46:43called a linear accelerator,
- 46:44so that's what's pictured here.
- 46:48So the you have these side panels that
- 46:52basically are imaging panels for alignment,
- 46:57so we can either do X rays or CT scans.
- 47:04To make sure that you're perfectly
- 47:06aligned for treatment and then the head
- 47:09of the machine which is the arm will
- 47:12move around you to deliver radiation.
- 47:15Targeting your tumor from all different
- 47:18angles basically so the the first
- 47:21part is the imaging and then the
- 47:24second part is the treatment from the
- 47:26machine that's moving around you.
- 47:32So the process of treatment.
- 47:38In order to have a radiation therapy
- 47:40course is we start with a consultation
- 47:42to determine if radiation will be
- 47:44helpful in your treatment plan.
- 47:46Obviously, and to discuss the risks
- 47:49and benefits of treatment logistics
- 47:52of treatment potential side effects.
- 47:54This is followed by something
- 47:57what we call a CT simulation,
- 47:59which is a planning process.
- 48:01We position your body how we would
- 48:03be positioned for treatment,
- 48:05make make marks to ensure that you're in the.
- 48:08Consistent position daily for
- 48:10treatment and then obtain a CT
- 48:13scan and use those images to plan
- 48:16your precise radiation treatment.
- 48:18Working closely with our physics
- 48:21team who we call our dosimetrists.
- 48:25The process then undergoes quality
- 48:28assurance checks with our physicists
- 48:31prior to your starting your treatment,
- 48:33and then this typically takes
- 48:36about two weeks.
- 48:43For rectal cancer patients,
- 48:45we typically position you prone.
- 48:47I'd like to call it a massage table,
- 48:49but it looks like a witch.
- 48:53Kind of looks like that,
- 48:54but basically the point of this
- 48:56positioning is to have your
- 48:58bowel move forward away from
- 49:00the treatment field such that
- 49:02we can avoid it for treatment.
- 49:08After the simulation process,
- 49:09we devise a treatment plan to target
- 49:12erect rectal cancer as best as possible,
- 49:15as well as lymph nodes in the pelvis
- 49:19which may harbor microscopic disease,
- 49:22and so this is just an example of how
- 49:24we're able to devise a treatment plan
- 49:27that's targeting the pelvic nodes and
- 49:29the rectal cancer while avoiding the
- 49:31normal tissues as much as possible.
- 49:40So for rectal cancer,
- 49:42typically treatments are
- 49:44daily Monday through Fridays.
- 49:46Over the course of five and a half weeks,
- 49:49typically with a chemotherapy pill
- 49:52that synergizes with the radiation
- 49:55acts as a radiation sensitizer.
- 49:58For certain patients,
- 50:00we do deliver radiation in five doses.
- 50:04Without chemotherapy prior to surgery,
- 50:07and I though those two regimens
- 50:09properly equivalent in terms
- 50:11of local control outcomes,
- 50:13so it's decided on a case by case basis.
- 50:25So. We usually employ
- 50:30radiation prior to surgery.
- 50:35And the goal is to reduce the likelihood
- 50:38of cancer growing back after surgery.
- 50:42So if your tumor in the other benefit is
- 50:45that if your tumor is lower in the ******
- 50:48radiation can improve the likelihood
- 50:50that your cancer can be removed while
- 50:52sparing the sphincter muscles to avoid
- 50:55the need for a permanent colostomy.
- 51:01So this is some of the data just to
- 51:04demonstrate why we use radiation in
- 51:08the care of rectal cancer patients.
- 51:11So this Dutch study is a classic study
- 51:15showing that the use of radiation prior
- 51:20to surgery significantly decreased.
- 51:23The risk of local recurrence after surgeries
- 51:25or your tumor growing back after surgery.
- 51:28In the classic German rectal study,
- 51:32the use of radiation prior to
- 51:35surgery versus after surgery.
- 51:37Improved local control.
- 51:40And also the ability to spare the sphincter
- 51:43meaning that you don't have to have a
- 51:45permanent colostomy and treatments.
- 51:47Also better tolerated in the pre op
- 51:50setting versus the post-op setting.
- 52:03Sorry.
- 52:12Alright, So what are the other
- 52:14reasons that we would consider?
- 52:18Radiation for rectal cancer care.
- 52:21So the other roles are if
- 52:24you have cancer that has
- 52:27spread and causing symptoms.
- 52:29So we do typically do short
- 52:31or short course radiation.
- 52:335 to 10 treatments to improve symptoms.
- 52:36If you're having pain,
- 52:38for example from something
- 52:39that's spread and caused.
- 52:43Pain from metastatic disease and
- 52:45then the other thing that I want.
- 52:47I wanted to focus on was the role
- 52:50of treatment for what we call
- 52:53oligo metastatic disease so.
- 52:55If your cancer has spread to
- 52:58a limited number of areas.
- 53:00We can use something called
- 53:03stereotactic radiation to try to
- 53:05ablate these areas of disease
- 53:08and provide local control.
- 53:16So there is data that.
- 53:20Approximately 20% of patients
- 53:22with rectal cancer present with.
- 53:25Metastatic disease up front liver liver.
- 53:32Metastatic disease but despite the
- 53:36presence of many static disease,
- 53:39we have lots of data to show that
- 53:42studies have shown curative intent.
- 53:45Therapy for these patients
- 53:47is definitely feasible,
- 53:49and so that's where local
- 53:51therapy comes into play.
- 53:53And so shown here in this slide set
- 53:56is just an overall survival curve
- 53:58from one such study in which patients
- 54:01with a solitary liver metastases were
- 54:04treated with curt curative intent,
- 54:07including liver resection or ablation,
- 54:09and we achieve.
- 54:11Overall survival long-term.
- 54:13Overall survival for many patients.
- 54:21So where do we use radiation in the setting
- 54:26of patients with metastatic disease?
- 54:29So in those who are not a candidate
- 54:32for resection of their liver meds,
- 54:35that's where we consider SPRT.
- 54:38So SBRT basically is using multiple
- 54:41conformal beams or arcs to deliver high
- 54:45doses of radiation so that we can.
- 54:49Tighten the dose with rapid dose
- 54:51falloff beyond the target volume,
- 54:54typically delivered in
- 54:55one to five treatments.
- 54:57The high radiation doses result in
- 54:59an ablative effect on the tumor
- 55:02through vascular injury to the tumor.
- 55:05In addition to DNA damage to the tumor,
- 55:09which we typically see with
- 55:11conventionally fractured radiation and
- 55:13depicted here in the picture below,
- 55:16is just an example of an SBRT.
- 55:19Plan delivered with arcs that
- 55:23move around you.
- 55:26Confirming the dose to your tumor
- 55:28so that we can target the dose.
- 55:31And as strictly as possible.
- 55:35So this is just an example of
- 55:38a liver SBRT plan and so.
- 55:42When we deliver esperti.
