Smilow Shares Greenwich: Understanding Colorectal Cancer - Screening and Treatment Advances

March 24, 2021

Information

March 23, 2021 | Smilow Cancer Hospital Care Center in Greenwich

Presentations by:

Pamela Kunz, MD - Director of the Center for Gastrointestinal Cancers

Xavier Llor, MD, PhD - Director, Screening & Prevention Program

Peter McWhorter, MD - Colorectal Surgeon

D. Barry Boyd, MD - Medical Oncology

M. Sung Lee, MD - Medical Oncology

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00:00Join in so I'll start on a screen share.
00:08Alright, so it is my pleasure to
00:11help moderate this smilow shares
00:13special Greenwich Addition tonight.
00:15Understanding colorectal cancer were doing
00:17this during colorectal Cancer Awareness
00:20Month and we have really wonderful
00:22representation from the whole team.
00:24My name is Doctor Pamela Kunze.
00:27I'm an associate professor of medicine
00:30and medical oncology and I practice
00:32at the main campus in New Haven.
00:35I am the new director for the Center.
00:39Sure of gastrointestinal cancers and
00:41arrived mid pandemic last summer.
00:43I I am joined by Doctor Shabeer
00:45your who's a professor of medicine
00:48and gastro enterology he is the
00:51director of screening and prevention
00:53and like leader of our newly
00:56formed Colorectal Cancer program,
00:58he'll be speaking about colorectal
01:01cancer screening and prevention.
01:03Also Doctor Peter Mcwhorter,
01:04who's a colorectal surgeon
01:06at Greenwich Hospital.
01:07He'll be speaking about surgical treatment
01:09of colon and rectal cancer Doctor Sung Lee,
01:12an assistant professor of clinical
01:14medicine and medical oncology,
01:16and the interim medical director
01:17of Smilow Care Center in Greenwich.
01:20And he'll be talking about the treatment
01:22before and after surgery called
01:24neoadjuvant in adamant treatment and
01:26Doctor Barry Boyd and Assistant Professor
01:28of Clinical medicine and medical oncology.
01:31Also practicing at the Smilow
01:32Care Center in Greenwich,
01:34and he'll be talking about
01:37treatment for metastatic disease.
01:39So just with a few brief
01:41comments to get us started,
01:43colorectal cancer is the third leading
01:45cause of cancer in the United States,
01:48among both men and women.
01:50And you can see the stars here,
01:53and it is also the third leading cause
01:56of cancer deaths in both men and women.
01:59But the good news is that it's
02:01preventable and we'll talk about that.
02:04Colon cancer has been in the news quite a
02:07bit over the course of the last 12 months.
02:11And there was the untimely death
02:13of the Black Panther star.
02:15Chadwick Boseman at the age of 43.
02:19And then also in the fall we
02:21saw in the headlines.
02:23Colon cancer screening should
02:24start earlier at the age of 45.
02:27This was on the basis of a new
02:29recommendation from the United States
02:31Preventive Services Task Force that the
02:34age should get lowered for average risk.
02:36Individuals and doctor will go
02:38into that a little bit later.
02:41So with that I am going to stop Sharon,
02:44I'm going to pass the baton to doctor your.
02:57Thank you very much like our kids.
02:59It's a real pleasure to be here with
03:03this wonderful panel of experts,
03:05so I'll try to give you my two cents
03:08on on the very summarized way about
03:11preventive measures for correct cancer
03:13and screening approaches for that.
03:20So taking a global view which is always
03:23helpful if we look at this map of the world,
03:27we see these incidence of colorectal
03:29cancer in 2018 and we read it goes
03:32from the very light areas like
03:34blue areas to the darkest areas,
03:37which are the ones that have the
03:39highest incidence of colorectal cancer.
03:41And as you can see there are huge differences
03:44in the incidence that's expressed.
03:47It's a common way to express it.
03:49Per 100,000 individuals and it's
03:51from less than 6.2 to more than
03:5527 per 100,000 individuals,
03:57that's a huge range difference between
03:59some areas with lower incidents
04:01like like Southeast Asia, Sub,
04:04Saharian, Africa or other areas,
04:06particularly in the more of
04:09the richer worlds,
04:10Western and Eastern Europe,
04:12North America, Australia and New Zealand.
04:14So the richer we get usually the higher the
04:19incidence of these countries and many others,
04:22unfortunately.
04:22And that must have something to do with the
04:26kind of things that go with being Richard.
04:29It's important also to to point
04:31out that there is good data showing
04:34that people migrating from lower
04:36risk areas to higher risk areas.
04:39Pretty soon they get to the
04:41similar levels of the locals,
04:43meaning that that changing environment
04:45really plays a very important role
04:48in terms of colorectal cancer risk.
04:50We've known also some factors for.
04:53For awhile and some of them quite confirm.
04:56For instance, heavy alcohol intake.
04:58That's the result in an increased risk.
05:01This is expressed here as relative risk,
05:03so one meaning no increased risk.
05:06Everything that's above one
05:07would be increased risk.
05:09Everything that's below one is is lower
05:12rates there for preventive effect.
05:14And again, as we went one further up,
05:17sorry about that.
05:18And as we can see here,
05:21alcohol is associated with that.
05:23Also,
05:23obesity is associated with an increased risk.
05:27Also an increased risk for red meat
05:30and consumption of processed meat
05:32and very important Association with
05:35smoking and even former smokers do
05:38still have carry a high risk daughter.
05:41Risk does go down so there are some
05:45environmental habits and and and aspects
05:47that really can modify our risk.
05:50Others like physical activity
05:52or dairy products,
05:53particularly physical activity.
05:55That's been very consistently
05:57associated with a lower.
05:58At risk so so a lot to be said about
06:01environmental factors that probably
06:03still don't have a good sense.
06:06And what other types of factors are
06:09playing a big role in this case?
06:12We've also known for a long time
06:14that there's familial clustering
06:16in corrective cancers,
06:18meaning that some families tend to have
06:21different relatives with colorectal cancer.
06:23Not wonder more.
06:24And as we can see here,
06:26for instance,
06:27having.
06:28Just one more first degree
06:30relative that would mean siblings,
06:32parents,
06:33sons,
06:33daughters that would increase
06:35the risk quite a bit.
06:372.2 very significant having one
06:39or more first of your relatives
06:42diagnosed before the age of 50.
06:45Stealing it increases the risk even higher,
06:48and having two more first
06:50degree relatives tax even a
06:52higher increase in the
06:54risk of colorectal cancer.
06:56That on the other hand.
06:58Even having a one more second degree
07:01relative or having a a one or more
07:05first degree relatives with what we
07:07call an advanced polyp like Canada, no ma'am.
07:11Not a cancerous polyp yet,
07:13but a what we often call premalignant polyp.
07:17That also increases the risk and
07:20that's why recommendations for
07:22individuals who have for family members
07:25who have a relative who has had.
07:28Call it like that.
07:29Get also enhanced screening too,
07:31so that's those are all important factors.
07:34And again,
07:34what they really speak for is that
07:37there is that classroom means that
07:39there are some factors that seem
07:41to be shared among family members,
07:44and that's why you see those clusters.
07:46And those factors really are
07:48the result of important.
07:50At once like lifestyle,
07:52we talked about environment Dyett,
07:54Andy genetic background and really did.
07:56Some of these have a higher weight
07:59in some cases and others and genetic
08:02defect will have a higher weighed in
08:05what we call the cancer syndromes.
08:07The ones that were there is
08:09a mutation in the family.
08:11There's a significantly higher
08:13risk of cancer and that's the
08:16example that I'm showing here.
08:18Those are if this is the.
08:20Tired of all colorectal cancers and we
08:23look at if they have any mutations of
08:26those that cause inherited cancer syndromes.
08:29If we take anyone with
08:31colorectal cancer older than 50,
08:33was it about 5% five?
08:358% will have an inherited predisposition
08:37most common while lynching room.
08:40But if we take younger people in
08:42this case right here in the middle of
08:46all individuals are younger than 50,
08:48you would see that the.
08:50Percentage of those having a inherited
08:53cancer syndrome would go up close to 20%,
08:56and if we only look at individuals who
09:00were diagnosed at an age younger than 35,
09:03that will go up to about a third
09:06of all the cases.
09:08So that's why family history and
09:11determining genetic defects is so important,
09:13particularly with the younger individuals,
09:15because they do have the highest risk
09:18of being due to inherited defects.
09:25And but the good news of the story
09:27that I wanted to share with you
09:30is what I'm showing right here.
09:33This is the graph that starts in
09:35the 1930s up to 2017. And that's.
09:40Incidents again per 100,000 individuals
09:42and as we can see here both for males
09:45and females there since in mid 1980s
09:48a very steady and significant decline
09:50in in both the incidence of colorectal
09:53cancer and mortality of colorectal cancer.
09:55That's certainly a very that's
09:57been very encouraging news.
09:58The trend has come.
10:00Seen it going down and that's
10:03the very positive news here.
10:05The fact, in fact, this has this.
10:09Decrease from 2006,
10:112000 to 2015 has been an average
10:14about 3.7% annually,
10:15so that means every year there's
10:18been that close to 4% decrease in
10:21this incident of colorectal cancer.
10:23Quite remarkable numbers and that
10:25decrease in incidents that we see here
10:29in this line going down from year 2000,
10:32no longer 2018 has really been
10:34matched by this steady increase
10:36in screening procedures,
10:38and here we are showing.
10:40Call a colonoscopies the more
10:42colonoscopies we've been doing,
10:44the lower incidence of colorectal cancer,
10:46so it it must have something to do with that.
10:51What we doing.
10:52Removing polyps even though there
10:54are some other trends showing that
10:57other factors may have had literal,
11:00but the most important role,
11:02definitely is that generalization
11:03of screening of colorectal cancer
11:06screening that's made the incidence
11:08significantly lower, so now.
11:10Doctor Kincel was referring to the
11:12United United States Preventive
11:15Services Task Force,
11:17which is this independent Organism.
