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

March 24, 2021
  • 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.