- 55:47Obviously we need to be quite accurate
- 55:50with target delineation precise.
- 55:53Immobilization and so this is an
- 55:57example of what a patient would
- 56:00look like for an SPRT plan.
- 56:03We build something called a VAC lock,
- 56:05which is something basically a cradle
- 56:08that holds you in position for treatment.
- 56:12We you put up something that looks like
- 56:15a blood pressure cuff on your abdomen,
- 56:18which limits your breathing motion.
- 56:21So that's the abdominal compression.
- 56:25We obtain a video cat scan,
- 56:27so we call it a 4D CAT scan,
- 56:29but it's basically just a video of how
- 56:31your tumor is moving as you breathe,
- 56:34so that we can tightly distribute
- 56:37the dose onto that area,
- 56:39and then we place markers to
- 56:42assist with treatment alignment,
- 56:44and we can often treat in something
- 56:49we call respiratory gating,
- 56:50which is treating only in certain.
- 56:56Phases of the respiratory cycle
- 56:59in order to focus our treatment.
- 57:04More precisely.
- 57:10So we have multiple studies that have
- 57:14evaluated outcomes for SBRT as treatment
- 57:17for unresectable liver metastases.
- 57:20These mostly looked at colorectal,
- 57:23breast and lung cancers,
- 57:25with patients having five or less metastases.
- 57:29Good performance status absent or
- 57:33stable extrahepatic disease adequate.
- 57:35Liver volume to be spared.
- 57:42And in these studies, so this is one example.
- 57:46This is a multi institutional study.
- 57:49Local control was over 90% two years
- 57:54and 100% for tumors that were smaller
- 57:58and toxicity was quite minimal.
- 58:01They only have one Grade 3 toxicity,
- 58:04so I think this is for
- 58:08non surgical candidates.
- 58:10Something that is.
- 58:13Quite tolerable.
- 58:19This is a Saber comment study that I
- 58:22wanted to bring up when we're talking
- 58:25about oligo metastatic disease.
- 58:27Meaning minimal metastatic disease that
- 58:30basically demonstrating the role of
- 58:34stereotactic radiation in that setting.
- 58:41And so in patients with
- 58:43less than five metastases.
- 58:44So if your disease is limited
- 58:47to less than five sites,
- 58:49and your primary tumors controlled and this
- 58:53included multiple primary tumor types,
- 58:56mostly breast cancers, prostate cancer,
- 58:59cancers, colorectal cancers,
- 59:01and lung cancers.
- 59:03Overall survival,
- 59:04which is a great prognosis right was
- 59:08improved with stereotactic radiation
- 59:10compared to just continuing on your
- 59:14standard palliative care chemotherapy
- 59:17with a doubling of over median over
- 59:21overall survival from 41 months.
- 59:24With the integration of SBRT versus
- 59:28just continuing on your chemotherapy,
- 59:31so increasingly we've been using.
- 59:33SBRT for patients with
- 59:35limited metastatic disease.
- 59:37Because of this study.
- 59:44So while I would say and I'm going
- 59:46to leave this to doctor Billingslea
- 59:47to discuss 'cause I know this is
- 59:50what he's going to be talking about.
- 59:52I think resection is definitely
- 59:54preferred as the management
- 59:56of limited metastatic disease.
- 59:59But SBRT, stereotactic radiation and
- 01:00:04ambulation techniques from interventional
- 01:00:07radiology are really promising alternative.
- 01:00:11Local therapy options when resection
- 01:00:14is not feasible with local control,
- 01:00:17that is quite good overall survival
- 01:00:20benefit seen in patients who
- 01:00:23have limited metastatic disease,
- 01:00:25so I would say in conclusion
- 01:00:28radiation we use as an integral
- 01:00:31role in the management of rectal
- 01:00:35cancer patients for local control.
- 01:00:38In the pelvis,
- 01:00:40but also as an option to address
- 01:00:43liver metastatic disease in
- 01:00:45non surgical candidates.
- 01:00:47With that I will hand it off,
- 01:00:50I think to doctor Billingsley.
- 01:00:541st, I'll just feel the question to you so.
- 01:00:58There are several questions
- 01:00:59about how you select patients
- 01:01:01for with multiple disease sites.
- 01:01:03For a local treatment like radiation,
- 01:01:05but I think you ultimately
- 01:01:06answer that quite well,
- 01:01:08so there's another question about
- 01:01:10the number of times that you can use
- 01:01:12radiation to the same area of treatment.
- 01:01:14Can you talk a little bit about that?
- 01:01:15Can you radiate the same area twice,
- 01:01:17right? So we can re radiate the pelvis.
- 01:01:20It's always just a risk
- 01:01:22benefit balance right so?
- 01:01:25For patients who have a recurrence
- 01:01:27in the pelvis, we do reradiate.
- 01:01:30Sometimes we do it with smaller doses
- 01:01:34twice a day in order to increase
- 01:01:38the ability to tolerate treatment.
- 01:01:41And four and then we can re radiate
- 01:01:45areas away from the site if right there.
- 01:01:49Limited metastatic sites
- 01:01:51that we're trying to treat.
- 01:01:53So I think those would be the two
- 01:01:55scenarios where where we would re radiate.
- 01:02:00Excellent. So next,
- 01:02:03we could certainly next week,
- 01:02:06Kevin Doctor Kevin Billingsley,
- 01:02:07professor of Surgery and Chief Medical
- 01:02:10Officer of Smile, Cancer Hospital,
- 01:02:11and he's going to speak about the
- 01:02:12role the surgical oncologist and
- 01:02:14management of colorectal cancer.
- 01:02:16Well, thank you very much.
- 01:02:18It is a pleasure to be
- 01:02:20with the audience this evening
- 01:02:22and with my Co panelists.
- 01:02:26I will be speaking about
- 01:02:28metastatic disease, predominantly
- 01:02:30colorectal cancer liver metastasis.
- 01:02:35Is it possible for me to screen share?
- 01:02:39Yeah doctor John. Can you stop sharing?
- 01:02:53Thank you folks.
- 01:02:59Good now Kevin. I think that is good.
- 01:03:05I can see your slides OK.
- 01:03:15Alrighty so. No, I'm a
- 01:03:19hepatobiliary surgeon, so
- 01:03:21a lot of what I do is take care of
- 01:03:24patients who have colorectal cancer,
- 01:03:26which has spread to their livers
- 01:03:28and the title of my talk is progress
- 01:03:32in multidisciplinary treatment
- 01:03:33of metastatic colorectal cancer,
- 01:03:35New Hope and opportunities.
- 01:03:37And this is certainly a field
- 01:03:40where we had surgeons have.