11:19The basically looks at the at the
11:22medical literature very carefully
11:24and ends up issuing recommendations
11:27for screening and prevention
11:29that really widely adopted by the
11:32primary care providers and,
11:34and they've been telling us for awhile
11:37that screening average risk individuals,
11:39asymptomatic ages.
11:4050 to 75 is definitely been has definitely
11:44been proven to be a substantial benefit,
11:47and there's really no question
11:49about it nowadays and there are
11:51not that many cancers were.
11:53Screening is clearly associated
11:55with a decrease in and cancer
11:57and cancer related mortality.
11:59The benefits of early detection
12:01according to the USPS TF.
12:03An intervention for colon cancer
12:05screening decline after age 75 and the
12:08decision to screen individuals aged 76 two.
12:1185 should be individualized,
12:13considering really the overall
12:15health and prior screening.
12:17History and benefit for adults 85
12:21and older in general has to be very.
12:26The potential adverse events usually
12:28probably outweighed the benefits.
12:29I must say that there is a recent
12:32literature showing that there are ways
12:34to re stratify and and that they are
12:37showing that actually even in older
12:40individuals they could also benefit,
12:42so I think we'll hear more about these,
12:45and this probably could be a little bit
12:49of moving moving target in the future.
12:53Modalities of screening.
12:53I think this is the one we are more
12:56familiar with the the colonoscopy.
12:58This insertion of this flexible rubber
13:00tube through the ****** where we can
13:03look at the entire colon with the
13:05camera and remove polyps which
13:07is at the end of the day.
13:09What really ends up saving lives because
13:12those polyps left and check would go
13:14and grow and develop into cancer,
13:16so that's really what we want to
13:18avoid and that's what's avoided.
13:20Removing those polyps,
13:21city Cornography is another.
13:23Option, which is sort of a CAT scan
13:25that's focusing on the column.
13:27And stool based tests.
13:29We have a couple of options nowadays.
13:32We're really using the stool
13:34based test that we've seen.
13:36A significant also decrease in
13:38both incidence and mortality
13:39from that approach too.
13:41So nowadays we do have a menu of options,
13:45all of them end up if positive in
13:48a colonoscopy, that's for sure,
13:50but some of those options are
13:52less invasive food,
13:54so they could be more attractive
13:56as initial pre screening.
13:58So we're dividing them between the
14:00the ones that are we call direct
14:02visualization ones who treated include
14:04the colonoscopy every 10 years.
14:06Sigmoid osca P will be the shorter version,
14:08or some way to ask would be every
14:1110 years plus a stool test or city
14:14colonography approved for every five
14:15years and then those two based as I
14:18was talking to you about Efobi teza know one.
14:21Most of it is no longer used but fit.
14:24Testing is definitely widely used
14:26and that African multi target
14:28DNA test is also another stool
14:29test that's being used again.
14:31Windows are positive,
14:32a colonoscopy is the thing to do here,
14:36but as doctor conventional so not
14:38all is good news and the fact that
14:42we're seeing more individuals
14:44not only not only movie stars,
14:47but really we hear of a significant
14:49number of young individuals
14:51developing colorectal cancer,
14:53that's truly a trend that's
14:55been documented since the 1990s.
14:57This,
14:58along with this very steady decline
15:01that we talked about in the.
15:03Older than 50 for the individuals
15:06that are 20 to 49,
15:08we see this steady rise in colorectal
15:12cancer incidence both for men and women.
15:15Very, very unfortunate trend.
15:17And actually,
15:17when we're looking at individuals
15:20that are each 50 here in this
15:23and these incidents for the age
15:2615 incidents for the 45.
15:28What we see here is that in 1993
15:31the risk of colorectal cancer.
15:34For a 50 year old is exactly
15:37the same as the risk that it is
15:40right now for a 45 year old.
15:43So so several years back actually
15:45their risk was pretty similar for 55,
15:48then that is right now for 45,
15:50so we see this steady decline in
15:53the incidence of of the of the
15:56age of diagnosis very unfortunate.
15:58Another important aspect is that for
16:00many years we have been recommending
16:02to screen start screening.
16:04Directed at an African Americans
16:07for colorectal cancer at 45.
16:10Just because there were significantly
16:13higher number of individuals
16:15being diagnosed at a younger age.
16:19Over the last few years,
16:21is that white and actually all the
16:23ethnic groups F with that trend
16:26increasing in the incidents,
16:28they basically pretty much are at the same
16:31level as African Americans are at this time.
16:34So really, that's extremely concerning
16:36because instead of all doing better,
16:39actually what we've done is just
16:41equalizing upwards towards the
16:43higher incidence with the African
16:45Americans who had the photos,
16:47the group with the highest.
16:49Levels of young onset cancer.
16:51So so because of these
16:54trends and what you've heard,
16:56the American Cancer Society couple
16:58years ago started recommending to
17:00screen for average risk individuals,
17:02meaning individuals who feel fine who
17:04do not have family history who do not
17:08have any reason to believe that they
17:10have an average higher than average risk
17:13of correct cancer again to start at 45.
17:17And while USPS TF that we mentioned before,
17:20has been recommended.
17:21MH 5050 as Africans mentioned,
17:24the USPS TF put a draft out last
17:27October that they were suggesting
17:29to revise that age of onset of
17:32colorectal cancer screening for average
17:35individuals to 45 instead of 50.
17:38That's probably going to be approved and I
17:42think that's where we're moving at this time.
17:46To really make sure that we are capturing
17:50more and more individuals, and.
17:53We're saving more lives.
17:55Thank you very much.
17:59Thank you so much Doctor,
18:01you are that was great.
18:02So I encourage the audience to
18:04please feel free to ask questions in
18:06the Q&A box we can get to them in
18:09writing or we will answer them by
18:11we will go next to Doctor Mcwhorter.
18:18Thank you.
18:23Quarter I'm a colon and rectal
18:25surgeon at Greenwich Hospital.
18:26Thank you for having me and
18:28welcome to all of the audience.
18:31I'm talking about the surgical treatment
18:33of colon cancer and rectal cancer.
18:38Tonight. I'm going to try to
18:41put my timer on so that I stay.
18:43Right on time, surgical treatment
18:45of colon cancer and rectal cancer.
18:47So I want to make a distinction
18:50between what the two things are.
18:53So a little bit of anatomy.
18:56I am a surgeon,
18:57so the colon and ****** are
18:59depicted in this diagram in the
19:02right upper portion of the screen.
19:04The colon is the 1st 5 feet
19:07of large intestine.
19:08The ****** is the continuation of the
19:11large intestine as it exits the body.
19:13Eliminate ING our waste.
19:15The purpose of the colon is to store
19:18our waste and draw water out of it.
19:21So colon cancer is doctor.
19:23Yours pointed out is.
19:25Is cancer that develops in the lining
19:28or mucosa of the colon or large
19:31intestine which are synonymous?
19:33I want to point out that there
19:35are differences in management
19:37between these two cancers.
19:39In colon cancer.
19:40I think even my oncology colleagues
19:43would agree surgery is primary.
19:47We removed the cancer in less.
19:50It has already spread to distant organs
19:53and then after removal of the cancer,
19:57there may be a role for chemotherapy.
20:01Some patients don't have to have
20:03chemotherapy, and that's fantastic.
20:06I want to draw the distinction to
20:09rectal cancer, where surgery is but
20:11one of the tools in the toolkit.
20:14Rectal cancer is much more of a
20:17multi modality, not the colon.
20:20Cancer isn't, but rectal.
20:22Cancer is very much a multi
20:25modality treatment disease,
20:27where chemotherapy,
20:28radiation and surgery are all utilized
20:32in the management of rectal cancer I.
20:36I often sort of mentioned in my patients.
20:39You can think of three.
20:41Treatment modalities for cancers.
20:43And this is pretty much true.
20:46I think for all cancers one is to do surgery.
20:50One is to do radiation and one
20:52is to give chemotherapy.
20:54So those are our three treatment
20:56modalities and surgery plays a role in
20:59both colon cancer and rectal cancer.
21:01However, it's more primary to colon cancer.
21:06What's the standard pathway for
21:07management of colon cancer?
21:09One make the diagnosis that's generally
21:11in the court of the gastroenterologist,
21:14who in most cases it's being
21:16diagnosed with colonoscopy,
21:17where a biopsy is taken of suspicious
21:19tissue in the colon and the pathologist
21:22confirms that this is cancer.
21:24I always tell my patients,
21:26regardless of the type of cancer your
21:29next step is to figure out is this
21:32early cancer or is this advanced
21:34cancer and that's called staging.
21:37Staging involves getting a CAT scan
21:39and doing a blood test called CEA to
21:43determine how we caught this early or or not.
21:47Step three is in most cases for colon
21:50cancer is the surgeon who removes the cancer.
21:54The removed piece of colon goes
21:56to the pathologist who tells us
21:59how advanced this cancer is,
22:01how deeply into the wall of
22:03the colon did it grow,
22:05and did lymph nodes becoming?
22:07Did the colon cancer spread into the
22:09lymph nodes and then after after
22:12the surgeon and pathologist are
22:14primarily involved, the oncologist?
22:17Takes the ball and either delivered
22:20is the chemotherapy,
22:21or if chemotherapy is not necessary
22:24in a case of colon cancer,
22:27young cologist is involved for
22:29their surveillance.
22:30That colon cancer doesn't come back,
22:32which includes having
22:34colonoscopies having blood tests,
22:35and in some cases having CAT scans.
22:40So who is the quarterback at first?
22:43The quarterback is the gastroenterologist
22:45here, depicted by a colonoscope.
22:49Second,
22:49after the diagnosis is made,
22:52the by the gastroenterologist,
22:54the quarterback in helping guide the
22:57patient through this experience is
23:00the surgeon who does the operation.
23:03Manage is the recovery from surgery
23:06and then three depicted down here
23:10in the lowest part of the diagram.
23:13The pills represent the oncologist,
23:16who gives the medicine that kills.
23:19Cancer that was not removed by surgery.
23:22What we call systemic disease disease
23:24that may be in the blood blood stream.
23:26Maybe in lymph nodes may be trying
23:29to set up shop in distant organs.