- 01:03:43Are very gratified to be able to offer
- 01:03:47patients new surgical approaches,
- 01:03:49but I emphasize the fact that this
- 01:03:51is a multidisciplinary endeavor and
- 01:03:53a lot of the progress we have been
- 01:03:56able to make in surgery is closely
- 01:03:59tide to progress that has been made
- 01:04:01in the efficacy of systemic therapy,
- 01:04:04particularly chemotherapy and the
- 01:04:07integration of biologic agents.
- 01:04:10So.
- 01:04:11You know, we know
- 01:04:13that colorectal cancer remains a major
- 01:04:16source of cancer related illness
- 01:04:19in Americans and around the world.
- 01:04:21There are about 1.4 million new
- 01:04:24cases of colon cancer every year,
- 01:04:26and unfortunately,
- 01:04:27the liver is a common sight for this disease.
- 01:04:30To spread it. In fact,
- 01:04:32it's the most common metastatic site.
- 01:04:35About 50% of patients.
- 01:04:39With colon cancer will develop
- 01:04:42colorectal liver metastasis at some
- 01:04:45point during their course, and in fact,
- 01:04:4815 to 25% of folks who present with this
- 01:04:52disease have synchronous liver disease.
- 01:04:55Or, in other words,
- 01:04:56they have liver metastasis at
- 01:04:59the time they're diagnosed.
- 01:05:00But the great news and the exciting
- 01:05:03news is that we have learned that
- 01:05:06long term survival is possible if
- 01:05:08we're able to completely remove.
- 01:05:11Or resect the disease in the liver.
- 01:05:17Now, why do we want to do this?
- 01:05:19Well, liver disease is often the major life
- 01:05:23limiter and metastatic colorectal cancer,
- 01:05:26because it can cause liver failure.
- 01:05:27It can cause biliary obstruction.
- 01:05:30And once folks get biliary obstruction,
- 01:05:32it's very difficult for Doctor
- 01:05:35Cicchini and company to give them
- 01:05:38affective systemic chemotherapy.
- 01:05:40So again, the exciting news is
- 01:05:42that we're at risk with resection
- 01:05:45of colorectal liver metastasis.
- 01:05:47Patients are experiencing well
- 01:05:49over 50% five year survival.
- 01:05:52Now the challenging thing is
- 01:05:54that not everyone is a surgical
- 01:05:56candidate for these operations,
- 01:05:58and roughly we say about 20% of
- 01:06:02patients with these metastatic lesions,
- 01:06:05or resectable at the time
- 01:06:07of their presentation.
- 01:06:08Now many of them were able to move into
- 01:06:10the realm of reception with some treatment,
- 01:06:13so increasing numbers of patients become
- 01:06:17surgical candidates and what has been
- 01:06:20gratifying for me over my career is that.
- 01:06:23Over the past 20 years,
- 01:06:25the median survival 5 and 10
- 01:06:27year survival for patients with
- 01:06:29surgically treated colorectal cancer.
- 01:06:31Liver metastasis steadily climbed from
- 01:06:34a five year survival of around 30%
- 01:06:37to well now over 45 in this series.
- 01:06:42But even you know now we're now.
- 01:06:44It's it's well over 50%,
- 01:06:46so very exciting progress.
- 01:06:50Now when we talk about liver surgery.
- 01:06:54We can do major surgery on the
- 01:06:57liver for one simple reason.
- 01:06:59The liver is a remarkable organ.
- 01:07:01As a matter of fact,
- 01:07:02we can do quite extensive surgery
- 01:07:05like this where we remove over
- 01:07:07more than half of the liver.
- 01:07:09We remove the right liver and a little
- 01:07:12bit more, and the remaining liver
- 01:07:14is able to regenerate or regrow,
- 01:07:17and this happens remarkably quickly.
- 01:07:19Most of the regeneration occurs
- 01:07:21within about 35 days after surgery.
- 01:07:25So these are the what we described
- 01:07:27as standard liver operations.
- 01:07:29But in recent years we have come to
- 01:07:32appreciate that the liver has a multitude
- 01:07:35of smaller anatomic segments in them,
- 01:07:38and we were able to do very
- 01:07:40carefully tailored operations where
- 01:07:42we remove these smaller segments
- 01:07:44to remove tumors that are multiple
- 01:07:47or on both sides of the liver.
- 01:07:50As I mentioned.
- 01:07:52We can't really talk about colorectal
- 01:07:56liver metastasis surgery without
- 01:07:58staging it in the background of
- 01:08:01the progress in chemotherapy and
- 01:08:03when I first started in this field,
- 01:08:06we really only had one or two drugs
- 01:08:09to treat the disease and the median
- 01:08:12survival was relatively short.
- 01:08:15We now are up in this era where
- 01:08:17we have multiple regimens,
- 01:08:19either oxaliplatin based or in attican based.
- 01:08:22We have biologic agents and often
- 01:08:25we combine all three of the active
- 01:08:28drugs to treat treat these tumors,
- 01:08:31particularly when we're trying
- 01:08:33to get them to down stage art or
- 01:08:36shrink to get people to surgery.
- 01:08:39So we have a lot of strategies to try
- 01:08:43to get people to these liver operations
- 01:08:46if they're not surgical candidates
- 01:08:49at the time we first see them.
- 01:08:51One approach is to use the
- 01:08:53chemotherapy to shrink the tumor
- 01:08:56away from critical structures.
- 01:08:58One strategy is to use something
- 01:09:01called portal vein embolization,
- 01:09:03which is something that they're
- 01:09:05interventional radiologists do to help
- 01:09:07grow or optimize the size of the liver.
- 01:09:10Remnant that we plan to leave after
- 01:09:13the operation if it appears too small.
- 01:09:15One approach is to break the
- 01:09:17liver operation into two segments,
- 01:09:20where we allow part of the liver
- 01:09:23to grow between the operations,
- 01:09:25and then something that I do a lot
- 01:09:27of is very complicated parenchymal
- 01:09:30sparing resections,
- 01:09:31which means removing multiple
- 01:09:34small tumors with narrow margins.
- 01:09:37So all of these are tools in
- 01:09:39our armamentarium to use.
- 01:09:43This is an example of
- 01:09:45one of the things that I'm describing
- 01:09:48where even a very large tumor like this.
- 01:09:51This is a patient CT scan and this
- 01:09:54is a metastatic tumor in the liver.
- 01:09:57With chemotherapy in advance of any surgery,
- 01:10:02the tumor was shrunk considerably
- 01:10:04and we were able to do quite a
- 01:10:07straightforward operation to get this out.
- 01:10:09We also see situations where these
- 01:10:11tumors in the liver can be quite large
- 01:10:14and they can be budding up against
- 01:10:16adjacent structures in the abdomen and by
- 01:10:19shrinking them again with chemotherapy.
- 01:10:22A safer and more effective operation
- 01:10:25is feasible.
- 01:10:26The other thing I talked about is doing
- 01:10:29the operation in two stages, 2 pieces,
- 01:10:32and this is 2 separate operations.
- 01:10:35But if we can do these operations safely,
- 01:10:38that is really.
- 01:10:39A priority,
- 01:10:40so this is for patients with multiple tumors
- 01:10:44in the liver on both sides of the liver.
- 01:10:46We start with an operation removing
- 01:10:49the tumors from one side of the liver,
- 01:10:51and then we do a procedure to grow this
- 01:10:55small area by blocking off the blood
- 01:10:58supply to the right side of the liver,
- 01:11:00and then we eventually take
- 01:11:01that right side out.
- 01:11:03So even very complicated multi
- 01:11:05site disease on both sides of
- 01:11:07the liver can in many cases.
- 01:11:09Be safely and effectively treated.
- 01:11:13Another tool that we often use is
- 01:11:16something called microwave ablation
- 01:11:18and this is a way that we can put a
- 01:11:20microwave antenna or probe into the liver.
- 01:11:23Often we do this laproscopically
- 01:11:25through these smaller incisions
- 01:11:27to avoid a larger operation,
- 01:11:29and this can be used to treat tumors
- 01:11:32that are not safely resectable or
- 01:11:34in patients who are otherwise not
- 01:11:37candidates for major abdominal operation.
- 01:11:40One of the things that we're excited
- 01:11:42to be offering here at Yale,
- 01:11:44New Haven, and throughout our system
- 01:11:47is robotic liver resection.
- 01:11:49Now,
- 01:11:49not every individual is a candidate for this.
- 01:11:52It depends on the anatomy and the
- 01:11:54location of the tumors in size.
- 01:11:56But as Doctor Reddy described,
- 01:11:58robotic technology has definitely
- 01:12:01extended the reach of minimally
- 01:12:04invasive surgery through the use
- 01:12:06of 3D stereoscopic vision and
- 01:12:08a wristed functionality.
- 01:12:10Inside of the the abdominal cavity
- 01:12:12and it allows us to do very
- 01:12:15precise resections with suturing,
- 01:12:17and we can also add.
- 01:12:21Optimizes our ergonomics and we can work
- 01:12:24with a trainee so they're learning as we go.
- 01:12:29So in the management of
- 01:12:31colorectal liver metastases,
- 01:12:33optimal care involves bringing
- 01:12:35all of these pieces together,
- 01:12:37including gastroenterology.
- 01:12:38My partners in colorectal surgery,
- 01:12:41including Doctor Reddy and colleagues.
- 01:12:45Medical oncology involving the
- 01:12:48systemic therapy pathology for
- 01:12:51accurate staging and sequencing.
- 01:12:53Compatibility surgery, which is what I do.
- 01:12:56Imaging radiation therapy,
- 01:12:59interventional radiology,
- 01:13:01and bringing those all together around
- 01:13:04our patient through tumor boards and
- 01:13:06through our care model is really our goal,
- 01:13:09and that's how we get the best
- 01:13:11care and best outcomes so.
- 01:13:15I am happy to take any questions
- 01:13:18either now or later.
- 01:13:20A very exciting time in this field.
- 01:13:24Thank you doctor Billingsley.
- 01:13:26So when you are considering a
- 01:13:27resection of the liver attacks to see
- 01:13:29this and there's also colon tumor,
- 01:13:32how do you prioritize what to do first?
- 01:13:34Or can you do them at the same time?
- 01:13:36Really a great question and it you
- 01:13:38know this is again points to the
- 01:13:41importance of multidisciplinary tumor
- 01:13:43boards where I'm having discussions
- 01:13:45with the colorectal surgeons,
- 01:13:47the medical oncologist,
- 01:13:49the gastroenterologist,
- 01:13:50and it is very much a patient dependent.
- 01:13:54There are times that we
- 01:13:56actually do prioritize.
- 01:13:57Removing the liver disease first
- 01:14:00because it is often kind of the the.
- 01:14:03The. Element that's going to.
- 01:14:07Impact the long term survival.
- 01:14:10Most it also requires some thoughtful
- 01:14:13sequencing with the chemotherapy.
- 01:14:15However, if the colon tumor is
- 01:14:19causing any symptomatology,
- 01:14:21pain, obstructive symptoms,
- 01:14:22we tend to deal with that first surgically.
- 01:14:27Excellent thank you and so
- 01:14:29we'll move on to our final,
- 01:14:31final speaker of the Evening Doctor Soomar,
- 01:14:34who's adjunct professor of Medicine
- 01:14:36and he practices at Hartford in
- 01:14:38Hartford at Saint Francis Hospital.
- 01:14:39And he's going to speak about the
- 01:14:41role of the medical oncologists
- 01:14:42in colorectal cancer management.
- 01:14:47Alright, good evening.
- 01:14:49Thank you all for joining tonight.
- 01:14:50I'm going to share my presentation.
- 01:14:59Alright.
- 01:15:09Alright. So my
- 01:15:12my goal is to give a a brief overview of
- 01:15:16colon cancer treatment tonight and I would
- 01:15:20like to discuss the following topics.
- 01:15:24The first is you know,
- 01:15:25how do we define stage in colon cancer
- 01:15:28and and what is the prognosis with
- 01:15:30individual stage of the colon cancer.
- 01:15:33I'll then talk about treatment for
- 01:15:36early stage and stage colon cancer.
- 01:15:41General overview of anti cancer medicines.
- 01:15:44Chemotherapy biological therapy
- 01:15:46immunotherapy will briefly discuss that
- 01:15:49I'll briefly talk about recent advances
- 01:15:51in colon cancer and and then we'll briefly
- 01:15:53talk about future and the research
- 01:15:55and clinical trials that we offer.
- 01:15:57It's Milo Cancer Center.
- 01:16:00So I'm going to start with a real life case.
- 01:16:03This is a gentleman JJ, he's 57.
- 01:16:05He's already 12 years late
- 01:16:08in getting colonoscopy.
- 01:16:11He is afraid of snakes and somebody told
- 01:16:13him the class who looks like a snake so
- 01:16:16he didn't want to go near colonoscopy.
- 01:16:19However, he started developing
- 01:16:20some fatigue and some symptoms.
- 01:16:22He saw his primary doctor.
- 01:16:24He was found to have iron deficiency
- 01:16:26and the the primary doctor offered
- 01:16:28him to do stool card testing.
- 01:16:31Which came back positive and then finally he
- 01:16:34he he must have courage to get a colonoscopy,
- 01:16:37which lo and behold showed
- 01:16:38a mass in his colon.
- 01:16:40He took up.
- 01:16:41There was a biopsy done box.
- 01:16:42He can from there he has colon cancer.
- 01:16:44Luckily he had a CAT scan of the chest,
- 01:16:46abdomen,
- 01:16:46pelvis for completion of staging and there
- 01:16:49was no cancer spread to other organs.
- 01:16:51He saw a train colorectal surgeon
- 01:16:54and had undergone surgery very
- 01:16:56successfully and then he saw me after
- 01:16:59the surgery to discuss further options.