23:33Rectal cancer again.
23:34To draw the distinction to colon cancer
23:37is not so cookie cutter.
23:38There are many options for
23:41how rectal cancer is managed.
23:43Number one, some patients will
23:45get chemotherapy and they will get
23:47radiation and they will get surgery at
23:49some point in their treatment course.
23:52Some patients who have a rectal
23:54cancer that is higher up in their
23:56****** may only get surgery and
23:59not need the other modalities.
24:02Some patients will have surgery
24:04before they get chemo and radiation.
24:06Some patients will get surgery
24:08after they get chemo and radiation.
24:11It's a very confusing landscape.
24:15For patients to understand,
24:16even frankly,
24:17for doctors to understand #5I point out,
24:21down here.
24:22Some patients now are getting
24:24chemotherapy and radiation for rectal
24:26cancer and not having to have surgery.
24:29That's because we have found over
24:31the last decade or so that in some
24:35cases delivery of chemotherapy
24:37and deliver radiation can actually
24:39eliminate the cancer altogether,
24:41and in certain highly selected patients,
24:44surgery may be avoided.
24:46So this is simply to point out that it is a.
24:50These are different.
24:51I'm not sure that they're biologically
24:53so different diseases.
24:55It's partly their anatomy where
24:57they're located.
24:57One could certainly talk about the
24:59biology of the two different diseases,
25:02but they're certainly managed differently.
25:05So a little bit of you know the
25:08the meat and potatoes of surgery
25:10for colon cancer or rectal cancer.
25:13Three modalities that I've shown
25:15here on the left.
25:17I've shown patients abdomen with an
25:19incision representing open surgery.
25:21The surgeon can make an incision
25:23on the belly and do their work
25:26fully inside the patient's abdomen
25:28with their hands in their in
25:31their instruments in there.
25:33The middle diagram shows a patient.
25:35Gent,
25:36who has small bandages on
25:38small keyhole incisions.
25:40If you will,
25:41which could represent laparoscopic surgery.
25:43Quite frankly,
25:44it could also represent laparoscopic
25:47surgery the the what's done for
25:50for both laparoscopic and robotic
25:52surgery is that air is placed
25:55inside the abdomen so that there's
25:57a greater working volume and then
26:00in the case of laparoscopic surgery,
26:03long skinny instruments that
26:05are like chopsticks.
26:06Are used to manipulate the tissues,
26:11eventually leading to the removal of the.
26:17Piece of intestine that has cancer in it
26:21and the reattachment of the intestines.
26:25Finally,
26:25over here on the right is what robotic
26:29surgery looks like in robotic surgery.
26:33The surgeon sits at the console and through
26:37the movements of his or her fingers,
26:41controls the movements of the robotic
26:44arms of robot that is executing.
26:48The surgeons motions to perform the surgery.
26:51That also is a minimally invasive type
26:54surgery where the scars might look
26:58something like the middle diagram.
27:00Regardless of how which modality
27:03of surgery is chosen,
27:05the principles are the same number.
27:08One complete removal of the cancer.
27:12#2 the lymph nodes as well.
27:15OK, what are lymph nodes?
27:17Lymph nodes are part of our immune system.
27:21They help us fight infections.
27:23They also screen abnormal cells
27:26such as cancer in our body.
27:29Call for colon and rectal cancer.
27:32Like for other cancers,
27:34usually one would expect that
27:36before a cancer metastasizes to
27:38different to distant organs,
27:40it often at most often will
27:42spread into lymph nodes which live
27:45immediately adjacent to the colon.
27:48So as part of it as part of
27:51a proper cancer operation,
27:53when the intestine itself is removed,
27:56the lymph nodes also are in order to remove.
28:00All potential sites where the
28:02colon cancer may have spread
28:05locali and then after the removal
28:07of the affected piece of colon,
28:10the intestines are reconnected.
28:12This diagram here shows that the
28:15blue portion of colon is the part to
28:18be respected and you can notice in
28:22the diagram immediately next to it.
28:24The small intestine has now
28:27been reconnected to the colon.
28:30What can a surgery patient expect?
28:32There will be pain for a couple of days
28:35after surgery beyond a couple of days.
28:38Most patients describe that they're
28:40uncomfortable more than that,
28:42they truly are in grimacing type pain.
28:45Most patients will resume a
28:47normal diet in a couple of days.
28:51Fatigue lingers longer.
28:52It is weeks before people
28:54feel their full strength back.
28:56One of the biggest determinants
28:58of of what is your time course of
29:01surgery going to be is is is your age?
29:05OK it's it's a quicker recovery the
29:08younger that you are and it takes longer.
29:12Sikaran, the older that the patient is.
29:16What can a patient expect in
29:18terms of their bowels?
29:20I will say that rectal cancer
29:22treatment affects bowel habits more
29:23than colon cancer treatment does.
29:25That's because the ****** is the
29:27lowest portion of our large intestine.
29:29It's where the storage of the waste
29:33happens before it's illuminated.
29:35So the elimination and the ultimate
29:37storage of our waste is more
29:40affected by rectal cancer treatment
29:42then colon cancer treatment is,
29:44and so rectal cancer patients
29:46will have more alterations to
29:48their bowel function and surgery.
29:51Patients will be nervous.
29:52That's normal.
29:53That's one of my job or any physicians
29:56job is to manage the psychosocial part of.
30:00A patient,
30:01I will say that across the board the
30:04most nervous part of for patients
30:07is waiting for treatment to happen.
30:10It's waiting for surgery to come
30:13and then once surgery happens.
30:16They though they have pain,
30:18and though they're not probably
30:19pleased to be in the hospital,
30:22they are nowhere near as sort of
30:24anxious as they are when they're
30:26waiting for surgery. What's new in surgery?
30:29Three things that I'll point out
30:31simplified recovery.
30:32We're trying to shorten the length
30:34of stay in the hospital by managing
30:37pain with with less narcotic medicine,
30:39trying to get balls to work more
30:42quickly so that patients can return
30:45to their lives quicker.
30:47Certainly technology things such as
30:49as robotic surgery have have changed
30:52the landscape, and as I touched on.
30:57For rectal cancer in particular,
30:59the treatment paradigm is
31:00changing all the time,
31:02and where surgery used to be.
31:04Arguably the mainstay of treatment,
31:06it is now it is a portion of the treatment,
31:10and it sometimes not even needed.
31:13Thank you for your time, and I'll answer
31:16questions with the rest of the group.
31:21Thank you so much Peter. That was great.
31:24So we will move on next to Doctor
31:26Lee who will talk with us some about
31:29treatment before and after surgery. These.
31:32Names are adamant and knew argument
31:34in fact still describe that some.
31:40Doctor Lee, you're on mute still.
31:54OK. Sorry about my sorry bout
31:57my technical difficulties.
31:58So my name is only I am one of the
32:01medical oncologist in Greenwich so
32:02I will be speaking to you about
32:05Azure Vintan Neways even therapy.
32:07So what does that mean? So now.
32:10A surgeon has well against Mr. Hodges.
32:13Lester has diagnosed with colon cancer.
32:15You have senior surgeon and
32:16you've had the curative surgery.
32:18So what do we get?
32:20After the curious surgery we
32:21get something called Pathologic
32:23Stage and I talked to Mcwhorter,
32:24has spoken to you about staging.
32:26Now there are two different type
32:28of stage and that's what we called
32:30clinical staging and there's
32:31something called pathologic staging.
32:33For those of you don't know,
32:35stating just simply means how
32:36advance is how advanced was the
32:39cancer at the time of the surgery,
32:41generally speaking.
32:41Stage one and stage two cancers
32:44are what we call limited disease,
32:46meaning that the cancer has been
32:48discovered to be contained within
32:50the walls of the walls of the large
32:53intestine stage three diseases
32:54in localized disease that is,
32:56the cancer that has spread into one
32:59or more of the adjacent lymph glands.
33:02And, as you probably know,
33:04Stage 4 means that the cancer has
33:06spread to distant organs under the
33:09terms that we will use is metastatic cancer.
33:12So I have to do surgeries done.
33:15The pathologist will assess what
33:17was taken out and provide us the
33:20clinician with the pathologic staging.
33:22Why do we care?
33:24Well,
33:24this is what we call the five
33:27year disease Free Survival,
33:28a meaning that at the within the five
33:31years after they have cured of surgery,
33:34what is the chance that the
33:36cancer will have recurrent?
33:38So if a person has stage one cancer,
33:41then the probability of the cancelled
33:44not requiring in the in the in the
33:47next five years is 30 high, 90%?
33:49That's pretty good for stage two is.
33:52Equally well, maybe not equally,
33:54but it's still excellent,
33:55say about 80%.
33:57The problem is stage three disease where
33:59disease free survival is about 50%.
34:01So another way of putting it is that
34:04if a person has had a presumed curative
34:06surgery and you have stage three
34:09disease within the next five years,
34:11there's a 50% chance that the cancer
34:14may may be discovered to have return.
34:17So what can we do about that?
34:20Is there something we can do to
34:22reduce that likelihood and that is
34:24where agile and therapies come in,
34:26so adamant therapy, as the name implies,
34:29means a treatment that we give
34:31to help a person's cure rate.
34:33So to reduce the chance of a relapse.
34:37In case of colon cancer that the the
34:40advent therapy that we use is chemotherapy.
34:43So what is chemotherapy,
34:44chemotherapy or any and all
34:46medications that destroy cancer cells?
34:48And I think Doctor Boyle probably
34:51going to more detail about different
34:54forms of chemotherapy now.
34:56Large chemotherapy often target
34:59rapidly growing cells.
35:01They are typically given either
35:03intravenously or you take it
35:05as a pill by mouth,
35:06and as such there affect
35:08our systemic for both good
35:10and bad. And when I'm by that,
35:12what I mean is that unlike surgery or
35:15radiation therapy that are targeted
35:17to particular part of the body,
35:19chemotherapy affects the entire body
35:21and therefore if a person were to have
35:25adverse effects than the adverse affect
35:27entire affect our entire body as well.
35:30So who gets argument therapy? What?