- 01:17:01So we started talking about the colon
- 01:17:04cancer stage and I described him.
- 01:17:06So for colon cancer, the stage,
- 01:17:08the way we define the stage.
- 01:17:10If you look at the the left
- 01:17:12hand side diagram.
- 01:17:14The the ring is the colon, colon.
- 01:17:16As you know it's a.
- 01:17:17It's like a garden hose.
- 01:17:19The cancer typically starts from
- 01:17:20the inner lining of the colon.
- 01:17:22If the cancer is confined in the inner
- 01:17:25lining and doesn't doesn't go deeper,
- 01:17:27we call that as stage one and for most
- 01:17:30patient with stage one colon cancer,
- 01:17:32it is curable.
- 01:17:33All they need is usually a surgery
- 01:17:36and of course Dr Reddy had mentioned
- 01:17:38about follow up after the surgery.
- 01:17:40So these benches these patients
- 01:17:42don't need chemotherapy.
- 01:17:43So that's stage one.
- 01:17:44JJ did not have stage one.
- 01:17:45He actually had stage 2 colon cancer,
- 01:17:48so stage 2 colon cancer.
- 01:17:49As you can see,
- 01:17:51the cancer is deeper penetrating
- 01:17:53into the wall of the intestine,
- 01:17:55and surgery is again curable for
- 01:17:59most patients.
- 01:18:00However,
- 01:18:01about 15.
- 01:18:0410 to 15% of patients can still develop
- 01:18:07recurrence after undergoing a successful
- 01:18:10surgery even though cancer had not spread
- 01:18:12to the lymph nodes or other organs,
- 01:18:14there's still risk of cancer recurrence
- 01:18:16and cancer spreading to other organs,
- 01:18:18so some patients in this particular
- 01:18:20category will require chemotherapy,
- 01:18:22and Joe was very upset with this number.
- 01:18:2415% he's a nuclear scientist and
- 01:18:2715% for him is a big number,
- 01:18:29and he he would not accept that.
- 01:18:31And he asked about what else
- 01:18:33can be done to minimize.
- 01:18:35The risk of this recurrence?
- 01:18:37So few patients with colon cancer.
- 01:18:39With this stage two we consider them
- 01:18:42as a candidate for chemotherapy.
- 01:18:43We look at the tumor and the
- 01:18:45microscope and we figure out
- 01:18:47how aggressive the tumor looks.
- 01:18:48If the tumor was invading the
- 01:18:50vessels and there's a marker
- 01:18:51called microsatellite instability.
- 01:18:53MSI marker.
- 01:18:54If somebody has MSI positive colon cancer,
- 01:18:57that's a good sign,
- 01:18:58and those patients typically do not
- 01:19:00need chemotherapy in JJ's case.
- 01:19:02He had no poor features,
- 01:19:05so there was no strong recommendation
- 01:19:07for us to offer him chemotherapy.
- 01:19:09And we briefly discussed the clinical trial.
- 01:19:13He remains very nervous and very confused,
- 01:19:16so I kind of try to explain him with
- 01:19:19this diagram that I draw for him.
- 01:19:21So I told him, you know,
- 01:19:22if if I have 100 judges like you,
- 01:19:25there are no real technology for me to
- 01:19:28tell you who are those 85% lucky JJS.
- 01:19:30And there are 15 of them.
- 01:19:32Unlucky judges,
- 01:19:33the unlucky patients are patients
- 01:19:35whose cancer will return if I don't,
- 01:19:37they don't give them chemotherapy.
- 01:19:40And if if I want to prevent.
- 01:19:44A small number of patients getting the
- 01:19:46cancer I have to treat all hundred patients,
- 01:19:48so in order for me to provide benefit
- 01:19:50to three patients, as you can see,
- 01:19:53the extreme right picture.
- 01:19:54There are three patients who are
- 01:19:56who do not develop chemotherapy
- 01:19:58do not develop recurrence.
- 01:19:59So he understood that a lot of patients
- 01:20:03will require chemotherapy in order for
- 01:20:05us to provide benefit to very few patients.
- 01:20:07And there are patients who will not
- 01:20:10even benefit from chemotherapy,
- 01:20:11and they will have still have a recurrence.
- 01:20:14And then we we talked about
- 01:20:16what other things can be done.
- 01:20:18So I discussed with him about what
- 01:20:21we call circulating tumor DNA test.
- 01:20:24This is the latest technology
- 01:20:25that we have now.
- 01:20:26It's a blood based test to
- 01:20:28detect tumor molecules.
- 01:20:30It is very sensitive and very
- 01:20:31specific and it's very complementary,
- 01:20:32or in fact it's superior to CAT
- 01:20:34scan in many situations.
- 01:20:36We are hoping that this technology this
- 01:20:38blood test will allow us identification
- 01:20:41of high risk patient like JJ maybe.
- 01:20:44Help in making a decision about
- 01:20:46who can get chemotherapy and
- 01:20:48who can avoid chemotherapy.
- 01:20:50This technology can also.
- 01:20:51We are hoping to monitor help
- 01:20:53us monitor for recurrence after
- 01:20:55they've done with their treatment
- 01:20:57along with CAT scan and other blood
- 01:20:58work and exam and colonoscopy.
- 01:21:01And we are also hoping this
- 01:21:03technology in future will help
- 01:21:04us monitor treatment for people
- 01:21:06who have advanced cancer.
- 01:21:08So I offered a clinical trial to JJ,
- 01:21:11which which which is being
- 01:21:13conducted at SMILOW.
- 01:21:14Ironically,
- 01:21:14the the name of the trial is COBRA trial,
- 01:21:17but Joho JJ actually looked into
- 01:21:19the trial and he's considering it.
- 01:21:22So essentially for stage one
- 01:21:24there is no chemotherapy,
- 01:21:25just surgery for stage 2.
- 01:21:28Some patients may require chemotherapy.
- 01:21:31We are still trying to figure
- 01:21:32out who are the patients who gets
- 01:21:34the benefit from giving, giving,
- 01:21:35getting chemotherapy for stage 2,
- 01:21:37colon cancer patients,
- 01:21:38and we strongly encourage patient
- 01:21:40to participate in clinical trial,
- 01:21:42which we hope will help
- 01:21:44us answer this question.
- 01:21:46I'm going to talk about a second case KB.
- 01:21:50He's 63, he's a.
- 01:21:52He's a gentleman who who's
- 01:21:54otherwise very healthy,
- 01:21:55had colonoscopy when he was due at age of 50,
- 01:21:58but he misses colonoscopy.
- 01:22:00Second colonoscopy because of COVID-19.
- 01:22:02He presents with rectal bleeding
- 01:22:05and he undergoes colonoscopy,
- 01:22:06which shows a mass in his
- 01:22:09colon and he subsequently had
- 01:22:10a biopsy in a staging work up.
- 01:22:12Fortunately again,
- 01:22:13the CAT scan did not show any spread
- 01:22:15of cancer to the other organs.
- 01:22:17He was seen by colorectal
- 01:22:19surgeon and underwent a surgery.
- 01:22:23He saw me after the surgery.
- 01:22:25Unfortunately in his case the cancer
- 01:22:27was actually not only invading the
- 01:22:30whole circumference of the intestine,
- 01:22:32but also had spread to the lymph nodes.
- 01:22:35So his stage is stage three.
- 01:22:37So stage three is a cancer that has
- 01:22:39metastasized to the lymph node.
- 01:22:41His CAT scan showed no cancer in the liver.
- 01:22:43No no cancer in the lung.
- 01:22:45So at this stage it is still curable.
- 01:22:49However, there is a substantial risk of
- 01:22:51recurrence or metastasis in these patients.
- 01:22:53About 60 or 30% of these patients
- 01:22:56are cured by surgery alone.
- 01:22:58However.
- 01:22:59If I combine surgery with chemotherapy,
- 01:23:03the as you said as as I said,
- 01:23:05the the chemotherapy adds benefit to surgery,
- 01:23:07and in this particular stage three case
- 01:23:10it improves the survival and we can cure
- 01:23:13almost 80% of patients with this strategy.
- 01:23:15So suddenly surgery alone is not
- 01:23:18sufficient for people who are healthy
- 01:23:20and we recommend them chemotherapy
- 01:23:22now chemotherapy for stage three,
- 01:23:25we have two different regimen
- 01:23:26that we currently use.
- 01:23:28One is called folfox 6.
- 01:23:30Which is an intravenous chemotherapy.
- 01:23:32The other option is called Cpox,
- 01:23:34which is a combination of a
- 01:23:36pill and Ivy chemotherapy.
- 01:23:38For a long time we were recommending six
- 01:23:40months of chemotherapy to all our patients
- 01:23:43very in last five to 10 years we were.
- 01:23:46We have been asking this question.
- 01:23:48Does everybody need six months of
- 01:23:50chemotherapy and there was a trial done,
- 01:23:51called IDEA study,
- 01:23:53and in that particular trial we were able
- 01:23:56to conclude that if we use capox regimen,
- 01:23:58the regimen with the pills
- 01:24:00and Ivy chemotherapy,
- 01:24:01we can conclude chemotherapy in three months.
- 01:24:04The three months of that regimen is
- 01:24:06equivalent to six months of that regimen.
- 01:24:08And therefore love our patients will choose
- 01:24:10three months of chemotherapy if they,
- 01:24:12if they want to shorten the
- 01:24:14course of chemotherapy.
- 01:24:15However,
- 01:24:15there's certain patients that we will
- 01:24:17still choose a full Fox versus Kapoks,
- 01:24:20and that that decision is usually
- 01:24:22based on discussion with with a
- 01:24:24physician and a patient and and
- 01:24:26medical issues of the patient as well.
- 01:24:31So this particular patient chose chose
- 01:24:34six months of folfox chemotherapy
- 01:24:36because he did not like taking pills
- 01:24:39and and other risk risk profile or side
- 01:24:42effects profile that we discussed,
- 01:24:44he chose folfox for six months.
- 01:24:47I'm gonna go to another case of mine.
- 01:24:50This is DK. She's 72.
- 01:24:53She does not like to see doctors.
- 01:24:54She barely saw her primary doctor
- 01:24:57and never had colonoscopy.
- 01:24:59She started experiencing weight loss,
- 01:25:01abdominal pain,
- 01:25:02and generalized weakness.
- 01:25:04Finally went to emergency department
- 01:25:06and had a CAT scan which showed
- 01:25:09multiple liver spots and multiple
- 01:25:11lung spots and a mass in her colon.
- 01:25:13She had a colonoscopy and biopsy
- 01:25:15deliver and that confirmed that she has.
- 01:25:18Mastery colon cancer originated
- 01:25:20from the colon traveling to lung
- 01:25:22and liver so she when she saw me
- 01:25:25you know she had the cancer already
- 01:25:27metastasized to lung and liver and
- 01:25:29I discussed treatment with her and
- 01:25:31I recommended that she should take
- 01:25:33chemotherapy with her biological
- 01:25:35therapy and I'm going to discuss
- 01:25:37that in a little bit detail.
- 01:25:39In subsequent slides we did discuss
- 01:25:41her case in multi separated GI
- 01:25:43tumor board at Smilow,
- 01:25:44Dr Billingslea and many other surgeons.
- 01:25:47We were able to review her scans.
- 01:25:49With other doctors and team and she
- 01:25:51was deemed not a surgical candidate
- 01:25:53because she has a lot of cancer in
- 01:25:55her liver as well as in the lung
- 01:25:57and therefore we chose her to start
- 01:25:58to give her chemotherapy as her
- 01:26:01first modality of treatment.
- 01:26:03So there are very few. There are few
- 01:26:05patients who can be cured and can have
- 01:26:07long term control of their disease
- 01:26:09with surgery and chemotherapy for stage
- 01:26:114 colon cancer, but she was clearly
- 01:26:13not that regular type of patient.
- 01:26:16So she has stage 4 colon cancer and she was
- 01:26:19really upset with her diagnosis reasonably,
- 01:26:23so you know she she understood that
- 01:26:26her cancer is likely incurable.
- 01:26:28However, I told her that there's certainly
- 01:26:30a silver lining if there is a silver lining.
- 01:26:33There are many recent advances
- 01:26:35in colon cancer treatment.
- 01:26:36We have many, many tools to treat
- 01:26:39patients with stage 4 colon cancer,
- 01:26:41and I mentioned to her that life expectancy,
- 01:26:44even with advanced stage 4 colon cancer,
- 01:26:46has improved.
- 01:26:47Significantly,
- 01:26:47the CIA database is what we we
- 01:26:51use as our sort of marker to tell
- 01:26:54patients how well people are doing.
- 01:26:56In last, you know, last many years.
- 01:26:58So if you from 1976 to 2014,
- 01:27:01the risk of death from colorectal cancer
- 01:27:04has substantially declined almost 50%,
- 01:27:06and on an average stage 4 colon
- 01:27:08cancer patients are living more than
- 01:27:10two years and three years nowadays,
- 01:27:12with chemotherapy and focusing
- 01:27:14on quality of life as well.
- 01:27:17So stage 4,
- 01:27:18colon cancer patient our treatment
- 01:27:19when we when we talk about treatment
- 01:27:22we talk about few things.
- 01:27:23First first is how does the patient look?
- 01:27:25You know what we what we really pay
- 01:27:28attention to is what we call a ****.
- 01:27:30Performance, status and age.
- 01:27:31How a patient is doing in general
- 01:27:34in terms of activity daily living.
- 01:27:36How many hours patient is walking,
- 01:27:38exercising, doing, taking care of the house,
- 01:27:40doing chores,
- 01:27:41driving all those things matter the most.