35:32What are the different types of
35:35treatment and when do you get it?
35:38So as shown earlier?
35:41Stage 3 colon cancer patients have
35:43a high risk of recurrence and they
35:46are again technical count ones.
35:48Overall health are often advised
35:50to receive adjutant chemotherapy.
35:52Now, besides giving us a clinical,
35:55staging pathologist can also provide
35:57additional information in the
35:59information that will give us ideas
36:01to whether a certain patients with
36:04stage two cancer's actually have
36:06high risk of relapse and in select
36:08patients with high risk features.
36:11We also can't cancel them and
36:13sometimes advise them to receive
36:15as even chemotherapy as well.
36:17The three most commonly used
36:20as you can chemotherapy R5 FU,
36:23Xeloda an oxaliplatin,
36:24and these medications are often
36:27used in combination,
36:29giving us a regiment of and going
36:33by the acronym of FOLFOX or K Box.
36:38When do we start the as you can
36:41chemotherapy well as soon as possible.
36:43Soon as a person has recovered
36:45at recovered and healed.
36:46Actually from the surgery,
36:48there are some data indicating
36:50that delaying the adjutant therapy
36:51beyond 6 to 8 weeks may render the
36:54Angevin therapy less effective,
36:56so we do want to get going on the
36:58treatment sooner rather than later.
37:03So what is new regimen therapy?
37:05Sort of Columbus in Word.
37:07And you know, from a linguistic perspective,
37:09it doesn't really make a lot of sense,
37:12but knew as you can.
37:14Therapy are are treatments that are
37:16given before the curative surgery.
37:18It is often give we radiation,
37:20but near as even chemotherapy
37:21can be given by itself.
37:23The purpose of the new regimen,
37:25therapy or similar to the Azure and therapy,
37:28that is to say that we want to, we will we.
37:32Give a treatment in hope of
37:34reducing the recurrence rate.
37:35It is often used in rectal cancer
37:39zanin select colon cancer as well.
37:41Doctor Mcwhorter has done a wonderful
37:43job describing to you the difference
37:45between rectal cancer and colon cancer.
37:47So as he had indicated,
37:49when a person is diagnosed with very early,
37:52that is to say, stage one rectal cancer.
37:55The treatment of choice is a
37:57proceeding with surgery, so again,
37:59I'm talking about clinical staging here.
38:01So when a person is found to have
38:04clinical stage two or stage three disease,
38:07and we determined that they
38:09threw presurgical,
38:10CT scan or MRI,
38:12they are very helpful in telling us
38:15whether a person is as a clinical stage,
38:18one stage two or stage three disease.
38:21So those individuals with clinical
38:23stage two and stage three disease,
38:25we recommend neoadjuvant therapy.
38:29As Doctor Mcwhorter had indicated,
38:32there are no one universally
38:36accepted regimen.
38:37The most commonly used treatment
38:40modality consists of combination
38:42of radiation therapy with either
38:445F U chemotherapy which is given
38:47intravenously or an oral chemotherapy
38:49which is oral version of fire.
38:51If you called Xeloda,
38:53these two chemo treatments are often
38:57administered roughly about 5 1/2 weeks.
39:00Generally speaking,
39:01after this five and a half week of
39:04preoperative radiation and chemotherapy,
39:07we wait about 8 weeks before a
39:11person proceed with surgery.
39:14At times when we give this
39:16radiation and chemotherapy,
39:18followed by several months of chemotherapy,
39:20that is called total neoadjuvant therapy.
39:23We typically try to have all of
39:26our pre surgical treatment wrapped
39:28up in less than a six month less
39:31than six months before a patient
39:35could proceed with surgery.
39:37This is a little treatment algorithm.
39:39I know this is a very simplified a picture,
39:42so when a person is diagnosed
39:45with colorectal cancer,
39:46if a person has say stage one
39:48clinical excuse me, stage one,
39:50stage two or three colon cancer.
39:52They proceed to surgery similarly
39:54for personal stage one rectal cancer.
39:57They proceed with surgery.
39:58The pathologist will assess a spell.
40:01Provide us with the pathologic
40:03staging stage one disease in case
40:06of a patient with stage one disease
40:09and they go into the observation
40:11of the surveillance mode.
40:13Stage two cancer's with with
40:15favorable features again,
40:17will go into the surveillance of
40:19patients with stage two cancers
40:21with high risk features,
40:23as well as those with State Street are
40:26counseled about as even chemotherapy.
40:31The clinical stage two and stage three
40:35rectal cancer patients are advised to
40:38receive pre operative neoadjuvant therapy.
40:41Or simplified said new item
40:43and radiation and chemo.
40:45By surgery and again we have surgical
40:48staging and based on the surgical features
40:50some patients are told to undergo
40:53surveillance and some patients will be
40:55counseled to receive as if in therapy.
40:59So follow up and surveillance consists
41:02of blood test and examination.
41:05In the beginning every few months
41:07and perhaps the interval becoming
41:10longer as years pass.
41:12For some few select patients.
41:14We also recommend CT scan mass.
41:17Doctor Mcwhorter indicated a
41:19screening colonoscopy is crucial.
41:21We recommend colonoscopy within a
41:23year of the surgery and we follow
41:26our patients for about five years.
41:32And that is the measurement,
41:33and new regimen.
41:34Therapy in a nutshell.
41:35And then I will let Doctor Boy
41:37Carry on on the management of
41:39advance or stage four cancers.
41:43Thanks so much Doctor Lee.
41:46Doctor Boyd, it's nice to see you.
41:49We will let you be their
41:51last speaker this evening.
41:53You'll need to unmute and
41:55then share your screen.
42:00Hopefully yeah, that worked good. Now
42:03I need to get my presentation.
42:07Nothing like being an old
42:10man with new technology.
42:12We see this at show up now. Sorry.
42:40But perhaps I can so Doctor Boyd,
42:42maybe Emily can assist you offline
42:44and then I'm happy to maybe ask our
42:46other panelists a few questions while
42:48we're helping you get your screen up.
42:50OK, yeah, great, that's OK.
42:52No worries. Maybe if you can go on
42:54mute for a moment and then Emily,
42:56and maybe she will.
43:00Alright great so we have had
43:02a few questions come through
43:04the chat and Doctor Mcwhorter.
43:06I know that you answered one,
43:09but maybe we can just talk a little
43:11bit about the question that came
43:14through was rectal cancer was
43:16removed with clean borders and 30
43:18negative lymph nodes and this is
43:20sort of a combo of a surgical and
43:23oncology question is is chemotherapy
43:25necessary necessary after the surgery
43:27to prevent for future recurrence?
43:29Maybe you can talk a little bit about.
43:32Why do you take so many lymph nodes?
43:35Is that a normal part of a rectal surgery?
43:38What? How does that help you?
43:40And and then maybe even Doctor Lee and
43:42I can comment someone the chemotherapy.
43:45Yeah, in the interest of getting all
43:48of the cancer out, we want to take
43:51out both where the cancer has grown
43:53into the intestinal wall but also the
43:56lymph nodes that it can spread into an.
43:59So in the interest of not leaving anything
44:02behind, we do harvest as many lymph
44:04nodes as we can for a cancer operation,
44:07which is different from if I take
44:10out somebody's colon for, say,
44:12diverticulitis or Crohn's disease.
44:15That's not a disease that spreads
44:17around the body so so we do consciously
44:20take lymph nodes.
44:21People don't miss them. They don't.
44:24They're not going to, you know.
44:26People ask that question sometimes,
44:28but you're not going to miss them,
44:31and so it's in the interest of
44:34removing every everything where
44:35the cancer may have spread.
44:37Locali the reason that we do it and
44:41then the pathologist tells us if the
44:44cancer is spread into those lymph
44:45nodes and the other really important
44:48piece of information that we look
44:50to is how deeply into the wall of
44:52the colon did the cancer grow.
44:54I think those are the two main pieces
44:56of information that the oncologist
44:58then uses to determine should you or
45:00should you not have agement chemotherapy?
45:04Great thank you Doctor Lee.
45:06Do you want to add some about you?
45:08Know lymph node negative?
45:11It looks like we may have Doctor Boydan.
45:16Alright. And then Doctor Boy,
45:19you'll just need to touch.
45:21There's a slide presentation button.
45:22Alright, let me let me go so we
45:24can just we can just go from here.
45:27That's fine too.
45:28Yeah, sorry bout my technological skills
45:30I do know how to drive a car though.
45:33That I learned. So I'm going to
45:36talk about the last part is going
45:39to be about how we deal with the
45:42complexity of metastatic colon cancer.
45:44We've heard about early stage
45:46and surgery attachment therapy,
45:48but really, critically,
45:49a substantial number of colon cancer
45:52patients up to 60% end up developing
45:54metastatic cancer within their
45:55period of time with their disease.
45:58Majority of these actually will
46:00turn out to be hepatic metastasis.
46:02I'll show you why most will develop.
46:05Most of the cancers that do metastasize
46:08often occur following successful or did
46:10surgery and may or may not have had
46:13with therapy and then at a later time.
46:15Development is static disease,
46:17but up to 1/3 of patients will
46:19actually develop metastatic cancer
46:21at the time of diagnosis.
46:22The goals in general for
46:24treating metastatic cancer,
46:25palliative because obviously for the
46:27most part we tend to think of this
46:30is not is not curative but we try to
46:33improve quality of life and goals are.
46:36Clearly to have prolong survival as
46:38best we can and identify the small
46:40number of patients who actually are
46:43potentially curable through surgical
46:44approaches such as metastatic to me,
46:47particularly liver Mets and Lung Mets,
46:49which may actually be curable.
46:53Just as an example,
46:54one of the ways to understand how this
46:56spreads is that the colon is somewhat unique.
46:59You see the left and the right colon there,
47:02with the blue showing you the blood
47:05flow going right into the liver,
47:07and that in part explains that
47:09disproportionately high level of
47:10metastatic disease into the liver.
47:12However,
47:12the lymphatics and green will also
47:14take it beyond the liver into the
47:16systemic circulation and to other areas,
47:18and so it's not unusual overtime to
47:21go from having liver metastasis to
47:23even brain Mets lung metastasis.