- 01:27:44So patients more act to the patient.
- 01:27:47Just there's a good chance that patient
- 01:27:49will be able to handle chemotherapy and
- 01:27:51there is very substantial chance that
- 01:27:52that patient can live longer on chemotherapy.
- 01:27:55Other health issues,
- 01:27:56certainly very important.
- 01:27:58Smoking, obesity and other
- 01:28:00health issues such as diabetes,
- 01:28:01high blood pressure,
- 01:28:03kidney problems.
- 01:28:04Physical activity and exercise is very
- 01:28:05important and we always we counsel
- 01:28:07our patients to stay physically
- 01:28:09active and choose a lifestyle.
- 01:28:10Even they have stage four cancer diagnosis,
- 01:28:13choosing an activity and also choosing
- 01:28:15a healthy diet and healthy lifestyle
- 01:28:17will still have a substantial
- 01:28:19impact on their life and their their
- 01:28:22their tolerance to chemotherapy.
- 01:28:24So that will be continuous
- 01:28:26counseling to the patients.
- 01:28:28Now.
- 01:28:28How does the cancer look?
- 01:28:30That's another another way to figure out what
- 01:28:33kind of chemotherapy we're gonna choose.
- 01:28:36So there are a few things that
- 01:28:37we will look at when somebody is
- 01:28:38diagnosed with stage 4 colon cancer.
- 01:28:40We look at the pathology and
- 01:28:42this information,
- 01:28:43cold microsatellite instability or
- 01:28:45MSI high or low will help us decide
- 01:28:48what type of first kind of first
- 01:28:51line treatment we will choose.
- 01:28:53The second most important test
- 01:28:54that we would check is called Ras
- 01:28:57gene mutation status.
- 01:28:58There are genes called Keras and B RAF.
- 01:29:00These gene if they are mutated
- 01:29:02or not mutated will
- 01:29:04help us decide.
- 01:29:05Our first step in terms of deciding
- 01:29:07chemotherapy and biological therapy.
- 01:29:08And the third test that we would use
- 01:29:11is called hurtle new testing and
- 01:29:13there are more and more molecular
- 01:29:16mutation testing that we are utilizing
- 01:29:18nowadays and we are hoping that
- 01:29:20will be tailoring our chemotherapy.
- 01:29:22In biological therapy to individual patients,
- 01:29:25but we we have done a substantial
- 01:29:28work in in science and science is
- 01:29:30advanced tremendously that we are
- 01:29:32at even at this point we are able
- 01:29:34to decide what kind of treatment
- 01:29:36is best for a particular patient.
- 01:29:39So statement for stage four.
- 01:29:40What is our goal? You know?
- 01:29:43She asked me what is gonna be my life
- 01:29:45and why are you giving me chemotherapy?
- 01:29:47If I if my cancer is gonna kill me
- 01:29:49eventually, why should I go through
- 01:29:51chemotherapy and and what we counsel?
- 01:29:53Patient is?
- 01:29:54I built purpose of chemotherapy.
- 01:29:55Here is first of all palliation
- 01:29:58of disease related symptoms.
- 01:29:59This particular patient actually had
- 01:30:01bloating, had minor rectal bleeding,
- 01:30:03abdominal thing, and we are.
- 01:30:06We hope that chemotherapy will provide
- 01:30:08relief of a lot of these symptoms,
- 01:30:09so that's our first purpose of giving
- 01:30:12chemotherapy called chemotherapy.
- 01:30:13Second is super on life,
- 01:30:16which is always a first thing
- 01:30:18that patient wants to know.
- 01:30:20But as a physician,
- 01:30:21my goal is to provide quality with life.
- 01:30:24And turning is the decrease the tumor
- 01:30:26burden for a successful surgery
- 01:30:27like Doctor Belinsky mentioned
- 01:30:29Billingsley mentioned earlier,
- 01:30:30patients who can potentially go for surgery,
- 01:30:32giving them chemotherapy upfront
- 01:30:33will reduce the burden of the cancer
- 01:30:36and will have successful surgery.
- 01:30:38And we hope that some of these
- 01:30:41patients can be cured.
- 01:30:42So for treatment for stage 4,
- 01:30:44colon cancer, the first line treatment.
- 01:30:45If somebody has MSI high colon cancer,
- 01:30:48we now have immunotherapy.
- 01:30:49Immunotherapy essentially
- 01:30:50is a cancer cancer vaccine.
- 01:30:53You want to call them.
- 01:30:54It allows your own immune
- 01:30:55system to fight cancer.
- 01:30:57This antibody,
- 01:30:58called pembrolizumab or KEYTRUDA,
- 01:31:00will enhance your immune system and allow
- 01:31:03your immune system to attack the cancer.
- 01:31:05This is a very effective treatment for
- 01:31:07people who are MSI high colon cancer.
- 01:31:08There are some patients who will have will.
- 01:31:11Have you know,
- 01:31:12cancer free or remission?
- 01:31:13Period for a long time.
- 01:31:14In some cases we have
- 01:31:16seen patients going many,
- 01:31:17many years on this immunotherapy treatment.
- 01:31:20Immunotherapy is very probable.
- 01:31:21It has side effects,
- 01:31:22but majority of patients on this
- 01:31:25particular treatment are our side effects
- 01:31:27free and enjoy their quality of life.
- 01:31:30If you have MSI low colon cancer,
- 01:31:33usually the chemotherapy is the
- 01:31:35first option for treatment.
- 01:31:37We usually combine chemotherapy
- 01:31:39with biological therapy,
- 01:31:40biological therapy, or antibodies
- 01:31:42like bevacizumab and panitumumab.
- 01:31:45The standard treatment there are two major.
- 01:31:48There are two major
- 01:31:49combination of chemotherapy.
- 01:31:50One is called Folfox,
- 01:31:51the other one is called Folfiri.
- 01:31:53They're both chemotherapy cocktail,
- 01:31:55a combination of two chemotherapy
- 01:31:58in each each each schedule.
- 01:32:00So this is typically we decide
- 01:32:02this regimen based on patients,
- 01:32:04mutation status, MSI status,
- 01:32:05and how healthy they are,
- 01:32:07and oncologists and and and a patient
- 01:32:10will have a long discussion before
- 01:32:12we come up with a treatment plan for
- 01:32:15them in some selected patients we use
- 01:32:17a regiment called Full Free Knox,
- 01:32:18which is in very aggressive regimen,
- 01:32:20particularly young and healthy patients,
- 01:32:22and particularly patients who would
- 01:32:24try were trying to get to the liver
- 01:32:26resection and try to get to almost near cure.
- 01:32:29Two type of surgery.
- 01:32:30So that regimen is also being
- 01:32:32more and more utilized for young
- 01:32:35and healthy patients.