47:25Info info.
47:25The principles of how we treat
47:27this go back to what Doctor Lee
47:30was originally talking about.
47:31With that red therapy, but it's beyond that.
47:34Because in metastatic cancer,
47:36the goal is to understand we now look
47:38at tumor Biology and we looked at
47:40biomarkers that will alter our treatment
47:43decisions very critically and very
47:44often in the first line of therapy,
47:47chemotherapy remains central,
47:48but we also often will add biological
47:50agents to improve outcomes.
47:51One of the concepts we all are
47:53dealing with as physicians is what
47:56we call sequential lines of therapy.
47:58The idea that we start with one.
48:00We continue on that and then
48:02when patients progress,
48:03we consider that resistant.
48:04We go on to another one and that
48:07has been altered in colon cancer
48:08uniquely to into this concept of
48:10continuum of care that we individualize
48:12therapy for each patient.
48:13We may start with an aggressive
48:15therapy depending on the patient's
48:17course and their status.
48:18We may then go onto a maintenance therapy.
48:20We may go into lower intensity
48:22treatments and then we may even
48:23give them treatment free intervals
48:25which had at
48:26one point not been considered rational.
48:28But because of side effects and the need
48:30to recover and the quality of life,
48:32we often will give them periods
48:34of time where there off treatment
48:36off some of the therapies.
48:37And then we may even go back and
48:39retreat with prior treatments
48:40depending on duration of time.
48:42But the key here is overtime.
48:44We tend to try to expose patients
48:46to all active agents during
48:47the course of their illness,
48:49which will clearly it has been shown
48:51to improve long term outcomes.
48:52This is an example for those
48:54of you in my age who we didn't
48:56have computers back then,
48:58and I started off learning to use
49:005F U as a way to treat colon cancer,
49:02and that was all we had.
49:04And then these this is evolved over
49:06from the early 80s into the 90s.
49:08When we started using combination
49:10therapies and newer agents that
49:12used as Doctor Lee mentioned,
49:14Folfox is an example where we
49:16user entity I'm sorry five.
49:18If you combined with oxaliplatin,
49:20an agent that became available in
49:22the early 90s and has been central
49:25to combination therapy and here
49:27combination therapies improve both
49:28median survival and as you can see
49:31in the blue increasing response rate.
49:33But we've even move beyond that now to
49:36the idea that we now use biological agents.
49:39In concert with that chemotherapy
49:41and you can see down the therapeutic
49:43concept with their targeted agents
49:46based on mutations as well as different
49:49approaches to inhibiting tumor growth,
49:51vascular growth factor inhibitors,
49:52such as bevacizumab,
49:54newer agents,
49:55and we can string out and improve long term,
49:58survivals quite substantially in patients.
50:01With this this sequential combination
50:03approach,
50:03but it's critical to understand the backbone
50:06of treatment still remains chemotherapy,
50:09the floral pyrimidines and
50:10it was mentioned earlier,
50:12Folfox which uses 5F U as a doublet
50:15because the look of Organism modulator
50:18and the two chemo agents are 5F,
50:21U, and oxaliplatin,
50:22oxaliplatin has its own unique side effects,
50:25particularly cold sensitivity in neuropathy,
50:27well as are in OT Canon,
50:30folfiri often has diarrhea.
50:31And other side effects as its consequence.
50:35What's interesting is many patients
50:37will come having had prior
50:39Azure in therapy with folfox,
50:41and so in those patients.
50:43The initial therapy maybe folfiri using
50:47a somewhat different combination.
50:49In very aggressive disease with very
50:51high tourbook, we may combine them,
50:52but this is really for younger people.
50:55People are good quality and performance
50:57status and we may actually combine Excel.
50:59Planner in OT can if they have large
51:02tumor bulk or aggressive disease.
51:04But importantly,
51:05we also try now to use biology and use
51:08these biomarkers to incorporate other
51:11approaches. To this we look early on.
51:14Once the patient is diagnosed
51:16with metastatic disease,
51:17the first step is to make sure
51:20that their mutation status,
51:22then they have critical mutations
51:24in a pathway called MAP kinase
51:27that's crass and Rasen.
51:28Be wrapping these three genes
51:31when mutated are activated,
51:32and it means that they will
51:35therefore change the sensitivity.
51:37To medicine, so for key resin
51:39resin be raff there are agents
51:41that are called EGFR agents.
51:43Epidermal growth factor inhibitors
51:45that are not active in those settings.
51:48Her to which many people are familiar
51:51with with breast cancer can also
51:53be upregulated in colon cancer.
51:55And really importantly,
51:56this subgroup that includes up to 6
51:59to 8% of patients will have defects
52:01in their ability to repair mutations.
52:04We call that mismatch repair and it's
52:06in a unique group who have a very
52:09high sensitivity to immune treatment.
52:11And Lastly, the tumor sidedness.
52:13This is the intriguing biology that left
52:16sided cancers are different than right sided.
52:19In terms of their biology and this is,
52:22these are the biological agents I mentioned.
52:25The EGFR targeted agents and whether
52:27or not they are affected is largely
52:30determined by mutation status.
52:32So patients who have mutated
52:33receptor mutated genes.
52:35The rats and Rask Eracer be raffine
52:37that may occur up to 4050% of patients,
52:40depending on the side of the colon,
52:43for instance, only in wild type
52:45patients who have normal jeans.
52:47These normal jeans.
52:49Do they effectively respond
52:51to these EGFR targeted agents?
52:53Erbitux invective, X?
52:55What's fascinating is that these
52:57are particularly effective in tumors
52:59in the left side of the colon.
53:02If they are what we call wild time.
53:04However,
53:05if they are in the right side of the colon,
53:08even if they're be even,
53:10if their mutation negative,
53:11they tend not to respond as well
53:13to these agents,
53:14so it's really in those with left
53:17sided colon cancers and have no
53:19mutations in these genes where we can
53:21use this in combination with chemotherapy.
53:24Alternatively,
53:24we have angiogenesis inhibitors,
53:26that is the classic one of vast
53:28nervous is a map which itself
53:31can be used in patients with.
53:33These mutations can be used often in
53:36combination with chemotherapy and those
53:38with these aggressive right sided cancers.
53:40And we,
53:41but critically,
53:42we need to balance risk and benefit
53:44because one of the problems with the
53:47the angiogenesis inhibitors as they
53:49carry their own set of side effects.
53:51For instance, hypertension is classic.
53:53They develop proteinuria,
53:54and particularly there's a
53:55risk for thrombotic disease.
53:57These are small percentages,
53:58but they can be devastating when they occur.
54:01And there's also the potential
54:03risk for bowel perforation.
54:04And most importantly,
54:05if you've had surgery,
54:07it is critical to wait because these
54:09agents actually impair wound healing.
54:11As the mechanism in which they
54:13were blocking vascular growth,
54:14which is central to developing
54:16effective words,
54:17and we prefer 6 to 8 weeks prior
54:19to surgery or 6 to 8 weeks after
54:22surgery to to use these agents and
54:24we must be careful in patients who
54:27are older or have had recent from
54:29botic events or we have for instance
54:32metastatic disease to brain with lead.
54:37And this is an example of the difference
54:39between left sided and right sided.
54:41I'm going to go to the
54:43here to re sightedness.
54:45The left and the right side of
54:47the colon have different origins.
54:49There biologically different,
54:49they have different blood
54:51supplies and interesting Lee.
54:52Part of this may reflect they have
54:54different composition of bacteria
54:55and their outcomes are different.
54:57Left sided colon cancers more common,
54:59they have better prognosis and those
55:01are patients where you can combine
55:02chemotherapy with these EGFR agents.
55:04If they don't have mutations likes
55:06to talk some AB or an attunement.
55:09Right study cancers are more aggressive.
55:11They start at the ****** up
55:12to the transverse colon.
55:14They have higher incidence of
55:15these mutations and Interestingly,
55:17these are the tumors in addition
55:18to be more aggressive,
55:20had this mismatch repair defects.
55:22It makes them potentially
55:23more vulnerable to Mutare.
55:25They tend to have worse outcomes
55:27and they get, as I mentioned,
55:29even with wild type the mutations
55:31they don't respond well to these
55:33EGFR agents and therefore better
55:35system app or the into Genesis
55:37inhibitors may be better and this
55:39is just an example of the curve
55:41here that shows you where the left
55:44tumors have greater overall survival
55:46to the right sided chambers and
55:48you can see we generally demarcate
55:50this around the splenic flexure.
55:52Which is where the descending colon
55:54begins into the sigmoid and into the ******.
56:00And Lastly, it's really
56:01important to look at the idea of
56:03the small percentage of patients who may
56:06have these defects in mismatch repair.
56:08This is a system that's designed to control
56:11to recognize an correct DNA mutations,
56:13and when these mutations because of a
56:16defect in one of these proteins is abnormal,
56:19there is an abnormal and more rapid
56:21accumulation of mutations and errors
56:23within the DNA of these cells.
56:25A surrogate for this is a thing
56:28called microsatellite instability
56:29and it may occur in three to.
56:316.5% but in fact it may be higher
56:33if we look at larger populations,
56:36and this leads to because of the
56:39inability to repair mutations,
56:40mutation birds,
56:41some of these mutations will generate
56:44proteins that are abnormal and the
56:46body will see these as antigens
56:48and generate an immune response.
56:50Now Fortunately when that occurs,
56:51the natural response of the body is to
56:54say we don't want an immune response.
56:57We want to turn this off because
56:59it is seen as autoimmunity.
57:02And it generates tolerance to these to
57:04this and therefore you get inhibition
57:07through what is called the checkpoint system.
57:10And these patients, therefore,
57:12when they have this feature.
57:14They're either mismatch repair,
57:16defective deficient,
57:17or they have high Ms I,
57:19as an alternative way of looking
57:21at this are very sensitive to
57:23inhibition of this checkpoint and a
57:26good example of this is the key no.
57:28177 trial where first line
57:30immunotherapy for metastatic cancer
57:31was more effective than chemotherapy.
57:33And I'll show you just a little
57:35bit of a slide about how this is
57:38just an example of how these
57:40checkpoint inhibitors work.
57:42The cancer cell through these
57:44increased mutations shows an antigen.
57:46The T cell cytotoxic T
57:49cell that attacks that.
57:51That is initially going to try
57:53to destroy the cancer cell,
57:55but the cancer cell puts up this.
57:58This protective molecule,
57:59called PDL one and PDL one therefore
58:02binds to PD one on the T cell and
58:04turns off the immune response.
58:06It's a very natural process that
58:08the that the immune system does
58:10to protect against autoimmunity.
58:12But we can do do when this occurs
58:14and there is a immune response to
58:17cancers with these high mutation
58:19rates we can come in and block that.
58:22PDL one with an animal with a
58:25inhibitor called a checkpoint
58:27inhibitor and block that inhibition
58:29activate the immune response.
58:32And this is an example of the curve
58:35that happened when they use this
58:37as first line therapy for patients
58:39who had deficient micro settle MMR
58:43or microsatellite instability.
58:44Who had this high mutation rate
58:47in this mismatch? Repair defects.
58:49And what you see here in the green
58:52are the patients who were simply
58:54given a single monotherapy with
58:56the this Pember Lizum app,
58:58which is a checkpoint inhibitor at it,
59:01markedly improved response rate
59:02and what we see in this that's
59:04not true for most other therapies
59:07is a continued response that may
59:09extend beyond five years,
59:10so a portion of these patients will
59:13actually have extended responses.
59:14We've heard this is KEYTRUDA,
59:16as many of you may have heard.
59:20So just as as a summary,
59:22if you look at this first line,
59:25therapy options include in metastatic cancer.
59:27In those that have be raft,
59:29mutations or interest.
59:32Mutations chemotherapy with bevacizumab.
59:34Those who have left sided colon cancers.
59:37We will often use epidermal growth
59:40factor inhibitors like some tucks map or.
59:44His parents had a tumor map.
59:46If they have right sided cancers,
59:48even if their wild type,
59:50we still give potentially bevacizumab
59:51and then at future therapy,
59:53if you have very aggressive disease,
59:55who may combine all of those agents,
59:57this sort of shows you
59:59that we continue therapy.
01:00:00The Beyond first line in the second line,
01:00:04we may alternate the therapy
01:00:06backbone if you've had folfox,
01:00:08we may switch to full fury.
01:00:10We may use alternative options
01:00:12beyond that combined with an
01:00:14anti Andrew Genesis bevacizumab.
01:00:16If tolerated well may continue into
01:00:18second line and even beyond that and
01:00:21there are even newer agents that we
01:00:24have that are available based on,
01:00:26you know the more recent research and
01:00:29most importantly just remember we can.
01:00:32On occasion,
01:00:32in small numbers of patients
01:00:34who develop attic metastasis,
01:00:36a small percentage may be resectable.
01:00:39Those recur later on with only
01:00:41liver metastasis,
01:00:42maybe resectable those who are diagnosed
01:00:45with metastatic cancer at the origin.
01:00:47We often give chemotherapy,
01:00:49and some of those may be salvageable
01:00:52with with surgery and have longer,
01:00:54survivals, and sometimes cures.
01:00:56So we always look for that possibility.
01:01:01I think that may cover most of what I.
01:01:06Unless you want me to talk about
01:01:07the last thing that I always think
01:01:09is important, what can you do?
01:01:12I just want to remind people
01:01:14the top line physical therapy,
01:01:16physical activity.
01:01:17After diagnosis improves outcome and I
01:01:19want to show you that this one slide
01:01:22prudent diet vitamin D has been shown
01:01:25to be potentially beneficial in survival.
01:01:27But this is interesting if you
01:01:30start exercise after diagnosis
01:01:31and you always account potato.
01:01:33This is an earlier stage disease.
01:01:35It reduces mortality and recurrence.
01:01:38If you increase your physical
01:01:40activity with metastatic cancer,
01:01:41your survival will improve,
01:01:43so it's an adjunct to your treatment.
01:01:45And it also, we know,
01:01:47helps to tolerate therapy.
01:01:49So be physically active during this
01:01:51long period when you're on treatment,
01:01:53and with each new therapy we can
01:01:56prolong and extend long term survival.
01:02:02Thank you Doctor Boy that's great,
01:02:04so if you can can share your screen,
01:02:07that would be wonderful and perfect.
01:02:09That's great so we have a little
01:02:12bit of time remaining for some Q&A.
01:02:15We will continue a little
01:02:17bit where we left off,
01:02:18and I think that so Doctor Lee.
01:02:21I don't think we got to finish the
01:02:24question that we were talking about,
01:02:26so I'll just read.
01:02:28Maybe I'll rephrase the question just so that
01:02:31the surgery 30 lymph nodes.
01:02:34Yes, exactly. And and when do you?
01:02:36When do you consider giving chemotherapy
01:02:37in that situation? So I mean, it's
01:02:39a great question. In some ways,
01:02:41it's sort of a trick question.
01:02:43He says. Well, yes, all that was done,
01:02:45or what did they find at
01:02:46the time of the surgery?
01:02:48And that's in part of my talk.
01:02:50That's what I touched upon that yes,
01:02:52you had all those lymph nodes taken
01:02:54out and the importance of being all
01:02:56those ******* I think have already been
01:02:58addressed because of the importance of
01:03:00determining whether the cancer is regional.
01:03:01Mattis said the lymph nodes are involved.
01:03:03We have to remove.
01:03:05At least 12.
01:03:06Preferably more lymph nodes,
01:03:07to make sure that we actually
01:03:09have an early stage disease at
01:03:11the lymph nodes are not involved.
01:03:13So out of those started lymph nodes.
01:03:16If you know a significant let's
01:03:18let's have a have involvement then
01:03:20I think you know that person should
01:03:22be advised to consider chemotherapy.
01:03:24I've been a 30 by there,
01:03:27but I think the question mean plus
01:03:2939 plus are removed and none are
01:03:31positive that there are all negative.
01:03:34So then he really comes down to.
01:03:36You know the features that I mentioned.
01:03:39You know it's a.
01:03:40It's then,
01:03:41by definition is a stage one
01:03:43or stage two disease,
01:03:44and are there any microscopic
01:03:46feature about the cancer that
01:03:48makes us particularly worry that
01:03:50this person against the odds right
01:03:52against the odds will have recurrent
01:03:54disease in the next five years?
01:03:56And I think that's what goes
01:03:57into making a decision about
01:03:59recommending or considering therapy,
01:04:01and I like to hear Doctor insist on that.
01:04:05Yeah, thanks Doctor Lee. Yes no.
01:04:07I mean I think that I answered
01:04:09a little bit in the chat,
01:04:11but it's you know,
01:04:13we really tailor our answers to
01:04:14the individual patient and that
01:04:16determine is determined by many things.
01:04:18It's determined by what their
01:04:20pathologist see under the microscope
01:04:22in terms of other high risk features
01:04:24that may predispose to cancer spreading.
01:04:26It depends on the patient's age and
01:04:29other medical conditions and health.
01:04:30So it depends on how they
01:04:32recover from surgery.
01:04:33So it's I think it's really shared decision
01:04:36making and I think that's something that.
01:04:39We as a team really talked about
01:04:42quite a bit with the patients.
01:04:44So I'm going to turn to Doctor your
01:04:47and with a couple of questions so,
01:04:49so this has been I guess I have a few,
01:04:52but I'll start with cotton.
01:04:54So a year where you know,
01:04:56we've certainly seen disparities in care.
01:04:59And I'm wondering if you can comment
01:05:01some on how we know that you know I'd
01:05:04say our black population is especially
01:05:06at increased risk for developing
01:05:08colorectal cancer an at earlier ages.
01:05:10Can you comment on that and
01:05:13what we're doing about it?
01:05:16Yeah, so yeah, certainly I'm.
01:05:17It's been a good year to bring up a lot
01:05:21of the disparities that we've seen for
01:05:23many many years and and in many ways
01:05:26we just have not been able to tackle
01:05:29an understanding them is is key to
01:05:32really be able to do something about
01:05:34it when it comes to early answered.
01:05:37Again, for for years and years we've
01:05:39seen those the African Americans
01:05:41were developing colorectal cancer
01:05:42younger ages and and some of the
01:05:45factors that we mentioned before.
01:05:47Seem to play a role,
01:05:48but we are missing some information.
01:05:50We clearly are missing some information,
01:05:53probably toxics,
01:05:53probably chemicals that were not
01:05:55really unclear about their affects.
01:05:57The information that we have regarding
01:05:59the risk factors just not does not
01:06:01add up to the entire difference,
01:06:03so there are some things that are
01:06:06still missing and and so we need to
01:06:08understand better in order to tackle
01:06:10things we need to understand them better.
01:06:13We need to study them better where
01:06:15the roots of those differences are.
01:06:17And really,
01:06:18making a deliberate effort to
01:06:20really tackle them,
01:06:21and I think that it's we're long
01:06:24overdue for that and hopefully will
01:06:26make a difference starting now.
01:06:29Yep, Yep, I agree there's
01:06:30actually a question that just
01:06:32came in the chat that Doctor
01:06:34that's very appropriate for you.
01:06:35I think I know the answer,
01:06:37but is the question is,
01:06:38is it overly aggressive to ask your
01:06:41primary care doctor to recommend
01:06:43a colonoscopy at the age of 45? So
01:06:46from all we know, there's already
01:06:48one society recommending that the
01:06:50USPS TF pretty soon is gonna do that.
01:06:52I understand the ACG one of
01:06:55the questions are logical.
01:06:56Society's is open to that too.
01:06:58I think that, as we mentioned before,
01:07:01the evidence is there an, and there are not.
01:07:04That many cancers were screening
01:07:06makes difference.
01:07:07And this is one of them.
01:07:09There are just not that many Ann and there,
01:07:12so the recommendations of
01:07:13the American Cancer Society.
01:07:15The new recommendations are probably
01:07:17are going to come out from the USPS TF.