- 01:32:36As I mentioned earlier,
- 01:32:37the treatment has advanced tremendously in
- 01:32:40last 20 years.
- 01:32:41Our main chemotherapy for years was
- 01:32:43five Piersall and up started planning.
- 01:32:46Chemotherapy came later and then
- 01:32:48then came in. So these are the
- 01:32:50main 3 chemotherapy molecules.
- 01:32:51However, in last 10 years we have now,
- 01:32:55uh at least 10 or 12 different
- 01:32:57treatment options for colon cancer.
- 01:33:00One is, as we mentioned, Bella Suzanne,
- 01:33:02which is a biological therapy.
- 01:33:04It is an antibody that actually.
- 01:33:06Allows the the chemotherapy
- 01:33:07to be more effective.
- 01:33:09There was soon will.
- 01:33:11Prevent the tumor developing
- 01:33:13vessels or artery and vein,
- 01:33:15and it will literally starve the tumor.
- 01:33:18And chemotherapy will
- 01:33:19enhance the effect of that.
- 01:33:20So toxic are again another
- 01:33:23antibody about logical therapy.
- 01:33:25The anti EGFR therapy enhances
- 01:33:27the chemotherapy effects,
- 01:33:29so we combine them with
- 01:33:31chemotherapy for treatment.
- 01:33:32We have now in third line treatment
- 01:33:36medication called Stivarga
- 01:33:38is an oral pill chemotherapy.
- 01:33:40There's another medication that approved,
- 01:33:42got approval about four or five
- 01:33:44years ago called Lonsurf or TS102.
- 01:33:49We mentioned pembrolizumab
- 01:33:50immunotherapy for people who
- 01:33:51have MSI high colon cancer.
- 01:33:53There's another immunotherapy Commission
- 01:33:57which we use for MSI high colon cancer.
- 01:34:00There are small percentage of patients
- 01:34:01who have heard to positive colon cancer.
- 01:34:04Hurt her toe is a type of receptor
- 01:34:07which which amplifies in some
- 01:34:09colon cancer cells and we use this
- 01:34:11combination of treatment called
- 01:34:13trans womeb and pertuzumab as
- 01:34:14well as another medication called
- 01:34:16trans to zoom web and stick and.
- 01:34:18Another medication for treatment
- 01:34:20of her two positive colon cancer.
- 01:34:22There are some of about 5% of colon cancer.
- 01:34:25Have B RAF mutation and we have
- 01:34:27this approval of medication called
- 01:34:29Encorafenib which is a chemotherapy
- 01:34:32pill and we combine them with an
- 01:34:34antibody called that also becomes our
- 01:34:36tool to treat beta positive colon cancer.
- 01:34:39So as you can see,
- 01:34:41there are many treatment options
- 01:34:42nowadays and therefore our
- 01:34:44patients are doing much better than
- 01:34:45than patients did 20 years ago.
- 01:34:49And in in quick form of all the patients
- 01:34:51that I have discussed so far in a
- 01:34:53quality of life becomes a real thing.
- 01:34:55We we want patients to remain active
- 01:34:58and healthy and also enjoy their
- 01:35:00life while they're on chemotherapy,
- 01:35:01which is counter intuitive. But yes,
- 01:35:03chemotherapy can be given to patients.
- 01:35:06Patient can still continue their lifestyle.
- 01:35:08You know, we provide treatment holidays.
- 01:35:10Liver directed therapy which will
- 01:35:12allow patients to stop chemotherapy
- 01:35:14for a brief period of time,
- 01:35:15lifestyle changes and we talk
- 01:35:17about maintenance treatment,
- 01:35:18a low dose of chemotherapy that we give.
- 01:35:20For patients for longer period of time,
- 01:35:22which will allow them to continue
- 01:35:24their life with lower toxicity.
- 01:35:25So there are Marius tools that we use
- 01:35:28for patients to to enjoy their life.
- 01:35:31JJ the first patient actually finally
- 01:35:33enrolling clinical trial at SMILOW and
- 01:35:36he remains cancer free at six months KB.
- 01:35:38Stacy colon cancer. He just finished
- 01:35:40his chemotherapy very recently.
- 01:35:42He did a lot milder apathy.
- 01:35:43He did have some fatigue.
- 01:35:44He was not able to work,
- 01:35:45so he took some break from his work.
- 01:35:47Very recent cat scan shows no evidence
- 01:35:49of cancer, so he's about 12 months out.
- 01:35:51Promise our diagnosis and he's doing well.
- 01:35:54DT remains DT.
- 01:35:56She's enjoying her life.
- 01:35:58She her pain completed result
- 01:36:00after chemotherapy.
- 01:36:01She gained healthy weight.
- 01:36:02She's about 3.5 years out
- 01:36:03now from original diagnosis.
- 01:36:05She goes to Florida all the time.
- 01:36:06She hates Connecticut except she
- 01:36:08likes Megan sons and she started.
- 01:36:10She started liking doctors
- 01:36:11recently so that's a good thing.
- 01:36:13She's on her second line of
- 01:36:15chemotherapy since last eight months
- 01:36:17and and she loves chemotherapy breaks
- 01:36:21in terms of future.
- 01:36:22Now we at Smilow offer many clinical
- 01:36:25trials without clinical trials.
- 01:36:26Without science we will not be able
- 01:36:28to advance our treatment for our
- 01:36:30patients and we are so thankful to our
- 01:36:32patients who volunteer and participate
- 01:36:34in many of these clinical trial which
- 01:36:36can lead to development of new drugs
- 01:36:38which can help to millions of patients.
- 01:36:41We are hoping Kira centimeter,
- 01:36:43which is one of the kind of drug which will
- 01:36:46be approved for colon cancer immunotherapy.
- 01:36:48Is is one of the treatment that we are
- 01:36:50all excited about in many other cancers.
- 01:36:53It has not been successful in routine
- 01:36:55kind of colon cancer which are MSI
- 01:36:58low and we are trying to do a lot of
- 01:37:01single trials to see how how we can
- 01:37:03harness the immune system and and
- 01:37:05and make the immunotherapy effective
- 01:37:06for all the colon cancer patients.
- 01:37:09Thank you so much and I will help
- 01:37:12you take any questions.
- 01:37:14Thank
- 01:37:14you Doctor Steinmark, we're we're at
- 01:37:15time and I think we did a good job
- 01:37:17of answering the questions in the.
- 01:37:19In the chat, so I want to be
- 01:37:21respectful to everybody's time and
- 01:37:23I want to thank our faculty members.
- 01:37:26Speaking today as well as Cindy
- 01:37:28from the Colon Cancer Foundation for
- 01:37:31joining us today, and most of all,
- 01:37:33I want to thank the patients and attendees
- 01:37:35from today for for your time this evening.
- 01:37:40This will be posted on online and we're
- 01:37:41happy to answer any more questions.
- 01:37:46My direct messages later,
- 01:37:47thank you so much, everybody.