01:07:20They're really based on some
01:07:22what they call modeling studies,
01:07:24because doing a large real life
01:07:26study here is a very complex
01:07:28thing that would take years,
01:07:30so they use three different groups of
01:07:33researchers that do what's called modeling,
01:07:35which is they put together a
01:07:38bunch of data in terms of and,
01:07:40and they come up with with scenarios.
01:07:43They look at risk.
01:07:44They look at what the potential
01:07:46complications could be from
01:07:48screening that 'cause they look
01:07:50a bunch of different things.
01:07:52And what they really saw is that
01:07:55when they corrected for these trends
01:07:57that we're seeing recently in terms
01:07:59of younger and younger people,
01:08:01developing cancer starting at
01:08:0345 makes a lot of sense.
01:08:05So we it's a moving target.
01:08:07But certainly I think that the
01:08:09consensus is there we have
01:08:11to move that that direction.
01:08:13There's still a group that's there.
01:08:15They are younger than 45.
01:08:17There are being diagnosed and naughty and
01:08:20and those who need to be addressed to.
01:08:23So what we can start shooting at
01:08:2510 but working what we can also
01:08:27do is to raise our awareness and
01:08:29in the past we as physicians with
01:08:31easily dismiss someone 35 year
01:08:33old who would have rectal bleeding
01:08:35and stuff like that was just when
01:08:37you have hemorrhoids and we would
01:08:39not pay much attention.
01:08:40Now we know that we can be
01:08:42that LAX about that.
01:08:43So I think that level of awareness
01:08:45is also very important because even
01:08:47going down to 45 there's still a
01:08:49significant number of individuals
01:08:50who are even younger than that like.
01:08:53The actor,
01:08:54who you know we would have been late
01:08:57for them too, so our awareness is very,
01:08:59very important.
01:09:00Great,
01:09:01thank you. I'm going to turn to Doctor
01:09:03Boyd and you know I think chemotherapy
01:09:06and oncologists get kind of a bad
01:09:09rap and I'm wondering if you can
01:09:11comment on sort of chemotherapy and
01:09:13is it really all that bad and maybe
01:09:16some about the side effects and how
01:09:18we help get patients through it.
01:09:22As I mentioned, one of the keys to treating
01:09:25particularly with metastatic disease
01:09:27is really tailoring it to the patient,
01:09:30so we have a way ways of using the
01:09:33medicines that will limit side effects.
01:09:36Potentially use alternating
01:09:37regiments or lower doses.
01:09:39When we think are developing side effect.
01:09:42The example, as I mentioned,
01:09:44is folfox contains the Asian oxaliplatin,
01:09:47which produces a significant or opathy,
01:09:49which, if continued on treatment,
01:09:51will worsen.
01:09:52And has effects on quality of life.
01:09:54You have a person's a musician
01:09:55is going to have a big effect on
01:09:57their ability to play the guitar.
01:09:59If they can't feel the strings.
01:10:01And those are things that we now think about.
01:10:03We think about how do we say OK,
01:10:06we're starting to get a little
01:10:07bit of the scientific.
01:10:08Let's hold off on the xle.
01:10:10Platten will keep you on the other
01:10:12edge on the rest of the regiment.
01:10:14The backbone of the five.
01:10:16If you look at Warren with the
01:10:18infusion and then we can give you
01:10:20a little holiday from that and
01:10:21then we can reintroduce it later.
01:10:23And so I think we're learning how with
01:10:25better agents and with more careful
01:10:27attention to these side effects.
01:10:29Another example is folfiri,
01:10:30which is a renote can't.
01:10:32And what's interesting,
01:10:33better in Attican is it has this ability
01:10:36to generate fairly significant diarrhea,
01:10:38and there's certain people interesting,
01:10:39Lee.
01:10:40It's been shown that people in the
01:10:42Southeastern US are more prone to
01:10:44adverse effects with the red attendance.
01:10:47We may start with a lower dose
01:10:49in some individuals is a very
01:10:51common condition called Gilbert's.
01:10:53We know that maybe 5 to 8% of
01:10:56patients will have a little mild
01:10:58elevation in bilirubin,
01:10:59but that's in clue to metabolic
01:11:01changes that may enhance the
01:11:03side effect of their energy.
01:11:05Yeah,
01:11:05so if we're alert to some of these genetic
01:11:08differences in metabolism of the drug,
01:11:10we can start ahead of time,
01:11:12reduce the dose and affectively treat them
01:11:14with lower doses without causing risk.
01:11:16And so I think that's always been the goal.
01:11:20How do we modulate the treatment?
01:11:22Pay careful attention to side effects,
01:11:24adjust it,
01:11:24lower doses when they're doing well,
01:11:26and even treatment Holidays to
01:11:28let them get past side effects.
01:11:30Retain quality of life.
01:11:32'cause I think quality of life is
01:11:34always the issue for all of these.
01:11:36For all our patients.
01:11:39Great thank you Doctor Mcwhorter.
01:11:41I have a question for you so I
01:11:43think that you know one question
01:11:45that patients often bring up when
01:11:47we're talking about surgery for
01:11:49rectal cancers is will I get a bag?
01:11:52Can you talk about what that means
01:11:55and the quality of life if they end
01:11:58up having to have a colostomy bag?
01:12:01Store. So I can sort of divide
01:12:06the conversation into two pieces.
01:12:09One is a permanent bag and
01:12:12one is a temporary bag.
01:12:15When do patients get permanent bags?
01:12:18That the time that a colostomy is
01:12:20permanent is when a rectal cancer is
01:12:23so low meaning so near the edge of
01:12:26your body near your **** that the
01:12:28sphincter muscles have to be removed
01:12:31in order to remove the cancer.
01:12:33In that scenario,
01:12:34a person is not going to be
01:12:36continent or in other words,
01:12:39able to control their bowels.
01:12:41In that one scenario where you will
01:12:44never be able to control your bowels,
01:12:47a colostomy needs to be a
01:12:51permanent situation.
01:12:52What's more common is to have a bag
01:12:56which is going to be temporary.
01:12:59And the reason that we do that
01:13:02sometimes is is that.
01:13:04One of the most risky parts of
01:13:07an intestinal operation is not
01:13:09the taking out of the cancer,
01:13:11but is in the putting back
01:13:13together of the intestine,
01:13:14and particularly for rectal cancer,
01:13:16which is low down in the pelvis.
01:13:19It is a technically more difficult
01:13:22operation for your surgeon to do.
01:13:24It's the healing can also be
01:13:27compromised when prior chemotherapy
01:13:28and prior radiation therapy have
01:13:31been delivered to those tissues,
01:13:33so they're not as good at healing.
01:13:37In that scenario,
01:13:38where where we've had a difficult
01:13:40operation that may or may
01:13:42not have involved radiation
01:13:43chemotherapy preoperatively,
01:13:44but we put the intestine back together,
01:13:47we have some concern that our handiwork
01:13:49is not going to is not going to hold up,
01:13:53and that a patient can have
01:13:55a leak at their connection.
01:13:58In that scenario,
01:13:59we sometimes leave a patient temporarily
01:14:02with a colostomy or ileostomy,
01:14:05meaning the stool gets diverted through
01:14:08their skin and into an appliance.
01:14:12Leaving time that their body could
01:14:14heal a a a connection that that
01:14:17had a leak to it and the patient
01:14:20would not suffer the frankly
01:14:23disastrous effects of having stool
01:14:26spill inside of their body.
01:14:28And it would be at a later date
01:14:32that another operation would
01:14:33be done to get rid of the bag.
01:14:37Once we have confirmation that
01:14:40the the connection healed so.
01:14:42Patients with rectal cancer have much
01:14:45higher incidences of having to have a bag,
01:14:48and Fortunately usually it's temporary
01:14:50as compared to colon cancer patients.
01:14:53Great
01:14:53thank you. Did you want to quickly?
01:14:55There was a quick question that
01:14:57was in there also on the average
01:14:59time span of a polyp becoming
01:15:01a cancer. Yeah, I'll I'll ask for
01:15:03doctor yours help with it too, but.
01:15:06To be simple. I think that most
01:15:11patient most people are aware
01:15:12that that our our societies have
01:15:15recommended that you can wait.
01:15:17If you're an average risk patient
01:15:19who's had prior normal colonoscopies,
01:15:21meaning there have not been polyps
01:15:23that you can wait up to 10 years to
01:15:26have your colonoscopy done again,
01:15:28and the reason for that.
01:15:30The recommendation of that time
01:15:32period is that it has been found that
01:15:35if you have a normal colonoscopy
01:15:37on day zero that you can wait.
01:15:40For up to those ten years before
01:15:43a new growth has gone through the
01:15:46polyp to cancer transformation,
01:15:48that's not one size fits all patients
01:15:51who have had prior colonoscopies that
01:15:53have included some or many polyps
01:15:56are going to be recommended by their
01:16:00gastrinologist to have a colonoscopy in
01:16:02two years or three years or five years.
01:16:06But there is some biology to the
01:16:10recommendation that you can wait.
01:16:12A different number of years.
01:16:16After
01:16:16you are anything
01:16:17to add to that no 100%
01:16:20agree. OK great.
01:16:24Yeah.
01:16:26Question is a technical one.
01:16:28Are the insurance companies covering?
01:16:32Colonoscopies for 45 year olds.
01:16:35So there there
01:16:36is a significant number of insurance
01:16:39companies that already now are covering.
01:16:41There's been a significant and quite
01:16:44fast move for coverage for 45 and older.
01:16:48Yeah, I'm going to answer a quick
01:16:51question that was in earlier on a
01:16:54topic that I happened to specialize in.
01:16:56So does treatment for a neuroendocrine
01:16:58rectal or colon cancer differ
01:17:00from that of an adenocarcinoma?
01:17:02So the most common type of colon or rectal
01:17:05cancer is this adenocarcinoma type that,
01:17:08if it's what the cells look like
01:17:10under the microscope in our pathology
01:17:12colleagues help us figure that out.
01:17:15I would say this surgical approach is
01:17:17very similar, and Doctor Mcwhorter.
01:17:19Comment on that.
01:17:20It's the pre and post treatment
01:17:23approach that differ considerably.
01:17:24I would say that we usually do
01:17:26not use radiation or chemotherapy
01:17:28and that diseases again.
01:17:30There are some nuances there,
01:17:32but that's the simple answer.
01:17:33I had some questions that
01:17:35came in quite a bit earlier,
01:17:37kind of before the web and R that I might
01:17:41ask to the group and it's a lot about.
01:17:44You know how we work as teams.
01:17:47Some of the questions are around.
01:17:49You know, if a patient sees
01:17:51a General Medical oncologist,
01:17:53how can they take advantage of using
01:17:55some of the specialists at Yale?
01:17:57And I think that's a great question,
01:18:00and actually one that we were just talking
01:18:02about as a panel before this started,
01:18:05and maybe I'll start so as a kind of the
01:18:08new director of the Yale GI Cancer program.
01:18:11I'm actually thrilled to be on
01:18:13the panel tonight with the,
01:18:14you know,
01:18:15Greenwich Care Center Dr.
01:18:16You and I are both primarily at main campus.
01:18:20I think that our goal is really
01:18:22to be broadly inclusive of all
01:18:25of our care center physicians,
01:18:27many of whom have special interests
01:18:29in GI cancers and expertise.
01:18:31And we have a lot of forums
01:18:34that we can interact,
01:18:36including something called a tumor board.
01:18:38The tumor Board is a multidisciplinary
01:18:40meeting of medical oncologists and surgeons
01:18:42and gastroenterologists and radiologists.
01:18:44And we all meet and talk about patient cases,
01:18:48but I might ask,
01:18:50you know?
01:18:51Where is Lee Boyd and Recorder to
01:18:52comment some on that too?
01:18:54And their vision for that.
01:18:58Whoever wants to go first. Doctor Lee.
01:19:01So yes, I think in many ways I having
01:19:05an expert available to counsel patients
01:19:09will enhance our program, obviously.
01:19:13Not surprisingly,
01:19:14when a person gets diagnosed with cancer,
01:19:17whether it be early or late stages,
01:19:19they meet with one of us on the medical
01:19:22oncologists received recommendation and
01:19:24it's not uncommon and quite natural to say,
01:19:27OK, you know you've explained things.
01:19:29Could we get a second opinion and we
01:19:32of course University saying that's
01:19:34a good idea and we do recommend well
01:19:37if you got to see a second opinion,
01:19:40please go see a person who specializes in.
01:19:43Or cancer of that specific type.
01:19:46And and an expert like doctor clients or her
01:19:50colleagues at Yale would be a big resource.
01:19:53And if we are able to then
01:19:56offer that type of service,
01:19:58well, you know with with.
01:20:01Covid one adventure we have now become
01:20:03quite adapted this this a Tele health where
01:20:06our clinicians can be viewed to pathology.
01:20:09The radio graphic data and get really good.
01:20:12You know, a recommendation.
01:20:14But in the past you would have to
01:20:17be that our patients would have to,
01:20:19you know, go to New Haven.
01:20:22But if we could have that
01:20:24expertise in our community,
01:20:25say, you know.
01:20:28A week or so many days a week,
01:20:32I think it'll be great and I think it'll
01:20:35be a great option for our patients.
01:20:38There are more common conditions where
01:20:41you know things appear to be much
01:20:44more following along an algorithm,
01:20:46but our our illness it you know it's
01:20:49it's quite different from one person
01:20:52to another and having an expertise
01:20:55as someone who has great number of.
01:20:58You know your situation where that
01:21:00person could have handled or come across
01:21:03the situation I think would be very
01:21:05helpful to all of our patients as well.
01:21:07Yeah,
01:21:07and you know I often tell patients that
01:21:10they have the best of both worlds by
01:21:12having a doc in their community and
01:21:14connection with an academic center
01:21:16and we can really share and taking
01:21:19care of the patient where they can
01:21:21get their infusions closer to home and
01:21:23maybe occasionally have if they need
01:21:25an extra input from a specialist or
01:21:27access to a clinical trial that may
01:21:30not be available at that care center.
01:21:32Although we're working on that,
01:21:34I think that that collaboration can
01:21:36work quite well, especially as.
01:21:38The Smilow Care Center Network is expanding.
01:21:41Doctor Boyd, do you have any comments
01:21:43on that? Yeah, I think it's
01:21:45actually a wonderful two way street.
01:21:47I think what I've found is not only is
01:21:49it great to get on the phone and call
01:21:52one of my colleagues at Yale with a
01:21:54difficult case and then be able to get
01:21:57the patient to be seen to discuss it.
01:21:59But on the other hand,
01:22:01patients are coming here because they
01:22:03live close to us and then they get
01:22:05the best of both worlds by getting
01:22:07there here in our center while
01:22:10simultaneously getting the expertise
01:22:11of yelling that's happened recently.
01:22:13Quite a few patients who would
01:22:15rather get care here.
01:22:16We have wonderful nursing care
01:22:18and yet still avail themselves of
01:22:20the expertise at Yale to be able
01:22:22to be sure there were overseeing
01:22:24everything at every step.
01:22:25Everyone is paying attention,
01:22:27so I think it really is a great
01:22:29collaboration. I agree.
01:22:30I agree, well we have a few minutes left.
01:22:33I'm going to end. We did a smile.
01:22:35Oh shares last week also with
01:22:36some kind of Northern arc.
01:22:38I guess near New Haven in northern
01:22:40Connecticut I'm going to end with
01:22:41the same questions. So Doctor,
01:22:43your nose knows what I'm gonna end,
01:22:44but I'd love for everyone to think about
01:22:46what you are most hopeful for in the
01:22:48world of colorectal cancer treatments.
01:22:50An and and S on a positive
01:22:52note for the evening,
01:22:53so I'm going to start with Doctor.
01:22:55You are since you knew
01:22:56I was going to ask that.
01:22:58Maybe I have the
01:22:59feeling I have to answer the same which is.
01:23:02Making sure we have less and less cancer,
01:23:05we can prevent it.
01:23:06This is a very among all of them.
01:23:08It's a very preventable one.
01:23:09We gotta keep working on that,
01:23:11and I'm not gonna say that I
01:23:13want the oncologist out of
01:23:14business as I did say before.
01:23:16But definitely I want to make sure
01:23:18that we have less and less business
01:23:20for you and more prevention.
01:23:22Yes, doctor Mcwhertor how about you? It's
01:23:26hard to argue with that.
01:23:29This is I I've done other lectures before.
01:23:32As Doctor your points out.
01:23:35There are a lot of nasty cancers out there,
01:23:38and some of them we don't know
01:23:40when they're going to get us.
01:23:42Whenever we at this point have no way of
01:23:45knowing when pancreatic cancer may get us,
01:23:48we have tools already at our disposal to
01:23:50prevent colon cancer and rectal cancer
01:23:53if we simply avail ourselves of them.
01:23:55That's the hope.
01:23:57Great doctor Lee.
01:24:01I just echo that presenting a problem,
01:24:03whether it be cancer. Any problem
01:24:06is is the best thing you could do.
01:24:09Taking care of the problem at this
01:24:11earliest is the second best and then
01:24:13tackling the problem head on and coming
01:24:16up with better means of doing it.
01:24:18More successful and it's you know,
01:24:20less ideal, but it's still an important goal,
01:24:23so from you know from my life
01:24:25in a talk on agile, in therapy,
01:24:27so actually therapy will reduce
01:24:29the chance of recurrence.
01:24:30So we would like better medications that will
01:24:33effectively prevent recurrence of cancer.
01:24:35We don't have that yet,
01:24:36but you know,
01:24:37as the medications may I make it better.
01:24:40What targeted treatments maybe?
01:24:42Maybe in the not too distant future.
01:24:45Instead of giving blanket or solid platinum,
01:24:47will be able to specifically
01:24:49design up medication for that
01:24:51particular person's tumor,
01:24:53and really significantly
01:24:54reduced the risk of recurrence.
01:24:58Great thank you and Doctor Boyd. Yeah I.
01:25:00I actually have kind of
01:25:02a mixture of all this.
01:25:03I have great hope that we'll have
01:25:05answers to some of the great conundrums.
01:25:08Like why do young people get colon cancer?
01:25:11No, Charlie Fuchs once said to me it's
01:25:13because there's more obesity and there's not.
01:25:15It's not obvious.
01:25:16There's something else going on and we're
01:25:18looking at everything from the microbiome.
01:25:20That's something that hadn't really
01:25:22been mentioned, but that's a huge issue.
01:25:24How does that play a role here?
01:25:26Learning about lifestyle,
01:25:27diet, all of the things that
01:25:29may early on influence this.
01:25:31Because why do black South Africans
01:25:33in 1970 never get colon cancer?
01:25:36They were doing something right
01:25:37and so I think we need.
01:25:39These are the future is to how
01:25:41do we affect our population,
01:25:43lower risk and then also how can we
01:25:46use really new or molecular techniques
01:25:48early on when somebody might recur
01:25:51and catch it before it occurs?
01:25:53With newer approaches,
01:25:54we don't yet have validated that
01:25:56can really start to impact patients
01:25:58before they get better static disease.
01:26:00After that edge of therapy and
01:26:02may still be at risk.
01:26:05Great, thank you.
01:26:07So I agree with all that has been
01:26:10said and I will also end with a
01:26:13a note of thanks to our audience
01:26:17for joining us this evening.
01:26:19Thank you to our panelists
01:26:21for their time tonight.
01:26:23We encourage our attendees to go to
01:26:26Yale Cancer website or or email us.
01:26:29I think those that that information
01:26:32was with the Lincoln Invitation
01:26:34and please spread the word about.
01:26:37Screening and prevention.
01:26:38I would say that you know Yale and our
01:26:41care centers are open for screening,
01:26:43even though we're still
01:26:45kind of in the pandemic.
01:26:46We really encourage you to get
01:26:48screened and get your colonoscopies.
01:26:50So with that I wish everyone a good evening.
01:26:53Thanks
01:26:54so much. Thank you thank you, bye.